Gerald D. Zahtz

Middle Turbinate Headache Syndrome

Sinus headaches are attributed to inflammatory disease of the sinus mucosa or ostium. In 1948 H.G. Wolff first recognized that sinus headaches may occur in the absence of inflammatory sinusitis, and may be due to contact between strategic “trigger points” in the sinonasal passages. Since this time there have been sporadic reports of headaches and facial pain due to an enlarged middle turbinate contacting either the septum or lateral nasal wall. It is theorized that an enlarged middle turbinate, most commonly due to pneumatization (concha bullosa), can contact the septum or lateral nasal wall and give headaches referred to the ophthalmic division of the trigeminal nerve, the main sensory innervation of the anterior middle turbinate. Middle turbinate headache syndrome is reviewed, with attention to pathophysiology, clinical presentation, and treatment. Eight cases of middle turbinate headache will be presented in support of this clinical entity. We hope to alert the clinician to a relatively unknown source of recurrent headaches, that may be readily treated by otolaryngologists.

Early efficacy trial of anakinra in corticosteroid-resistant autoimmune inner ear disease

BACKGROUNDnAutoimmune inner ear disease (AIED) is a rare disease that results in progressive sensorineural hearing loss. Patients with AIED initially respond to corticosteroids; however, many patients become unresponsive to this treatment over time, and there is no effective alternative therapy for these individuals.nnnMETHODSnWe performed a phase I/II open-label, single-arm clinical trial of the IL-1 receptor antagonist anakinra in corticosteroid-resistant AIED patients. Given that the etiology of corticosteroid resistance is likely heterogeneous, we used a Simon 2-stage design to distinguish between an unacceptable (≤10%) and an acceptable (≥30%) response rate to anakinra therapy. Subjects received 100 mg anakinra by subcutaneous injection for 84 days, followed by a 180-day observational period.nnnRESULTSnBased on patient responses, the Simon 2-stage rule permitted premature termination of the trial after 10 subjects completed the 84-day drug period, as the target efficacy for the entire trial had been achieved. Of these 10 patients, 7 demonstrated audiometric improvement, as assessed by pure tone average (PTA) and word recognition score (WRS). In these 7 responders, reduced IL-1β plasma levels correlated with clinical response. Upon discontinuation of treatment, 3 subjects relapsed, which correlated with increased IL-1β plasma levels.nnnCONCLUSIONnWe demonstrated that IL-1β inhibition in corticosteroid-resistant AIED patients was effective in a small cohort of patients and that IL-1β plasma levels associated with both clinical hearing response and disease relapse. These results suggest that a larger phase II randomized clinical trial of IL-1β inhibition is warranted.nnnTRIAL REGISTRATIONnClinicalTrials.gov NCT01267994.nnnFUNDINGnNIH, Merrill & Phoebe Goodman Otology Research Center, and Long Island Hearing & Speech Society.

Obstructive congenital epulis: prenatal diagnosis and perinatal management.

Objective To describe a multidisciplinary approach for delivery room management of congenital epulis.

Mentoring in otolaryngology training programs

Objective: The Accreditation Council for Graduate Medical Educations focus on outcome-based training has made the mentoring process critical for resident education. It is unknown how otolaryngology training programs mentor residents. Our objective was to determine the current state of mentoring in otolaryngology training programs and describe resident perceptions of mentoring. Study Design: Cross-sectional survey. Setting: Accredited U.S. otolaryngology training programs. Subjects and Methods: All U.S. otolaryngology residents and program directors were contacted via e-mail with a link to an online survey. Results: Of the 1411 residents contacted, 27.7 percent responded, representing 71 of the 103 accredited otolaryngology programs. Of the 103 program directors contacted, 37.9 percent responded. Of these programs, 26 had formal mentoring programs, 45 did not have formal mentoring programs, and 12 programs were listed in both categories. Fifty-one percent of male residents and 49 percent of female residents had mentors. The most important mentor characteristics were personality match, good clinical role model, and similar subspecialty interests. Least important characteristics were race, gender, and age. Twenty-six percent of residents felt that mentoring was critical to their training, while 63 percent of residents listed mentoring as important but not critical. Programs with fewer faculty and residents were less likely to offer formal mentoring (P = 0.007 and 0.054, respectively). Of residents who did not have mentors, 80 percent lacked a mentor because their residency had no formal mentoring program. Conclusion: Residents perceive mentoring as important, and formal mentoring programs should be incorporated into otolaryngology training programs.

Recurrent attacks of facial nerve palsy as the presenting sign of leukemic relapse.

Objective To present an unusual case of recurrent facial palsy resulting from acute leukemic infiltration of the parotid gland.

Pediatric Hemophilic Pseudotumor of the Paranasal Sinus

Objectives/Hypothesis: Hemophilic pseudotumors are rare clinical entities in otolaryngology. An unusual case of a pediatric hemophilic pseudotumor of the paranasal sinus in a previously undiagnosed hemophiliac is presented.

Resident Research Experience and Career Path Association A National Survey of Recent Otolaryngology Graduates

Objective To determine whether the research rotation experience affects the career path of otolaryngology residents. Study Design/Setting Two web-based surveys were disseminated by the AAO-HNS; one to current and former resident trainees and the other to current residency program directors. Subjects and Methods A web-based survey was disseminated to all AAO-HNS members classified as otolaryngology residents or residency graduates within the last 6 years, regarding their research rotation and its potential influence on their career path. A second web-based survey was delivered simultaneously to program directors to evaluate their perception of the need for research in a training program and their role in the rotation. Chi-square tests for independence as well as multivariate analyses were conducted to determine whether aspects of the resident research rotation related to career path. Results The resident survey was completed by 350 respondents (25% response rate), and 39 program directors completed the second survey (37% response rate). Multiple factors were examined, including federal funding of faculty, mentorship, publications prior to residency, success of research project measured by publication or grant submission, and type of research. Multivariate analyses revealed that factors most predictive of academic career path were intellectual satisfaction and presence of a T32 training grant within the program (P < .05). Conclusion The composition and quality of the residency research rotation vary across institutions. Factors that enhance stronger intellectual satisfaction and the presence of T32 grant, which demonstrates an institution’s commitment to research training, may promote pursuit of a career in academia versus private practice.

Benign adenoma of the middle ear cavity causing facial paralysis.

The otologic surgeon infrequently encounters tumors confined to the middle ear cavity. A 30-year-old man had a right facial nerve palsy that was believed to be secondary to chronic otitis media. At surgical exploration, an adenoma of the middle ear involving the ossicles and overlying the facial nerve was found, a radical mastoidectomy performed, and subsequent complete recovery of the facial nerve noted. To our knowledge, this is the first case of a middle ear benign adenoma causing a facial paralysis and the pathology, cause, and differential diagnosis will be discussed.

Computed tomographic findings of paranasal sinuses following application of a topical nasal decongestant

There are no established guidelines for the use of nasal decongestants before computed tomographic (CT) scanning in patients with inflammatory sinonasal disease. A prospective, double-blinded, placebo-controlled study was undertaken to compare the radiologic interpretation of the ostiomeatal complex and related sinus mucosa before and after topical application of oxymetazoline. The CT scans were interpreted by a radiologist who was blinded to the content of the nasal preparation (placebo vs oxymetazoline). Changes in turbinate hypertrophy were readily apparent after application of oxymetazoline; however, significant changes of the ostiomeatal complex were not demonstrated. The results of this study will help determine the role of nasal decongestants before CT scanning of inflammatory sinus disease.

Masson's Lesion of the Maxillary Sinus

Intravascular papillary endothelial hyperplasia (IPEH), or Massons lesion, is a benign reactive lesion that can be located anywhere in the body, including the head and neck region. Common head and neck locations include the lip, tongue, buccal mucosa, cheek, and parotid, although two cases have been described in the nasal cavity. We present the first case to be described in the paranasal sinuses, in a patient presenting with chronic self-limiting epistaxis. Although the radiographic appearance resembled that of a polyp or cyst, histological analysis demonstrated IPEH. The importance of this lesion lies in its similarity to other vascular lesions, from which it must be distinguished.