Sharon H. Gnagi

Nasal Obstruction in Newborns

Nasal obstruction is a serious clinical scenario in the newborn infant with a large differential diagnosis. This article reviews the etiologies of nasal obstruction to aid the pediatrician in prompt evaluation, diagnosis, and treatment.

Analysis of Intraoperative Radiographic Electrode Placement During Cochlear Implantation.

Objective To investigate the clinical value of intraoperative plain radiographs in determining correct placement of cochlear implants. Patients All cochlear implant insertions over a 10-year period by a single surgeon. Interventions Cochlear implantation with intraoperative imaging. Main Outcome Measure Whether intraoperative imaging affects clinical/surgical management. Results A consecutive retrospective review of 207 cochlear implantations performed in 187 patients was performed. All implants performed had intraoperative plain film imaging. Etiology of hearing loss, surgical variations, gender, age, and implant type did not affect intraoperative imaging. Four cases were identified where variations in intraoperative imaging interpreted by the surgeon warranted further discussion. In one patient, the intraoperative x-ray interpretation missed an incorrectly placed electrode. Postoperative CT scan confirmed implant electrode within the superior semicircular canal. In three patients, intraoperative x-ray results aided management by confirming surgical findings; however, no subsequent clinical or surgical alterations were made based on imaging. One of these three patients experienced a noticeable function decline postoperatively that correlated with altered positioning of the cochlear implant on intraoperative radiographs. In all surgeries, no changes were made to the electrode placement based on the intraoperative radiographs. Conclusion Intraoperative plain film imaging during cochlear implantation, although commonly employed, does not typically affect clinical management. For select cases, imaging may continue to be useful based on the surgeon’s discretion and intraoperative findings for confirmatory purposes.

Idiopathic Subglottic and Tracheal Stenosis A Survey of the Patient Experience

Objectives: To report and compare patients’ experiences with acquired subglottic stenosis (AS) versus idiopathic subglottic and tracheal stenosis (ISTS). Methods: A survey was made available to patients with AS and ISTS. Results were analyzed for inter- and intragroup differences using a 2-tailed t test. Results: The study included 160 survey participants (AS n = 28; ISTS n = 132), with a predominance of female participants (82% AS, 98% ISTS). Acid reflux was the most prevalent comorbidity across groups (42%-43%). A significant difference in time to diagnosis was found between groups, with 32% of AS patients diagnosed within 3 months of symptom onset, compared to 2% with ISTS. A diagnosis delay greater than 18 months occurred for 58% of ISTS patients. There was no difference in treatment approach, with the most common treatment being balloon dilation, followed by laser dilation. Tracheal resection was performed in 36% of patients in both groups. Patient satisfaction with surgical outcomes was significantly higher after tracheal resection (76%) compared to other treatment modalities (39%). Conclusions: ISTS remains a diagnostic challenge as highlighted by the delay in diagnosis compared to AS. There appears to be no historical or symptomatic factors specific to ISTS. Additionally, patients report increased satisfaction and symptom resolution after tracheal resection.

Hyalinizing Trabecular Tumor Masquerading as Papillary Thyroid Carcinoma on Fine-Needle Aspiration

Background/Aims: Hyalinizing trabecular tumors are rare neoplasms of the thyroid gland often mistaken for thyroid carcinoma on fine-needle aspiration. We review the distinguishing characteristics of hyalinizing trabecular tumors and their management. Methods: We present the case of a patient diagnosed with papillary thyroid carcinoma on fine-needle aspiration as well as a review of the literature. Results: Intraoperative findings were felt to be inconsistent with papillary thyroid carcinoma and only a thyroid lobectomy was performed pending the results from pathologic evaluation, which confirmed a benign process and a diagnosis of hyalinizing trabecular tumor. Due to the diagnostic difficulty in distinguishing hyalinizing trabecular tumors from thyroid carcinomas on fine-needle aspiration, many patients receive overtreatment for what is primarily a benign disease. Conclusions: Recognition of hyalinizing trabecular tumors as a possible benign etiology of a thyroid mass can facilitate appropriate management.

Management of rhinosinusitis during pregnancy: systematic review and expert panel recommendations.

BACKGROUND Management of rhinosinusitis during pregnancy requires special considerations. OBJECTIVES 1. Conduct a systematic literature review for acute and chronic rhinosinusitis (CRS) management during pregnancy. 2. Make evidence-based recommendations. METHODS The systematic review was conducted using MEDLINE and EMBASE databases and relevant search terms. Title, abstract and full manuscript review were conducted by two authors independently. A multispecialty panel with expertise in management of Rhinological disorders, Allergy-Immunology, and Obstetrics-Gynecology was invited to review the systematic review. Recommendations were sought on use of following for CRS management during pregnancy: oral corticosteroids; antibiotics; leukotrienes; topical corticosteroid spray/irrigations/drops; aspirin desensitization; elective surgery for CRS with polyps prior to planned pregnancy; vaginal birth versus planned Caesarian for skull base erosions/ prior CSF rhinorrhea. RESULTS Eighty-eight manuscripts underwent full review after screening 3052 abstracts. No relevant level 1, 2, or 3 studies were found. Expert panel recommendations for rhinosinusitis management during pregnancy included continuing nasal corticosteroid sprays for CRS maintenance, using pregnancy-safe antibiotics for acute rhinosinusitis and CRS exacerbations, and discontinuing aspirin desensitization for aspirin exacerbated respiratory disease. The manuscript presents detailed recommendations. CONCLUSIONS The lack of evidence pertinent to managing rhinosinusitis during pregnancy warrants future trials. Expert recommendations constitute the current best available evidence.

Human Papillomavirus Vaccination Counseling in Pediatric Training: Are We Discussing Otolaryngology-Related Manifestations?

Objective Demonstrate the need for increased education regarding otolaryngology-related manifestations of human papillomavirus (HPV). Highlight a need to incorporate otolaryngology-related manifestations of HPV in vaccine counseling. Study Design Survey. Setting Tertiary care academic children’s hospital. Subjects Pediatric residents, fellows, and staff. Methods An online survey was made available regarding HPV education and vaccination. Results Participants (N = 348) initiated the survey representing 28.4%, 25.6%, and 19.0% postgraduate year 1, 2, and 3 residents, respectively, as well as 17.5% chief residents/fellows and 9.5% attendings. Participants rated their prior education as none or fair regarding recurrent respiratory papillomatosis (63.8%) and oropharyngeal squamous cell carcinoma (68.3%). In contrast, 60.6% and 70.9% rated their education on genital warts and cervical cancer correspondingly as good or excellent. When asked what was routinely discussed during HPV vaccine counseling, 63.3% reported “never” discussing recurrent respiratory papillomatosis and 52.9% “never” discussing oropharyngeal squamous cell carcinoma. A range from 92.7% to 95.5% responded that there was a need for increased education regarding HPV and its role in recurrent respiratory papillomatosis and oropharyngeal squamous cell carcinoma. Conclusions Increased education about HPV and its otolaryngology-related manifestations should be undertaken to increase provider, patient, and parent awareness of recurrent respiratory papillomatosis and oropharyngeal squamous cell carcinoma. We propose that discussing the risks of otolaryngology-related disease be routinely included in HPV vaccination counseling.

Facial Nerve Meningioma: A Cause of Pediatric Facial Weakness

OBJECTIVE To present an unusual case of a temporal bone meningioma with intrafascicular spread throughout the temporal facial nerve from cerebellopontine angle (CPA) to stylomastoid foramen. PATIENT Four-year-old female with progressive facial weakness and normal hearing. MAIN OUTCOME MEASURE Clinical, radiological, and histopathological findings of temporal bone meningiomas. RESULTS A patient presented with progressive facial weakness and normal hearing. Imaging demonstrated a mass within the left internal auditory canal radiologically consistent with a schwannoma. Asymmetric enlargement with enhancement of the left facial nerve from CPA to the stylomastoid foramen suggested facial schwannoma. At surgery, gross tumor was noted in the internal auditory canal, the fallopian canal seemed expanded and the facial nerve was enlarged and had an irregular contour. Resection of the facial nerve from the CPA to just proximal to its exit at the stylomastoid foramen was necessary to achieve negative margins. Cable grafting was performed. The histopathologic diagnosis was transitional meningioma with intraneural growth throughout the length of the resected facial nerve segment. CONCLUSION Meningiomas involving the temporal bone are exceedingly rare. We report a rare case of a child presenting with progressive facial weakness due to a presumed facial schwannoma spreading along the facial nerve throughout its intratemporal course that at surgery was found to be an intrafascicular CN VII meningioma.

Acute contained ruptured aortic aneurysm presenting as left vocal fold immobility.

Objective. To recognize intrathoracic abnormalities, including expansion or rupture of aortic aneurysms, as a source of acute onset vocal fold immobility. Methods. A case report and review of the literature. Results. An 85-year-old female with prior history of an aortic aneurysm presented to a tertiary care facility with sudden onset hoarseness. On laryngoscopy, the left vocal fold was immobile in the paramedian position. A CT scan obtained that day revealed a new, large hematoma surrounding the upper descending aortic stent graft consistent with an acute contained ruptured aortic aneurysm. She was referred to the emergency department for evaluation and treatment by vascular surgery. She was counseled regarding surgical options and ultimately decided not to pursue further treatment. Her vocal fold immobility was subsequently treated via office-based injection medialization two weeks after presentation and again 5 months after the initial injection which dramatically improved her voice. Follow-up CT scan at 8 months demonstrated a reduction of the hematoma. The left vocal cord remains immobile to date. Conclusion. Ortners syndrome, or cardiovocal syndrome, is hoarseness secondary to left recurrent laryngeal nerve palsy caused by cardiovascular pathology. It is a rare condition and, while typically presenting gradually, may also present with acute symptomatology.

Adult laryngeal rhabdomyoma with extralaryngeal extension: surgical excision and reconstruction with aortic homograft.

Objectives:1) Review the presentation, pathology, and treatment of rhabdomyomas. 2) Recognize the potential need for open resection with reconstruction as a treatment of benign laryngeal lesions in rare cases.Methods:A 67-year-old female presented with dyspnea and hoarseness. On examination she had a soft, mobile, centrally-located neck mass. Fiberoptic laryngoscopy revealed a large, submucosal supraglottic mass. Computed tomography (CT) showed a 3-cm supraglottic tumor with extralaryngeal extension. Needle aspiration suggested rhabdomyoma, confirmed by direct laryngoscopy with biopsy. She subsequently underwent awake tracheostomy, hemilaryngectomy, and reconstruction with aortic homograft. Pathology showed adult rhabdomyoma with representative large, polygonal cells with abundant cytoplasm, focal cross-striations, and occasional “strap” cells. Three weeks postoperatively she was decannulated and found to have a functional voice and swallow. After six months of follow-up she is without evidence of recurre...

Sarcoidosis Presenting as Bilateral Vocal Fold Immobility

Bilateral true vocal fold paralysis is rarely attributable to inflammatory diseases. Sarcoidosis is a rare but important etiology of bilateral true vocal fold paralysis by compressive lymphadenopathy, granulomatous infiltration, and neural involvement. We describe the first reported case of sarcoidosis presenting as bilateral vocal fold immobility caused by direct fixation by granulomatous infiltration severe enough to necessitate tracheostomy insertion. In addition, we discuss the presentation, the pathophysiology, and the treatment of this disease with a review of the literature of previously reported cases of sarcoidosis-related vocal fold immobility. Sarcoidosis should therefore be an important consideration for the otolaryngologists differential diagnosis of true vocal fold immobility.