Effects of Aging on Nasal Structure and Function

The aging nose undergoes structural and functional changes, which can cause alterations in olfaction, breathing, cosmesis, and nutrition, as well as exhibiting increased incidence of epistaxis and rhinitis. A review of these factors and suggestions for management is presented.

Vocal Cord Paresis After Posterior Spinal Fusion to Treat Adolescent Idiopathic Scoliosis: A Case Report

CASE

A 15-year-old girl with adolescent idiopathic scoliosis with a 50° curve underwent posterior spinal fusion from T3 to T11. After discharge from the hospital, the patient reported dysphonia and dysphagia. Flexible nasendoscopy confirmed left vocal cord paresis. Stretch injury to the recurrent laryngeal nerve from the left T5 pedicle screw or intubation may have caused the vocal cord paresis. The pedicle screw was removed during revision surgery. Postsurgically, the patient demonstrated immediate and ultimately full recovery and no longer had any symptoms.

CONCLUSION

To our knowledge, this is the first case report of vocal cord paresis most likely caused by pedicle screw position after posterior spinal fusion.

Alternative Payment Models and Academy Advocacy

Program Description:

The physician payment landscape is changing as quality measures become more intertwined with payment. This miniseminar outlines the efforts of the Physician Payment Policy Work Group (3P) to prepare members for the implementation of the Affordable Care Act by giving them the tools to participate in diverse payment systems. Topics include public and private payment models including accountable care organizations (ACOs), bundling, and the importance of measures in the future of quality and payment initiatives. Presenters will discuss strategies including how resources such as Clinical Indicators and Policy Statements are used to advocate for appropriate policies by health insurance companies for coverage of services.

Educational Objectives:

1) Comprehend future healthcare reform initiatives, new payment models, and Academy efforts to prepare members for changes to how they will receive payment for services. 2) Recognize the measure sets we have formally developed in otolaryngology (sinusitis, otitis externa/otitis media) and how many providers can and will apply these measures to practice. 3) Be aware of Academy strategies for interaction with public and private payers and effective membership involvement.

Business of Medicine

Program Description: Declining reimbursement over many years now threatens the viability of physician practices across specialties and practice settings. This miniseminar will outline the efforts of our Academy, specifically the Physician Payment Policy Work Group (3P), to advocate for fair reimbursement for our members in increasingly challenging public and private payer environments. Topics include updates on government health care reform, the Current Procedural Terminology (CPT) and Relative Value Update Committee (RUC) processes, coding and reimbursement for new technology, and new public and private payment models including the Accountable Care Organization concept. Strategies will be described as to how members can become actively involved to make a difference for our specialty.

Educational Objectives: 1) Learn current healthcare reform initiatives, new payment models, and Academy efforts on Capitol Hill. 2) Understand Academy interaction with the AMA’s CPT Editorial Panel and Relative Value Update Committee. 3) Know Academy strategies for interaction with public and private payers, and effective membership involvement.

Mucosal swabs detect HPV in laryngeal papillomatosis patients but not family members

Seven patients, aged 2-7 years, with active recurrent respiratory papillomatosis (RRP) attending the University of Michigan Pediatric Otolaryngology Clinic were studied to determine if human papillomavirus (HPV) is harbored in sites of the upper aerodigestive tract other than in the laryngeal papilloma itself. We also determined if close family members had detectable virus in their oral cavities. Noninvasive swabs of buccal mucosa, posterior pharynx, nasal vestibule, and tonsillar pillar of patients, as well as buccal mucosa and posterior pharyngeal swabs of family members were studied. Swabs of the patients' papillomas served as the positive controls. HPV was detected using polymerase chain reaction (PCR) amplification and Southern hybridization techniques. Six of seven patients had detectable HPV in papilloma and endolaryngeal swabs. Four were HPV type 6, and two were HPV type 11. The patient whose swab was negative for HPV was found to be biopsy negative for papilloma 3 weeks after a single laser excision which was performed 6 months prior to the endolaryngeal swab. HPV types 16, 18 and 31 were not found in any of the patients. No swabs from other sites in patients or family members were HPV positive despite the presence of adequate DNA in the swabbed material for successful amplification of beta-actin sequences. The absence of HPV (other than in the papilloma itself) in the upper aerodigestive tract of patients and caregivers is consistent with the absence of reported cases of horizontal transmission to siblings or other family members. The findings are also consistent with the conventional view that juvenile respiratory HPV is transmitted vertically from vaginal condylomas in the mother.

High-risk human papillomavirus types and squamous cell carcinoma in patients with respiratory papillomas

Respiratory papillomas (RPs) are benign, virally induced tumors of the larynx and respiratory epithelium that may obstruct the airway and tend to recur frequently. RPs are thought to be the result of infection with the human papillomaviruses (HPVs) types 6 and 11. We surveyed archival RP specimens to determine whether there were correlations of HPV type with patient characteristics or clinical course. Paraffin-embedded papilloma specimens of 45 different patients were analyzed. We assessed HPV types using the polymerase chain reaction with E6 consensus primers, hybrid capture assays (high or low risk), and dot blot hybridization of generic E6 PCR products with E6 type-specific oligonucleotide probes. The presence and type of HPV were correlated with patient data from a retrospective chart review. We found that RPs may have either low- or high-risk HPV types and some contain multiple HPV types. Respiratory infection with high-risk HPV apparently introduces a long-term risk of squamous cell carcinoma development, even in the absence of conventional cofactors. Low-risk HPV infection may also act in association with these cofactors to promote carcinogenesis. Our data also show a racial imbalance in RP that may indicate a difference in genetic resistance and/or susceptibility to HPV infection and the development of RP.

Pediatric myofibromatosis of the head and neck

OBJECTIVES

To examine the clinical and pathological features of pediatric myofibroma of the head and neck and to discuss the challenges in diagnosis and treatment.

DESIGN

A retrospective search of pathology department and clinical records to identify patients with myofibroma and a retrospective review of English-language medical publications.

SETTING

Academic medical center.

PATIENTS

Thirteen pediatric patients (aged from birth to 8 years old) diagnosed as having myofibroma of the head and neck.

RESULTS

Nine of 13 patients were cured with conservative surgical excision. Four patients (31%) had recurrence, requiring multiple surgical procedures. One third showed spontaneous regression clinically or by histological examination. The clinical course did not parallel the histological appearance, as high cellularity and mitotic figures were commonplace among the specimens. A misdiagnosis of malignancy was not unusual in this series, as 3 patients had an initial diagnosis of fibrosarcoma, which on review was revised to myofibroma.

CONCLUSIONS

Myofibromatosis is a distinct disorder among the great number of fibrous proliferations occurring in infants and children, with a particular predilection for the head and neck region. These lesions should be clearly distinguished from conventional adult-type fibromatoses (desmoid tumors), which are more aggressive. Most patients have solitary lesions that respond well to conservative surgical excision, whereas a few of these lesions behave more aggressively, requiring several surgical procedures for the management of recurrent or persistent tumor. Many of these lesions show spontaneous regression, suggesting that lesions not affecting vital functions, resulting in growth anomalies, or demonstrating rapid aggressive growth may be managed conservatively.

Neonatal choristoma of the tongue containing glial tissue: diagnosis and surgical considerations

There are only six case reports documenting the presence of glial tissue in the tongue. Because of the small number of cases, the presentation and biologic behavior of these lesions is poorly characterized. We present the case of a 10-day-old male infant who arrived at the University of Michigan Medical Center with a history of positional dyspnea, with resultant cyanosis and bradycardia, dysphagia, and a mass at the base of the tongue. Histopathologically, this lesion was initially labeled as a hamartoma, but was ultimately defined as a choristoma based on the exclusive presentation of glial tissue in the specimen. This paper will discuss the presentation, diagnostic evaluation, and therapeutic management of this case. In addition, the role of intraoperative electrodiagnostic monitoring to preserve neuromuscular function will be addressed.

Cutaneous wound healing. An overview

This article is a general discussion of the mechanisms of soft-tissue wound healing with an emphasis on tissue. The overall phases of cutaneous wound healing and their influencing factors are described as are concepts for managing skin incisions to achieve a more optimal scar appearance.

Radiation therapy as an alternative to surgery in the management of intracranial juvenile nasopharyngeal angiofibroma

Juvenile nasopharyngeal angiofibroma is a benign, vascular tumor which typically presents in adolescent males. Although surgical resection is usually recommended for the management of this tumor, external beam radiation therapy has also been advocated in the literature. We report three cases of large juvenile nasopharyngeal angiofibromas with extensive intracranial extension primarily managed with external beam radiation therapy. Although there was not complete resolution of the tumors, there was significant alleviation of symptomatology with no serious side effects from the radiation therapy. Based on these cases, we feel that external beam radiation therapy in the management of extensive juvenile nasopharyngeal angiofibromas with intracranial extension is warranted in certain select cases.

Flutamide-induced regression of angiofibroma

Juvenile nasopharyngeal angiofibroma (JNA) appears to be an endocrine-responsive tumor. This concept was tested in five young men with JNA by treating them with a testosterone receptor blocker (flutamide) for 6 weeks preoperatively. Tumor size was evaluated by axial computed tomography both before and after flutamide therapy. Four of the five patients had an average tumor shrinkage of 44%. The patients tolerated the drug well, and the serum testosterone levels 2 or more years posttherapy were normal. This pilot study demonstrate that preoperative hormonal pharmacoreduction of JNA is a feasible adjunct to surgical therapy that offers the possibility of reduced blood loss. However, the authors believe that a formal clinical trial of this treatment approach is warranted and should be done before widespread adoption of this agent.

Otolaryngologic (head and neck) problems in the elderly

This article is designed to give the reader an appreciation of some of the more common or important facets of the management of head and neck disorders in the elderly patient. Readers are referred to the references for more detailed descriptions of the topics.

Intracranial complications of paranasal sinusitis: a combined institutional review

Intracranial complications of paranasal sinusitis constitute true surgical and medical emergencies. The charts of all patients (n = 649) admitted for acute or chronic sinusitis to the University of Minnesota Hospital and to the University of Michigan Medical Center during a 13-year period (1975 to 1988) were retrospectively reviewed to determine the incidence of complications. The clinical presentation, bacteriology, involved sinuses, influencing host factors, white blood cell count on presentation, length of hospitalization, and postinterventional complications are presented. Twenty-four patients with intracranial complications from paranasal sinusitis are studied for an incidence of 3.7%. Aggressive medical and semi-emergent surgical intervention are required to prevent excessive morbidity and/or mortality. Intracranial complications included subdural empyema, frontal lobe abscesses, intrahemispheric abscesses, cavernous and superior sagittal sinus thrombosis, and osteomyelitis.

The use of biopsy in the evaluation of pediatric nasopharyngeal masses

Pediatric nasopharyngeal tumors are rare, and few clinicians possess more than anecdotal experience. The differential diagnosis includes a diverse group of benign and malignant tumors, but can be narrowed further based on the clinical and radiographic appearance of the mass. Nasopharyngeal angiofibroma has such characteristic angiographic and CT imaging that many authors suggest biopsy is not essential in the evaluation of this lesion. We present a case of a pediatric nasopharyngeal neoplasm with angiographic, CT, and clinical findings consistent with angiofibroma. We then discuss the preoperative evaluation of, operative approach to, and postoperative staging and treatment of the biopsy-proven embryonal rhabdomyosarcoma. A review of the literature pertinent to this case is presented, and recommendations made concerning biopsy of lesions resembling juvenile nasopharyngeal angiofibroma. We believe this report reaffirms the use of histologic study whenever possible, in addition to radiographic imaging, in the diagnosis of pediatric nasopharyngeal masses.

Juvenile myasthenia gravis: an unusual presentation

Myasthenia gravis is a disease characterized by muscular weakness and fatigability which afflicts 2-10 patients per 100,000 with 20% of cases presenting in childhood. Muscles innervated by cranial nerves are frequently involved with ptosis and diplopia being the most frequent presenting complaints. We review the literature and report a case of a 20-month-old infant presenting with inspiratory stridor and cyanosis, resembling foreign body aspiration.

Sleep apnea--an historical perspective

In this article the authors have attempted to give the reader a brief overview of some of the development of recognition of obstructive sleep disorders and early aspects of their surgical therapy. They have avoided detailed descriptions of radiographic and other diagnostic measures, since many of these are summarized in other articles.

Facial nerve paresis as the presenting symptom of leukemia

Leukemic involvement of the temporal bone is not uncommon and may present in a variety of ways including auricular or external canal skin lesions, red or thick tympanic membrane, middle ear effusions, otitis media, hearing loss or mastoiditis. Symptomatic facial nerve involvement, on the other hand, is extremely unusual. We discuss a pediatric patient whose sudden onset facial nerve paresis was the presenting symptom that led to her diagnosis of leukemia. At the time of mastoidectomy, a granulocytic sarcoma or chloroma was noted to be overlying the VIIth nerve.

Surgical management of obstructive sleep apnea

The authors have reviewed the surgical management of patients with OSA. They have emphasized not only surgical techniques but also the method of preoperative evaluation of the patients and have presented some considerations in the postoperative management of patients in an attempt to avoid catastrophic results. As our diagnostic techniques improve, we should have fewer problems with the determination of the amount of tissue to remove and also the selection of the appropriate procedure. The advent of flexible laryngoscopy, cineradiography, and cine CT may indeed improve our diagnostic and therapeutic capabilities.

The anterior cricoid split. Clinical experience with extended indications

A recommended approach to postextubation infant subglottic stenosis secondary to subglottic edema employs the recently described anterior cricoid split (ACS) procedure. This technique provides an expanded subglottic airway with minimal paratracheal dissection and does not require concomitant tracheotomy. We applied this procedure in managing extubation difficulty in pediatric as well as neonatal patients. Five of ten patients in our series did not fulfill the traditional criteria for ACS. Relief of stridor and avoidance of tracheotomy were accomplished in nine of ten patients. One patient in whom mechanical ventilation was reinstituted developed an interesting complication. In properly selected infants with subglottic airway compromise, the ACS appears to be an effective adjunct in facilitating extubation.

Arthrogryposis multiplex congenita: otolaryngologic diagnosis and management

Arthrogryposis multiplex congenita (AMC) is an uncommon congenital disorder characterized by multiple fixed joint deformities and non-progressive neuromuscular dysfunction. A small fraction of these infants will present with otolaryngologic problems resulting from cranial nerve weakness, muscle dysplasia, or structural dysharmony of the head and neck. The charts of 50 patients with AMC were reviewed to determine the incidence of these findings. A summary of the literature is presented discussing the etiology, pathophysiology, diagnosis and management of this interesting clinical problem.

The "Pinocchio" nasal deformity--hemangioma vs. angiolipoma: esthetic correction and etiology

The author presents the first reported case of a nasal angiolipoma presenting as "Pinocchio" nasal tip deformity. The two types of angiolipomas (infiltrating and non-infiltrating) are discussed as are two surgical approaches to this deformity. The author feels that the external rhinoplasty technique is an excellent way to approach this problem, especially in patients who are suffering severe emotional stress due to peer pressure.

Non-organic stridor in children

A 4.75-year-old male presented with several episodes of expiratory stridor leading, on one occasion, to a respiratory arrest and intubation. A detailed evaluation emphasizing physiological and anatomical studies revealed no organic basis for the patient's upper airway obstruction. Emphasis is placed on one method found to be helpful in the differentiation of an organic versus a psychogenic type of respiratory disorder. Recognition of functional airway obstruction in children may prevent inappropriate therapy and allow proper psychiatric intervention.

Neonatal respiratory distress secondary to nasal fibrous histiocytoma

A full term one-day-old neonate developed respiratory distress secondary to a right intranasal mass. After exploratory craniotomy revealed no intracranial lesions, the child was observed for 6 months. At that time he experienced severe apnea with cyanosis necessitating removal of the mass, which was diagnosed histologically as a fibrous histiocytoma. Seven year follow-up reveals no further problems. A discussion of fibrous histiocytoma of the nose and paranasal sinuses is briefly given.

Lethal midline granuloma with a novel T-cell phenotype as found in peripheral T-cell lymphoma

Lethal midline granuloma (LMG), initially a clinical description, includes an uncommon group of disorders characterized by a relentless, destructive process involving the upper respiratory structures. Its etiology and pathogenesis are uncertain, probably varied, and the distinction between inflammatory and malignant processes is difficult despite extensive clinical and histopathologic evaluation. The need for new techniques for rapid diagnosis has important therapeutic implications. Using an extensive panel of T- and B-cell monoclonal antibodies the authors describe a patient with clinically and pathologically typical LMG demonstrating an "activated" T-cell phenotype with a "novel" pattern characteristic of peripheral T-cell lymphoma, strongly implying that some cases of LMG are more closely related to neoplastic T-cell lymphoproliferative disorders than to inflammatory conditions. Further studies using these immunotyping techniques may help clarify the pathogenesis of LMG, and may uncover specific diagnostic and prognostic phenotypic patterns.

The surgical treatment of skull-base tumors with intracranial extension

As a discipline, skull-base surgery via the transtemporal route has matured since 1975. Previously considered unresectable, skull-base tumors with intracranial extension can now be successfully removed by means of modification of contemporary exposures with neurosurgical collaboration. Between September 1970 and February 1986, 126 skull-base tumors have been operated on by The Otology Group, P.C. Of these, 49 had intracranial extension. In this article, techniques for tumor removal and dural defect reconstruction are outlined. A single-staged procedure is advised. The advantages of and exceptions to this format are described. Techniques that will prevent postoperative cerebrospinal fluid leakage are highlighted. Results and complications of this surgical series are discussed, and team aspects of this surgery are emphasized.

Mucosal melanoma of the head and neck

Nine cases of primary malignant melanoma of the upper respiratory tract treated at the University Hospital over the past 10 years are presented. Of the 9 cases, 6 had primary lesions located in the nasal cavity with the remaining 3 presenting in the nasopharynx, hard palate, and larynx, respectively. The authors review presenting symptoms, diagnostic evaluation, current therapeutic modalities, and clinical course in these cases. Specific cases are discussed to emphasize items of clinical or therapeutic importance.

Sialadenitis in children

Sialadenitis in children has been discussed. A literature review highlighting salient points in sialadenitis is presented. Classification of sialadenitis is discussed using the categories of several authors. An unusual case involving acute suppurative parotitis in a child is presented. The development of contralateral disease while treatment was in progress was unusual. In this case, association with mumps parotitis was strongly suspected despite previous immunization. Progression of disease with abscess formation is also unusual. Mumps virus parotitis has been rarely reported in association with acute suppurative parotitis. Immunization affords protection, but a definite failure rate exists. Based upon histologic examination, mumps parotitis would seem to be a predisposing factor for bacterial infection.

Laryngeal carcinoma--or is it laryngeal blastomycosis

A patient is described who was evaluated for persistent hoarseness. Although an initial diagnosis of squamous cell carcinoma of the larynx was made, review of the pathology slides revealed pseudoepitheliomatous hyperplasia, acanthosis, and what appeared to be a fungal infection. After a detailed work-up was initiated the patient was treated successfully with ketoconazole for a blastomycosis infection of the larynx. The literature relative to blastomycosis infections of the respiratory larynx is reviewed. The authors emphasize that patients who show evidence of acanthosis and pseudoepitheliomatous hyperplasia along with the diagnosis of squamous cell carcinoma should be suspected as having a potential fungal infection.