Getting Started with Endoscopic Ear Surgery.

Because endoscopic technology has matured over the past several decades, ear surgeons have increasingly used endoscopy to address some of the limitations of operative microscopy. The wide field of view and high-resolution images provided by endoscopes allow for improved visualization of the tympanic cavity using minimally invasive surgical portals compared with the standard operative binocular microscope. The endoscope is becoming an essential tool in the otologist's armamentarium. In this article, the authors discuss rationale for endoscopic ear surgery, terminology and classification, surgical indications, essential equipment, surgical ergonomics, and practical steps to incorporate endoscopic ear surgery into practice.

Schwannoma of the hard palate.

Schwannomas are rare, benign neoplasms that can arise from any cranial, peripheral, or autonomic nerve that contains Schwann cells. Approximately 25% to 45% of all schwannomas occur in the head and neck. They occur most commonly in the eighth cranial nerve, but it has been reported that 20% to 58% arise in the oral cavity, with approximately 10% of these located on the hard palate. We report a case of schwannoma of the hard palate, present important pathologic considerations for diagnosis, and provide a review of the literature regarding extracranial schwannomas.

Endoscopic and minimally-invasive ear surgery: A path to better outcomes.

The development of endoscopic ear surgery techniques promises to change the way we approach ear surgery. In this review paper, we explore the current evidence, seek to determine the advantages of endoscopic ear surgery, and see if these advantages are both measureable and meaningful. The wide field of view of the endoscope allows the surgeon to better visualize the various recesses of the middle ear cleft. Endoscopes make it possible to address the target pathology transcanal, while minimizing dissection or normal tissue done purely for exposure, leading to the evolution of minimally-invasive ear surgery and reducing morbidity. When used in chronic ear surgery, endoscopy appears to have the potential to significantly reduce cholesteatoma recidivism rates. Using endoscopes as an adjunct can increase the surgeon's confidence in total cholesteatoma removal. By doing so, endoscopes reduce the need to reopen the mastoid during second-look surgery, help preserve the canal wall, or even change post-cholesteatoma follow-up protocols by channeling more patients away from a planned second-look.

Endoscopic excision of a tympanic paraganglioma: Training the next generation of ear surgeons.

Tympanic paragangliomas are uncommon vascular tumors of neural crest origin. Classically these lesions have been surgically managed via a transcanal or transmastoid approach using binocular microscopy. We describe a case in which a tympanic paraganglioma was removed via a transcanal approach, using the endoscope exclusively. Endoscopic ear surgery enhances visualization, helping to ensure complete tumor removal, while reducing unnecessary dissection and its associated morbidity. For small middle ear neoplasms, a purely endoscopic approach is feasible, with excellent results. Resident education in ear surgery has also been enhanced by the use of endoscopes. The wide field of view provided by the endoscope helps trainees understand the intricate three-dimensional anatomy of the middle ear cleft.

Blue Ear Cyst: A Rare Eccrine Hidrocystoma of the Ear Canal and Successful Endoscopic Excision.

Aims. Hidrocystomas are benign cystic growths of the apocrine and eccrine sweat glands. These cystic lesions have been well documented on the face, head, and neck, but rarely in the external auditory canal. Presentation of Case. A 67-year-old woman presented with a bluish cystic mass partially occluding the external auditory canal and interfering with hearing aid use. Lesion was excised completely via a transcanal endoscopic approach with excellent cosmetic results, no canal stenosis, and no recurrence at 1-year follow-up. Discussion. We present a rare eccrine hidrocystoma of the external auditory canal and successful excision of this benign lesion. We describe the surgical management using a transcanal endoscopic approach and follow-up results. An eccrine gland cyst that presents as a mass occluding the external auditory canal is quite rare. There are only a few such cases reported in the literature. These masses can be mistaken for basal cell carcinomas or cholesterol granulomas but can be easily differentiated using histopathology. Conclusion. Eccrine hidrocystoma is a cystic lesion of sweat glands, rarely found in the external auditory canal. A characteristic bluish hue aids in diagnosis and surgical excision using ear endoscopy provides excellent control.

Autoimmune inner ear disease in a melanoma patient treated with pembrolizumab.

BACKGROUND: Immune related adverse events affecting various organ systems are a recognized potential consequence of immune checkpoint inhibition. However, autoimmune inner ear disease is one complication not previously associated with the use of checkpoint inhibitors, though it has been reported after adoptive cell immunotherapy. CASE PRESENTATION: Here we present what we believe is the first case of autoimmune inner ear disease resulting from treatment with an immune checkpoint inhibitor in a patient with metastatic melanoma. An 82 year old male presented with widespread metastatic mucosal melanoma and was initially treated with the CTLA-4 inhibitor ipilimumab but had progression of disease after four doses. He was subsequently treated with the PD-1 inhibitor pembrolizumab and after two doses the patient noted bilateral hearing loss. Otology evaluation was significant for the development of bilateral sensorineural hearing loss and the patient was started on treatment with bilateral intratympanic dexamethasone injections. He experienced significant recovery of his hearing deficit with the intratympanic injections and restaging imaging after 12 weeks of pembrolizumab demonstrated a dramatic reduction in tumor burden. CONCLUSION: Autoimmune inner ear disease has been previously associated with the therapeutic transfer of genetically engineered lymphocytes as an on-target effect of donor T-cells recognizing antigens on cells in the inner ear. It is important for physicians to have a high clinical index of suspicion for the appropriate recognition and management of any potential autoimmune toxicity with checkpoint inhibitors given the variability of presentation and unique aspects of toxicity.

A quantitative survey of gravity receptor function in mutant mouse strains.

The purpose of this research was to identify vestibular deficits in mice using linear vestibular evoked potentials (VsEPs). VsEP thresholds, peak latencies, and peak amplitudes from 24 strains with known genetic mutations and 6 inbred background strains were analyzed and descriptive statistics generated for each strain. Response parameters from mutant homozygotes were compared with heterozygote and/or background controls and all strain averages were contrasted to normative ranges. Homozygotes of the following recessive mutations had absent VsEPs at the ages tested: Espn(je), Atp2b2dfw-2J, Spnb4qv-lnd2J, Spnb4qv-3J, Myo7ash1, Tmie(sr), Myo6sv, jc, Pcdh15av-J, Pcdh15av-2J, Pcdh15av-3J, Cdh23v-2J, Sans(js), hr, Kcne1pkr and Pou3f4del. These results suggest profound gravity receptor deficits for these homozygotes, which is consistent with the structural deficits that have been documented for many of these strains. Homozygotes of Catna2cdf, Grid2ho4J, Wnt1sw, qk, and Mbpshi strains and heterozygotes of Grid2lc had measurable VsEPs but one or more response parameters differed from the respective control group (heterozygote or background strain) or were outside normal ranges. For example, qk and Mbpshi homozygotes showed significantly prolonged latencies consistent with the abnormal myelin that has been described for these strains. Prolonged latencies may suggest deficits in neural conduction; elevated thresholds suggest reduced sensitivity, and reduced amplitudes may be suggestive for reduced neural synchrony. One mutation, Otx1jv, had all VsEP response parameters within normal limits--an expected finding because the abnormality in Otxljv is presumably restricted to the lateral semicircular canal. Interestingly, some heterozygote groups also showed abnormalities in one or more VsEP response parameters, suggesting that vestibular dysfunction, although less severe, may be present in some heterozygous animals.

Feasibility of endoscopic treatment of middle ear myoclonus: a cadaveric study.

Stapedius and tensor tympani tenotomy is a relatively simple surgical procedure commonly performed to control pulsatile tinnitus due to middle ear myoclonus and for several other indications. We designed a cadaveric study to assess the feasibility of an entirely endoscopic approach to stapedius and tensor tympani tenotomy. We performed this endoscopic ear surgery in 10 cadaveric temporal bones and summarized our experience. Endoscopic stapedius and tensor tympani section is a new, minimally invasive treatment option for middle ear myoclonus that should be considered as the first line surgical approach in patients who fail medical therapy. The use of an endoscopic approach allows for easier access and vastly superior visualization of the relevant anatomy, which in turn allows the surgeon to minimize tissue dissection. The entire operation, including raising the tympanomeatal flap and tendon section, can be safely completed under visualization with a rigid endoscope.

Retropharyngeal calcific tendonitis mimics a retropharyngeal abscess.

Retropharyngeal calcific tendonitis (RCT) is an uncommon, self-limiting condition that is often omitted in the differential diagnosis of a retropharyngeal fluid collection. This condition mimics a retropharyngeal abscess and should be considered when evaluating a fluid collection in the retropharyngeal space. Although calcific tendonitis at other sites has been well described in the medical literature, it appears that this entity has been underreported in the otolaryngology literature where only a few case reports have been identified. Presumably, the actual incidence is higher than the reported incidence, due to lack of familiarity with this disorder. As an otolaryngologist's scope of practice includes the managements of retropharyngeal lesions, it is important for the otolaryngologist to recognize the presentation of acute RCT and be familiar with appropriate treatment strategies. Retropharyngeal calcific tendonitis presents with neck pain, limitation of neck range of motion and includes inflammation, calcifications, and a sterile effusion within the longus colli muscle. Treatment is medical with nonsteroidal anti-inflammatory medications. RCT does not require surgical treatment, and an accurate diagnosis can prevent unnecessary attempts at operative drainage. In this study, we discuss two cases of RCT, summarize the salient features in diagnosis, including key radiologic features, discuss treatment options, and review the literature.

Treatment of palatal myoclonus with botulinum toxin injection.

Palatal myoclonus is a rare cause of pulsatile tinnitus in patients presenting to the otolaryngology office. Rhythmic involuntary contractions of the palatal muscles produce the pulsatile tinnitus in these patients. Treatment of this benign but distressing condition with anxiolytics, anticonvulsants, and surgery has been largely unsuccessful. A few investigators have obtained promising results with botulinum toxin injection into the palatal muscles. We present a patient with palatal myoclonus who failed conservative treatment with anxiolytics. Unilateral injection of botulinum toxin into her tensor veli palatini muscle under electromyographic guidance resolved pulsatile tinnitus in her ipsilateral ear and unmasked pulsatile tinnitus in the contralateral ear. A novel method of following transient postinjection symptoms using a diary is presented in this study. Botulinum toxin dose must be titrated to achieve optimal results in each individual patient, analogous to titrations done for spasmodic dysphonia. Knowledge of the temporal onset of postinjection side effects and symptomatic relief may aid physicians in dose titration and surveillance. We present suggestions on titrating the botulinum toxin dose to optimal levels. A review of the literature on the use of botulinum toxin for palatal myoclonus and some common complications are discussed.

Thiersch skin grafting in otologic surgery.

Thiersch skin grafting is an old but highly effective surgical technique in otology. We frequently place a Thiersch graft after otologic procedures that either create a mastoid cavity or result in reduced skin coverage of a portion of the external auditory canal. The purpose of this article is to introduce this surgical technique to a new generation of otologists. We discuss its indications, the surgical technique, tips for a successful outcome, and postoperative care. A key to successful skin grafting is to perform the procedure about 10 days after the primary procedure to allow sufficient time for the formation of an adequate vascular bed at the recipient site. The goal in all cases is to achieve a safe, dry ear that is covered with keratinizing squamous epithelium. Thiersch grafting accomplishes this very well.

Endometrioid adenocarcinoma metastatic to the thyroid, presenting like anaplastic thyroid cancer.

Metastasis of uterine cancer to the head and neck is extremely rare. We report what we believe to be the first documented case of endometrioid adenocarcinoma metastasizing to the thyroid gland. An 80-year-old woman was referred to the otolaryngology service with a rapidly growing neck mass. The mass appeared to originate from the thyroid gland. Her clinical presentation was consistent with anaplastic thyroid carcinoma. A tracheostomy was performed. An open biopsy established the diagnosis of moderately differentiated adenocarcinoma, consistent with a gynecologic primary. The patient had undergone a hysterectomy 5 years prior for endometrioid adenocarcinoma. The thyroid tumor histology and immunophenotype corresponded well with her prior endometrial carcinoma, indicating that the thyroid mass was a metastasis from the endometrial primary. Radiotherapy appears to offer good local disease control in this rare case of endometrioid adenocarcinoma metastatic to the thyroid.

Delayed facial nerve palsy after endolymphatic sac surgery.

Data on delayed facial nerve palsy (DFNP) following endolymphatic sac enhancement surgery are limited. We conducted a retrospective chart review to determine the incidence, possible predisposing factors, treatment, and prognosis of DFNP in such cases. We reviewed the records of 779 patients who had undergone endolymphatic sac surgery for intractable Ménière disease from January 1997 through December 2007 at a tertiary care otologic referral center. We found 5 cases (0.64%) of postoperative DFNP. The length of time between surgery and the onset of DFNP ranged from 7 to 20 days (mean: 11). Paralysis was incomplete in all 5 patients. Four of these patients had an abnormal mastoid bone anatomy, as the sigmoid sinus was either anteriorly or anteromedially displaced. The 5 patients had been treated with a steroid, either with or without an antiviral, and all 5 experienced a complete recovery of facial nerve function within 8 weeks of the onset of their paralysis. It is difficult to delineate the exact etiology of DFNP following endolymphatic sac surgery, but we speculate that factors such as physical injury to the nerve and/or a viral reactivation might have played a role. Also, the unusual mastoid bone anatomy seen in 4 of these patients might have been responsible, as well.

Removal of an intra-parotid foreign body without parotidectomy and dissection of the facial nerve.

EDUCATIONAL OBJECTIVES: At the conclusion of this presentation, the participants should be able to discuss how imaging and intra-operative facial nerve monitoring may be used in the removal of selected intraparotid foreign body without parotidectomy and dissection of the facial nerve. OBJECTIVES: 1) To present a rare case of a metallic intraparotid foreign body introduced as a projectile; 2) to discuss how CT images were used to guide the surgical exploration; and 3) To discuss the surgical approach used to retrieve an intraparotid foreign body without facial nerve dissection. STUDY DESIGN: This is a clinical case report with a review of literature. METHODS: We present the pertinent history and physical examination findings. We discuss the CT images. The technique of surgical exploration and foreign body retrieval is presented. RESULTS: This is the case of a man who presented to the emergency department with a metallic foreign body lodged in the parotid introduced accidentally as a projectile. CT images were analyzed and the patient underwent successful removal of the intraparotid foreign body with out parotidectomy and facial nerve dissection via a posterior approach and using facial nerve monitoring. CONCLUSION: Selected intraparotid foreign bodies may be removed without parotidectomy and facial nerve dissection if imaging shows it can be approached safely and intra-operative facial nerve monitoring is used.