Tympanoplasty Outcomes for Blast-Induced Perforations from Iraq and Afghanistan.

Objective To describe characteristics of blast-induced tympanic membrane perforations that do not spontaneously heal, evaluate the outcomes of tympanoplasty techniques, and understand the factors associated with surgical success. Setting Two tertiary military health care institutions. Study Design Case series with chart review. Subjects and Methods This study reviewed the practice of 1 military neurotologist and included all tympanoplasties for combat blast-induced perforations from 2007 to 2012, which comprised a total of 55 patients. Surgical outcomes and associated perioperative factors were examined to include size, location, bilateral involvement, timing of surgery, and surgical technique. Results Fifty-five patients (68 ears) met inclusion criteria. Thirty-six (53%) were total or near-total perforations, and 51% of patients had bilateral perforations. The overall success rate was 77%. It was 82% for lateral grafts and 70% for medial grafts, but the difference between these was not statistically significant. Age was a significant factor, with a success rate of 56% for ages 25 to 34 years, compared with 90% for 20 to 24 and >34 years. Patients who had bilateral sequential tympanoplasties also had lower success rates than those who had only unilateral surgery (62% vs 87%, P = .002). Ossicular disruptions were found in 5 ears, and cholesteatoma was discovered in 8. Surgical timing did not predict success, as the average time until repair was 153 days in successful cases and 151 days in failures. The mean conductive hearing improvement was 13.6 dB, and there were no major complications. Conclusion Tympanoplasty can be challenging in this population. Age and bilateral surgery were the only independent variables that showed significance.

Retained crossbow bolt after penetrating facial trauma.

We present an unusual case of a retained crossbow bolt in the maxillofacial area of a 31-year-old man. While crossbow injuries are rare, this case is of interest because otolaryngologists are often faced with treating retained foreign objects after penetrating facial trauma. These cases are difficult to manage because of the complexity and variety of injuries that can occur during both the initial trauma and the removal. We focus on the management of the bolt's removal and provide a brief discussion of the relevant literature on crossbow injuries to the head and neck.

Tympanoplasty for blast-induced perforations: the Walter Reed experience.

OBJECTIVE: To review our tympanoplasty results for blast-induced tympanic membrane perforations and evaluate the association of various clinical factors with surgical success. STUDY DESIGN: Case series with chart review. SETTING: Two tertiary military healthcare institutions. METHODS: This is a retrospective review of all patients who had nonrevision tympanoplasty during a 1-year period for blast-induced perforations by the 2 neurotologists at Walter Reed Army Medical Center and National Naval Medical Center. Various perioperative clinical factors were analyzed for relations to successful perforation closure, the need for a second operation, and postoperative hearing. RESULTS: Thirty-four patients met inclusion criteria. All were male, and the average age was 24.0 years. Twenty-two (65%) were total or near-total perforations, of which 12 (35%) were repaired using lateral graft technique. The remainder had various medial graft procedures. Ossicular abnormalities were found in 6 (18%) patients. Cholesteatoma was discovered in 3 (9%) patients. Closure was complete in 82% of patients. The incomplete closures were with large perforations, those with foreign bodies (shrapnel), and in 1 with postoperative water exposure. There were no major complications, and the mean conductive hearing improvement was 11.3 dB. CONCLUSION: Blast-induced tympanic membrane perforations are common in our population of wounded warriors. These cases are challenging because most have total or near-total perforations, the ossicles can be out of place, the blast itself can implant epithelium in the middle ear, and foreign bodies can create a hostile middle ear environment. However, given attention to detail, we found that standard tympanoplasty techniques work well.

Primary squamous cell carcinoma of the thyroid gland: a case report and review.

BACKGROUND: Primary squamous cell carcinoma (SCC) of the thyroid gland is a rare malignancy that presents with advanced disease and poor prognosis. METHODS: A 75-year-old woman with a history of Hashimoto thyroiditis presented with 6 months of dysphagia and stridor. Imaging revealed a thyroid mass invading the larynx. Primary SCC of the thyroid was diagnosed by histopathologic and immunohistochemical evaluation. Total thyroidectomy, total laryngectomy, bilateral modified neck dissection, and adjuvant radiotherapy (RT) were performed. Radiologic follow-up at 21 months demonstrated no disease and total length of survival was 31 months. RESULTS: Despite an aggressive T4aN0M0 tumor, survival in this case was more than double the median survival rate previously reported. Concomitant Hashimoto thyroiditis is rare and histopathologic and immunohistochemical evaluation is imperative for an accurate diagnosis. CONCLUSION: The case and literature reported here support that a thorough diagnostic workup of primary SCC of the thyroid with aggressive locoregional surgery and adjuvant RT may improve the length of survival.

Genetic testing in head and neck paraganglioma: who, what, and why?

Background Genetic testing in head and neck paragangliomas (HNPG) can have profound implications in patient and family counseling. Methods Retrospective review was performed of patients with HNPG at a cancer care center from 1970 to present. Patient demographics, disease patterns, outcomes, and genetic mutations were analyzed. Results We identified 26 patients with available genetic testing results. Sixteen had mutations. Succinate dehydrogenase gene, sub unit D (SDHD) accounted for 75% of mutations, of which P81L accounted for 75%. The remainder had SDHB mutations. Patients with mutations were younger (average age 39.5 years versus 48.4 years), 63% (versus 40%) had multiple tumors, 94% (60%) had at least one carotid body tumor, and family history was positive in 38% (20%). Conclusion Patients suspected of heritable HNPG should undergo testing first at the SDHD and SDHB loci, and those with younger age, multiple tumors, carotid body tumors, and positive family history are more likely to have mutations.

The "Spoke Sign": An otoscopic diagnostic aid for detecting otitis media with effusion.

OBJECTIVE To determine the prevalence and diagnostic usefulness of the "spoke sign" (SS), a specific otoscopic finding, in detecting the presence of pediatric middle ear effusion (MEE). METHODS The SS was defined as a dull gray appearance of the tympanic membrane with engorged vasculature in an arrangement similar to the spokes of a bicycle wheel, covering 50% or more of the inferior tympanic membrane by area. An observational screening test study was performed prospectively with enrollment of consecutive pediatric patients scheduled for tympanostomy tube placement. Intraoperatively, the presence or absence of SS was noted before myringotomy and that of MEE was noted after myringotomy. Statistical analysis was performed to determine the value of SS as a predictor of MEE, with myringotomy as the criterion standard. Videos taken before myringotomy were subsequently shown to independent pediatricians and otolaryngology residents to analyze interrater concordance in evaluating the presence of SS. RESULTS Seventy-six patients (150 ears) were included in the study. Forty-nine patients (64%) had SS in at least 1 ear. The sensitivity, specificity, positive predictive value, and negative predictive value for the SS for MEE were 100% (79/79), 93% (66/71), 94% (79/84), and 100% (64/64), respectively. The Fleiss κ score for interrater concordance among pediatricians was 0.21 (residents) to 0.24 (staff), and that among otolaryngology residents was 0.61 (all P < .001). CONCLUSIONS The presence of SS may represent a useful adjunct in the detection of pediatric MEE, with high measured sensitivity and specificity. Incorporation of SS in clinical practice may require focused training to detect this specific examination finding.