Epidermoid Cyst in the Submandibular Region Mimicking Plunging Ranula: A Case Report.

Epidermoid cysts rarely present in the submandibular area, constituting approximately less than 7% of all cystic lesions in the head and neck region and less than 0.01% of all oral cavity cysts. Therefore, epidermoid cysts can be easily misdiagnosed, as the differential diagnosis for a submandibular area mass is very broad. Imaging can help define characteristics of the mass; however, a pathologic specimen is usually required for the final diagnosis. Surgical excision is often required and tolerated well by most patients. However, there is a risk of recurrence of the cyst after excision, as well as a rare chance for malignant transformation if not excised, which must be discussed with the patient at the time of diagnosis of epidermoid cyst. We present a 33-year-old Caucasian female with a left submandibular cystic mass measuring 4.7 cm x 2.9 cm, that was originally thought to be a plunging ranula and subsequently diagnosed as an epidermoid cyst. This report is meant to raise awareness of the possibility of a submandibular mass being an epidermoid cyst as well as appropriate workup, treatment, and prognosis of epidermoid cysts in the submandibular region. This report also describes a unique approach to a submandibular epidermoid cyst of which the submandibular gland is divided for access to the cyst for safe and effective excision. To the author's knowledge, this surgical approach has not been described in the literature for a submandibular epidermoid cyst.

A Rare Case of Vocal Cord Paralysis in the Setting of Ramsay Hunt Syndrome.

Ramsay Hunt syndrome (RHS) with concomitant vocal cord paralysis (VCP) is a rare finding. This case is particularly rare because the patient lacked the symptoms of otalgia or hearing loss when in fact, a majority of cases typically demonstrate both hearing loss and otalgia. Unique to this case is also the fact that it was complicated by a concomitant infarction of the splenium corpus callosum and a right temporal meningioma. The purpose of this study was to bring awareness to the fact that RHS can cause multiple cranial nerve neuropathies including VCP and should be included in the differential diagnosis for VCP.

Visualization of ex vivo rabbit olfactory mucosa and foramina with three-dimensional optical coherence tomography.

There is increasing interest in developing a minimally invasive imaging modality to safely evaluate dynamic microscopic changes of the olfactory mucosa and cribriform foramina. Herein, we utilized three-dimensional (3D) optical coherence tomography (OCT) to characterize the ex vivo stratified substructure of olfactory mucosa in rabbits and create 3D reconstructed images of olfactory foramina. Olfactory mucosa and cribriform plates from four New Zealand White rabbits were dissected and imaged using two swept-source OCT systems: (1) 1.3-µm (µm) center wavelength, 100-nm bandwidth, 200-kHz sweep rate, and (2) 1.7-µm center wavelength, 120-nm bandwidth, 90-kHz sweep rate. Volumetric OCT images were compiled to create a 3D reconstruction of the cribriform plate. The ability of OCT to distinguish the olfactory mucosa substructure and foramina was compared to histology. To estimate imaging penetration depth of each system, the first-order exponential decays of depth-resolved intensity were calculated and compared using a paired t-test. Three-dimensional OCT depicted the stratified layered structures within the olfactory mucosa correlating with histology. The epithelium and lamina propria were measured to be 32 µm and 107 µm in 1.3-µm OCT compared to 30 µm and 105 µm in histology. Olfactory foramina were visualized via 3D reconstruction. The 1.7-µm system provided greater depth penetration compared to the 1.3-µm system, allowing for improved foramina visualization. We have shown that OCT can be used to image non-pathologic olfactory mucosa and foramina. Implications for this work include diagnostic and therapeutic potentials for neurorhinological and neurodegenerative diseases.

Features associated with surgically significant abscesses on computed tomography evaluation of the neck in pediatric patients.

BACKGROUND: Neck-related chief complaints are common in the pediatric Emergency Department (ED), and although the incidence of pathology such as retropharyngeal abscesses is rare, the ability to rule out abscesses requiring surgical/procedural intervention is essential. However, there are no clear clinical guidelines regarding work-up and diagnosis in this population, possibly contributing to an excess use of potentially harmful and costly computed tomography (CT) imaging. OBJECTIVE: In this study we sought to identify historical, physical exam, and laboratory findings associated with surgically significant neck abscesses to better delineate CT neck imaging criteria. METHODS: We conducted a retrospective chart review of all patients ≤18 years presenting to a pediatric ED between 2013 and 2017 who underwent CT neck imaging. Surgically significant abscesses (SSAs) were defined as abscesses ≥2 cm, retropharyngeal abscesses (RPA), parapharyngeal abscesses (PPA), or peritonsillar abscesses (PTA). Historical factors, physical exam findings, laboratory results, demographics, and CT results were analyzed using univariate statistical analysis and regression models. RESULTS: A total of 718 patients received neck CTs and 153 SSAs were identified. In children younger than 6 years, factors associated with statistically significant increased odds of an SSA were reported throat pain (OR 1.18; 95% CI 1.05, 1.33), fussiness (OR 1.18; 1.01, 1.39), lethargy (OR 1.43; 1.07, 1.91), tonsillar enlargement (OR 1.17; 1.02, 1.34), C-reactive protein (CRP) > 10 (OR 1.22; 1.07, 1.40), and an ED visit within the preceding week (OR 1.18; 1.04, 1.33). In children older than 6 years, the factors associated with statistically significant increased odds of an SSA included current antibiotic use (OR 1.12; 1.02, 1.22) and a CRP >10 (OR 1.14; 1.03, 1.26). CONCLUSION: Some historical, physical exam, and laboratory findings are associated with SSAs, and while not definitive in isolation, may be beneficial additions to routine SSA assessment, as a supplement to clinical judgement regarding CT and observation decisions. This may potentially allow for the identification of patients requiring CT versus those who may not, and thus the opportunity to safely reduce the use of CT imaging in select patients.

Complications in Rhinoplasty: A Literature Review and Comparison with a Survey of Consent Forms.

Importance: Informed consent in rhinoplasty is a challenging process due to the technically demanding surgery with a wide array of potential complications. Objective: To underscore the significance of informed consent in rhinoplasty, its complications, and identify gaps in the consent process. Design, Setting, and Participants: Dual search and comparison. First a review of the literature for rhinoplasty articles was carried out between January 2000 and November 2017 with at least 100 patients to identify complications and their incidences. Then a comprehensive online search for rhinoplasty consent forms was carried out to identify consent form topics and their incidences. Main Outcomes and Measures: Consent form topics and complication rates from the literature review were reported and directly compared. Results: A total of 117 articles were included, with 36 different complications reported. Twenty-four consent forms were evaluated, yielding 80 different topics. Common complications within the literature included skin problems such as acne (18.3%), numbness (16.7%), hospital revisit (6.5%), primary source revision rate (5.3%), and dissatisfaction (5.0%). The most commonly covered consent topics included infection (100%), bleeding (95.8%), and scarring (95.8%). Unsatisfactory results and need for revision were only covered in 83.3% and 75.0% of consent forms, respectively, despite both being in the top 5 complications cited in the literature. Conclusions and Relevance: Rhinoplasty consent forms generally cover a wide range of topics, with varying incidences of complications cited within the literature. Certain complications such as dissatisfaction and revision surgery should be included in every consent process. These data help provide a contextual framework as well as valuable information in preoperative counseling for patients and physicians regarding rhinoplasty and its potential complications Level of Evidence: NA.

Adult ambulatory otologic surgery: Unplanned revisits and complications.

OBJECTIVES: Determine rates and reasons for unplanned revisits after ambulatory otologic surgery. METHODS: Cross-sectional analysis of State Ambulatory Surgery Databases of California, Florida, Iowa, and New York was performed for years 2010 and 2011. Ambulatory adult otology surgical procedures were linked to ambulatory, emergency, and inpatient databases for revisit encounters occurring within 30 days. The numbers of revisits and associated diagnoses were analyzed. RESULTS: A total of 16,709 ambulatory otologic cases were extracted (mean age, 50.3 years; 54.2% female). The most common primary procedures performed were tympanoplasty (n = 7,919), stapedectomy (n = 2504), cochlear implantation (n = 1444), tympanomastoidectomy (n = 713), and mastoidectomy (n = 697). The 30-day revisit rate was 5.2% (n = 875; 95% confidence interval [CI] 4.9%-5.6%). Urinary retention/urinary tract infection (UTI) (n = 93, 10.6%; CI 8.8%-12.9%) was the most common diagnosis at revisit, followed by otalgia (n = 85, 9.7% of revisits; CI: 7.9%-11.9%) and dizziness (n = 80, 9.1%; CI 7.4%-11.2%). Revisits most frequently occurred within the first 10 days postoperatively (47.2% of revisits), and a second revisit occurred 134 times (0.8% of cases). Fewer than 10 cases of facial nerve palsy were diagnosed (CI 0.03%-0.11%). CONCLUSION: With a relatively low unplanned revisit rate, ambulatory otologic surgery demonstrates a favorable safety profile. Common reasons for revisit included pain, urinary retention, and dizziness. Quality improvement measures should be directed at addressing these postoperative issues to minimize rates of complications and unplanned revisits. LEVEL OF EVIDENCE: NA Laryngoscope, 130:1788-1791, 2020.

Functional Outcomes, Quantitative Morphometry, and Aesthetic Analysis of Articulated Alar Rim Grafts in Septorhinoplasty.

IMPORTANCE: The design, use, and indications for the articulated alar rim graft (AARG) and the functional and aesthetic improvements that can be achieved have not been fully characterized. OBJECTIVE: To analyze the functional and aesthetic outcomes of AARG placement on nasal airway function, nasal base shape change, and appearance. DESIGN, SETTING, AND PARTICIPANTS: A case series study of patients who underwent septorhinoplasty with placement of AARG at University of California, Irvine Medical Center, from 2015 to 2018 was carried out. Surgical data recorded included stage of rhinoplasty (primary vs revision), use of spreader grafts, rim grafts (and dimensions), caudal septal extension graft (CSEG), lateral crural tensioning (LCT), and turbinate reductions. MAIN OUTCOMES AND MEASURES: Preoperative and postoperative Nasal Obstruction Symptom Evaluation Survey (NOSE) surveys were analyzed and correlated with AARG geometry, use of CSEG, and the LCT maneuver. Preoperative and postoperative alar base views were evaluated by fitting base shape to a parametric numerical model to categorize each to 1 of 6 shape categories. Blinded reviewers rated alar furrow severity and the alar ridge presence using a Likert scale for both preoperative and postoperative images to subjectively gauge aesthetic outcomes. RESULTS: Overall, 90 patients with both preoperative and postoperative NOSE scores who underwent septorhinoplasty and placement of an AARG were included. Of the 90 patients, 60 were women (mean age, 38.2 years). Patient NOSE scores (70.4 preoperatively to 25.1 postoperatively) significantly improved from preoperation to postoperation (P < .001), regardless of AARG size, CSEG, or LCT. Alar base shape parametric analysis showed preoperative to postoperative improvements were significant for anterior-to-posterior ratio mass distribution (95% CI, -0.16 to 0.02; P = .05) and vertical projection-to-horizontal base width ratio (95% CI, 0.01-0.32; P = .02) in flat noses and cloverleafing for narrow noses (95% CI, -0.05 to -0.01; P = .001); enhancement approached significance for reduction in lateral scalloping in cloverleaf noses (P = .06). Aesthetic analysis showed that there was a statistically significant improvement for the alar furrow (95% CI, -0.68 to -0.29 for rater 1; -0.54 to -0.27 for rater 2; and -0.59 to -0.27 for rater 3; P < .001) for all raters and for the alar ridge (95% CI, 0.16-0.48; P < .001) for 1 rater. CONCLUSIONS AND RELEVANCE: To our knowledge, this is the first study to demonstrate that AARG use is associated with statistically significant improvement in NOSE scores. Placement of AARGs may improve posterior mass ratios in flat noses and lateral cloverleafing in narrow noses as suggested by quantitative shape change parameter analysis. The placement of AARGs was associated with aesthetic and functional enhancement in the cloverleaf deformity, which is associated with a prominent alar furrow, and often external nasal valve collapse. Patient selection is key when placing AARGs. LEVEL OF EVIDENCE: NA.

The Online Support Group as a Community: A Thematic Content Analysis of an Online Support Group for Idiopathic Subglottic Stenosis.

OBJECTIVE:: Idiopathic subglottic stenosis (iSGS) is a rare disease with few local resources for individuals to use. With the explosive growth of online social networking, platforms such as Facebook possess compelling potential to facilitate user-driven sharing of health information and peer support. This study was performed to better understand the content shared in a busy online community for individuals with iSGS. METHODS:: The largest online community (OC) for individuals with iSGS, Living With Idiopathic Subglottic Stenosis (LwiSGS), was examined. A thematic content analysis of the communications shared in February of 2018 was performed. A conventional qualitative analysis model was employed to analyze aggregated data. The data were then codified. RESULTS:: Analysis demonstrated that communications primarily encompassed three major thematic elements: (1) information sharing; (2) emotional support, expression, and experience sharing; and (3) community building. Positively toned posts grossly overshadowed negatively toned posts by almost a factor of 3. A significant portion of group members requested information from their peers, suggesting a high level of trust toward the resources provided in this group, even those involving a surgical procedure or medication. CONCLUSION:: LwiSGS is a forum for patients with a rare chronic condition to share informational resources, personal experiences, and emotional support, as well as a community with their peers. These data suggest that LwiSGS could be a powerful resource for individuals with iSGS to share information, personal experiences, or emotional support.

Burns in the head and neck: A national representative analysis of emergency department visits.

OBJECTIVES/HYPOTHESIS: Head and neck burns (HNBs) engender serious sequelae including airway edema, speech/swallowing dysfunction, sensory deficits, and scarring/disfigurement, often requiring significant reconstructive surgery. We used a nationally representative resource to estimate the number of visits to emergency departments (EDs), analyze burn types and demographic patterns, and identify specific consumer products involved. METHODS: The National Electronic Injury Surveillance System was evaluated for the most recent 5-year period available. HNB ED visits were identified, and patient records were evaluated for consumer products facilitating injury, along with other ED visit and patient characteristics. RESULTS: From 2009 to 2013, 6,326 cases extrapolating to 233,431 ED visits nationally were identified. Males were predominantly impacted (64.1%). Although adults overall comprised the majority of patients (59.7%), children between 1 and 2 years of age had the highest incidence (21,544 ED visits nationally). The most common consumer products facilitating HNB included welding equipment, hot water, gasoline, bleaches, and cookware. Most injuries involved the face (55%), whereas the most common etiologies included thermal (40%), chemical (23%), and scald (22%) burns. Consumer products and injury patterns varied by patient age. CONCLUSIONS: HNBs significantly impact healthcare delivery, as over 200,000 visits reportedly presented to EDs over the 5-year period studied. Consumer products facilitating visits and associated patient demographics described may guide history, clinical examination, and identification of secondary injuries. In particular, age-specific patterns detailed may be included in consumer education and patient counseling to facilitate injury prevention, as office visits provide an opportunity to counsel patients.