Case 223: Arytenoid Dislocation.

A 71-year-old man with a history of atrial fibrillation refractory to medical therapy and lung cancer status after left upper lobectomy presented to our hospital for elective cardioversion and rate control with tikosyn. Overnight, the patient became unresponsive and was found to be in a state of cardiogenic shock. A code was called, and he was stabilized after cardioversion and bedside intubation. His stay in the intensive care unit was complicated by ventilator-associated pneumonia. The patient subsequently underwent multiple failed extubation attempts, requiring two additional reintubations. He was finally extubated 18 days after his initial admission to the intensive care unit. After he was discharged, he reported a hoarse voice and was only able to whisper. His voice varied in timbre and volume, and it became hoarser with use. Otolaryngology evaluation, including laryngoscopy and video stroboscopy, showed immobility of the right vocal cord. He was referred for speech therapy, and a computed tomographic (CT) examination of the neck was ordered.

The role of screening sinus computed tomography in pediatric hematopoietic stem cell transplant patients.

OBJECTIVE: The objective of this study was to evaluate pretransplant sinus computed tomography (CT) as predictor of post-hematopoietic stem cell transplant sinusitis. METHODS: We evaluated pretransplant and posttransplant CT findings in 100 children using the Lund-Mackay system and "common-practice" radiology reporting and correlated these with the presence of acute sinusitis. RESULTS: Fourteen percent of patients with normal screening CT developed posttransplant sinusitis, compared with 23% with radiographic abnormalities and 22% with clinical sinusitis alone, not statistically significant. Sensitivity of CT findings for clinical sinusitis ranged between 19% and 56%. Except for mucosal thickening (71% specificity), other findings had high specificity between 92% and 97%, particularly when combined. Lund-Mackay score change of 10 or greater from baseline was associated with a 2.8-fold increased likelihood of having sinusitis (P < 0.001). CONCLUSIONS: Screening CT can serve as a baseline, with a Lund-Mackay score change of 10 or greater constituting a significant threshold. The strongest correlation with the presence of acute sinusitis was seen with combined CT findings.

MDP uptake in peritoneal carcinomatosis and Krukenberg tumors from mucinous adenocarcinoma.

Altered biodistribution of Tc-99m methylene diphosphonate is a common occurrence on bone scintigraphy and mucin-producing neoplasms of the gastrointestinal tract are associated with dystrophic uptake. In addition to the uptake in the primary tumor, activity has been reported in metastasis within lymph nodes and liver. We present a case of Tc-99m methylene diphosphonate uptake in peritoneal carcinomatosis and metastatic Krukenberg tumors from a primary mucinous adenocarcinoma of the descending colon. Each of these findings is uncommon and their combination in this case is particularly unique.

Cervical vascular and upper airway asymmetry in Velo-cardio-facial syndrome: correlation of nasopharyngoscopy with MRA.

PURPOSE: Velo-cardio-facial syndrome (VCFS), the most common genetic syndrome causing cleft palate, is associated with internal carotid and vertebral artery anomalies, as well as upper airway asymmetry. Medially displaced internal carotid arteries, often immediately submucosal, present a risk of vascular injury during pharyngeal flap surgery for velopharyngeal insufficiency (VPI). We evaluate the frequency and spectrum of cervical vascular anomalies in a large cohort of VCFS patients correlating MRA with nasopharyngolaryngoscopy in detecting at risk carotid arteries. Furthermore, we assess the relationship with respect to laterality between cervical vascular patterns and the asymmetric abnormalities of these subjects' upper airways. METHODS: Cervical MRAs of 86 subjects with VCFS and 50 control subjects were independently reviewed by three neuroradiologists. The course of the internal carotid and vertebral arteries was identified within the pharyngeal soft tissues. Medial deviation, level of bifurcation, dominance, anomalous origin, and vessel tortuosity were recorded. Nasopharyngoscopy examinations were available for retrospective review in 43 patients and were assessed for palatal and posterior pharyngeal wall symmetry, true vocal cord motion and size, and for the presence or absence of carotid pulsations. The endoscopic findings were compared with MRA results. RESULTS: Of the 86 subjects, 80 (93%) had one or more vascular anomalies. 42 subjects (49%) were found to have medial deviation of at least one internal carotid artery. In 24 subjects (28%) the anomalous internal carotid artery was directly submucosal; four of these were bilateral (5% of the total sample, 17% of those with a submucosal internal carotid). Other carotid anomalies included low carotid bifurcation (44 subjects or 51%), anomalous origin of the right common carotid (32 cases, or 37%), and two cases of internal carotid agenesis/hypoplasia. Vertebral artery anomalies included vessel tortuosity (34 cases, or 40%), hypoplasia (10 cases, or 12%), looping (4 cases, or 5%), and one case of a double left vertebral artery. Though patients in our study showed an asymmetric distribution of vascular anomalies, no association was found between the laterality of palatal motion, pharyngeal fullness, or laryngeal movement and structure with ipsilateral vertebral or carotid artery anomalies. Of the 33 pulsatile carotid arteries visualized at nasopharyngoscopy, only nine were found to be submucosal on MRA. In contrast, 11 submucosal carotid arteries confirmed at MRA demonstrated no visible pulsations. Positive and negative predictive values of pulsative arteries seen endoscopically for MRA confirmation of a submucosal carotid course was 27% and 79% respectively. CONCLUSIONS: Carotid and vertebral artery anomalies are common in VCFS including marked medial deviation of the internal carotid artery in close proximity to the donor site for pharyngeal flap surgery. Lack of correlation between laterality of vascular anomalies and upper airway structural asymmetry in VCFS does not support the hypothesis that palatal, pharyngeal, and laryngeal anomalies are due to secondary developmental sequences caused by in utero vascular insufficiency. The presence or absence of carotid pulsations seen by nasopharyngoscopy does not correlate with the carotid arterial depth identified on MRA. Furthermore, identification of the relative medial-lateral retropharyngeal position of a submucosal carotid affords the opportunity to modify the surgical approach. These findings further support the routine use of pre-operative neck MRA in VCFS patients in surgical planning.