A Multidisciplinary Approach to Castleman Disease of the Neck.

Castleman disease (CD) is a rare lymphoproliferative disorder that occurs in adults and rarely in the pediatric population. The disease is characterized by slowly enlarging masses that can form anywhere within the lymphatic system. It is an uncommon cause of a neck mass in both children and adults that presents insidiously and nonspecifically. A 21-year-old woman was referred to the otolaryngology service because of an asymptomatic neck mass found incidentally on computed tomographic imaging 15 months earlier. On repeat imaging, the lesion was characterized as a homogenously enhancing soft tissue mass and appeared stable in size compared with previous studies. Given the nondiagnostic radiologic features, tissue sampling was pursued, first using fine-needle aspiration and ultimately excisional biopsy. The excision revealed histopathology consistent with unicentric, hyaline-vascular CD. Excision is the gold standard for treatment of this variant of CD. The patient was referred to the hematology/oncology service but was subsequently lost to follow-up. This case illustrates a rare cause of a neck mass in a young adult and exemplifies the extremely broad differential in this setting. In addition, it highlights the importance of a systematic and thorough approach to diagnosing neck masses in children and adults.

Organic vs. Inorganic Tracheobronchial Airway Foreign Body Aspiration: Does Type/Duration Matter?

OBJECTIVE: We sought to determine the time course of clinical and histologic differences between aspirated inorganic and organic foreign bodies. STUDY DESIGN: In-vivo. METHODS: Twenty Sinclair miniature swine (Sus scrofa domesticus) were divided into two groups-inorganic or organic foreign bodies. Either an organic (peanut) or an inorganic (Lego) foreign body was placed within a bronchus and left for 3, 5, 7, 14 or 21 days. The airway was reassessed at the predetermined endpoint at which time endoscopic, gross, and histopathological findings were documented. Specimens were scored with a pathologic scoring system to assess injury severity from the foreign body. RESULTS: Foreign bodies were successfully placed in all 20 swine. Two animals required early euthanasia due to respiratory compromise. The foreign body was identified grossly in eight (40%) animals. An additional three (15%) had microscopic evidence suggestive of a previous foreign body of an undetermined duration. There was no difference in injury severity between organic and inorganic foreign bodies. The 3-day group had injuries limited to the bronchial lining, whereas the longer duration groups had bronchial and adjacent lung parenchymal involvement. There was no difference in injury severity between days 5 and 21. CONCLUSIONS: Airway foreign bodies initially cause bronchial damage. After 5 days, the foreign body causes lung parenchymal changes. There was no difference in airway lesion severity between organic and inorganic foreign bodies. LEVEL OF EVIDENCE: N/A Laryngoscope, 131:490-495, 2021.

Isolated posterior table frontal sinus fractures do not form mucoceles in a goat model.

OBJECTIVE: The goal of this study was to investigate how patency of the nasofrontal outflow tract would affect frontal sinus healing in the setting of displaced, comminuted, posterior table fractures in the adult goat (Capra hircus). STUDY DESIGN: Prospective animal study. SUBJECTS AND METHODS: Posterior table fractures were created in 20 adult goats. The nasofrontal outflow tract was left patent in 10 goats (Group 1) and obstructed in 10 (Group 2). Gross, radiologic, and histologic evaluation were carried out six months postoperatively. RESULTS: One of nine subjects subjects (11%) in Group 1 developed a mucocele while eight of 10 (80%) in Group 2 developed mucoceles (P = 0.004). No subjects (100%) in Group 1 had gross, radiologic, or histologic evidence of mucosal ingrowth into the posterior table, while two of 10 (20%) in Group 2 showed evidence of mucosal ingrowth into, but not through, the posterior table. In both groups 100% of the subjects had gross and histologic evidence of intact posterior tables abutting the dura. CONCLUSION: An occluded nasofrontal outflow tract leads to an increased mucocele formation rate at six months. In an unobstructed nasofrontal outflow tract there is no gross, radiologic, or histologic evidence of mucosal ingrowth into the posterior table at six months. These findings would suggest that not all comminuted, significantly displaced posterior table fractures need to be surgically addressed if the nasofrontal outflow tract is patent.

Effect of high-dose vocal fold injection of cidofovir and bevacizumab in a porcine model.

OBJECTIVES: Perform a follow-up study to investigate the histologic impact of high-dose intralaryngeal cidofovir injections in porcine vocal cords, either alone or in combination with bevacizumab, and compared to saline controls. STUDY DESIGN: This was an in vivo study involving 24 pigs with blinded pathologist review of specimens. Six groups were created, with four subjects in each group. Each subject received 10 or 20 mg of either cidofovir or bevacizumab alone, or in combination, injected into the right vocal cord. The left vocal fold was used as a saline control. Three separate injections were made at 2-week intervals. Larynges were harvested at 8 and 12 weeks, stained with hematoxylin and eosin and trichrome stain, and reviewed for histologic changes by two blinded pathologists. RESULTS: Minimal inflammation, edema, and atypia were noted with all treatments. Increased glandular inflammation was noted with 10 mg bevacizumab (P < 0.05), which decreased when combined with 10 mg cidofovir (P < 0.05). No lamina propria or muscle fibrosis was observed. Drug duration had no statistically significant histologic impact. CONCLUSION: High-dose cidofovir and bevacizumab do not induce detrimental vocal fold changes. Combination cidofovir and bevacizumab do not cause vocal fold scarring. Further work is needed to assess systemic concentration with this high-dose combination in humans. LEVEL OF EVIDENCE: N/A. Laryngoscope, 127:671-675, 2017.

Submucosal minimally invasive lingual excision: an effective, novel surgery for pediatric tongue base reduction.

OBJECTIVES: The aim of this study was to develop an effective single intraoral, minimally invasive technique to reduce the enlarged tongue base in children with obstructive macroglossia. METHODS: We present the anatomic dissection of fresh cadavers and a representative case series of children who underwent submucosal minimally invasive lingual excision (SMILE) with a plasma-mediated radiofrequency device (coblation) under intraoral ultrasonic and endoscopic guidance. Multiple anatomic dissections determined the relative location of the hypoglossal nerve and lingual neurovascular bundle in relation to removable tongue base musculature. A pediatric case series demonstrates the straightforward SMILE technique. RESULTS: Laboratory anatomic dissection and clinical lingual ultrasonography revealed the surgical safety borders for SMILE. The surgical safety and efficacy of SMILE is demonstrated by preoperative and postoperative clinical examinations and polysomnograms in children with obstructive macroglossia (such as Beckwith-Wiedemann and Down syndromes and tongue vascular malformation). Coblation submucosally removes excessive tongue base tissue through a small anterior tongue incision. SMILE was performed without excessive pain, bleeding, edema, infection, or tongue dysfunction. CONCLUSIONS: SMILE is an effective novel operation that incorporates coblation with ultrasonography and endoscopic guidance for children who need tongue base reduction. Anatomic dissection and clinical cases demonstrate the potential for aggressive yet relatively safe tissue removal by this minimally invasive technique. SMILE also has significant potential for adults with obstructive sleep apnea due to a large tongue base.

Pediatric laryngeal electromyography.

Vocal fold immobility (VFI) is a challenging management issue in pediatric otolaryngology. VFI is most commonly distinguished between unilateral (UVFI) and bilateral (BVFI) dysfunction. UVFI and BVFI are different pathophysiologic and clinical entities with distinct symptoms and etiologies. It has been generally accepted in the adult literature to wait at least 1 year prior to carrying out more permanent type procedures for VFI. This period has been extended out even further in children as the literature has suggested that vocal fold function may return many years later. Unfortunately, there is no simple test or procedure to help predict return of vocal fold function. In adult patients LEMG has been used to help guide management decisions, but it has not been widely investigated in children. In this chapter the authors describe a LEMG technique that has been a useful adjunct in managing children with VFI.

Juvenile-onset recurrent respiratory papillomatosis.

Juvenile-onset recurrent respiratory papillomatosis, caused by the human papilloma virus, is the most common benign neoplasm of the larynx in children. Recurrent respiratory papillomatosis is relatively rare, but it can have a significant impact on afflicted children and their family's quality of life as dysphonia and multiple surgical procedures are hallmarks of this disease. The current standard of care is surgical therapy with a goal of complete papilloma removal and preservation of normal structures. The technique in this atlas combines both the microdebrider and the pulse KTP laser. The microdebrider allows for rapid removal of bulky lesions without the risk of thermal injury, yet it cannot provide precise removal in areas such as the anterior commissure and ventricle. The pulse KTP laser allows for removal of sessile lesions and in sensitive areas such as the vocal folds. The authors describe this technique as well as discuss adjuvant therapies and pearls for success.

Pediatric lingual tonsillectomy.

Tonsillectomy and adenoidectomy are an effective surgical treatment of pediatric obstructive sleep apnea; however, up to 20% of these patients can have persistent disease. In this select patient population, the lingual tonsil may be an occult source of obstruction. Lingual tonsillectomy can be a challenging procedure due to poor access and visualization, airway edema, postoperative pain and hemostasis during tissue removal. In this chapter, we describe our preferred technique for lingual tonsillectomy including surgical pearls for success.

Pediatric airway balloon dilation.

Over the past decade, there has also been renewed interest in serial dilatation for the management of subglottic and tracheal stenosis with the advent of new technologies such as airway balloons designed for the pediatric airway. In this chapter, the authors describe the technique of application of airway balloons as a useful adjunct for management of airway lesions.

Intraoperative laryngeal electromyography in children with vocal fold immobility: results of a multicenter longitudinal study.

OBJECTIVES: To determine whether laryngeal electromyography (LEMG) can predict recurrent laryngeal nerve function return in children and whether LEMG can aid in the management of vocal fold immobility (VFI). DESIGN: Prospective case series. SETTING: Tertiary pediatric aerodigestive centers. PATIENTS: Twenty-five children aged 14 days to 7 years at the time of first LEMG (mean age, 21.4 months) with VFI who underwent flexible fiberoptic laryngeal examination, intraoperative LEMG of the thyroarytenoid muscles, and 12-month follow-up. MAIN OUTCOME MEASURES: To compare results of LEMG with flexible fiberoptic laryngeal examination in children with vocal fold paresis and to determine if LEMG can predict vocal fold return. RESULTS: In children who had a patent ductus arteriosus ligation, the LEMG data suggest that if there is no activity 6 months after injury, then the nerve is unlikely to regain function. In 3 of 3 children with central causes of VFI, normal LEMG findings predicted return of nerve function 2 to 7 months before vocal fold movement on fiberoptic examination. Finally, in 3 of 3 children with idiopathic VFI, LEMG predicted return within 2 to 14 months of vocal folds with normal findings. CONCLUSIONS: Intraoperative LEMG is a safe, easy-to-use method for determining the likelihood of recurrent laryngeal nerve function return in children who have undergone patent ductus arteriosus ligation, in children with centrally correctable lesions, and in children with idiopathic VFI. More work is needed in the area of pediatric LEMG, but it is possible that LEMG data can be used to aid in management strategies and provide families with more information to make better informed decisions regarding their child's care.

Transantral endoscopic repair of orbital floor fractures with the use of a flexible endoscope holder: a cadaver study.

We conducted a cadaver study to determine the ease of use and functionality of a flexible endoscope holder in the visualization and repair of orbital floor fractures via a transantral approach. Four fresh cadaver heads were dissected through a sublabial antrotomy incision with a 30 degrees endoscope attached to a flexible holder. An implant was placed to restore the normal anatomy. With the use of this exclusive endoscopic approach, all orbital floor fractures were identified in their entirety and completely reduced with alloplastic material. We conclude that the flexible endoscope holder provides clearer visualization, greater instrument mobility, and an overall superior dissection and placement of implants in the endoscopic repair of orbital floor fractures.

Primary branchiogenic carcinoma: the confusion continues.

As in many specialties, otolaryngology is not without diagnosis surrounded by controversy. This report discusses the entity known as the primary branchial cleft carcinoma, which has been argued by some to be no more than metastatic disease of the unknown primary. Although the disease is rare, the consideration of this diagnosis requires careful thought and analysis by the otolaryngologist, pathologist, and radiation oncologist so that a rational treatment plan can be offered to the patient.