Sclerotherapy vs. surgical excision for lymphatic malformations of the head and neck: a systematic review and meta-analysis.

OBJECTIVES: Lymphatic malformations (LMs) are abnormal lymphatic vessels with cystic characteristics, categorized as macrocystic, microcystic, or a combination of both. They represent the second most common vascular malformations, and their management involves multidisciplinary approaches based on clinical assessments and imaging studies. LMs manifest as a challenge to medical professionals in the head and neck, posing functional and aesthetic concerns. Our systematic review aims to compare the efficacy of sclerotherapy and surgery for LMs, identifying optimal treatment modalities for each scenario. METHODS: We searched four electronic databases for related studies. Data were extracted from the included studies. We calculated the pooled rate ratios with 95% confidence intervals (CIs). The I2 test was used to detect heterogeneity. The inclusion of the studies required the following prerequisites: 1- Studies focusing on any lymphatic malformations in the head and neck, whether microcystic, macrocystic, or a mix of both; 2- Studies performed on more than ten patients; 3- All interventions used as surgery, sclerotherapy, or both. RESULTS: We included 58 studies in our systematic review, of which 45 were eligible for the meta-analysis. For macrocystic LMs, sodium tetradecyl sulfate (STS) mixed with ethanol and excision achieved the highest complete response rates at (92.9%) and (92.5%), respectively. Surgical excision showed the lowest poor response rate. Polidocanol microfoam had the highest poor response rate (11.1%). In microcystic LMs, combining sclerotherapy with excision showed the highest complete response rate (70.3%) and the lowest poor response rate (1.3%). Picibanil had the lowest complete response rate (9.1%) and the highest rate of poor response (61.4%). In mixed LMs, surgical excision had the highest complete response rate (70.3%). CONCLUSION: Both surgical excision and STS combined with ethanol are highly effective for treating macrocystic LMs, achieving similar complete response rates. The combination of sclerotherapy and surgical excision demonstrated the best outcomes in microcystic LMs. Surgical excision demonstrates superior efficacy over sclerotherapy for mixed LMs. These findings suggest that excision is generally more effective in achieving complete and excellent responses across all LM subtypes. Further high-quality studies are necessary to standardize and optimize treatment protocols.

Endoscopic balloon dilatation for pediatric subglottic stenosis: a meta-analysis of successful outcomes.

OBJECTIVES: The primary goal of this study was to systematically identify all relevant published articles on the use of primary endoscopic balloon dilation for the management of pediatric patients with subglottic stenosis, critically assess the technique's success, and determine which patients are the best candidates for the procedure. METHODOLOGY: This was a systematic review and meta-analysis that aimed to investigate the use and success rate of EBD for treating pediatric SGS. An electronic systematic literature search of three major databases, PubMed, EBSCO, and Web of Science&MEDLINE through Clarivate, was conducted to include the eligible articles. RESULTS: A total of 14 unique studies were included in the final analysis, with 473 cases of pediatric SGS. The pooled success rate of EBD in treatment of pediatric SGS was 76% (k = 14 studies, 95% confidence interval [CI] = 0.65-0.86, P < 0.001, Q test for heterogeneity = 0.03, P < .001, I2 = 91%). CONCLUSIONS: We reported a high success rate of EBD in treating pediatric SGS. The reported complications were uncommon, although they can be serious and life threatening. The intensity of SGS may be related to the likelihood of therapy failure.

Management of embedded metallic stents used in the treatment of grades III and IV subglottic, and upper tracheal stenosis in adults.

The aim of this study was to evaluate the post-operative complications of using balloon-expandable metallic stents in treatment of benign, major subglottic and tracheal stenosis in adult patients whom conventional therapy has failed and to demonstrate how to deal with these complications in the long run. A retrospective review of five cases; adlut patiets with benign, major subglottic and upper tracheal stenosis whom were treated with balloon expandable metallic stents at King Abdulaziz University Hospital, in the years between 2008 and 2013. Granulation tissue formed in five of the four cases and restenosis occurred. Other complications encountered were stent infection and dislodgment. The complications were managed by removing the stents surgically via a laryngofissure incision and required the placement of a Montgomery T-tube. Managing the restenosis due to granulation tissue formation around the metallic stents is best achieved by removing the embedded metallic stents surgically via open technique and then by placement of a Montgomery T-tube as a bridging option to successful decannulation. Open surgical procedures remain the mainstay treatment for advanced airway stenosis.

Glottic widening procedures (GWPs) to avoid tracheostomy in infants' bilateral vocal cord paralysis: A systematic review and meta-analysis.

OBJECTIVE: This systematic review and meta-analysis evaluated the efficacy of various glottic widening procedures (GWPs) in avoiding tracheostomy in infants with bilateral vocal cord paralysis (BVCP). METHODS: A systematic literature search was conducted in PubMed, Scopus, Web of Science, and Cochrane Library from inception to July 2023, without any timeframe limitations. Studies reporting GWPs (Endoscopic anterior-posterior cricoid split, Botox injection, suture lateralization, and other procedures including laser posterior cordotomy/arytenoidectomy) in infants with BVCP were included. Meta-analysis was performed to assess tracheostomy avoidance and secondary outcomes including voice, swallowing, and resolution of airway symptoms. RESULTS: Thirteen studies with 100 patients were included. The mean age was 51.6 days. The etiology of BVCP was idiopathic (83 %), neurologic (10 %), and acquired (7 %). The GWP interventions were successful in 88 % of patients, with only 12 % requiring tracheostomy after surgery. The pooled proportion for avoiding tracheostomy was 0.88 (95 % CI 0.82-0.94) across interventions, with no significant differences between techniques. Among patients who avoided tracheostomy, 64 % had normal voice, 86 % tolerated oral feeding, 77 % had airway symptom resolution, and 70 % had recovery of vocal cord mobility. CONCLUSION: GWPs prevent a majority of infants with BVCP from undergoing tracheostomy, without permanent alterations to laryngeal function. All interventions were comparable in efficacy. Further research with larger sample sizes is warranted.

Implications of Rigid Bronchoscopy: An Eight-Year Review in a Pediatric Intensive Care Unit.

Introduction: Rigid bronchoscopy is an endoscopic technique used to visualize the airway, and rigid bronchoscopy is performed for both diagnostic and therapeutic indications. We defined the clinical characteristics of pediatric intensive care unit (PICU) patients undergoing bronchoscopy to establish a predictive model for early discharge from the PICU. Prediction can provide tangible aid in managing PICU patients. Objectives: The primary objectives of this research are to evaluate the impact of different bronchoscopic procedures on the duration of PICU stay and to determine the Predictors of PICU discharge. Methods: We retrospectively reviewed records of 451 PICU admissions from 2012 to 2019 at our institution. In total, 36 pediatric patients under 12 years of age undergoing interventional rigid bronchoscopy during their PICU stay were studied. This study examined the impact of bronchoscopic procedures on the duration of PICU stays. Patients were categorized into three groups according to the number of bronchoscopic interventions used to evaluate the implications of different bronchoscopic procedures on the duration of PICU stay. Results: Multiple linear regression analysis was used to test the predictors of PICU discharge. Tracheostomy and gender were significant predictors (p = 0.072 and 0.060, respectively), but first bronchoscopy showed strong significance (p = 0.002). Conclusion s: Our findings have shown that early bronchoscopic interventions assisted in early critical care unit discharge, and most patients who did not benefit from the first bronchoscopy were complicated cases that could explain the long stay in the PICU.

Comparison of Cochlear Implantation Complications with Subperiosteal Pocket Technique Versus Well-Drilling Technique in Pediatric Patients: A Retrospective Study.

Aims: Cochlear implantation is becoming the standard treatment for rehabilitating patients with sensorineural hearing (SNH) impairment. Various techniques can be used to achieve this goal. In the current study, we compared the subperiosteal technique (SPT) with the development of a subperiosteal pocket without fixation to the well-drilling method (WD) by constructing an incision into the scalp with suture fixation. Materials and methods: Our study weighted the efficiency of children who underwent WD or SPT from 2017 to 2021 at King Abdulaziz University Hospital. In this retrospective records review, we compared 63 SPT cases with 104 WD cases during a 5-year period who were followed for 1 month or more. Results: There were 88 females (50.9%) and 79 male (45.7%) with a mean age of 4.49 ± 3.06 years at the time of surgery. The mean WD duration was 2.47 ± 1.05 h, and 2.91 ± 1.05 h for SPT (P = 0.01). Moreover, there was a significant relationship between comorbidities and electrode complications (P = 0.022). There was no significant correlation between the surgical method and intraoperative complications (P = 0.714), electrode array issues (P = 0.88), or serious postoperative complications including device failure and migration skin problems (P = 0.207). Conclusion: Overall, the WD technique was faster. However, both methods can be used safely and effectively, as no significant intraoperative or postoperative complications were observed. Further long-term studies are required to validate our findings. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03735-z.

Impact of diabetes mellitus and co-morbidities on mortality in patients with COVID-19: A single-center retrospective study.

OBJECTIVES: To describe the effect of diabetes mellitus (DM) on clinical outcomes of patients admitted with COVID-19 infection. METHODS: We carried out a single center, observational, retrospective study. We included adult patients with laboratory-confirmed diagnosis of COVID-19 admitted to a tertiary hospital in Jeddah, Saudi Arabia, from April 2020 to December 2020. Electronic medical records were reviewed for demographics, clinical status, hospital course, and outcome; and they were compared between the patients with or without DM. RESULTS: Out of 198 patients included in the study, 86 (43.4%) were diabetic and 112 (56.5%) were non-diabetic. Majority of the patients were males 139 (70.2%) with a mean age of 54.14±14.89 years. In-hospital mortality rate was higher in diabetic patients than in non-diabetic patients (40 vs. 32; p=0.011). The most common comorbidity was hypertension (n=95, 48%) followed by ischemic heart disease (n=35, 17.7%), chronic kidney disease (n=17, 9.6%), and bronchial asthma (n=10, 5.1%). CONCLUSION: The risk of SARS-CoV-2 infection is higher among diabetic patients; particularly, those with preexisting co-morbidities or geriatric patients. Diabetic patients are prone to a severe clinical course of COVID-19 and a significantly higher mortality rate.

A Case-Control Study of Titanium and Fluoroplastic Ventilation Tubes.

Background Tympanostomy ventilation tube (VT) insertion is one of the most common procedures performed in otorhinolaryngology. VTs have been proven to effectively manage otitis media (OM) with effusion (OME) and to improve the quality of life of children postoperatively. Although there are multiple types of VT shapes, materials, and sizes, few studies have investigated and compared the effects of titanium VT with those of VTs made of other materials. This study aimed to compare titanium VTs and the more commonly used fluoroplastic VTs in a retrospective, age-matched, case-control study. We studied the postoperative outcomes and rates of extrusion, infection, otorrhea, tube obstruction, and residual perforation. Methodology Medical records of patients who underwent myringotomy with VT insertion from January 2018 to December 2020 were reviewed. A total of 34 patients met the inclusion criteria, of whom 17 had undergone titanium VT insertion bilaterally (titanium group) and 17 had undergone fluoroplastic VT insertion bilaterally (control group). Both groups were followed up with regular postoperative examinations for 18 months. Results Postoperative complications were categorized as early and late complications. The most common early postoperative complication was early extrusion of VT (six months or less after insertion) (67.6%); this was documented most often in the titanium group. Other early postoperative complications included transient otorrhea (14.7%), tube blockage (8.8%), and recurrent acute otitis media (AOM) (occurring within one month from completion of therapy of AOM episode) (5.9%); these rates were similar in both groups. Late complications were not significantly variable between groups. Tympanic membrane retraction was the most common late complication (8.8%). Conclusions VT insertion is associated with the risk of complications with varying degrees. Although factors affecting the VT complication rates are multiple and various, these rates were not different between groups in this study. However, further studies including larger population samples are needed to statistically confirm these results and their generalizability.

Treatment of Childhood High-Grade Subglottic Stenosis (SGS) Through Laryngotracheoplasty (LTP) in a Tertiary Pediatric Center from 2013 to 2020.

Laryngotracheal reconstruction is the most common and effective treatment in childhood subglottic stenosis (SGS). Our aim is to review the success rate of laryngotracheoplasty (LTP) in pediatric high grade SGS cases in our tertiary center. The retrospective review was conducted on children with high grade subglottic stenosis who had undergone laryngotracheoplasty over a 7-year period (2013-2020) in tertiary pediatric care. A total of 20 patients who had history of high grade SGS during the stipulated period were included. All of them had undergone LTP. Decannulation was considered the primary outcome measure of success. Surveillance bronchoscopy was performed one year post airway reconstruction to detect residual stenosis. From January 2013 to December 2020, 20 patients aged between 1 and 16 years old underwent LTP. Among them, 10 patients (50%) had Grade III SGS while 5 had Grade III SGS with glottis stenosis (25%). The remaining 5 (25%) had severe Grade IV stenosis. Decannulation was achieved in 14 patients overall (70%) including 1 with revision. These 14 patients who achieved decannulation included 7 out of the 10 patients (70%) with Grade III, 2 out of the 5 (40%) patients with Grade III with glottic involvement, and 4 out of the 5 patients (80%) with Grade IV SGS. Fifteen (80%) patients had double stage LTP while 5 patients had single stage LTP. The study suggests that LTP is a promising approach in the treatment of Complex SGS. Furthermore, pediatric SGS, which is inherently complicated, can be treated with LTP effectively.

The Association Between Vitamin D Level and PFAPA Syndrome: A Systematic Review.

Periodic Fever, Aphthous Ulcers, Pharyngitis and Adenitis (PFAPA) Syndrome's etiology is not well understood. The objective of this study is to explore the association between vitamin D level and PFAPA syndrome. A systematic review of all publications addressing the association between vitamin D level and PFAPA syndrome prior to May 2019 was conducted. Data were collected from online medical databases namely, PubMed, Ovid Medline, Embase, Cochrane Library, Google Scholar, and Scopus. The review adhered to the PRISMA statement and was performed in 3 main phases; an initial screening review of abstracts was performed, followed by a detailed review of full articles based on inclusion and exclusion criteria, and lastly a final review to extract data from selected articles. 3 prospective review-based and one case report articles were included with a total of 281 patients, 98 of whom were cases of PFAPA, while 183 were controls. Vitamin D levels were deficient in 27% of PFAPA group as compared with the control. Vitamin D supplementation was given as an initial treatment in 25/98 of the patients. Only 1 patient received it as a second treatment. After vitamin D supplementation, a marked reduction of the number of febrile episodes and modification of the mean duration were recognized. There may be an association between Vitamin D deficiency and a higher frequency of PFAPA episodes. Vitamin D supplementation in children with PFAPA may reduce the frequency of episodes and help manage the condition.

The Association between Adenotonsillectomy and Frequency of Vaso-Occlusive Crises in Patients with Sickle Cell Disease.

Sickle cell disease (SCD) typically manifests in early childhood as attacks of pain known as vaso-occlusive crises. Infection and hypoxemia have been linked with these recurrent episodes and with prolonged hospitalization in SCD patients. However, adenoids and tonsils as sources of infection and causes of hypoxemia have not been adequately investigated in association with vaso-occlusive crises in SCD. To assess the association between adenotonsillectomy and frequency of vaso-occlusive crisis in SCD patients who underwent this procedure at our Hospital, and between adenotonsillectomy and frequency of blood transfusions and emergency department and intensive care unit admissions. We used medical record data to conduct a retrospective review of SCD patients who underwent adenoidectomy and/or tonsillectomy between 2005 and 2017. Eligible subjects were assessed for frequency of vaso-occlusive crises, blood transfusions, and emergency department and intensive care unit admissions. Using the Wilcoxon signed rank test, we compared the frequencies of each outcome preoperatively and 1, 3, 5, and 10 years postoperatively. Of 524 records reviewed, 40 eligible patients were included in the study. Minimal reduction was observed in the frequency of vaso-occlusive crisis episodes within 1 and 3 years after adenotonsillectomy (p = 0.337 and p = 0.549, respectively). Although the 5- and 10-year postoperative vaso-occlusive crisis frequency tended to be higher than that in the preoperative period, none of the results reached statistical significance. The number of emergency department admissions showed a statistically significant increase 3 years postoperatively compared with that in the preoperative period (P = 0.043). There were no statistically significant differences in perioperative blood transfusion frequency or number of intensive care unit admissions in any period. Adenotonsillectomy in SCD patients does not seem to be related to the frequency of vaso-occlusive crises, blood transfusions, or emergency department or intensive care unit admissions. Prospective studies with larger sample sizes are recommended to further evaluate these findings.

Prophylactic Central Neck Dissection for Clinically Node-Negative Papillary Thyroid Carcinoma.

OBJECTIVE: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) that scrutinized the oncological benefits and postsurgical complications of total thyroidectomy (TT) plus prophylactic central neck dissection (pCND) versus TT alone among clinically node-negative (cN0) papillary thyroid cancer (PTC) patients. METHODS: We screened five databases from inception to September 4, 2021 and evaluated the risk of bias of the eligible studies. We pooled dichotomous outcomes using the risk ratio (RR) with 95% confidence interval (CI). RESULTS: Overall, we included 5 RCTs with low risk of bias comprising 795 patients (TT plus pCND = 410 and TT alone = 385). With regard to efficacy endpoint, the rate of structural loco-regional recurrence did not significantly differ between both groups (n = 4 RCTs, RR = 0.49, 95% CI [0.19, 1.27], P = .14). With regard to safety endpoints, the rates of hypoparathyroidism (n = 5 RCTs, RR = 1.48, 95% CI [0.73, 2.97], P = .27), recurrent laryngeal nerve injury (n = 5 RCTs, RR = 1.34, 95% CI [0.59, 3.03], P = .48), and bleeding (n = 3 RCTs, RR = 1.75, 95% CI [0.42, 7.26], P = .44) did not significantly differ between both groups. CONCLUSION: For cN0 PTC patients, there was no significant difference between TT plus pCND and TT alone with regard to the rate of structural loco-regional recurrence or frequency of postsurgical complications. Adaptation of pCND in cN0 PTC patients should be contemplated by taking into consideration the clinical oncological benefits and rate of postsurgical adverse events. LEVEL OF EVIDENCE: 1 Laryngoscope, 132:1320-1328, 2022.

Supraglottoplasty in the management of laryngomalacia in children with down syndrome: A systematic review.

INTRODUCTION: Children with Down syndrome (DS) who have Laryngomalacia represent a specific management challenge due to their inherent multiple levels of airway obstruction and hypotonia. Therefore, the purpose of this study is to determine the outcome of supraglottoplasty (SGP) in children with DS. DATA SOURCE: A systematic review was performed following the PRISMA guideline. Data were collected from online medical databases- CINAHL, Cochrane Library, Google Scholar, Ovid MEDLINE, Ovid MEDLINE in process, PubMed, and Scopus. REVIEW METHODS: all publications that address the outcome of supraglottoplasty in children who are less than 18 years old with Down syndrome prior to December 2018 were collected. The data were collected on different phases: Screening review using search words and controlled vocabularies during the period of November-December 2018, followed by a detailed review of screened articles based on inclusion and exclusion criteria, then a full review that included screening the references of selected articles. RESULTS: Nine articles were included in the qualitative analysis. These articles included 231 subjects, out of which 32 children with DS met the inclusion criteria. Twenty patients (62.5%) were considered successfully treated and 12/32 failed including 1/32 (3.1%) mortality in the postoperative period. The duration of follow-up was 12-102 days. All of the patients whose treatment failed had significant comorbidities. CONCLUSION: Although the success of SPG in children with DS is less than in otherwise healthy children, it remains an option especially in patients without comorbidities. Preoperative counseling of the families and thorough assessment are necessary to determine candidacy for SPG in children with DS.

The Association Between Vitamin D Deficiency and Recurrent Tonsillitis: A Systematic Review and Meta-analysis.

OBJECTIVES: The role of vitamin D deficiency has been linked with recurrent upper respiratory tract infections, but its impact on the frequency of tonsillitis is not yet fully understood. The objective of this study is to determine the association between vitamin D deficiency and recurrent tonsillitis based on current literature. DATA SOURCE: A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Data were collected from online medical databases (PubMed, MEDLINE, EMBASE, and Cochrane Collaboration Registry of Controlled Trials). REVIEW METHODS: All studies addressing the association of vitamin D deficiency and recurrent tonsillitis prior to March 2019. The data were collected in different phases: screening review using search words and controlled vocabularies followed by detailed review of screened articles based on inclusion and exclusion criteria, then a full review that included screening the references of selected articles. RESULTS: Fifty-three studies were potentially eligible; of these, 4 publications met the inclusion criteria and were included in the quantitative synthesis. There was a statistically significant reduction of vitamin D levels in patients with recurrent tonsillitis as compared to healthy controls (mean difference, -10.71; 95% CI, -19.12 to -2.31; P = .01). The odds of vitamin D insufficiency were significantly higher in patients with recurrent tonsillitis as compared to the control group (odds ratio, 4.37; 95% CI, 2.78-6.88; P < .001). CONCLUSION: Vitamin D deficiency was present in patients with recurrent tonsillitis and might be associated with an increase in the risk of recurrent tonsillitis. There is a need to explore these findings via clinical trials based on large populations.

Thyroid gland management in total laryngectomy: meta-analysis and surgical recommendations.

OBJECTIVES: 1) Review the incidence of thyroid gland invasion by squamous cell laryngeal carcinoma reported in the literature. 2) Assess the association between thyroid gland invasion and anatomical characteristics of the laryngeal tumor. DATA SOURCES: MEDLINE (1967-2007) and EMBASE (1980-2007). These databases were supplemented with 61 patients from McGill University who underwent total laryngectomy with hemi- or total thyroidectomy from 2001-2006. REVIEW METHODS: Systematic review for series of laryngeal carcinoma that commented on thyroid gland invasion according to tumor subsite and pathological characteristics. Total laryngectomy specimens for primary laryngeal squamous cell carcinoma with concomitant thyroid resection were included in the analysis. RESULTS: In total, eight series (n = 399) were included in the meta-analysis. Thyroid gland invasion was present in 33 laryngectomy specimens (8%); the principal method of invasion of the gland was by direct extralaryngeal extension. Subglottic extension > 10 mm (OR 7.22 [2.05 to 25.46]; P = 0.002), transglottic tumors (OR 3.23 [1.16 to 9.00]; P = 0.025), and subglottic subsite (OR 5.66 [1.34 to 23.87]; P = 0.018) were all significantly associated with thyroid gland invasion. Cartilaginous invasion by tumor was not a significant predictor of thyroid gland invasion (P > 0.05). CONCLUSIONS: Thyroid gland invasion is not a general feature of squamous cell laryngeal carcinoma. When present, it is strongly associated with anteroinferior spread of advanced laryngeal tumors. Thyroidectomy may only be required during total laryngectomy for transglottic tumors, subglottic tumors, and tumors with subglottic extension >10 mm.

Denture Impaction Causing an Upper Esophageal Diverticulum.

BACKGROUND: Dentures are a common cause of inadvertent foreign body ingestion particularly in the elderly. Due to their radiolucent nature, they often present a diagnostic challenge to care providing physicians. CASE PRESENTATION: A 66-year-old female presented to our otolaryngology clinic with a 2-year history of dysphagia. Her physical examination was unremarkable. Computed tomography scan of the neck and barium swallow suggested Zenker diverticulum. She was planned for endoscopic diverticulotomy; however, during surgery, a foreign body was incidentally found and retrieved, which was a partial lower denture. The diverticulum resolved thereafter, and the patient's symptoms abated. CONCLUSION: The authors recommend evaluating the esophagus endoscopically first in cases of upper esophageal diverticular formation, even when planning an open repair approach, to rule out any concealed foreign bodies.

Comparison of two approaches to lateral nasal osteotomy in Saudi patients

BACKGROUND: Nasal deformity is an abnormality in the appearance of the nose due to either congenital defect or trauma. In traumatic cases, patients often present with combined functional and cosmetic complaints. Therefore, otolaryngologists take into account both breathing and aesthetic nasal issues. OBJECTIVES: To evaluate the changes in the nasal dorsum and base; compare breathing and aesthetic satisfaction scores between two approaches to lateral nasal osteotomy: low-to-low and low-to-high. DESIGN: Comparative observational; data gathered retrospectively and prospectively. SETTING: Head and Neck and Skull Base Center, King Abdullah Medical City, Makkah, Saudi Arabia. PATIENTS AND METHODS: Patients who received hump reduction rhinoplasty from 2013 to 2016 met the inclusion criteria. MAIN OUTCOME MEASURE(S): The differences in dorsal (DW) and ventral (VW) widths with a fixed interpupillary distance (IPD). Satisfaction scores for both cosmetic perspective and breathing functionality. RESULTS: We included 46 patients; 28 patients underwent low-to-low osteotomy and 18 patients underwent low-to-high osteotomy. With both approaches, there were statistically decreases from preoperative to postoperative ratios of VW/IPD and DW/IPD. However, differences in DW/IPD ratio and VW/IPD ratio (pre- versus post-op) were significantly higher in the low-to-low group (P < .0001). All showed breathing satisfaction postoperatively regardless of the operative approach. Patients with a low satisfaction level for aesthetic sensibility (neutral and dissatisfied) underwent low-to-high osteotomy. CONCLUSION: Both types of osteotomy showed a satisfactory outcome in both objective and subjective measures. However, low-to-low osteotomy was superior in pre- to post-operative differences in DW/IPD and VW/IPD ratios. LIMITATIONS: Sampling was by convenience. The study was conducted in a single tertiary center and was a small sample.

Endoscopic anatomy of the lacrimal sac for dacryocystorhinostomy. A cadaveric study.

OBJECTIVES: To assist the endoscopic localization of the lacrimal sac (LS)  relative to nearby landmarks. Methods: This is a descriptive prospective anatomical study. Sixteen lateral nasal walls were dissected endoscopically to identify and localize the LS between October and November 2015. Multiple measurements were obtained from the NS to the anterior and posterior walls of the LS, as well as to the middle turbinate axilla (MTA) and from the MTA to the LS borders. Results: The average distance from the NS to the anterior border of the LS was 42.0 mm and the posterior border was 48.5 mm. The average widths of the LS were 7.55 mm superiorly, and 6.6 mm inferiorly representing a mathematical proof that the LS is a trapezoid shape. The mean distance from the NS to the MTA was 47.3 mm. Nine of the 16 lacrimal sacs (56.3%) were found to be partially overlapped by the MTA. The LS was only totally overlapped and lying posterior to the MTA in one side (6.3%), while in 6 sides (37.5%) the LS lay anterior to the MTA. Conclusion:  Endoscopic surgeons should be aware of the location of the LS relative to nearby landmarks, particularly the MTA. Representing a mathematical proof that the LS is wider at it upper part than lower part best presented as a trapezoid shape. We have provided additional measurements that may prove useful in cases of difficult exposure.

Accuracy of preoperative fine needle aspiration in diagnosis of malignant parotid tumors.

OBJECTIVES: To determine the diagnostic accuracy of fine needle aspiration (FNA) for detecting malignant parotid tumors. Methods: We conducted a retrospective study of all patients diagnosed with benign or malignant parotid gland tumors in King Abdulaziz University Hospital,  Jeddah, Saudi Arabia, between January 2004 and May 2015. The records of 65 subjects were obtained. Histopathological findings and data from FNA examinations were obtained from medical records. Twenty-three subjects were excluded due to missing FNA, histopathology results or both. The sensitivity, specificity, negative predictive value, and positive predictive value of FNA for detecting malignant lesions were estimated and compared with the gold standard, histopathology. Results: The specimens of 5 cases were insufficient for diagnosis; therefore, 38 cases were diagnosed by FNA and had histopathological reports. Three cases were diagnosed positive for cancer using histopathology and missed by FNA, 3 were diagnosed as malignant lesions using both FNA and histopathology, and 32 cases were determined benign based on histopathology and FNA analysis. The total prevalence of parotid malignancies was 15.8%. The sensitivity of FNA for detecting malignancy was 50%, and the specificity was 100%; with a positive predictive value of 100% and negative predictive value of 91.4%. Conclusion: Fine needle aspiration  is a highly specific, but only moderately sensitive test. We support the use of this method as an initial tool for diagnosing parotid gland malignancies, as it is a safe, rapid, and painless procedure, compared to histopathology.

Carotid Body Tumor with Skull Base Extension.

BACKGROUND Carotid body tumors are rare tumors that arise from the paraganglionic cells of the carotid body. They are usually benign, requiring surgical resection as the treatment of choice. CASE REPORT We present a case of a 59-year-old man with a benign left carotid body tumor that progressed to a very large size, compromised the patient's airway, completely encased the carotid vessels, vagus and hypoglossal nerves ipsilaterally, and reached the contralateral carotid vessels and ipsilateral skull base. Because of the cranial extension of the tumor, the patient had to undergo preoperative endovascular coiling of the carotid vessels prior to total excision of the tumor. CONCLUSIONS Due to the critical location of carotid body tumors, their vascularity, and high risk of neurovascular complications, surgical resection can be quite challenging, especially when the tumor is large. We propose an approach to managing large parapharyngeal tumors by endovascular occlusion of the internal carotid artery above the skull base. Further, a suggestion is made to add a category to Shamblin's classification - Shamblin IV - for patients with skull base extension requiring preoperative endovascular intervention.