A Case Report of Refractory Postherpetic Neuralgia After Ramsay Hunt Syndrome Treated With Tympanic Nerve Neurectomy.

Ramsay Hunt syndrome is a facial nerve palsy that arises from herpes zoster infection. In rare cases, postherpetic neuralgia is a complication following Ramsay Hunt syndrome. Pain management to address postherpetic neuralgia includes facial nerve blocks, medications such as gabapentin, carbamazepine and botulinum toxin injections, and pulsed radiofrequency. Despite the reported benefits for patients with glossopharyngeal nerve pain, neurectomy as a treatment has rarely been described. A 45-year-old patient visited our ENT clinic for chronic right-sided facial, ear, and jaw pain that persisted for 9 years following the development of Ramsay Hunt syndrome. She trialed multiple medications including gabapentin, carbamazepine, and botulinum toxin injections with minimal relief to her symptoms. The patient underwent a diagnostic myringotomy with topical application of lidocaine to the tympanic nerve. This resulted in temporary relief of her pain until the effects of the lidocaine subsided. The patient was subsequently offered lysis of the right tympanic nerve for more definitive management. The patient experienced significant pain reduction after the right tympanic neurectomy procedure. Chronic postherpetic neuralgia following Ramsay Hunt syndrome can cause significant impairment in a patient's quality of life. For patients with ear pain refractory to conservative management, a tympanic neurectomy can be considered.

Assessing the role of ultrasound for the evaluation of adult neck masses.

Objectives: The American Academy of Otolaryngology clinical practice guidelines recommend cross-sectional imaging or fine needle aspiration for any neck mass in an adult that persists beyond 2 weeks that is not convincingly related to a bacterial infection. We aimed to assess the role of ultrasound in the evaluation and management of neck masses. Methods: A retrospective chart review was performed of adult patients evaluated in the Otolaryngology clinic at a single institution from December 2014 to December 2015 for a visible or palpable neck mass persistent beyond 2 weeks who had an ultrasound exam as part of their initial workup. Patients with a history of head and neck malignancy or those presenting wtih primary salivary or thyroid gland lesions were excluded. Sonographic features, demographics, imaging, and biopsy results were recorded. Results: Of the 56 patients who met inclusion criteria, 36 (64.3%) received FNA or biopsy, of which 18 (50%) demonstrated malignant pathology. Twenty patients (35.7%) demonstrated benign features on ultrasound and did not undergo tissue sampling. Two of these 20 patients underwent subsequent cross-sectional imaging. Eight of these 20 patients were followed with serial ultrasound with an average of 3 exams over 14.7 months. The remaining 12 patients had spontaneous resolution of their adenopathy. None of these 20 patients was subsequently diagnosed with malignancy. Conclusion: In this study, approximately one third of patients presenting with a visible or palpable neck mass were able to safely avoid cross-sectional imaging and/or tissue sampling when ultrasound demonstrated features consistent with benign pathology. Our results suggest that ultrasound can play a useful role in the initial evaluation and management of adults presenting with a neck mass. Level of Evidence: IV.

Feasibility of fine needle aspiration for diagnosis of b-cell lymphoma of the thyroid: a case series and review of the literature.

BACKGROUND: Primary thyroid lymphoma (PTL) is a rare cancer accounting for approximately 5% of thyroid malignancies. Historically, incisional biopsy has been the gold standard for definitive diagnosis of PTL, however, the use of cell block as an adjunct to fine needle aspiration (FNA) provides a high sensitivity and specificity for diagnosis and classification. METHODS: Three patients presented with a symptomatic enlarging thyroid mass. Patient 1 underwent incisional biopsy under general anesthesia, Patient 2 underwent core needle biopsy to avoid high risk intubation, and Patient 3 underwent fine needle aspiration alone with the use of cell block. RESULTS: All patients were diagnosed with a fully classified non-Hodgkin's lymphoma using immunohistochemistry, flow cytometry, and fluorescence in situ hybridization (FISH) analysis. CONCLUSIONS: FNA for diagnosis of some subtypes of PTL is feasible and preferred in cases that are particularly high risk for general anesthesia. This minimally invasive technique is safe and cost effective as it avoids expenses associated with operative intervention.

Techniques in Otolaryngology: Ultrasound-Guided Transcervical Fine-Needle Aspiration of Laryngeal Masses.

Traditionally, laryngeal masses are diagnosed with direct laryngoscopy with biopsy under general anesthesia. The use of transcervical ultrasound-guided fine-needle aspiration for the diagnosis of base of tongue lesions, thyroid nodules, and cervical lymph node metastases has been well documented, and its use in the diagnosis of laryngeal masses has increased in recent years. We report a technique for office-based transcervical ultrasound-guided fine-needle aspiration for laryngeal masses without cervical metastasis (N0), with outcomes from 6 patients. Benefits of this approach included limited side effects, rapid in-office diagnosis, avoidance of aerosolizing procedures during the COVID-19 pandemic, and avoidance of tracheostomy.

Effect of PPIs on symptomatic hypocalcemia after thyroidectomy: A retrospective cohort study.

OBJECTIVE: To determine differences in incidence and duration of postoperative symptomatic hypocalcemia between those taking and those not taking proton pump inhibitors (PPIs) at the time of total or completion thyroidectomy. METHODS: A retrospective chart review of adult patients who underwent total or completion thyroidectomy at a tertiary medical center between January 2013 and January 2018 was performed. Development of symptomatic hypocalcemia, duration of symptoms, postoperative parathyroid hormone levels, PPI usage and emergency department (ED) visits were recorded. RESULTS: Data from 371 patients were analyzed. Sixty of 371 (16.2%) patients developed symptomatic hypocalcemia. Sixteen of 89 (18.0%) patients on a PPI developed symptomatic hypocalcemia compared to 44 of 282 (15.6%) not on a PPI (P = .63). The overall average duration of symptoms was 4.3 days (SD [SD] 3.77 days). The average duration of symptoms in those on a PPI was 4.8 days (SD 2.8 days) compared to 4.2 days (SD 4.1 days) in those not on a PPI (P = 0.16). Six of 282 patients (2.1%) not taking a PPI had a postoperative ED visit, compared to two of the 89 patients (2.3%) taking a PPI (P = 1.00). CONCLUSIONS: There was no clinically significant difference in incidence and duration of symptomatic hypocalcemia or ED visits after total or completion thyroidectomy between patients that were and were not taking PPIs perioperatively. While the decision to continue PPI should be made on an individual basis, these data suggest that patients may be counseled to continue their PPI perioperatively without increased risk of symptomatic hypocalcemia. LEVEL OF EVIDENCE: 3.

Feasibility of In-office Fine-Needle Aspiration for Base of Tongue Tumors.

We aim to demonstrate the feasibility of in-office transcervical ultrasound (TCUS)-guided fine-needle aspiration (FNA) of base of tongue (BOT) tumors in a single-institution. Retrospective chart review was performed and 3 patients met criteria, with BOT tumors ≥3 cm . Two patients had no cervical adenopathy, while FNA of a cervical lymph node was inconclusive in patient 3. Two patients had multiple medical comorbidities rendering them high risk for general anesthesia, and 1 patient had a BOT tumor obscuring visualization of the glottis, which would have precluded intubation and potentially required tracheostomy to proceed. All patients underwent successful in-office TCUS-guided FNA, with results showing squamous cell carcinoma. There were no related complications. In-office TCUS-guided FNA can be used for diagnosis of BOT lesions that are evident on ultrasound. This is beneficial in cases where general anesthesia is considered high risk. Additionally, 1 patient safely continued anticoagulation, and another was able to avoid tracheostomy. This technique is cost-effective as it avoids the expenses associated with operative intervention.

Right-sided pyriform sinus fistula: a case report and review of the literature.

Objectives. Pyriform sinus fistulae arise from disturbances in the development of the fetal third and fourth branchial pouches and are predominantly found on the left side. We report the rare case of a right-sided pyriform sinus fistula presenting as a lateral neck abscess. Study Design. Case report. Methods. A 24-year-old woman presented with a two-week history of right-sided neck abscess. A fluoroscopic sinogram revealed a fistulous tract extending from the abscess to the apex of the right pyriform sinus. It was determined that the fistula was likely a third or fourth branchial remnant, a rare right-sided finding. Chemocauterization of the fistulous tract with 40% trichloroacetic acid was used to successfully treat the patient. Results. Approximately 93-97% of branchial pouch anomalies are left sided. Treatment options include surgical excision and cauterization. Conclusions. Branchial cleft cyst and pyriform sinus fistula must be considered in the diagnosis of cervical abscess in either side of the neck.