Giant Cholesteatoma: A Case Report and Review of the Literature.

OBJECTIVE: To present a case of giant cholesteatoma and review of the contemporary literature. PATIENTS: A 61-year-old male presented with foul-smelling discharge from his right ear in the setting of a previous canal wall down mastoidectomy. Otomicroscopy demonstrated a mastoid cavity filled with infected keratinous debris. Neuro-imaging revealed soft tissue inflammatory changes in the mastoid cavity, with involvement of the temporomandibular joint (TMJ) and parotid gland and tegmen erosion. Biopsies showed evidence of desquamated epithelium consistent with cholesteatoma, with no malignant cells identified. Audiogram demonstrated a mean hearing loss of 65 dB on the right ear and an air-bone gap of 45 dB. Review of literature was also performed on giant cholesteatoma. INTERVENTIONS: He underwent a modified Fisch Type B infratemporal fossa approach to completely remove the cholesteatoma and a vascularized free flap was utilized to fill the surgical defect. MAIN OUTCOME MEASURES: Complete extirpation of choles-teatoma and resolution of otorrhoea. RESULTS: Repeat imaging showed complete removal of cholesteatoma and clinically there was resolution of the otorrhea. Review of the literature has shown a lack of consensus around the definition of giant cholesteatoma. Most cases in the literature demonstrated extensive involvement of anatomical spaces beyond the confines of the temporal bone to qualify for the diagnosis of giant cholesteatoma. CONCLUSIONS: Giant cholesteatoma should be suspected in cases of recurrent ear discharge following canal wall down mastoidectomy. The case we report add to the literature to benefit future patients in preoperative counseling and better inform management.

Postoperative pain after transcanal endoscopic ear surgery: A systematic literature review.

OBJECTIVE: Transcanal endoscopic ear surgery is hypothesized to result in less postoperative pain when compared to nonendoscopic techniques due to its minimally invasive nature. In this systematic literature review, we aim to summarize and evaluate the evidence surrounding postoperative pain control and analgesic utilization after transcanal endoscopic ear surgery. DATABASES REVIEWED: PubMed, EMBASE, and Cochrane. METHODS: A systematic literature search was performed using standardized methodology. Computerized and manual searches were performed to identify studies that evaluated postoperative pain outcomes following endoscopic ear surgery. Only studies that met predetermined criteria were selected and evaluated for quality and bias. Extracted data included demographics, pain scores, analgesic administered as well as the diagnosis and type of surgery undertaken. Exclusion criteria included letters/commentaries and reviews, lack of pain outcome data and studies not concerning endoscopic ear surgery. RESULTS: The systematic literature review included 24 studies. Seven were RCTs, 10 were prospective and 7 were retrospective observational studies. A total of 1859 patients were evaluated for surgical approach and postoperative pain levels and analgesic use. Due to the lack of sufficient reporting of the data, a meta-analysis was not applicable. In the qualitative synthesis for the primary outcome, weighted pooled analysis showed that there was a slight reduction in postoperative pain after transcanal endoscopic ear surgery. Based on the Cochrane risk of bias tool, the quality for the finding is low. CONCLUSION: There is a small reduction in postoperative pain after transcanal endoscopic ear surgery when compared to nonendoscopic approaches, however, the clinical significance of this reduction is unclear. The evidence was from studies of only low to moderate quality.

Middle ear myoclonus: Systematic review of results and complications for various treatment approaches.

OBJECTIVE: To perform a systematic review of the diagnosis and treatment of patients with pulsatile tinnitus secondary to middle ear myoclonus. DATABASES REVIEWED: PubMed, EMBASE, and Scopus. METHODS: A systematic review was performed using standardized methodology. Computerized and manual searches were performed to identify studies of all ages (patients) who had middle ear myoclonus (intervention). All study designs were assessed. Extracted data included demographics, clinical features, duration of followup as well as the diagnosis and reversibility of symptoms with medical or surgical intervention. Studies were included if they included subjects with middle ear myoclonus. Exclusion criteria included letters/commentaries and reviews. RESULTS: Twenty articles representing 115 subjects with middle ear myoclonus were included. The mean age was 29.7 (range 6-67). The follow-up period ranged from 5 weeks to 36 months. Primary treatment consists of medical therapy utilising anxiolytics, antiepileptics, botulinum toxin and surgical treatment involving division of middle ear muscular tendon(s). In total, 60 patients underwent middle ear muscular tenotomies, with division of both stapedius and tensor tympani tendons being the most prevalent (88%). Limitations in the data arose from study design, related comorbidities such as palatal myoclonus, and concomitant drug administration. No study provided any objective criteria to diagnose this condition or evaluate post-treatment outcome. CONCLUSION: Middle ear myoclonus is an entity that is poorly assessed in the literature. There is a lack of consensus regarding the criteria and strategies for both diagnosing and treating this condition. Although level of evidence of current studies remains modest, it is felt that a stepwise approach is deemed best, with therapeutic decisions being made on an individual basis, evaluating each patient's specific circumstances and priorities.

Isolated Congenital Round Window Atresia: Report of 2 Cases.

Round window atresia (RWA) is an uncommon condition and can result in a conductive hearing loss. Two cases of nonsyndromal bilateral RWA in 2 members of the same family are reported. Both cases presented with a conductive hearing loss of 20 to 30 dB. High-resolution computed tomography scanning was used to diagnose the condition. The patients were rehabilitated with hearing aids. Review of the literature has shown disappointing results in hearing improvement with cochlear fenestration in an attempt to address this condition. Patients presenting with unexplained conductive hearing loss should be offered computed tomography scanning. The cases we report add to the literature to benefit future patients in preoperative counseling and better inform management.

What is the Role of Hyaluronic Acid Ester in Myringoplasty? Systematic Review and Meta-Analysis.

OBJECTIVE: To reveal odds of tympanic membrane closure and postoperative hearing outcomes for myringoplasty utilizing hyaluronic acid ester via systematic review and meta-analysis. DATA SOURCES: 1) Search of English articles in PubMed/Medline, Embase, and Cochrane databases published between January 1, 1998 and March 31, 2018. STUDY SELECTION: Inclusion criteria: 1) English language; 2) clinical studies; 3) reported posttreatment perforation status, hearing outcomes, or complications. EXCLUSION CRITERIA: hyaluronic acid used for middle ear packing or topical application of hyaluronic acid solution. DATA EXTRACTION: Number of patients, surgical technique, mean age, overall rate of tympanic membrane closure, success rate based on size of perforation, mean air-bone gap improvement, and postoperative speech scores and complications. DATA SYNTHESIS: Ten studies encompassing 531 patients met criteria. Reported success rates for closure of chronic perforation ranged from 70.0 to 92.7% (mean, 85.21%). Smaller perforation predicted success in complete closure. Mean air-bone gap closure was 10.6 dB (4-24 dB). There were five complications reported. Meta-analysis was performed on five studies. No difference was noted in the success rates between hyaluronic acid ester myringoplasty and conventional tympanoplasty using fascia or perichondrium, with an overall closure rates of 89.8 and 89.4%, respectively (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.59-1.82, p = 0.896). A higher closure rate was seen in hyaluronic acid ester myringoplasty (87.9%) when compared with fat graft myringoplasty (70.8%), (OR 3.01, 95% CI 1.42-6.35, p = 0.004). CONCLUSIONS: Hyaluronic acid (HA) ester myringoplasty appears to be safe and effective at attaining complete closure of tympanic membrane perforation, although there exists significant selection bias and inconsistent reporting among existing papers.

Management of retrosternal goiter: Retrospective study of 72 patients at two secondary care centers.

OBJECTIVE: Data pertaining to the outcomes of retrosternal goiter surgeries performed at secondary care centers, where thoracic surgery expertise is not readily available, is infrequently reported. Careful patient selection is crucial to avoid an unexpected need for a sternotomy during surgery. We sought to evaluate the surgical management of patients with retrosternal goiters treated at two secondary care centers. METHODS: Retrospective review of clinical records and computed tomographic (CT) scans of 557 patients who underwent thyroid surgery at the Departments of Otolaryngology, Head and Neck Surgery of Manukau Surgery Center and Whangarei Base Hospital. Inclusion criterion was extension of goiter below the plane of the thoracic inlet on CT scan. Clinicopathologic features and surgical outcomes were recorded. RESULTS: The prevalence of retrosternal goiter was 72 of 557 patients (12.9%). All patients in this series underwent thyroidectomy transcervically. Dyspnea was present in 48 patients (66.7%). On preoperative CT scans, the goiter was noted to extend beyond the aortic arch in seven patients (9.7%), tracheal bifurcation in five patients (6.9%) and posterior mediastinum in 15 patients (20.8%). Malignancy was diagnosed in eight patients (11.1%) histologically. Postoperatively, vocal cord paralysis was temporary in 5 patients (6.9%) and permanent in 1 patient (1.4%). Hypocalcaemia was transient in 10 patients (13.9%). No permanent hypocalcemia, tracheomalacia, postoperative hematoma or patient death was reported. During the study period, 4 patients were encountered in the outpatients setting whereby the evaluation of their CT imaging demonstrated features deemed to be at high risk of requiring a sternotomy: primary mediastinal goiter (n=2) and inferior extent of goiter to the level of right atrium (n=2). These patients were pre-emptively referred to a tertiary center where thoracic surgery service was available and their data was reported separately. CONCLUSION: With careful patient selection, the majority of retrosternal goiter can be resected transcervically with minimal morbidities. Preoperative CT scan yielded useful surgical information; in the presence of primary mediastinal goiter or inferior extent of goiter to the level of the right atrium, surgery should be planned in a tertiary center where thoracic surgeon is available.

Comparison between endoscopic and external dacryocystorhinostomy by using the Lacrimal Symptom Questionnaire: A pilot study.

BACKGROUND: Epiphora has a significant impact on the patient's quality of life and is commonly caused by nasolacrimal duct obstruction. Dacryocystorhinostomy (DCR) has traditionally been performed via an external approach, which involves a skin incision. With the advent of endoscopes, the endonasal approach to DCR has gained significant popularity. METHOD: To prospectively compare the quality of life of adult patients who underwent either an endonasal or an external DCR for acquired nasolacrimal duct obstruction, the Lacrimal Symptom Questionnaire (Lac-Q) was administered before and after surgery. The treatment group assignment was nonrandom and performed based on patient preference. The Lac-Q is a validated questionnaire that assesses the subjective perception of one's well-being from an eye-specific symptom and social impact standpoint. Total scores range from 0 (no concerns) to 33 (maximal degree of ocular symptoms and social impact). RESULTS: Sixty patients (22 in the endonasal group, 38 in the external group) were recruited between January 1, 2014, and January 1, 2016. Postoperative assessment was performed at 3 and 6 months. Patients who underwent external DCR reported a median 7.0-point improvement (interquartile range [IQR], 3.0-11.0) in total Lac-Q scores. A 12.0-point improvement (IQR, 10.0-18.5) was seen in the endonasal group (p = 0.005). The median change in the social impact score was 3.0 and 4.0 in the external group and the endoscopic group, respectively (p = 0.029). Changes in the median lacrimal symptom score were 4.0 in the external group and 8.0 in the endoscopic group (p = 0.014). The anatomic patency rate was lower in the external group (60.0%) when compared with the endonasal group (90.4%). Patients in the external DCR group were significantly older (median age, 51 versus 41 years). CONCLUSION: Our study indicated that both endonasal and external DCR can lead to improvement in quality of life by using a validated questionnaire. Although there are differences in age and anatomic success rates between the two groups, subgroup analyses indicated that the differences in the Lac-Q scores persisted when age and anatomic patency were removed as potential confounding factors. Further larger, randomized studies would be helpful.

The extent of surgery for benign parotid pathology and its influence on complications: A prospective cohort analysis.

BACKGROUND: The surgical management of benign parotid tumors is aimed at complete extirpation of the mass with preservation of facial nerve function. There is a relative paucity of literature pertaining to complications after benign parotid surgery and related risk factors. We aim to critically review the outcomes following treatment of benign parotid pathology when surgery entailed either complete superficial parotidectomy (CSP), partial superficial parotidectomy (PSP) or extracapsular dissection (ECD). MATERIAL AND METHODS: This is a review of prospectively collected data of all parotidectomies performed between June 2006 to June 2016 for histologically-proven benign pathology of the parotid. Median follow-up time was 31.6weeks. RESULTS: A total of 101 parotidectomies were carried out on 97 patients (40 CSP, 56 PSP and 5 ECD). Pleomorphic adenoma (48.4%) and Warthin's tumors (32.7%) were the most common pathologies. Temporary facial weakness occurred after 7 operations (6.9%). Facial weakness was permanent in 4 cases (3.9%). The rates of sialocele and salivary fistula were 4.9% and 0.9%, respectively. Only one patient (0.9%) developed Frey Syndrome postoperatively. No significant associations between extent of parotid surgery and postoperative facial nerve dysfunction (p=0.674) or wound complications (p=0.433) were observed. Univariate analyses for potential contributing factors such as advanced age, smoking status, tumor location or histology did not demonstrate any increased risk with developing postoperative complications. CONCLUSION: Partial superficial parotidectomy was associated with low rates of morbidity to the facial nerve and surgical wound. The results were comparable to complete superficial parotidectomy. We recommend offering patient partial superficial parotidectomy where appropriate and this is in line with the current trend of minimising surgical dissection, thereby potentially decreasing the risk of short-term and long-term complications.

Classification of parotidectomy: a proposed modification to the European Salivary Gland Society classification system.

Parotidectomy remains the mainstay of treatment for both benign and malignant lesions of the parotid gland. There exists a wide range of possible surgical options in parotidectomy in terms of extent of parotid tissue removed. There is increasing need for uniformity of terminology resulting from growing interest in modifications of the conventional parotidectomy. It is, therefore, of paramount importance for a standardized classification system in describing extent of parotidectomy. Recently, the European Salivary Gland Society (ESGS) proposed a novel classification system for parotidectomy. The aim of this study is to evaluate this system. A classification system proposed by the ESGS was critically re-evaluated and modified to increase its accuracy and its acceptability. Modifications mainly focused on subdividing Levels I and II into IA, IB, IIA, and IIB. From June 2006 to June 2016, 126 patients underwent 130 parotidectomies at our hospital. The classification system was tested in that cohort of patient. While the ESGS classification system is comprehensive, it does not cover all possibilities. The addition of Sublevels IA, IB, IIA, and IIB may help to address some of the clinical situations seen and is clinically relevant. We aim to test the modified classification system for partial parotidectomy to address some of the challenges mentioned.

Immunoglobulin G4-related disease of the orbital cavity, cervical lymph nodes and greater auricular nerve: case report.

IgG4-related disease (IgG4-RD) is a novel clinicopathological entity characterised by elevated tissue levels of IgG4-positive plasma cells. It can present in almost every organ systems. We present a case of a 48year-old man with recurrent intra-orbital and cervical lymph node swelling and found to have greater auricular nerve involvement intraoperatively during open surgical biopsy. Histopathological evaluation of biopsied specimens from these lesions yielded IgG4-positive plasma cell infiltration on immunohistochemistry. Key pathological features such as prominent lymphoplasmacytic population, storiform fibrosis and obliterative phlebitis were also seen. A diagnosis of IgG4-RD was made. Oral prednisone therapy ameliorated the symptoms and patient remained in remission at followup. Literature review indicated that IgG4-RD is a rare condition that seldom occurs concurrently in the orbital cavity, cervical lymph nodes and involving the greater auricular nerve. The condition may often masquerade as malignancy or infection due to formation of tumefactive lesions but tend to respond favourably to glucocorticoid or immunosuppressants. The differential diagnosis of unusual mass lesions in these locations should include IgG4-RD. The otolaryngologist, as well as other health professionals, should be familiar with this novel disease to ensure timely diagnosis and treatment.

Non-islet Cell Tumour Hypoglycaemia (NICTH) in Malignant Mesothelioma: Case Report.

Non-islet cell tumour hypoglycaemia (NICTH) is an uncommon but important clinical condition. It can occur in a setting of known malignancy. Here, we report the case of a 56-year-old, non-diabetic, female patient with unresectable malignant pleural mesothelioma who presented with unexplained recurrent hypoglycaemia. Surreptitious use of insulin or other hypoglycaemic agents were ruled out. Investigations revealed markedly suppressed insulin-like growth factor-I, normal insulin-like growth factor-II and elevated "big"-insulin-like growth factor-II, supporting the diagnosis of NICTH. Plasma growth hormone concentration was low. Initial treatments using prednisone alone, as well as the subsequent addition of diazoxide, were unsuccessful in maintaining euglycaemia. A combination of dexamethasone and recombinant human growth hormone was used successfully to ameliorate the hypoglycaemic episodes. We herein describe an uncommon clinical manifestation of malignant mesothelioma and provide an overview of the pathophysiology of this syndrome, as well as explore a different treatment regimen as reported in the literature.

Epithelioid angiomatous nodule of the nasal cavity: Report of 2 cases.

Epithelioid angiomatous nodule (EAN) is a novel clinicopathological entity characterized by a benign proliferation of endothelial cells with prominent epithelioid features. It can arise from any region of the body although it is increasingly being recognized in the head and neck. This paper presents two cases of EAN arising in the nasal cavity where the clinical presentations were recurrent unilateral epistaxis. In both cases, the lesions were excised endoscopically. Histopathologic analysis showed well-circumscribed proliferation of solid sheets of epithelioid endothelial cells and vascular channels in a background of mild chronic inflammatory infiltrate. Cytologic atypia was absent with rare mitotic figures seen. Immunohistochemical studies with CD31 and CD34 were strongly positive, thus confirming a vascular origin. Postoperative recovery was uneventful and no recurrence was seen in the follow-up period. EAN can be differentiated from other lesions demonstrating epithelioid vascular proliferation by means of clinical and histopathological characteristics. The present series seeks to inform that EAN should be regarded as a possible, albeit rare, cause of recurrent unilateral epistaxis. We advocate for endoscopic excision of EAN of the nasal cavity for diagnostic and therapeutic purposes.

Elective management of cervical and parotid lymph nodes in stage N0 cutaneous squamous cell carcinoma of the head and neck: a decision analysis.

There is uncertainty regarding the threshold for recommending elective regional nodal treatment in the management of stage N0 cutaneous squamous cell carcinoma of the head and neck (cSCCHN). Elective treatment in the form of nodal surgery or irradiation is associated with morbidity. However, patients managed with careful observation sometimes present with advanced disease which often require more extensive therapy or may be unsalvageable altogether. We used decision analysis to examine the tradeoffs and benefits of different management approaches in the stage N0 patient. A decision tree comprising the three different treatment strategies was built: surveillance, elective nodal dissection (END) and elective nodal irradiation (ENI). Probabilities of nodal recurrence and likelihood of successful salvage were obtained from the literature. A convenience sample of patients previously treated for metastatic and non-metastatic cSCCHN was interviewed using the standard gamble technique to determine utility for post-treatment health states. Sensitivity analysis was performed and the effect on the expected utility was examined. When the probability of occult metastasis was >19 %, ENI resulted in a higher expected utility than observation. When the probability of occult metastasis exceeds 25 %, END has a higher expected utility compared to observation. Given the current available evidence, a wait-and-see approach is justified in patients with a probability of occult metastases <19 %.

Role of intraoperative CT-updates during image-guided endoscopic sinus surgery for sinonasal fibro-osseous lesions.

Fibrous dysplasia, ossifying fibroma and osteomas are collectively known as fibro-osseous lesions. Occurrence in the sinonasal region is rare, and its management can be technically challenging. We report a case of an 8-year-old female with cemento-ossifying fibroma of the ethmoid sinus who underwent a two-staged, endoscopically assisted, transfacial resection of the lesion and a 31-year-old male with fibrous dysplasia of the ethmoid sinus who underwent endoscopic removal of the tumor. Both cases utilized intraoperative computed tomography (CT)-updated image-guided systems (IGS) to improve surgical precision. In the second patient, further resection was undertaken after CT-update in the same surgery. The postoperative courses were uneventful, and at 1-year follow-up no tumor recurrence was observed in either patient. Our experience suggested that the use of intraoperative CT-updated IGS in endoscopic or endoscopically assisted surgeries for sinonasal fibro-osseous lesions will lead to more optimal tumor control, which can translate into greater patient safety.