Recurrence morbidity of olfactory neuroblastoma.

BACKGROUND: With modern treatment paradigms, olfactory neuroblastoma (ONB) has favorable overall survival (OS); however, the incidence of recurrence remains high. The primary aims of this study were to delineate the prognosis of recurrence of ONB and explore how recurrence subsites are associated with OS, disease-specific survival (DSS), and further recurrence. METHODS: A retrospective chart review of ONB cases from nine academic centers between 2005 and 2021 was completed. Tumor characteristics, recurrence subsites, timelines to recurrence, additional recurrences, and survival estimates were determined using descriptive and time-to-event analyses. RESULTS: A final cohort of 233 patients was identified, with 70 (30.0%) patients recurring within 50.4 (standard deviation ±40.9) months of diagnosis on average, consisting of local (50%), neck (36%), intracranial (9%), and distant (6%) recurrence. Compared with subjects without recurrence, patients with recurrence had significantly different primary American Joint Committee on Cancer T stage (p < 0.001), overall stage (p < 0.001), and modified Kadish scores (p < 0.001). Histopathology identified that dural involvement and positive margins were significantly greater in recurrent cases. First recurrence was significantly associated with worse 5-year DSS (hazard ratio = 5.62; p = 0.003), and subjects with neck or local recurrence had a significantly better DSS compared to intracranial or distant recurrence. CONCLUSIONS: Recurrent cases of ONB have significantly different stages and preoperative imaging factors. Patients with local or neck recurrence, however, have better DSS than those with intracranial or distant recurrence, independent of initial tumor stage or Hyams grade. Identifying specific factors that confer an increased risk of recurrence and DSS is important for patient counseling in addition to surveillance planning.

Primary ciliary dyskinesia: An update on contemporary diagnosis.

KEY POINTS: Primary ciliary dyskinesia (PCD) is a complex diagnosis without a universal diagnostic test Clinicians must have some skepticism of historic diagnoses of PCD Clinicians should consider a diagnosis of PCD in patients with recalcitrant disease.

Superiorly Based Middle Turbinate Flap for Repair of Cerebrospinal Fluid Rhinorrhea: A Cadaveric Feasibility Study and Case Series.

Objectives Cerebrospinal fluid (CSF) leaks of the anterior cranial base are frequently repaired with endonasal, multilayered reconstructions. Vascularized tissue flaps are superior to free mucosal grafts and biomaterials in many cases. Limitations of previously described flaps include reach, rotation, pedicle availability, and postoperative sinonasal morbidity. The objective of this study is to describe the superiorly based middle turbinate flap, a novel vascularized mucosal reconstruction option, and to present a case series demonstrating flap utility. Design Cadaveric feasibility study with technical description and illustrative case series. Setting Tertiary medical center. Participants Three silicone-injected cadaveric specimens (6 sides); 7 patients with CSF rhinorrhea from bony dehiscence of the anterior cranial fossa repaired with a superiorly based middle turbinate flap. Outcome Measures Cadaveric feasibility, in vivo repair outcomes, sinonasal symptoms, and postoperative healing. Results Cadaveric dissection demonstrated a consistent vascular plexus arising from the anterior and posterior ethmoid arteries, originating at the superior attachment of the middle turbinate and traveling inferiorly to supply the mucosa of the middle turbinate. Mean surface area of the flap was 776.67 ± 114.60 mm 2 . The clinical series of 7 patients involved leaks around the cribriform plate and fovea ethmoidalis. There were no instances of repair failure. All cases showed rapid and complete remucosalization without significant sinonasal morbidity. Conclusion The superiorly based middle turbinate flap is a reliable, versatile, and effective option for a vascularized mucosal flap onlay that can be used in anterior skull base reconstruction. This flap is particularly useful in the repair of defects involving the cribriform plate and fovea ethmoidalis.

Multicenter Survival Analysis and Application of an Olfactory Neuroblastoma Staging Modification Incorporating Hyams Grade.

Importance: Current olfactory neuroblastoma (ONB) staging systems inadequately delineate locally advanced tumors, do not incorporate tumor grade, and poorly estimate survival and recurrence. Objective: The primary aims of this study were to (1) examine the clinical covariates associated with survival and recurrence of ONB in a modern-era multicenter cohort and (2) incorporate Hyams tumor grade into existing staging systems to assess its ability to estimate survival and recurrence. Design, Setting, and Participants: This retrospective, multicenter, case-control study included patients with ONB who underwent treatment between January 1, 2005, and December 31, 2021, at 9 North American academic medical centers. Intervention: Standard-of-care ONB treatment. Main Outcome and Measures: The main outcomes were overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) as C statistics for model prediction. Results: A total of 256 patients with ONB (mean [SD] age, 52.0 [15.6] years; 115 female [44.9%]; 141 male [55.1%]) were included. The 5-year rate for OS was 83.5% (95% CI, 78.3%-89.1%); for DFS, 70.8% (95% CI, 64.3%-78.0%); and for DSS, 94.1% (95% CI, 90.5%-97.8%). On multivariable analysis, age, American Joint Committee on Cancer (AJCC) stage, involvement of bilateral maxillary sinuses, and positive margins were associated with OS. Only AJCC stage was associated with DFS. Only N stage was associated with DSS. When assessing the ability of staging systems to estimate OS, the best-performing model was the novel modification of the Dulguerov system (C statistic, 0.66; 95% CI, 0.59-0.76), and the Kadish system performed most poorly (C statistic, 0.57; 95% CI, 0.50-0.63). Regarding estimation of DFS, the modified Kadish system performed most poorly (C statistic, 0.55; 95% CI, 0.51-0.66), while the novel modification of the AJCC system performed the best (C statistic, 0.70; 95% CI, 0.66-0.80). Regarding estimation of DSS, the modified Kadish system was the best-performing model (C statistic, 0.79; 95% CI, 0.70-0.94), and the unmodified Kadish performed the worst (C statistic, 0.56; 95% CI, 0.51-0.68). The ability for novel ONB staging systems to estimate disease progression across stages was also assessed. In the novel Kadish staging system, patients with stage VI disease were approximately 7 times as likely to experience disease progression as patients with stage I disease (hazard ratio [HR], 6.84; 95% CI, 1.60-29.20). Results were similar for the novel modified Kadish system (HR, 8.99; 95% CI, 1.62-49.85) and the novel Dulguerov system (HR, 6.86; 95% CI, 2.74-17.18). Conclusions and Relevance: The study findings indicate that 5-year OS for ONB is favorable and that incorporation of Hyams grade into traditional ONB staging systems is associated with improved estimation of disease progression.

Racial and Ethnic Bias in Letters of Recommendation and Personal Statements for Application to Otolaryngology Residency.

INTRODUCTION: The persistent lack of racial and ethnic diversity within the field of otolaryngology calls for an analysis of potential bias within the residency application system. Letters of recommendation (LORs) and personal statements (PSs) are the most important subjective application constituents. This subjectivity predisposes these components to implicit bias. In applications to various surgical subspecialties, prior linguistic studies assessing bias in reviews of LOR show race-based differences. Thus far, racial and ethnic linguistic differences in LORs for otolaryngology applicants have not been analyzed in the literature. METHODS: LORs and PSs were abstracted from otolaryngology - head and neck surgery applications in the Electronic Residency Application Service for the 2019-20 and 2020-21 application cycles. Linguistic Inquiry and Word Count 2015 was used for quantitative analysis of emotional, cognitive, and structural components of written text. RESULTS: Race-pair analysis of the 2019-2021 application cycles revealed higher mean "teaching" scores for LORs for Asian, black, Hispanic, and white applicants when compared to applicants who self-identified as Other. White applicants had lower scores for the terms "research" and "analytic" when compared to Asian and black applicants, respectively. Analysis of PSs revealed greater scores for an "authentic" writing style for white versus Asian applicants. White applicants were found to have higher scores for "tone" compared to black applicants. CONCLUSION: Minor racial and ethnic language differences exist in both LORs and PSs. A statistically significant difference was observed among LORs, with the "teaching" term used more frequently for Asian, black, Hispanic, and white applicants compared to self-identified Other individuals. For PSs, statistically significant differences were observed among white applicants, who wrote about themselves using more "authentic" language when compared with Asian applicants and who also had higher scores for "tone" compared to black applicants. Although these differences were statistically significant, the practical impact of the variances is likely small.

Radiographic predictors of occult intracranial involvement in olfactory neuroblastoma patients.

BACKGROUND: Traditional management of olfactory neuroblastoma (ONB) includes margin-negative resection with removal of cribriform plate, dura, and olfactory bulb, regardless of intracranial disease. This approach may be overtreating certain patients. Our investigation examines risk factors associated with occult intracranial disease to optimize therapeutic outcomes. METHODS: This retrospective, multi-institutional cohort study examined clinical covariates associated with occult intracranial involvement. Patient demographics, staging, Hyam's grade, and pathologic involvement of dura, olfactory bulb/tract, and brain were collected. Diagnostic imaging was reviewed. Positive and negative predictive value (NPV) were estimated along with effect size estimates. Cox hazard regression examined associations with overall survival (OS) and disease-free survival (DFS). RESULTS: A total of 224 subjects with new diagnoses of ONB (2005-2021) were identified. Skull base bone involvement on computed tomography (CT) had the highest NPV for pathologic dura (88.0%), olfactory bulb (88%), and brain involvement (97.3%). Hyam's grade category was significantly associated with dural involvement (φC  = 0.26; 95% confidence interval [CI]: 0.16, 0.42). Subjects without radiologic skull base involvement (n = 66) had pathologic positivity of 12.1%. Within this subgroup, Hyam's grade was clinically significant for dural positivity (φ = 0.34; 95% CI: -0.12, 0.71) with 28.6% involvement in high grade tumors. Neither clinical nor pathologic positivity of intracranial structures were associated with significantly different OS or DFS. CONCLUSIONS: Both CT and magnetic resonance imaging (MRI) had reasonably good NPV for involvement of dura and olfactory bulb. Higher Hyam's grade was associated with dural involvement. Patients with low-grade tumors not involving the skull base may be suitable for avoiding skull base resection; however, further investigation is warranted.

Reconstruction of the Anterior Skull Base Using the Nasoseptal Flap: A Review.

The nasoseptal flap is a workhorse reconstructive option for anterior skull base defects during endonasal surgery. This paper highlights the versatility of the nasoseptal flap. After providing a brief historical perspective, this review will focus on the relevant primary literature published in the last ten years. We will touch upon new applications of the flap, how the flap has been modified to expand its reach and robustness, and some of the current limitations. We will conclude by discussing what the future holds for improving upon the design and use of the nasoseptal flap in anterior skull base reconstruction.

The next step: Replacing step 1 as a metric for residency application.

Objective: As of January 2022, USMLE Step 1 scores are reported as pass/fail. Historically, Step 1 scores have been a critical component of residency applications, representing one of the few metrics standardized across all applicants independent of the school they attended. In competitive specialties, such as otolaryngology, programs routinely get 100+ applicants for each residency spot and use Step 1 as a screening tool. This study seeks to assess quantifiable metrics in the application that highly competitive residency programs could use for screening in place of Step 1 scores. Methods: Otolaryngology applications to an academic medical center for the 2019-20 and 2020-21 ERAS cycles were reviewed. Board scores and quantitative research data were extracted. The relationships between Step 1 score and the other metrics were examined by computing Pearson's correlation coefficients and building regression models. Similar analyses were done separately for three different score tiers defined by Step 1 cutoffs at 220 points and 250 points. Results: Step 2 score was the only variable that had meaningful correlation with Step 1 score (R = .67, p < 2.2e-16). No other objective metric such as journal articles, posters, or oral presentations correlated with Step 1 scores. Conclusion: Step 1 scores were moderately correlated with Step 2 scores; however, using a Step 2 cutoff instead of a Step 1 cutoff would identify a different cohort of applicants for interview. No other quantifiable application metric had a positive correlation. In future match cycles, highly competitive residency programs will need to adopt new methods to screen candidates.Level of Evidence: Level 3.

Sex bias in letters of recommendation and personal statements for otolaryngology residency.

Objective: Application for otolaryngology residency is highly competitive, with letters of recommendation (LORs) and applicant personal statements (PSs) representing important components of the application process. However, their inherently subjective nature predisposes them to potential implicit bias. Otolaryngology has historically been predominated by male physicians and while implicit sex bias has been demonstrated in LORs for application to residency of multiple specialties, data is limited for otolaryngology. Methods: LORs and PSs for all otolaryngology applicants to an academic medical center during the 2019-20 and 2020-21 cycles were abstracted. Quantitative analysis was performed using Linguistic Inquiry and Word Count 2015 (LIWC2015), a validated software application designed to analyze various emotional, cognitive, and structural components of written text. Results: LORs written for females were found to be written from a perspective of higher expertise and confidence while LORs written for males were associated with a more honest, personal, and disclosing tone. Moreover, LORs written for female applicants were found to reference achievement and "grindstone" terminology more than those written for men. No differences were observed in any word category between PSs written by male and female applicants. Conclusion: Minor linguistic differences exist in multiple domains between LORs written for male and female applicants for otolaryngology residency. These tended to favor female applicants, with their letters demonstrating higher clout, achievement, and grindstone scores. This trend was unexpected in this historically predominantly male specialty. While differences were statistically significant, the overall difference in an entire letter of recommendation is likely subtle. Level of Evidence: 3.

A Single Layer Synthetic Dural Substitute Inlay is an Effective Sellar Reconstruction Technique in Endoscopic Transsphenoidal Pituitary Surgery.

Objectives A variety of endonasal sellar repair techniques have been described; many are complex, multilayered, and carry potential morbidity. We propose an effective, technically simple single-layer repair for select sellar defects, including those with an intraoperative cerebrospinal fluid (CSF) leak. Our technique utilizes only a synthetic dural substitute inlay and dural sealant glue without packing or lumbar drainage. Design This is a retrospective review-based study. Setting This study was conducted at tertiary care center. Participants Patients who underwent endoscopic transsphenoidal surgery for pituitary adenoma and sellar reconstruction with the aforementioned inlay technique. Patients were selected for this technique if they had an identified intraoperative CSF leak, a patulous diaphragm (expanded and thinned diaphragma sella), or a comorbidity excluding them from a simpler onlay only reconstruction. Outcome Measures Postoperative CSF leak and sinonasal morbidity included in the study. Results A total of 409 subjects were identified; 368 were initial resections. Gross total resection of the pituitary adenoma was achieved in 356 (87.0%) cases. Average tumor size was 2.6 ± 1.1 cm. Average tumor volume was 10.8 ± 12.1 cm 3 . There were 135 intraoperative CSF leaks and 196 patulous diaphragms. There were five postoperative CSF leaks (1.2%), all of which occurred in the first half of our series. Pre- and postoperative sino-nasal outcomes test-22 scores were 19.2 ± 18.2 and 18.8 ± 21.3 ( p = 0.492), respectively. Conclusion A synthetic dural substitute inlay and dural sealant glue is an excellent single-layer repair for sellar defects, even those with an intraoperative CSF leak. This technique is highly effective in preventing postoperative CSF leaks and does not utilize packing or lumbar drainage. It also avoids the potential cost and morbidity associated with more complex and multilayered closures.

Safety of restarting continuous positive airway pressure (CPAP) therapy following endoscopic endonasal skull base surgery.

Objectives: Patients with obstructive sleep apnea (OSA) are at increased risk of perioperative and postoperative morbidity. The use of continuous positive airway pressure (CPAP) in the perioperative period may be of potential benefit. However, among patients who have undergone endonasal skull base surgery, many surgeons avoid prompt re-initiation of CPAP therapy due to the theoretical increased risk of epistaxis, excessive dryness, pneumocephalus, repair migration, intracranial introduction of bacteria, and cerebrospinal fluid (CSF) leak. The objective of this article is to review the most up-to-date literature regarding when it is safe to resume CPAP usage in the patient undergoing endonasal skull base surgery. Data Sources and Methods: This review combines the most recent literature as queried through PubMed regarding the safety of CPAP resumption following endonasal skull base surgery. Results: Recent surveys of skull base surgeons demonstrate little consensus regarding the post-operative management of OSA. Recent cadaveric studies suggest that approximately 85% of delivered CPAP pressures are transmitted to the sphenoid sinus. Further, at frequently prescribed CPAP pressure settings, common sellar reconstruction techniques maintain their integrity while preventing very little transmission of pressure into the sella. In small retrospective case series, patients with OSA who received CPAP immediately following transsphenoidal pituitary surgery had similar rates of surgical complications as OSA patients who did not receive CPAP in the immediate post-operative period. Concerns of re-initiating CPAP too early, such as the development of pneumocephalus, rarely develop. Conclusions: There remains a paucity of objective data regarding when it is safe to resume CPAP following endonasal skull base surgery. Recent cadaveric studies and small retrospective case series suggest that it may be safe to resume CPAP earlier than is often practiced following endonasal skull base surgery.

Unique volatile metabolite signature of sinonasal inverted papilloma detectable in plasma and nasal secretions.

BACKGROUND: Sinonasal inverted papilloma (SNIP) is a benign neoplasm with aggressive features, including a high recurrence rate and a propensity for malignant transformation. Accurate diagnosis with complete resection and the need for close long-term surveillance is widely accepted as standard management. In this study, we investigate whether SNIP produces a unique volatile metabolite signature, which may ultimately lead to a novel approach to diagnose and monitor SNIP. METHODS: Whole blood and nasal secretions from patients with SNIP and healthy age-, sex-, and smoking-status-matched controls, were collected. There were 56 blood samples and 42 nasal secretion samples collected. The volatile metabolite signature of SNIP plasma and nasal secretion samples were compared with those of healthy controls using chromatography. RESULTS: Seventy-two volatiles were identified in plasma samples. Multivariate analysis of variance results, even when controlled for smoking status, indicated toluene as a significant univariate result with lower levels of toluene identified in SNIP plasma samples than healthy control plasma samples. A linear discriminant analysis (LDA) model for plasma volatiles correctly classified 23 of 24 SNIP patients and 26 of 27 control patients, with a cross-validation error rate of 6.02%. Sixty-nine volatiles were identified in nasal samples. For nasal secretion samples, no single univariate response was significant. The LDA model correctly classified 21 of 21 SNIP patients and 11 of 12 control patients, with a cross-validation error rate of 6.55%. CONCLUSION: This study suggests that SNIP produces a unique, detectable volatile metabolite signature. With further investigation, this can have dramatic clinical implications for diagnosis and monitoring. Although most volatile metabolite studies have investigated solid-organ malignancy, this novel study addresses a benign sinonasal neoplasm by using nasal secretions and plasma as an analysis medium, representing the first such study.

An algorithm for sellar reconstruction following endoscopic transsphenoidal surgery for pituitary adenoma: A review of 582 cases.

BACKGROUND: Several sellar reconstruction algorithms stratify patients based on risk of postoperative cerebrospinal fluid (CSF) leak. Many proposed algorithms employ techniques that are overly complex and confer morbidity. We review our experience with sellar reconstruction following transsphenoidal pituitary surgery and propose a highly effective, yet simple and low morbidity, algorithm. METHODS: A retrospective review of 582 patients who underwent transsphenoidal surgery for pituitary adenoma by a single neurosurgeon between 2005 and 2020 was performed. Patients without an intraoperative CSF leak and without a patulous diaphragm were repaired with an oxidized cellulose onlay (group 1). Patients with a low-flow intraoperative CSF leak or a patulous diaphragm were repaired with a synthetic dural substitute inlay (group 2). Patients with a persistent leak around the inlay repair or a high-flow leak were reconstructed with a synthetic dural substitute inlay and a nasoseptal flap onlay (group 3). RESULTS: There was an overall leak rate of 1.5% (9/582) to 1.0% (2/197) in group 1, 1.7% (6/347) in group 2, and 2.6% (1/38) in group 3. Group 3 had the highest rate of postoperative morbidity, including sinusitis (23.7% vs. 8.6% and 15.0% in groups 1 and 2, p = 0.018) and crusting (42.1% vs. 4.6% and 6.3% in groups 1 and 2, p < 0.001). All techniques healed equally well radiographically. CONCLUSION: The proposed algorithm for sellar reconstruction is highly effective and minimizes complexity and morbidity, primarily utilizing single-layer reconstructions without the addition of packing material or lumbar drainage.

A Simple Onlay Sellar Reconstruction Does Not Increase the Risk of Postoperative Cerebrospinal Fluid Leak in Well-Selected Patients.

Objective A variety of endonasal sellar repair techniques have been described; many of which are complex, expensive, and carry potential morbidity but are felt to be necessary to prevent postoperative cerebrospinal fluid (CSF) leaks. We propose an effective, technically simple repair for select sellar defects utilizing an onlay of regenerated oxidized cellulose. Design Retrospective review of patients from a single neurosurgeon who underwent endoscopic transsphenoidal surgery for pituitary adenoma and sellar reconstruction with only an onlay of regenerated oxidized cellulose. Patients were selected for this repair technique based on the absence of: (1) intraoperative identification of a CSF leak, (2) patulous diaphragm (expanded diaphragm sella herniating to or through sellar floor defect), and (3) other prohibiting comorbidities. Setting The present study was conducted at a tertiary care center. Participants In this study, pituitary adenoma patients were the participants. Outcome Measures Main outcome measure of the study is postoperative CSF leak. Results A total of 172 patients were identified. Of these, 153 were initial resections of pituitary adenomas. Gross total resection was achieved in 142 (82.6%) cases. Average tumor size was 2.2 ± 1.1 cm. Average tumor volume was 10.4 ± 19.8 cm 3 . No patients had intraoperative CSF leaks. All cases were repaired with only an onlay of regenerated oxidized cellulose. There were two postoperative CSF leaks (1.16%). Pre and postoperative SNOT-22 scores were 12.9 ± 11.9 and 14.3 ± 14.9 ( p = 0.796), respectively. Conclusion The use of an onlay of regenerated oxidized cellulose alone is an effective repair technique for select sellar defects. This technique does not result in increased postoperative CSF leak rates and avoids the higher relative cost and potential morbidity associated with more complex, multilayered closures.

Orbital Schwannoma.

Orbital schwannomas are rare neoplasms of the orbit. The presenting symptoms are often nonspecific. Classic imaging characteristics seen on magnetic resonance imaging (MRI) and orbital ultrasound can be useful to help aid in the diagnosis of orbital schwannoma. When diagnosed, the goal of treatment is complete surgical excision. The location of the tumor within the orbit dictates which surgical approach would provide the best exposure. When complete excision is achieved, recurrence rates are very low. This article addresses the etiology, patient population, presentation, natural history, and differential diagnosis of orbital schwannomas. Imaging characteristics and histopathologic subtypes are reviewed. Treatment goals, approaches, and specialties involved in the management of these patients is discussed. Finally, a representative case is presented.

Myopericytoma of the Neck Originating From the Middle Scalene: A Case Report.

We report the case of a myopericytoma of the neck. A 23-year-old female noticed a small, nontender mass in her left supraclavicular fossa. The mass grew over a period of 5 months, prompting the patient to seek evaluation. There were no motor or sensory deficits. Imaging suggested a mass originating from the middle scalene muscle. Computed tomography-guided core needle biopsy demonstrated a spindle cell neoplasm with smooth muscle differentiation. Complete surgical excision was performed. Histopathological and immunohistochemical evaluation of the tissue sample suggested myopericytoma. Myopericytoma is an extremely rare tumor of the head and neck. To our knowledge, this is the first reported case of a myopericytoma originating from a scalene muscle.

Myopericytoma of the neck originating in the middle scalene muscle: A case report.

We report a case of myopericytoma of the neck. A 23-year-old woman noticed a small, nontender mass in her left supraclavicular fossa. The mass had grown over a period of 5 months, prompting her to seek evaluation. On examination, no motor or sensory deficits were present. Imaging suggested that a mass had originated in the middle scalene muscle. Computed-tomography-guided core needle biopsy demonstrated a spindle-cell neoplasm with smooth-muscle differentiation. Complete surgical excision was performed. Histopathologic and immunohistochemical evaluations of the tissue sample suggested a myopericytoma. Myopericytoma is an extremely rare tumor of the head and neck. To the best of our knowledge, this is the first reported case of a myopericytoma originating in a scalene muscle.

Presumed hydrochlorothiazide-associated immunologic-hypersensitivity-induced pericardial effusion.

A 50-year-old Caucasian female presented for a second opinion regarding a newly diagnosed pericardial effusion. Seven months previously, hydrochlorothiazide was introduced into her pharmacologic regimen to aid in the management of her hypertension. A routine echocardiogram indicated a large pericardial effusion with signs of early cardiac tamponade. The patient subsequently underwent successful pericardiocentesis with complete drainage of the pericardial effusion. The effusion was empirically attributed to a viral etiology. Repeat echocardiograms showed recurrence of the pericardial effusion. Prior to undergoing a second pericardiocentesis with pericardial biopsy, as her physicians recommended, the patient sought a second opinion. While obtaining the patient's history, an allergy to sulfa was elicited. The possibility that the pericardial effusion may be secondary to an immunologic-hypersensitivity reaction was considered. It was recommended the patient discontinue the use of hydrochlorothiazide. Nine days following discontinuation of hydrochlorothiazide and without any other intervention, an echocardiogram was reported to show the size of the pericardial effusion had subsided substantially. Nine weeks following discontinuation, almost complete resolution of the pericardial effusion was reported. It is hypothesized that when treated with hydrochlorothiazide, the patient had an immune response leading to the pericardial effusion.