B-cell Lymphoblastic Lymphoma of the Paranasal Sinuses: A Case Study of a Rare Clinical Entity.

Lymphoblastic lymphoma is a rare and aggressive form of non-Hodgkin lymphoma (NHL). The tumor can derive from T-cell or B-cell and is clinically similar to acute lymphoblastic leukemia with minimal to no bone marrow involvement distinguishing the two. We present a rare case of lymphoblastic lymphoma originating from the paranasal sinuses. A 40-year-old male presented to the emergency department and was diagnosed with right-sided acute sinusitis complicated by pre-septal cellulitis. After failing medical management, he underwent endoscopic sinus surgery. Pathologic analysis of nasal contents stained for CD79a, CD34, and PAX5, suggesting a B-cell lymphoblastic lymphoma (B-LBL). He was referred to hematology-oncology and was treated with hyperfractionated cyclophosphamide, vincristine, Adriamycin, dexamethasone (Hyper-CVAD). Short-term follow-up has thus far demonstrated near-complete resolution of the tumor. Non-Hodgkin lymphomas of the paranasal sinuses are rare, and B-cell lymphoblastic lymphomas comprise just 0.3% of adults with NHL. Immunohistochemical phenotyping for B-LBL is typically positive for B-cell markers CD19, CD20, CD22 and CD79a. Classic treatment involves a chemotherapy regimen of Hyper-CVAD with an overall survival rate of 66%. B-cell lymphoblastic lymphoma is rarely reported in the paranasal sinuses. A thorough history and physical exam along with a complete workup, including biopsies with histopathological and immunohistochemical analysis, needs to be obtained. Little is known about its prognosis when the primary site is within the paranasal sinuses, and therefore, patients need prompt and aggressive treatment when the diagnosis is made.

Inverted Papilloma of the Middle Ear and Mastoid Cavity: A Case Report, Literature Review, And Surveillance Proposal.

INTRODUCTION TO THE TOPIC: Inverted papilloma is a rare condition of the middle ear. In this paper, the authors present a case report of a patient at a Midwestern health system with inverted papilloma. To supplement the case report, a literature review was also performed to identify clinical trends predisposing such cases to recurrence, malignant transformation, and response to radiation. In addition, the authors also propose a surveillance algorithm derived from this case and previously published surveillance strategies. CASE REPORT: The authors present a rare case of inverted papilloma of the middle ear. To the authors' knowledge, this is the youngest case presentation (mid-teenage years) of this condition to have been reported in the literature. The patient underwent surgical excision, had recurrence, and has been disease free since revision surgery. SUMMARY OF THE EVIDENCE: Our literature review identified 25 cases previously published with ours being the 26th. An inadequate number of cases exist to abstract statically relevant clinical trends in presentation and tumor behavior. Additionally, no tumor characteristics have been identified that predispose tumors to future malignant transformation. No assessments can be made regarding the benefits of radiation therapy. Most cases to date have been surveyed with a combination of CT, MRI, and clinical follow-up. CONCLUSIONS: Inverted papillomas of the middle ear space are rare. Although this case report adds to the literature, additional cases are needed to draw statistically relevant clinical characteristics and responses to medical and surgical therapy.

Acoustic Reflex Screening of Conductive Hearing Loss for Third Window Disorders.

OBJECTIVE: This study examines the effectiveness of acoustic reflexes in screening for third window disorders (eg, superior semicircular canal dehiscence) prior to middle ear exploration for conductive hearing loss. STUDY DESIGN: Case series with chart review. SETTING: Outpatient tertiary otology center. SUBJECTS AND METHODS: A review was performed of 212 ears with acoustic reflexes, performed as part of the evaluation of conductive hearing loss in patients without evidence of chronic otitis media. The etiology of hearing loss was determined from intraoperative findings and computed tomography imaging. The relationship between acoustic reflexes and conductive hearing loss etiology was assessed. RESULTS: Eighty-eight percent of ears (166 of 189) demonstrating absence of all acoustic reflexes had an ossicular etiology of conductive hearing loss. Fifty-two percent of ears (12 of 23) with at least 1 detectable acoustic reflex had a nonossicular etiology. The positive and negative predictive values for an ossicular etiology were 89% and 57% when acoustic reflexes were used alone for screening, 89% and 39% when third window symptoms were used alone, and 94% and 71% when reflexes and symptoms were used together, respectively. CONCLUSION: Acoustic reflex testing is an effective means of screening for third window disorders in patients with a conductive hearing loss. Questioning for third window symptoms should complement screening. The detection of even 1 acoustic reflex or third window symptom (regardless of reflex status) should prompt further workup prior to middle ear exploration.

The association between pediatric general emergency department visits and post operative adenotonsillectomy hospital return.

PURPOSE: To define the association between pre-operative general emergency department visits, gender, and pre-operative diagnosis with post-operative emergency department return following adenotonsillectomy. METHODS: Retrospective chart review of 1468 pediatric patients who underwent adenotonsillectomy at a tertiary pediatric hospital between 2011 and 2013. RESULTS: There was a significant relationship between patients who visited the ED pre-operatively, 25% (N=96) returned to the ED post-procedure, compared to 10% who did not have a pre-operative ED visit. There was an overall significant relation between having a pre-operative visit (χ(2)=53.6, df=1, p<0.001), female gender (female=56.9%; male=43.1%; χ(2)=4.2, df=1, p=0.04), and having a preoperative diagnosis of recurrent strep tonsillitis (OSA and RST=18%; RST=17.5%; OSA=11.8%; χ(2)=12.8, p=0.002) and having a post-operative ED visit. CONCLUSION: Generalized pre-operative visits along with gender and diagnosis of recurrent streptococcal tonsillitis were found to be positively associated with post-operative ED visits for common post-operative complaints.

The utility of common surgical instruments for pediatric adenotonsillectomy.

OBJECTIVES/HYPOTHESIS: To evaluate the correlation between surgical instrumentation and intraoperative surgical time, postoperative hemorrhage, and associated healthcare cost for pediatric adenotonsillectomy. STUDY DESIGN: Retrospective chart analysis. METHODS: Chart data were collected from pediatric patients who underwent adenotonsillectomy from 2011 to 2013. Monopolar electrocautery, radiofrequency ablation, and PlasmaBlade instruments were compared for intraoperative surgical time and postoperative hemorrhage rate. Univariate analysis of variance (ANOVA) and χ(2) analysis was utilized to evaluate differences between instrumentation and variables. Cost analysis examining instrumentation and intraoperative anesthesia was also reviewed. RESULTS: A total of 1,280 patients who underwent adenotonsillectomy were evaluated. There was no significant overall difference in age, sex, or preoperative diagnosis identified between the three instrumentation groups. When examining the various instruments' effect on procedure time in minutes, univariate ANOVA demonstrated a significant difference overall among the three groups (F = 8.79; P < .001). Post-hoc pairwise comparisons identified significantly faster surgical times for monopolar cautery than either PlasmaBlade (P = .03) or radiofrequency ablation (P < .001). The difference in the number of patients who experienced a postoperative bleed by instrument was not statistically significant (χ(2) = 2.36; P = .31). After instrumentation expenses were added to anesthesia cost, the overall average costs by instrument and surgical time were estimated to be $30.04 for monopolar cautery, $246.95 for PlasmaBlade, and $244.32 for radiofrequency ablation. CONCLUSIONS: The ideal surgical instrumentation should be cost and time efficient with a low complication rate. Monopolar cautery was associated with a statistically significant lower intraoperative surgical time, similar postoperative hemorrhage rates, and lower operative costs when compared to radiofrequency ablation and PlasmaBlade. LEVEL OF EVIDENCE: 4.

Pelvic fracture patterns and their corresponding angiographic sources of hemorrhage.

The association between pelvic arterial injuries and associated fracture patterns has been investigated directly in a post mortem study and indirectly in an earlier clinical study evaluating an overall management approach to pelvic fractures. One previous report has correlated the angiographic findings of a group of patients with pelvic ring disruptions. The authors' study was designed to further define the anatomic sites of hemorrhage associated with specific pelvic ring injury patterns and evaluate patient survival in each of these groups.