Changes in tongue morphology predict responses in pharyngeal patency to selective hypoglossal nerve stimulation.

STUDY OBJECTIVES: The major goal of the study was to determine whether changes in tongue morphology under selective hypoglossal nerve therapy for obstructive sleep apnea were associated with alterations in airway patency during sleep when specific portions of the hypoglossal nerve were stimulated. METHODS: This case series was conducted at the Johns Hopkins Sleep Disorders Center at Johns Hopkins Bayview Medical Center. Twelve patients with apnea implanted with a multichannel targeted hypoglossal nerve-stimulating system underwent midsagittal ultrasound tongue imaging during wakefulness. Changes in tongue shape were characterized by measuring the vertical height and polar dimensions between tongue surface and genioglossi origin in the mandible. Changes in patency were characterized by comparing airflow responses between stimulated and adjacent unstimulated breaths during non-rapid eye movement sleep. RESULTS: Two distinct morphologic responses were observed. Anterior tongue base and hyoid-bone movement (5.4 [0.4] to 4.1 [1.0] cm (median and [interquartile range]) with concomitant increases in tongue height (5.0 [0.9] to 5.6 [0.7] cm) were associated with decreases in airflow during stimulation. In contrast, comparable anterior hyoid movement (tongue protrusion from 5.8 [0.5] to 4.5 [0.9] cm) without significant increases in height (5.2 [1.6] to 4.6 [0.8] cm) were associated with marked increases in airflow during sleep. CONCLUSIONS: Tongue protrusion with preservation of tongue shape predicted increases in patency, whereas anterior movement with concomitant increases in height were associated with decreased pharyngeal patency. These findings suggest that pharyngeal patency can be best stabilized by stimulating lingual muscles that maintain tongue shape while protruding the tongue, thereby preventing it from prolapsing posteriorly during sleep. CITATION: Fleury Curado T, Pham L, Otvos T, et al. Changes in tongue morphology predict responses in pharyngeal patency to selective hypoglossal nerve stimulation. J Clin Sleep Med. 2023;19(5):947-955.

Distribution of leptin receptors in the brain stem: possible route in the pathophysiology of neuromuscular control of airway resistance during sleep.

INTRODUCTION: Leptin, a hormone related to satiety, has been studied because of its association with obesity and sleep apnea. The distribution of leptin receptors in the brain stem, and in the hypoglossal nucleus, has not yet been described. The stimulation of these muscles has been studied in the treatment of sleep apnea. OBJECTIVE: to detail the presence of leptin receptors in the nuclei of these nerves to enable studies of stimulation of this region through leptin. METHODS: the brains of five cadavers, removed during necropsy, collected at the Death Verification Service were included. An informed consent was signed by a family member (wife, mother or son/daughter) who answered specific questionnaire concerning comorbities. Anthropometric measurements were recorded. The medulla oblongata and pons fragments were identified. Immunohistochemical staining analysis was performed to identify the location of the leptin receptors. RESULTS: In the immunohistochemical analysis an intense staining signal of the brownish coloration of neurons was evidenced in the hypoglossal nerve nucleus, moderate in the olivary nucleus and mild in the dorsal nucleus of the vagus and trigeminal nucleus. In motor neurons, more intense brown pigmentation can be observed in the nucleus and cytoplasm when compared to sensory neurons. CONCLUSION: The immunoexpression of leptin receptor was demonstrated in the motor neurons of the human hypoglossal nucleus. These results may contribute to unravel details of the pathophysiology of neuromuscular control of airway collapse during sleep and to the development of new drugs capable of improving the neuromuscular tone of upper airway in apneic individuals.

Bipedicled Vocal Fold Mucosal Flap: An Experimental Study.

OBJECTIVE: To determine the dimensions of mucosal defects that can be covered by a bipedicled vocal fold mucosal flap. METHODS: We used 20 adults human larynges (10 of each gender) excised from cadavers, divided into 2 groups of 10 larynges (5 of each gender) each. In one group (the normal flap group), we created the largest possible bipedicled vocal fold mucosal flap and then quantified the dimensions of the largest defect that could be covered by displacing the flap medially. In the other group (the augmented flap group), the flap was augmented laterally with mucosa from the laryngeal ventricle and we determined whether the larger flap would effectively cover larger defects. RESULTS: The mean width of mucosal defect capable of being covered was 1.51 mm when the normal bipedicled flap was employed and was 1.67 mm when the augmented flap was applied. However, the difference was not statistically significant. We found that defect size correlated with vocal fold length, width and flap size in the normal flap group, whereas it correlated only with vocal fold length in the augmented flap group. The bipedicled flap is capable of covering larger defects in males. CONCLUSION: Enlargement of a bipedicled vocal fold mucosal flap with laryngeal ventricular mucosa does not necessarily translate to an increase in the size of defect that can be covered. On average, the flap should be 30% larger than the width of the defect. The statistical model for predicting the defect size based on the vocal fold length, vocal fold width, and flap size has excellent predictive quality when a normal flap is employed.

Master Regulators of Epithelial-Mesenchymal Transition and WNT Signaling Pathways in Juvenile Nasopharyngeal Angiofibromas.

Juvenile nasopharyngeal angiofibroma (JNA) is a rare fibrovascular benign tumor showing an invasive growth pattern and affecting mainly male adolescents. We investigated the role of epithelial-mesenchymal transition (EMT) and WNT signaling pathways in JNA. Gene expression profiles using nine JNA paired with four inferior nasal turbinate samples were interrogated using a customized 2.3K microarray platform containing genes mainly involved in EMT and WNT/PI3K pathways. The expression of selected genes (BCL2, CAV1, CD74, COL4A2, FZD7, ING1, LAMB1, and RAC2) and proteins (BCL2, CAV1, CD74, FZD7, RAF1, WNT5A, and WNT5B) was investigated by RT-qPCR (28 cases) and immunohistochemistry (40 cases), respectively. Among 104 differentially expressed genes, we found a significantly increased expression of COL4A2 and LAMB1 and a decreased expression of BCL2 and RAC2 by RT-qPCR. The immunohistochemistry analysis revealed a low expression of BCL2 and a negative to moderate expression of FZD7 in most samples, while increased CAV1 and RAF1 expression were detected. Moderate to strong CD74 protein expression was observed in endothelial and inflammatory cells. A significant number of JNAs (78%) presented reduced WNT5A and increased WNT5B expression. Overall, the transcript and protein profile indicated the involvement of EMT and WNT pathways in JNA. These candidates are promising druggable targets for treating JNA.

Bipedicled Vocal Fold Mucosal Flap Use in Phonomicrosurgery: Case Series.

OBJECTIVES: The objective of this study was to present a novel surgical technique involving the use of a "bipedicled vocal fold mucosal flap" to repair a mucosal defect and to evaluate the outcomes of patients in whom it was used. MATERIAL AND METHODS: This was a retrospective study of 6 clinical cases. All patients underwent surgery between November 2000 and July 2018, and all procedures were performed by the same surgeon. For the auditory-perceptual assessment, the Grade-Roughness-Breathiness-Asthenia-Strain hoarseness scale was used. We based the stroboscopic evaluation on the European Laryngological Society protocol, analyzing the parameters glottal closure, mucosal wave, and phase symmetry. RESULTS: Ages at the time of surgery ranged from 10 to 52 years, and all of the patients were male. Preexisting vocal fold lesions included polyps, cysts, a sulcus, and mucosal bridges. Among the stroboscopic parameters, only the mucosal wave differed significantly between the preoperative and postoperative periods (P = 0.046). There were also significant postoperative improvements in the overall grade of dysphonia (P = 0.025) and in the degree of breathiness (P = 0.025). CONCLUSIONS: The use of a bipedicled vocal fold mucosal flap appears to promote significant improvements in the mucosal wave and in voice quality. In the patients evaluated here, the technique was used without preoperative planning. However, it proved to be a safe and appropriate means of repairing mucosal defects in the vocal folds, with the potential to preserve rheological properties and promote healing with less chance of fibrosis.

Comparison of upper airway obstruction during zolpidem-induced sleep and propofol-induced sleep in patients with obstructive sleep apnea: a pilot study.

STUDY OBJECTIVES: Drug-induced sleep endoscopy (DISE) using propofol is commonly used to identify the pharyngeal structure involved in collapse among patients with obstructive sleep apnea. DISE has never been compared with zolpidem-induced sleep endoscopy. We hypothesized that propofol at recommended sedation levels does not influence upper airway collapsibility nor the frequency of multilevel pharyngeal collapse as compared with zolpidem-induced sleep. METHODS: Twenty-one patients with obstructive sleep apnea underwent polysomnography and sleep endoscopy during zolpidem-induced sleep and during DISE with propofol. A propofol target-controlled infusion was titrated to achieve a bispectral index between 50 and 70. Airway collapsibility was estimated and compared in both conditions by peak inspiratory flow and the magnitude of negative effort dependence. Respiratory drive was estimated by the difference between end-expiratory and peak-negative inspiratory pharyngeal pressure (driving pressure). Site and configuration of pharyngeal collapse during zolpidem-induced sleep and DISE with propofol were compared. RESULTS: The frequency of multilevel collapse during zolpidem-induced sleep was similar to that observed during DISE with propofol (72% vs 86%, respectively; difference: 14%; 95% confidence interval: -12% to 40%; P = .453). The endoscopic classification of pharyngeal collapse during both conditions were similar. Peak inspiratory flow, respiratory drive (effect size: 0.05 and 0.03, respectively), and negative effort dependence (difference: -6%; 95% confidence interval: -16% to 4%) were also similar in both procedures. CONCLUSIONS: In this pilot study, recommended propofol doses did not significantly increase multilevel pharyngeal collapse or affect upper airway collapsibility and respiratory drive as compared with zolpidem-induced sleep. CLINICAL TRIAL REGISTRATION: Registry: clinicaltrials.gov; Name: Natural and Drug Sleep Endoscopy; URL: https://clinicaltrials.gov/ct2/show/study/NCT03004014; Identifier: NCT03004014.

Anatomical terminology of the internal nose and paranasal sinuses: cross-cultural adaptation to Portuguese / Anatomical terminology of the internal nose and paranasal sinuses: cross-cultural adaptation to Portuguese

Abstract Introduction: Functional endonasal endoscopic surgery is a frequent surgical procedure among otorhinolaryngologists. In 2014, the European Society of Rhinology published the "European Position Paper on the Anatomical Terminology of the Internal Nose and Paranasal Sinuses", aiming to unify the terms in the English language. We do not yet have a unified terminology in the Portuguese language. Objective: Transcultural adaptation of the anatomical terms of the nose and paranasal cavities of the "European Anatomical Terminology of the Internal Nose and Paranasal Sinuses" to Portuguese. Methods: A group of rhinologists from diverse parts of Brazil, all experienced in endoscopic endonasal surgery, was invited to participate in the creation of this position paper on the anatomical terms of the nose and paranasal sinuses in the Portuguese language according to the methodology adapted from that previously described by Rudmik and Smith. Results: The results of this document were generated based on the agreement of the majority of the participants according to the most popular suggestions among the rhinologists. A cross-cultural adaptation of the sinonasal anatomical terminology was consolidated. We suggest the terms "inferior turbinate", "nasal septum", "(bone/cartilaginous) part of the nasal septum", "(middle/inferior) nasal meatus", "frontal sinus drainage pathway", "frontal recess" and "uncinate process" be standardized. Conclusion: We have consolidated a Portuguese version of the European Anatomical Terminology of the Internal Nose and Paranasal Sinuses, which will help in the publication of technical announcements, scientific publications and the teaching of the internal anatomical terms of the nose and paranasal sinuses in Brazil.

Resumo: Introdução: A cirurgia endoscópica funcional endonasal é um procedimento cirúrgico frequente entre os otorrinolaringologistas. Em 2014, a Sociedade Europeia de Rinologia publicou o "Documento Europeu para Posicionamento sobre a Terminologia Anatômica Interna do Nariz e das Cavidades Paranasais" com o objetivo de unificar os termos na língua inglesa. Ainda não dispomos de uma terminologia unificada na língua portuguesa. Objetivo: Adaptação transcultural dos termos anatômicos do nariz e das cavidades paranasais para o português da "European Anatomical Terminology of the Internal Nose and Paranasal Sinuses". Método: Um grupo de rinologistas de todo o Brasil, com experiência em cirurgia endoscópica endonasal, foi convidado a participar da elaboração desse posicionamento sobre os termos anatômicos do nariz e das cavidades paranasais para o português conforme metodologia adaptada da previamente descrita por Rudmik e Smith. Resultados: Os resultados desse documento foram gerados a partir da concordância da maioria dos participantes conforme as sugestões mais populares entre os rinologistas. Uma adaptação transcultural da terminologia anatômica nasossinusal foi consolidada. Sugerimos que se busque uniformizar termos como "concha inferior", "septo nasal", "porção (óssea/cartilaginosa) do septo nasal", "meato (médio/ inferior) nasal", "via da drenagem do seio frontal", "recesso frontal" e "processo uncinado". Conclusão: Consolidamos uma versão adaptada em português da "European Anatomical Terminology of the Internal Nose and Paranasal Sinuses" que auxiliará a publicação de comunicados técnicos, publicações científicas e o ensino dos termos anatômicos internos do nariz e das cavidades paranasais no Brasil.

Anatomical terminology of the internal nose and paranasal sinuses: cross-cultural adaptation to Portuguese.

INTRODUCTION: Functional endonasal endoscopic surgery is a frequent surgical procedure among otorhinolaryngologists. In 2014, the European Society of Rhinology published the "European Position Paper on the Anatomical Terminology of the Internal Nose and Paranasal Sinuses", aiming to unify the terms in the English language. We do not yet have a unified terminology in the Portuguese language. OBJECTIVE: Transcultural adaptation of the anatomical terms of the nose and paranasal cavities of the "European Anatomical Terminology of the Internal Nose and Paranasal Sinuses" to Portuguese. METHODS: A group of rhinologists from diverse parts of Brazil, all experienced in endoscopic endonasal surgery, was invited to participate in the creation of this position paper on the anatomical terms of the nose and paranasal sinuses in the Portuguese language according to the methodology adapted from that previously described by Rudmik and Smith. RESULTS: The results of this document were generated based on the agreement of the majority of the participants according to the most popular suggestions among the rhinologists. A cross-cultural adaptation of the sinonasal anatomical terminology was consolidated. We suggest the terms "inferior turbinate", "nasal septum", "(bone/cartilaginous) part of the nasal septum", "(middle/inferior) nasal meatus", "frontal sinus drainage pathway", "frontal recess" and "uncinate process" be standardized. CONCLUSION: We have consolidated a Portuguese version of the European Anatomical Terminology of the Internal Nose and Paranasal Sinuses, which will help in the publication of technical announcements, scientific publications and the teaching of the internal anatomical terms of the nose and paranasal sinuses in Brazil.

Sleep-disordered breathing in C57BL/6J mice with diet-induced obesity.

Obesity leads to sleep-disordered breathing (SDB) manifested by recurrent upper airway obstructions termed obstructive sleep apnea (OSA) and carbon dioxide retention due to hypoventilation. The objective of this work was to characterize breathing during sleep in C57BL6/J mice with diet-induced obesity (DIO). Arterial blood gas was measured in nine obese and nine lean mice during wakefulness. Nine male mice with DIO and six lean male C57BL/6J mice were head mounted with electroencephalogram (EEG) and electromyogram (EMG) electrodes. Sleep recordings were performed in the whole body plethysmography chamber; upper airway obstruction was characterized by the presence of inspiratory flow limitation in which airflow plateaus with increases in inspiratory effort. Obese mice showed significantly lower pH and higher partial pressure of arterial CO2 (PaCO2) in arterial blood gas compared to lean mice, 7.35 ± 0.04 versus 7.46 ± 0.06 (p < 0.001) and 38 ± 8 mm Hg versus 30 ± 5 mm Hg (p < 0.001). Obese mice had similar levels of minute ventilation to lean mice during sleep and wakefulness, despite higher body weight and temperature, indicating an increase in the metabolic rate and hypoventilation. Obese mice also showed baseline hypoxemia with decreased mean oxyhemoglobin saturation across sleep/wake states. Obese mice had a higher prevalence of flow-limited breathing compared to lean mice during sleep. However, the oxygen desaturation index in lean and obese mice did not differ. We conclude that DIO in mice leads to hypoventilation. Obesity also increases the frequency of inspiratory limited breaths, but it does not translate into progression of OSA.

HLA-C*17, DQB1*03:01, DQA1*01:03 and DQA1*05:05 Alleles Associated to Bullous Pemphigoid in Brazilian Population.

BACKGROUND: Bullous pemphigoid (BP) is an autoimmune disease with bullous vesicles and an incidence of 0.2 to 1.4 per 100,000 inhabitants. Many studies have been published demonstrating the association of pemphigoid with HLA class II system alleles in different populations, however there are no data on the BP, one of the most heterogeneous in the world. OBJECTIVE: To typify HLA alleles in Brazilians with Bullous pemphigoid. METHODS: The study group included 17 Brazilian patients with a confirmed diagnosis of BP from a hospital in Sao Paulo city, southeast Brazil. DNA was extracted from peripheral blood using Qiagen kits and HLA A, B, C, DR and DQ typing was performed using polymerase chain reaction. The control group was composed of a database of 297 deceased donors from the city of Sao Paulo. The statistical significance level was adjusted using the Bonferroni correction depending on the phenotypic frequencies evaluated for HLA class I (A, B and C) and class II (DRB1, DQB1 and DQA1). RESULTS: Our findings show that alleles HLA C*17, DQB1*03:01, DQA1*01:03 and DQA1*05:05 are associated with the onset of the disease in the Brazilian population, with relative risks of 8.31 (2.46 to 28.16), 3.76 (1.81 to 7.79), 3.57 (1.53 to 8.33), and 4.02 (1.87 to 8.64), respectively (p<0.005). CONCLUSION: Our data indicate that Brazilian patients with BP present the same genetic predisposition linked to HLA-DQB1*03:01 previously reported in Caucasian and Iranian individuals and our study introduces three new alleles (C*17, DQA1*01:03 and DQA1*05:05) involved in the pathophysiology of BP.

Effects of organic and inorganic compounds of diesel exhaust particles on the mucociliary epithelium: An experimental study on the frog palate preparation.

The toxic actions of acute exposition to different diesel exhaust particles (DEPA) fractions on the mucociliary epithelium are not yet fully understood due to different concentrations of organic and inorganic elements. These chemicals elements produce damage to the respiratory epithelium and exacerbate pre-existent diseases. In our study we showed these differences in two experimental studies. Study I (dose-response curve - DRCS): Forty frog-palates were exposed to the following dilutions: frog ringer, intact DEPA diluted in frog-ringer at 3mg/L, 6mg/L and 12mg/L. Study II (DEPF) (DEPA fractions diluted at 12mg/L): Fifty palates - Frog ringer, intact DEPA, DEPA treated with hexane, nitric acid and methanol. Variables analyzed: relative time of mucociliary transport (MCT), ciliary beating frequency (CBF) and morphometric analysis for mucin profile (neutral/acid) and vacuolization. The Results of DRCS: Group DEPA-12mg/L presented a significant increase in the MCT (p<0.05), proportional volume of acid mucus (p<0.05) and decreased proportional volume of neutral mucus and vacuoles (p<0.05). In relation of DEPF: A significant increase in the MCT associated to a decrease in the proportional volume of neutral mucus was founded in nitric acid group. In addition, a significant increase in the proportional volume of acid mucus was found in methanol group. We concluded that: 1) Increasing concentrations of intact DEPA can progressively increase MCT and promote an acidification of intra-epithelial mucins associated to a depletion of neutral mucus. 2) Intact DEPA seem to act as secretagogue substance, promoting mucus extrusion and consequently reducing epithelial thickness. 3) Organic fraction of low polarity seems to play a pivotal role on the acute toxicity to the mucociliary epithelium, by promoting a significant increase in the MCT associated to changes in the chemical profile of the intracellular mucins.

Surgical approach to the thyroarytenoid branch of the inferior laryngeal nerve through the thyroid cartilage.

PURPOSE: To describe the anatomical course of the intralaryngeal portion of the inferior laryngeal nerve (ILN) and to standardize the surgical access to its thyroarytenoid branch (TAb) through the thyroid cartilage. METHODS: Under surgical microscopy, 33 adult human excised larynges were dissected, to expose the intralaryngeal portion of ILN. The point of entry of TAb, ILN's terminal branch, in the thyroarytenoid (TA) muscle was determined and correlated with thyroid cartilage dimensions. RESULTS: After entering the larynx, the ILN consistently traveled between the thyroid cartilage and the lateral cricoarytenoid muscle in an anterior and slightly cranial course. The distance from the point of entry of the TAb in the TA muscle to the midline (TAb-H) and to the inferior border (TAb-V) of the thyroid cartilage differed according to gender. In females, mean distances of TAb-H and TAb-V were 20.5mm and 5.2mm and in males, 22.3mm and 5.9mm, respectively. CONCLUSION: The intralaryngeal course of the inferior laryngeal nerve presents low variability and measures from landmarks in the thyroid cartilage help to estimate the point of entry of thyroarytenoid branch in thyroarytenoid muscle.

Surgical approach to the thyroarytenoid branch of the inferior laryngeal nerve through the thyroid cartilage

ABSTRACT PURPOSE: To describe the anatomical course of the intralaryngeal portion of the inferior laryngeal nerve (ILN) and to standardize the surgical access to its thyroarytenoid branch (TAb) through the thyroid cartilage. METHODS: Under surgical microscopy, 33 adult human excised larynges were dissected, to expose the intralaryngeal portion of ILN. The point of entry of TAb, ILN's terminal branch, in the thyroarytenoid (TA) muscle was determined and correlated with thyroid cartilage dimensions. RESULTS: After entering the larynx, the ILN consistently traveled between the thyroid cartilage and the lateral cricoarytenoid muscle in an anterior and slightly cranial course. The distance from the point of entry of the TAb in the TA muscle to the midline (TAb-H) and to the inferior border (TAb-V) of the thyroid cartilage differed according to gender. In females, mean distances of TAb-H and TAb-V were 20.5mm and 5.2mm and in males, 22.3mm and 5.9mm, respectively. CONCLUSION: The intralaryngeal course of the inferior laryngeal nerve presents low variability and measures from landmarks in the thyroid cartilage help to estimate the point of entry of thyroarytenoid branch in thyroarytenoid muscle.

Speech and Swallowing Data in Individual Patients Who Underwent Glossectomy after Prosthetic Rehabilitation.

Maintaining oral function in patients undergoing glossectomy boosts interventions such as prosthetic rehabilitation. However, current literature still fails in the presentation of results of prosthetic rehabilitation in relation to speech or swallowing. The objective of this research is to evaluate the effectiveness of prosthetic rehabilitation on voice, speech, and swallowing in patients undergoing glossectomy by performing a systematic literature review and meta-analysis of individual cases. Studies were identified by relevant electronic database and included all dates available. The criteria used were sample with any n; resection due to malignant tumors, restricted to tongue and/or floor of mouth; type of prosthetic rehabilitation; and description of the oral functions outcomes with prosthesis. For the meta-analysis of individual data, associations between the variables of interest and the type of prosthesis were evaluated. Thirty-three of 471 articles met the selection criteria. Results on speech and/or voice and swallowing were reported in 27 and 28 articles, respectively. There were improvement of speech intelligibility and swallowing in 96 patients and in 73 patients, respectively, with prosthesis. Based on the available evidences, this article showed that prosthetic rehabilitation was able to improve oral functions and can be a strategy used with surgical reconstruction in selected cases.

Transpterygoid Approach to a Dermoid Cyst in Pterygopalatine Fossa

Objective: To describe a case of dermoid cyst arising from the pterygopalatine fossa and review the literature. Methods: We report a case of a 23-year-old man who suffered a car accident 2 years before otolaryngologic attendance. He had one episode of generalized tonic-clonic seizure and developed a reduction of visual acuity of the left side after the accident. Neurologic investigation was performed and magnetic resonance imaging revealed an incidental finding of a heterogeneous ovoid lesion in the pterygopalatine fossa, hyperintense on T2-weighted imaging. Results:  Endoscopic sinus surgery with transpterygoid approach was performed. The ovoid lesion was noted in the pterygopalatine fossa. Puncture for intraoperative evaluation showed a transparent thick fluid. Surprisingly, hair and sebaceous glands were found inside the cyst capsule. The cyst was excised completely. Histologic examination revealed a dermoid cyst. The patient currently has no evidence of recurrence at 1 year postoperatively. Conclusion:  This unique case is a rare report of a dermoid cyst incidentally diagnosed. An endoscopic transnasal transpterygoid approach may be performed to treat successfully this kind of lesion. Although rare, it should be considered in the differential diagnosis of expansive lesions in the pterygopalatine fossa, including schwannoma, angiofibroma, esthesioneuroblastoma, osteochondroma, cholesterol granuloma, hemangioma, lymphoma, and osteoma...

Transpterygoid approach to a dermoid cyst in pterygopalatine fossa.

Objective To describe a case of dermoid cyst arising from the pterygopalatine fossa and review the literature. Methods We report a case of a 23-year-old man who suffered a car accident 2 years before otolaryngologic attendance. He had one episode of generalized tonic-clonic seizure and developed a reduction of visual acuity of the left side after the accident. Neurologic investigation was performed and magnetic resonance imaging revealed an incidental finding of a heterogeneous ovoid lesion in the pterygopalatine fossa, hyperintense on T2-weighted imaging. Results Endoscopic sinus surgery with transpterygoid approach was performed. The ovoid lesion was noted in the pterygopalatine fossa. Puncture for intraoperative evaluation showed a transparent thick fluid. Surprisingly, hair and sebaceous glands were found inside the cyst capsule. The cyst was excised completely. Histologic examination revealed a dermoid cyst. The patient currently has no evidence of recurrence at 1 year postoperatively. Conclusion This unique case is a rare report of a dermoid cyst incidentally diagnosed. An endoscopic transnasal transpterygoid approach may be performed to treat successfully this kind of lesion. Although rare, it should be considered in the differential diagnosis of expansive lesions in the pterygopalatine fossa, including schwannoma, angiofibroma, esthesioneuroblastoma, osteochondroma, cholesterol granuloma, hemangioma, lymphoma, and osteoma.

Diffusion of aniline blue injected into the thyroarytenoid muscle as a proxy for botulinum toxin injection: an experimental study in cadaver larynges

Endolaryngeal injection of botulinum toxin into the thyroarytenoid (TA) muscle is one of the methods for treatment of focal laryngeal dystonia. However, after treatment, there is variation in laryngeal configuration as well as the side effects reported by patients. As a consequence of the functional variability of results, it was hypothesized that botulinum toxin diffuses beyond the limits of the muscle into which it is injected. OBJECTIVES: After injection of botulinum toxin into the TA muscle for the treatment of focal laryngeal dystonia, patients differ in terms of laryngeal configuration and side effects. We hypothesized that this toxin diffuses from the target muscle to adjacent muscles. METHOD: The TA muscles of 18 cadaver larynges were injected with aniline blue (0.2 mL). After fixation in formaldehyde and nitric acid decalcification, the larynges were sectioned in the coronal plane and the intrinsic muscles were analyzed. RESULTS: We found diffusion of aniline blue to the lateral cricoarytenoid muscle, cricothyroid muscle, and posterior cricoarytenoid muscle in 94.3%, 42.9%, and 8.6% of the cases, respectively. In terms of the degree of diffusion to adjacent muscles, we found no differences related to the size (height and width) of the TA muscle or to gender. CONCLUSIONS: Our findings suggest that diffusion of botulinum toxin from its injection site in the TA muscle to the lateral cricoarytenoid muscle is likely in most cases. On the other hand, diffusion to the cricothyroid muscle occurs in approximately half of cases and diffusion to the posterior cricoarytenoid muscle occurs in very few cases...