PURPOSE:

To compare the accuracy of preoperative parathyroid adenoma localization in patients with primary hyperparathyroidism (pHPT) due to a single adenoma using a detailed 4-quadrant analysis and to identify patient and tumor characteristics associated with accurate preoperative localization.

MATERIALS AND METHODS:

Retrospective review of 203 patients who underwent parathyroidectomy for pHPT due to a single adenoma between 2008 and 2011. Results from preoperative ultrasound and Tc-99m-sestamibi were compared to operative findings to determine accuracy of localization studies. Associations between clinicopathologic features and accurate preoperative adenoma localization were evaluated.

RESULTS:

Ultrasound was performed on 198 patients, sestamibi on 177 patients, and both on 172 patients. Accurate localization occurred significantly more often for ultrasound than sestamibi (63% vs. 41%, P<0.001). For ultrasound, accurate localization was found in patients with larger or heavier adenomas, those with adenomas located inferiorly, patients not having a reoperative procedure, and patients with higher post-operative serum calcium levels. For sestamibi, greater adenoma size or weight, adenomas located inferiorly, and patients with associated thyroid cancer on pathology were most predictive of accurate preoperative localization.

CONCLUSIONS:

Our results provide evidence that ultrasound is more accurate in localizing parathyroid adenomas in patients with pHPT due to a single adenoma when compared to sestamibi scan using 4-quadrant location analysis and may be the preferred preoperative imaging modality in these patients. No significant preoperative patient factors were associated with accurate localization by ultrasound or sestamibi, but adenoma size, weight, and location in an inferior position were predictive of accurate preoperative localization.

PURPOSE:

The ocular vestibular evoked myogenic potential (oVEMP) represents the sound-induced activation of extraocular muscles and is believed to originate from the utricle and superior vestibular nerve. Isolated unilateral oVEMP abnormalities with otherwise normal balance function test (BFT) results have not yet been characterized in a large patient series, and their clinical significance remains unclear.

MATERIALS AND METHODS:

Retrospective review of adult patients with vestibular complaints at a tertiary academic neurotologic referral center was performed. Patients with isolated unilateral oVEMP abnormalities were identified. The prevalence of vestibular symptoms and results of the Dizziness Handicap Inventory (DHI) and Hospital Anxiety and Depression Scale (HADS) were compared between these patients and those with normal BFT results.

RESULTS:

Thirty-one adult patients with isolated unilateral oVEMP abnormalities were identified (71% female, mean age 48±14years). Presenting complaints included vertigo in 53%, non-vertiginous dizziness in 68%, postural instability in 52%, and swaying/rocking sensation in 13%. Significant differences were observed in the percentage of patients with postural instability (p=0.046) and swaying/rocking sensation (p=0.04) when comparing the abnormal oVEMP group to patients with a normal BFT battery. No differences were observed when comparing other symptoms, age, gender, diagnoses, and DHI/HADS scores between groups.

CONCLUSION:

This is the largest series to date reporting on patients with isolated unilateral oVEMP abnormalities. Our results suggest this population may demonstrate an increased prevalence of postural instability and swaying/rocking sensation. Other measures of postural stability may further characterize the vestibular impairments associated with isolated unilateral utricular dysfunction.

PURPOSE:

Sinonasal rhabdomyosarcoma (SNRMS) is a rare malignancy which often presents with nasal obstruction, rhinorrhea and epistaxis. It is the most common sarcoma in children. In this study, we analyze the incidence and long-term survival for SNRMS using a national population-based database.

METHODS:

The United States National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry was utilized to calculate incidence and survival trends for SNRMS between 1973 and 2009. In addition, data were grouped by age, gender, race, and histopathological subtype.

RESULTS:

A total of 181 cases of SNRMS were analyzed for incidence trends, showing a 1.23:1 female to male ratio. While the overall incidence of SNRMS increased by 1.02% annually over the last 20years, this pattern was not equal amongst gender and racial groups. The incidence in males has increased, while in females incidence has decreased. An increase in incidence was noted in white and "others," but decreased in blacks. Using a total of 314 cases for survival analysis, we found that the rate in the white population has been consistently highest with a 5-year survival of 49.45%, 10- and 20-year survival of 48.81%. Survival rates in cases of embryonal SNRMS were also consistently higher than in cases of alveolar SNRMS.

CONCLUSIONS:

Overall incidence of SNRMS is increasing. Histologic subtype and race are important considerations in the long-term prognosis of SNRMS. Future studies will further elucidate gender and race related trends.

OBJECTIVES:

The position of human maxillary ostia is high on their superomedial walls, which may be suboptimal for natural drainage. Human maxillary sinuses exhibit better passive drainage through their ostia when tilted anteriorly to mimic a quadrupedal head position. We all know that sufficient drainage is very important for the treatment of chronic rhinosinusitis (CRS). Chronic maxillary sinusitis (CMS) is the high incidence of CRS. The aim of this study was to investigate the efficacy of quadrupedal head position in patients with CMS.

METHODS:

One hundred six patients diagnosed with CMS were enrolled. Patients were randomized to quadrupedal head position group and non-quadrupedal head position group for 6weeks of treatment. Treatment outcomes were measured using 1) Lund-Mackay scoring system of pre-and post-treatment computer tomography (CT); and 2) Sinonasal Quality-of-Life (QoL) Survey completed at baseline and 6weeks of therapy.

RESULTS:

There were statistically significant differences in QoL scores and CT scores between quadrupedal head position group and non-quadrupedal head position group. The quadrupedal head position group had much more improvements in QoL scores and CT scores than that of non-quadrupedal head position group. One patient in the quadrupedal head position group required functional endoscopic sinus surgery (ESS) due to persistent symptoms, and nine patients in non-quadrupedal head position group needed ESS. There were less patients that required ESS in the quadrupedal head position group than in the non-quadrupedal head position group.

CONCLUSIONS:

The improvements of QoL scores and CT scores were significantly better in the quadrupedal head position group than that in the non-quadrupedal head position group. Quadrupedal head position can be valuable adjuvant therapy for patients with CMS.

PURPOSE:

Sinonasal teratocarcinosarcoma (SNTCS) is a rare and highly malignant neoplasm that often involves the anterior skull base. This study reviews the published literature related to SNTCS. Clinical presentation, demographics, radiographic diagnosis, pathology, treatment, and management outcomes of this uncommon disease are reported.

METHODS:

A systematic review in the published English literature was conducted. A MEDLINE/PubMed search and bibliographic examination of articles pertaining to SNTCS were performed. Each case was analyzed for patient demographics, clinical presentation, tumor location, diagnosis, treatment, and survival outcome.

RESULTS:

A total of 49 journal articles were included. Individual patient data were reported in 86 cases. The average age of the patients was 54.5years (range, 0.1 to 85years), with a strong male predilection (7:1). Average follow-up was found to be 38.9months (range, 2 to 372months). The most common treatment method was surgery with radiation therapy, utilized in 59.3% of patients. Out of 71 cases with reported outcome and follow-up, there were 21 cases of recurrence, 8 cases with metastasis, and 6 cases reporting both recurrence and metastasis. Forty-two out of 71 (59.2%) patients survived at the time of follow-up.

CONCLUSIONS:

This study describes the largest pool of SNTCS patients to date. SNTCS is a rare and aggressive malignant skull base tumor with a poor prognosis with frequent recurrence and metastasis. Although a variety of treatment paradigms have been reported in the literature, radical surgical resection followed by radiation therapy appears to be the most commonly used treatment option.

PURPOSE:

To describe systematic methods developed over 40years among over 5000 patients at The Taste and Smell Clinic in Washington, DC to evaluate taste and smell dysfunction.

MATERIALS AND METHODS:

A tripartite methodology was developed. First, methods to determine clinical pathology underlying the multiple disease processes responsible for taste and smell dysfunction were developed. Second, methods to determine biochemical parameters responsible for these pathologies were developed. Third, methods to implement these techniques were developed to form a unified basis upon which treatment strategies can be developed to treat these patients.

RESULTS:

Studies were performed in 5183 patients. Taste loss was present in 62% of patients, smell loss in 87%. Most patients with taste loss (52%) exhibited Type II hypogeusia; most patients with smell loss (56%) exhibited Type II hyposmia. Sensory distortions were present in 60%. Four common diagnostic entities were found: post influenza-type hyposmia and hypogeusia (27% of patients), idiopathic causes (16%), allergic rhinitis (15%) and post head injury (14%). Regardless of clinical diagnosis the major biochemical abnormality found in most patients (~70%) was diminished parotid salivary and nasal mucus secretion of cAMP and cGMP.

CONCLUSIONS:

Taste and smell dysfunctions are common clinical problems associated with chronic disease processes. These symptoms require a systematic, integrated approach to understand their multiple and complex components. The approach presented here can and has led to effective treatment.

PURPOSE:

Physiologically acidic nasal pH depends on intact nasal mucosal function. The aim of this study was to determine nasal pH in patients with chronic rhinosinusitis and to investigate the changes in pH related to mucosal healing after endoscopic sinus surgery.

MATERIALS AND METHODS:

Normal subjects and the patients with chronic rhinosinusitis who showed no recurrence after endoscopic sinus surgery were enrolled. Using a portable pH meter and a glass-tipped probe, nasal pH was measured in the inferior meatus in normal subjects and patients before and after surgery at 3months.

RESULTS:

The mean (±SD) nasal pH was 6.5±0.5 (5.9 to 7.3) in 19 normal subjects, and 6.7±0.6 (5.3 to 7.6) in 19 CRS patients before surgery, which showed no significant difference between the groups. The nasal pH values were in the range of 3.8-7.7 (mean±SD 5.7±0.9) at 3months after surgery, and significantly lower than the preoperative values in patients (P=.004). The patients showing pH lower than 6.0 accounted for 10.5% before surgery, but 68.4% after surgery.

CONCLUSIONS:

Normal nasal pH was in the slightly acidic range, and the mean nasal pH of patients with chronic rhinosinusitis fell within normal limits as well, which indicates that chronic rhinosinusitis may not disturb the electrolyte milieu of the nasal mucosa. The average nasal pH measured at 3months after endoscopic sinus surgery exhibited acidity of pH5.7. The factors causing a fall in nasal pH during the healing period after the sinus surgery remain to be elucidated.

OBJECTIVES:

To evaluate the impacts of obstructive adenotonsillar disease on periodontal health and to assess the efficacy of adenotonsillectomy in the prevention of chronic periodontitis in children.

METHODS:

This prospective and controlled clinical study was conducted between August 2012 and February 2013 with 35 pediatric patients who had permanent anterior dentition. The study group included twenty patients (n=20) who had complaints of chronic mouth breathing and snoring and were diagnosed with obstructive adenotonsillar disease. These patients underwent adenoidectomy with or without tonsillectomy. We performed periodontal examinations to assess the periodontal health status in these children before and two months after surgery. The periodontal measures included plaque index (PI), pocket depth (PD) and gingival index scores (GI). Subsequently, these periodontal measures were compared with healthy control group who had no adenotonsillar disease (n=15).

RESULTS:

Among the study group six patients underwent adenoidectomy and 14 patients underwent adenoidectomy combined with either tonsillectomy or tonsillotomy. The preoperative PI, PD and GI scores of the study group were 1.27±0.39, 1.34±0.31 and 0.97±0.37 respectively. These scores were significantly higher compared to the control group (p<0.001). These periodontal index scores were significantly improved after surgery (p=0.008 for PI and p<0.001 for both PD and GI). In addition, we found no difference in postoperative values of PD and GI between the study group and control group.

CONCLUSION:

We concluded that obstructive adenotonsillar disease adversely affects periodontal health in children and surgical management of obstruction improves the clinical findings. However, more comprehensive research is required to elucidate the association between adenotonsillar hypertrophy and periodontal disease.

We present a rare case of primary subglottic schwannoma in a 51-year-old man. He presented with subacute dyspnea and progressively worsening stridor. Videoendoscopy revealed the presence of a submucosal mass in the subglottic area, which measured 2 cm in diameter and had occluded approximately 80% of the lumen. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a tumor arising from the left posterior wall of the subglottis and extending from the level of the cricoid cartilage to the first tracheal ring. After tracheostomy for airway management, subglottic schwannoma was diagnosed via fiberscopy-assisted punch biopsy. We removed the tumor via a medial thyrotomy (laryngofissure), and the post-excisional raw surface of the cricoid and tracheal cartilage was covered with a free buccal mucosal flap, which was attached using absorbable sutures and fibrin glue. No complications including recurrent nerve palsy developed after the procedure, and early postoperative ambulation was successfully performed. The patient is currently well, and the subglottic wound is clear. Although long-term follow-up is required, medial thyrotomy and coverage of the exposed cartilage with a free buccal mucosal flap is more effective for large subglottic schwannomas than laryngeal or tracheal resection with permanent tracheal tunnel formation from the viewpoint of phonation disability and the risk of complications.

The Ewing's sarcoma family of tumors is a group of cancers that commonly arises in young adults during their second decade of life. It frequently involves the trunk and long bones of the body with primary Ewing's sarcoma of the paranasal sinuses being exceedingly rare. We describe the case of a 39year-old female with primary Ewing's Sarcoma originating from the ethmoid sinus with intracranial extension into the anterior cranial fossa and the orbit. The radiologic and histopathologic profiles are presented with a review of the literature. To our knowledge, this is the second reported case with the tumor involving the anterior cranial fossa, but the only case where immunochemical staining and molecular genetic analysis are available for definitive diagnosis.