Paragangliomas are rare, typically benign neuroendocrine tumors that represent a small portion of head and neck tumors. A small percentage of these are known to have malignant potential. They arise from the carotid body, jugular bulb or vagus nerves. There is limited literature discussing the management of malignant vagal paragangliomas. We present a case of a 25 year old female with a left malignant vagal paraganglioma. The following case presentation will describe the presentation, classic radiologic findings, and management of a malignant vagal paraganglioma along with a review of the literature.Keywords Paraganglioma Á Carotid body tumor Á Malignant paraganglioma HistoryA 25 year-old female reported to the emergency department for evaluation of a severe headache. An avid singer, she incidentally complained of difficulty with vocal range and stamina over several months. Family history was negative for head and neck cancer. Physical exam revealed fullness with mild generalized erythema of both the left posterior nasopharynx and the oropharynx. On palpation of the left oropharynx there was no discrete mass, however, the patient endorsed mild tenderness on palpation. Flexible fiberoptic laryngoscopic exam revealed normal bilateral true vocal fold motion and appearance. No cervical lymphadenopathy was appreciated and cranial nerves II-XII were intact. Radiographic FeaturesComputed tomography (CT) identified a 6 9 4 9 3 cm left post-styloid parapharyngeal space avidly enhancing mass (Fig. 1). Magnetic resonance imaging (MRI) confirmed a mass within the left parapharyngeal space that was isointense on T1, slightly hyperintense on T2, and showed multiple flow voids with gadolinium enhancement. The mass was posterior to the carotid bifurcation and anterolateral to the internal jugular vein. Radiographic findings were highly suspicious for a vagal paraganglioma or nerve sheath tumor. Urine catecholamines, vanillylmandelic acid (VMA) panel and thyroid function studies were all within normal limits. Succinyl dehydrogenase (SDH) gene testing was negative.Disclaimer: The opinions and assertions expressed herein are those of the authors and are not to be construed as official or representing the views of the Department of the Navy or the Department of Defense. I certify that all individuals who qualify as authors have been listed; each has participated in the conception and design of this work, the writing of the document, and the approval of the submission of this version; that the document represents valid work; that if we used information derived from another source, we obtained all necessary approvals to use it and made appropriate acknowledgements in the document; and that each takes public responsibility for it. We are military service members.
and unusual in that the tumor demonstrated a high grade olfactory neuroblastoma and a divergent, epithelial-marker reactive cell population in the same tumor. This combined appearance is unusual and may represent an "olfactory carcinoma". Only one previous case has reported carcinomatous involvement of an ONB. There is insufficient information in the literature to draw conclusions on the impact these divergent cell populations have on prognosis or treatment.
Orthognathic surgery utilizing a Le Fort I osteotomy is performed regularly by oral surgeons to correct midface and dental occlusal abnormalities, yet little has been written discussing the impact these operations may have on sinonasal function. The objective of this study was to assess the incidence of objective sinonasal inflammation and subjective sinonasal symptoms following the use of Le Fort I osteotomies for maxillary advancement surgery. Thirty-eight subjects who previously underwent Le Fort I osteotomies for purposes of elective orthognathic surgery were enrolled retrospectively to assess for evidence of rhinosinusitis (RS). Post-operative and, when available, preoperative maxillofacial computed tomography (CT) scans were obtained and evaluated using Lund Mackay scoring (LMS). The Chronic Sinusitis Survey – Duration Based (CSS-D) was completed to compare subjective symptoms before and after surgery. Evaluation of the CT scans demonstrated radiographic evidence of RS and subjective worsening of symptoms in 87% and 89% respectively. The mean CSS-D pre- and post-operative scores were 7.6 and 14.8 respectively (P < 0.0001). The mean calculated LMS was 3.39 (2.38–4.40, 95% C.I.). Further sub-analyses demonstrate an increase in both radiographic LMS and subjective CSS-D for patients who had persistent inferior meatal antrostomies after Le Fort I osteotomy. Le Fort I osteotomies performed during orthognathic surgery result in a higher prevalence of post-operative RS than what has been previously described. A better understanding of sinonasal mucocilliary function and the aberrancy that may be caused following such operations deserves further evaluation in order to identify and optimize postsurgical outcomes.
Objective Development of a novel pediatric airway kit and implementation with simulation to improve resident response to emergencies with the goal of improving patient safety. Methods Prospective study with 9 otolaryngology residents (postgraduate years 1-5) from our tertiary care institution. Nine simulated pediatric emergency airway drills were carried out with the existing system and a novel portable airway kit. Response times and time to successful airway control were noted with both the extant airway system and the new handheld kit. Results were analyzed to ensure parametric data and compared with t tests. A Bonferroni adjustment indicated that an alpha of 0.025 was needed for significance. Results Use of the airway kit significantly reduced the mean time of resident arrival by 47% ( P = .013) and mean time of successful intubation by 50% ( P = .007). Survey data indicated 100% improved resident comfort with emergent airway scenarios with use of the kit. Discussion Times to response and meaningful intervention were significantly reduced with implementation of the handheld airway kit. Use of simulation training to implement the new kit improved residents' comfort and airway skills. This study describes an affordable novel mobile airway kit and demonstrates its ability to improve response times. Implications for Practice The low cost of this airway kit makes it a tenable option even for smaller hospitals. Simulation provides a safe and effective way to familiarize oneself with novel equipment, and, when possible, realistic emergent airway simulations should be used to improve provider performance.
Oral surgeons remove third molars (wisdom teeth) to prevent impaction. Given the close anatomical relationship to the maxillary sinus, perforation and displacement of third molars into the maxillary sinus is a well-known phenomenon that is typically removed with a buccal mucoperiosteal flap or through a Caldwell–Luc approach. However, a less invasive route of endoscopic removal has been utilized to success in one report. A literature review shows few reports of displaced molars into the maxillary sinus and no reported patient below the age of 18. A 14-year-old patient presented with a displaced third molar into her maxillary sinus following third molar extraction with her oral surgeon. The tooth was removed successfully, utilizing endoscopic sinus surgery (ESS) with a transition to transoral retrieval to prevent nasal trauma. This is the first reported case of displaced third molar into the right maxillary sinus in a pediatric patient that was removed via ESS.
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