Faculty Bibliography

PURPOSE: To present the CT characteristics of histologically confirmed venous vascular malformations limited to the submandibular triangle in patients without clinical stigmata of venous vascular malformations. METHODS: The clinical records and CT scans of five women with venous vascular malformations limited to the submandibular triangle were reviewed. Patients ranged from 39 to 70 years of age. None of the patients had a history of malignant tumors. All patients presented with a solitary suprahyoid neck mass. None of the patients demonstrated cutaneous manifestations of venous vascular malformation. RESULTS: Contrast-enhanced CT scans in all five patients demonstrated a lobulated, heterogeneously enhancing, well-circumscribed solid mass, separable from the submandibular gland. Areas of contrast enhancement within each mass were isodense to the internal jugular vein in four of five cases. Only two of five lesions demonstrated focal calcifications. Excisional biopsy (two patients) demonstrated pathologic features compatible with venous vascular malformation. Fine needle aspirations (three patients) yielded venous blood or blood-tinged fluid. CONCLUSIONS: Venous vascular malformations may present as isolated neck masses in adults without typical clinical stigmata. Clues to the CT diagnosis include a lobulated appearance to the mass with intense but heterogeneous contrast enhancement. This appearance, in combination with results of fine needle aspiration, may be sufficiently diagnostic to preclude excisional biopsy

Postoperative cerebrospinal fluid (CSF) leak is a serious complication of acoustic neuroma surgery. The authors retrospectively reviewed the charts of 492 patients who underwent acoustic neuroma surgery to determine the efficacy of fibrin glue in preventing postoperative CSF leak. Thirteen of 92 patients (14%) undergoing retrosigmoid/transmeatal surgery experienced CSF leak when fibrin glue was used; 29 of 199 patients (15%) when it was not used. Nineteen of 85 patients (22%) experienced CSF leak when fibrin glue was used following translabyrinthine surgery; 23 of 116 patients (20%) when it was not used. No decrease was noted in the incidence of CSF leak following acoustic neuroma surgery with the use of autologous fibrin glue

Neurotologic manifestations are apparent in human immunodeficiency virus (HIV) infection, but are poorly understood. Symptoms related to the vestibular system include episodes of vertigo, imbalance, ataxia, and nausea. Although patients present more often with hearing impairment, vestibular complaints are described and electrophysiologic studies indicate vestibular dysfunction in HIV-infected patients. Whether the disease involvement includes the central, or the peripheral nervous system has not been established. Ultrastructural analysis of vestibular end-organs obtained from HIV autopsy cases revealed pathologic changes in the labyrinth wall, the epithelial lining, and the receptor maculae and cristae. Cytologic changes in hair cells included inclusion bodies, viral-like particles, and hair bundle malformations. Epithelial lining cells, supporting cells, and connective tissue cells had inclusions and viral-like particles. These findings are consistent with those of a previous cochlear study demonstrating intracellular viral-like particles with the morphologic characteristics of HIV. Further cytologic evaluation of decalcified temporal bones and immunohistochemical analysis of freshly harvested HIV-infected temporal bones may provide further insight into the pathogenesis of viral-induced hearing loss and vestibular impairment

Otologic disease often extends into the hypotympanum, posterior mesotympanum, and infralabyrinthine compartments. Surgical access to these areas can be difficult because of the proximity of the facial nerve. In patients with a normal bone anatomy, these regions can be accessed by a retrofacial approach, which spares the posterior canal wall and avoids transposition of the facial nerve. The anatomy of the hypotympanum, posterior mesotympanum, and infralabyrinthine compartments will be reviewed emphasizing gross anatomic documentation. We will detail the surgical approach to these areas along the retrofacial air cell tract, and will present an appropriate case history

Massive skull base injuries require detailed preoperative neurological and neurovascular assessment prior to undertaking surgical repair of isolated cranial nerve deficits. We present the management of a patient with traumatic facial paralysis, cerebrospinal fluid leak, and carotid artery cavernous sinus fistula as the result of a gunshot wound to the skull base. The carotid artery cavernous sinus fistula was ultimately controlled with super-selective embolization via the vertebral artery. The facial nerve injury was then safely treated with mobilization of the labyrinthine and vertical segments to allow a primary anastomosis

Eight patients 45 years of age and under (range, 29 to 45) with squamous cell carcinoma of the head and neck and infection with the human immunodeficiency virus are reported. Primary tumor sites include nasopharynx, oral cavity, oropharynx, and larynx. Probes for the human papillomavirus were positive in two of the patients. Therapy consisted of surgery followed by radiation therapy in five patients, surgery alone in one patient, and radiation therapy in the remaining two patients. Follow-up ranged up to 2 years and revealed four deaths, three patients alive without disease, and one patient recently posttreatment with residual disease. The significance of the presence of the human papillomavirus in these individuals remains to be determined. The incidence of squamous cell carcinoma of the head and neck under age 45 is low, and whether there may be a higher incidence in HIV-positive patients cannot be determined from this small series