Faculty Bibliography

AIM: To evaluate the relationship between intraoperative blood loss and juvenile nasopharyngeal angiofibroma (JNA) vascular supply and tumour stage in patients who underwent superselective external carotid artery (ECA) embolization. This series is unique in that all embolizations were performed by dedicated paediatric interventional radiologists at a tertiary referral paediatric centre. MATERIALS AND METHODS: Seventeen male patients treated from January 2002 to August 2009 underwent preoperative angiography and embolization using polyvinyl alcohol (PVA) particles. Tumours were graded using three different staging systems based on preoperative imaging and correlated to surgical blood loss. All patients underwent bilateral internal and external carotid angiography, with embolization of ECA tumour supply via microcatheter delivery of PVA particles. Particle size ranged from 150-500 mum with a mean size of 250-355 mum. Surgical resection was performed with either endoscopic or open techniques within 24 h and intraoperative blood loss was reported. RESULTS: Seven lesions were supplied strictly by the ECA circulation and had mean surgical blood loss of 336 ml. Twelve lesions had both ECA and internal carotid artery (ICA) supply and had mean surgical blood loss of 842 ml. The difference in blood loss in these two groups was statistically significant (p = 0.03). There was no case of inadvertent intracranial or ophthalmic embolization. There were statistically significant correlations between estimated surgical blood loss and the Andrews (p = 0.008), Radkowski (p = 0.015), and University of Pittsburgh Medical Center (UPMC; p = 0.015) preoperative tumour staging systems, respectively. CONCLUSION: Preoperative embolization of JNA tumours can be safely performed without neurological complications. The present study identified a statistically significant difference in intraoperative blood loss between those lesions with a purely ECA vascular supply and a combination of ECA and ICA vascular supply. Angiography is helpful in delineating ICA supply and can help guide surgical planning.

OBJECTIVES/HYPOTHESIS: To characterize the anatomic distribution of lymphatic malformations of the upper airway. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care referral center specializing in the diagnosis and treatment of vascular anomalies. METHODS: A 7-year (2004-2011) retrospective chart review of patients with lymphatic malformations was performed at a tertiary care referral center. Patients with airway lymphatic malformations were identified. The anatomic distribution of lymphatic malformations within the airway was reviewed. RESULTS: A total of 141 patients with lymphatic malformations of the upper aerodigestive tract (UADT) were studied. Of these, 15 (11%) had laryngeal (supraglottic) involvement. In all of these patients, the disease was above the true vocal folds. Seventy-four (52%) patients had involvement of 1 anatomic zone (most common was the oral cavity), and 67 (48%) had involvement of multiple zones. With regard to each zone, 105 (75%) patients had involvement of the oral cavity, 50 (36%) the oropharynx, 8 (6%) the hypopharynx, 42 (30%) the parapharynx, and 12 (9%) had retropharygeal disease (some patients had multiple zones involved). No patients were identified with glottic, subglottic, or tracheal involvement. CONCLUSIONS: Based on our large series, airway involvement in head and neck lymphatic malformations may occur at multiple sites above the glottis. A high percentage of these patients have involvement of the oral cavity (75%) and oropharynx (35%). None involve the glottis, subglottis, or trachea.

OBJECTIVES: Laryngotracheal involvement in relapsing polychondritis (RP) is rare. However, it is one of the most common causes of death in this patient population. We present three patients who primarily presented with laryngeal manifestations of RP and a novel treatment option for bamboo nodules. STUDY DESIGN: Retrospective chart review and comprehensive review of the literature. RESULTS: Two patients first presented to an otolaryngologist because of hoarseness and chronic cough that eventually progressed to dyspnea upon exertion. Laryngeal examination revealed subglottic stenoses. Upon rheumatologic workup both were diagnosed with RP. After treatment with steroids and immunosuppressive drugs, one of the patient's laryngeal symptoms improved, whereas the other required dilation procedures. Neither patient had classic auricular or nasal symptoms upon initial presentation. The third patient was being treated for spasmodic dysphonia and was noted to have bamboo nodules with accompanying dysphonia. Rheumatologic workup revealed RP and systemic treatment ensued. Unfortunately, her symptoms of hoarseness persisted despite systemic treatment. A pulsed-potassium-titanyl-phosphate (KTP) laser was applied to the bilateral bamboo nodules, which eventually caused resolution of her vocal fold lesions and dysphonia. CONCLUSIONS: We present three patients with RP, all of whom sought health care by an otolaryngologist primarily. Awareness of this disease entity and the possibility for early laryngeal involvement is crucial for proper care of those with this life-threatening disease

OBJECTIVES/HYPOTHESIS: To analyze existing evidence regarding utility of laryngeal electromyography (LEMG) for prognosis in cases of vocal fold palsy (VFP). STUDY DESIGN: Meta-analysis of studies reporting LEMG results and clinical outcomes in 503 patients with of VFP identified by literature search. METHODS: Studies were identified by literature search. Method of diagnosis, interval to LEMG, criteria for prognostication, and outcome were assessed. Criteria for prognosis were standardized to the extent possible across all studies, and studies were checked for consistency in outcome measures and assessments. Pooled data were subjected to statistical analysis. RESULTS: A total of 296/503 patients (58.8%) had findings predictive with poor prognosis, whereas 207/503 (41.2%) had findings of recovery. According to laryngoscopic examination, 269/296 patients with predicted poor recovery had poor recovery (positive predictive value = 90.9%), whereas 27/296 (9.1%) had good recovery. In patients with findings consistent with recovery, 115/207 (negative predictive value = 55.6%) noted return of motion, whereas 88/207 (44.4%) did not. The odds ratio was 11.56 with 95% confidence interval of 7.10-18.81. CONCLUSIONS: LEMG is a good predictor of poor recovery in patients with VFP and is clinically useful in identifying candidates for early definitive intervention

PURPOSE: Spasmodic dysphonia (SD) is an idiopathic voice disorder that is characterized by either a strained, strangled voice quality or a breathy voice with aphonic segments of connected speech. It has been suggested that environmental factors play a role in triggering the onset. Clinical observation suggests that some patients associate onset with specific events or factors while others do not. The purpose of this study was to examine a large database of SD patients to determine if specific triggers are associated with the onset of SD. PROCEDURES: Retrospective chart review. RESULTS: A total of 350 charts of patients with SD were identified and were categorized as either 'sudden onset' or 'gradual onset.' One hundred sixty-nine recalled their circumstances surrounding onset. Forty-five percent of these patients described the onset as sudden. Patient perceptions of inciting events in the sudden onset group were identified 77% of the time and 2% of the time in the gradual onset group. The most common factors identified were stress (42%), upper respiratory infection (33%), and pregnancy and parturition (10%). CONCLUSIONS: Thirty-five percent of SD patients perceive their disorder to have a sudden onset with identified inciting events. This prevalence raises questions regarding possible behavioral and environmental factors surrounding the onset of this disorder