Otolaryngology–Head and Neck Surgery

BACKGROUND: Inflammatory products, such as oxygen radicals generated during the course of bacterial meningitis, can damage nerve endings, hair cells, and/or supporting cells in the cochlea. Superoxide dismutase (SOD), an O₂-scavenger, has been shown to play an important role in the protection against radical toxicity in various animal experiments.

OBJECTIVE: To study the antioxidant effects of SOD on the inflammatory response of gerbils with bacterial meningitis.

STUDY DESIGN: Meningitis was induced in three groups of 10 gerbils by intrathecal (IT) injection of Streptococcus pneumoniae into the cisterna magna. Group 1 received IT SOD, group 2 received intramuscular (IM) SOD, and group 3, the control group, received IM normal saline. Histologic data and auditory brainstem responses (ABR) were obtained from each gerbil.

RESULTS: Fibrosis and/or neo-ossification were near absent in the IT SOD group and significantly less fibrosis occurred in the IM group (IT vs. IM: P = 0.010; IT vs. control group: P = 0.001). The amount of surviving spiral ganglion cells correlated inversely with the extent of fibrosis (r = −0.753, P < 0.00001).

CONCLUSIONS: IT injection of SOD significantly reduced cochlear fibrosis and neo-ossification, reduced the spiral ganglion cell loss, and decreased damage of the cochlear components following bacterial meningitis.

OBJECTIVE: Plasma cytokine concentrations from patients with head and neck squamous cell carcinoma (HNSCC) were measured to determine whether the potential modulation of host Th1 vs Th2 immune responses are associated with advanced clinical disease.

STUDY DESIGN AND SETTING: The concentrations of IL-4, IL-6, IL-10, and IL-12 were measured in the plasma of 58 patients with histologically proven HNSCC. These data were examined with respect to the histologic size (T-stage) of the primary tumor, and presence of nodal metastasis.

RESULTS: The concentrations of IL-12 were greater from patients without nodal metastasis, and with T₁/T₂-stage tumors. IL-10 levels were greater from patients with nodal metastasis, and with T₃/T₄-stage tumors. The concentrations of IL-6 were greater from patients with T₃/T₄-stage tumors.

CONCLUSIONS: Using parameters of primary tumor size and presence of nodal metastasis, patients with advanced HNSCC have significantly less plasma IL-12 levels, and greater plasma IL-10 and IL-6 levels.

SIGNIFICANCE: Patients with advanced HNSCC have a potentially diminished Th1 immune response, and a stronger potential Th2 immune response when compared to that of patients with less advanced disease. EBM rating: D-5.

OBJECTIVES: To describe the phenotypic and gene expression differences in monolayer and tri-dimensional cultures systems.

METHODS: Normal oral epithelial cells (NOEC), primary head and neck squamous cell carcinoma (HNSCC), and HNSCC cell lines were used to create and study modeled tri-dimensional tissue. Using cDNA microarray analysis, monolayer and raft-modeled tri-dimensional HNSCC cell lines were compared.

RESULTS: NOEC, HNSCC, and both together can be modeled with tri-dimensional differentiation and cytokeratin characteristics analogous to in vivo tissue. Modeling of primary HNSCC resulted in a morphology of invasive HNSCC with areas of direct collagen invasion and MMP2 expression. Gene array analysis suggests that the individual cell lines themselves are the primary gene expression predictor and not the presence of tri-dimensional tissue architecture.

CONCLUSIONS: This tissue culture modeling system approximates the differentiation and tri-dimensional structure of in vivo tissues, and that raft modeled tri-dimensional HNSCC does not have a significantly different gene expression profile than the corresponding monolayer culture.

OBJECTIVE: To determine alterations in Th2 chemokines eotaxin and monocyte chemoattractant protein-4 (MCP-4), and cytokines interleukin-5 (IL-5) and interleukin-13 (IL-13), in nasal polyps (NP) after steroid treatment.

STUDY DESIGN: Cytokine/chemokine levels were measured in NP before and after steroid therapy and compared to control sinus mucosa.

RESULTS: Twenty-one patients (control = 7, NP = 14) were enrolled. Eotaxin and MCP-4 were significantly higher than control tissue (P = 0.004 and 0.003). All four mediators decreased after steroid treatment (P < 0.03). IL-5 and IL-13 in untreated polyps were not significantly different from controls. Patients showed clinical improvement according to SNOT-20 scores (average presteroid score 19, post-steroid score 13) and endoscopic grading (1.75 each side presteroid, 1.13 poststeroid).

CONCLUSIONS: Steroids significantly decreased all cytokine/chemokine levels, but the impact on Th2 chemokines was of a much greater magnitude.

SIGNIFICANCE: Novel approaches to block inflammatory mediators, particularly Th2 chemokines, may lead to better control of nasal polyposis in the future.

OBJECTIVES: To develop a method for characterizing the transcriptome of individual cell types in the inner ear sensory epithelia.

STUDY DESIGN: We employed the technique of laser capture microdissection to obtain enriched populations of hair cells and supporting cells. The respective mRNAs were extracted, reverse transcribed, and amplified using PCR.

RESULTS: We were able to isolate RNAs with good integrity from enriched cell populations obtained with laser capture microscopy and amplify specific mRNA targets.

CONCLUSIONS: We can now investigate the molecular differences between the different cell types in the inner ear sensory epithelia as identified by morphological criteria.

SIGNIFICANCE: Analysis of gene expression profiles in the inner ear cell types has been hampered by the small size of this tissue and by the compact histoarchitecture of the sensory epithelia; however, the present technique offers new possibilities for the analysis of transcriptomes in the vestibular periphery using available high-throughput gene expression analysis methods.

OBJECTIVE: To determine if continuous laryngeal nerve integrity monitoring (NIM) during thyroidectomy is associated with a decreased risk of postoperative recurrent laryngeal nerve (RLN) injury.

STUDY DESIGN AND SETTING: Retrospective cohort study of 165 patients who underwent thyroidectomy at a resident teaching institution between 1999 and 2002. The control group had 120 nerves at risk (NAR) whereas the NIM group consisted of 116 NAR. Primary outcome measures included postoperative RLN paralysis, paresis, and total injury rates.

RESULTS: RLN paralysis occurred in 2.54% NAR in the control group and 0.86% in the NIM group (relative risk (RR) = 0.34, 95% confidence interval (CI95) = 0.04-3.27, P = 0.62). Temporary RLN paresis occurred in 4.24% NAR in the control group and 3.45% in the NIM group (RR = 0.9, CI95 = 0.23-3.55, P = 0.89). Total RLN injury occurred in 6.78% NAR in the control group and 4.31% in the NIM group (RR = 0.66, CI95 = 0.21-2.09, P = 0.48). When compared to all other NAR, advanced T-stage malignancy was associated with a significantly increased risk of RLN paresis (T4 RR = 9.0, CI95 = 2.56-31.67, P = 0.0006; T3+T4 RR = 7.5, CI95 = 2.17-25.86, P = 0.0001) but not paralysis. NIM did not significantly reduce the risk of RLN paresis in the advanced T-stage subset (T3+T4 RR = 0.36, CI95 = 0.04-3.0, P = 0.59).

CONCLUSION: There were no statistically significant differences in RLN paralysis, paresis, or total injury rates between control and NIM groups, even in subsets with advanced T-stage and increased baseline risk. Advanced T-stage is a significant predictor of RLN paresis in this cohort.

PROBLEM ADDRESSED: Floseal is a novel matrix hemostatic sealant composed of collagen-derived particles and topical bovine-derived thrombin. It is applied as a high-viscosity gel for hemostasis and has been clinically proven to control bleeding. This study is a prospective, randomized, controlled clinical trial of Floseal sealant compared to traditional suction cautery hemostasis in children undergoing adenoidectomy.

METHODS AND MEASURES: Seventy patients (mean age 7.0 yrs, 45.7% male) with obstructive sleep apnea underwent traditional cold steel adenoidectomy with an adenoid curette and were then randomized to receive the hemostatic sealant (Floseal) or cautery to obtain hemostasis. Patients were crossed over to the other hemostatic technique if hemostasis was not achieved after more than 100 mL of blood loss or 15 minutes elapsed time. Objective data collected included time to hemostasis and blood loss during hemostasis. Visual analog scales (VAS) were used to record subjective data by the operating surgeon including bleeding following adenoid pack removal (0 = none, 3 = brisk) and ease of operation (1 = extremely easy, 6 = extremely difficult). Parents recorded diet on a journal and were contacted by phone at postoperative day 7 and questioned with regard to return to regular diet and use of narcotics.

RESULTS: Compared to patients in the cautery group (n = 35), Floseal patients (n = 35) had significantly shorter times to hemostasis (0.6 ± 1.3 minutes vs 9.5 ± 5.4 minutes (mean ± SD), P < 0.001), less blood loss (2.5 ± 9.2 mL vs 29.4 ± 27.1 mL, P < 0.001), less subjective bleeding (0.0 ± 0.6 vs 2.0 ± 0.7, (median 4-point VAS ± SD), P < 0.001), and subjectively easier operations (2.6 ± 1.0 vs 5.2 ± 1.0 (mean 6-point VAS ± SD), P < 0.001). Furthermore, Floseal patients returned to regular diet earlier (2.7 ± 0.7 vs 4.1 ± 0.5 days (mean ± SD), P < 0.001) and had less use of narcotics at 7 days postoperatively (40% vs 69%, P < 0.05). Lastly, three patients in the cautery group were crossed over to the Floseal group, but no Floseal subjects were crossed over to the cautery group. The retail cost of Floseal is $85. Operating room costs are estimated at $12/minute. Reducing the operative length by 8.9 minutes on average produces a cost savings of $106.80 per operation. There were no complications in either experimental group including postoperative hemorrhage, hospitalization, blood transfusion, or aspiration.

CONCLUSIONS: Floseal matrix hemostatic sealant is a safe, efficacious, easy, and cost-effective technique for obtaining hemostasis in children undergoing adenoidectomy. Limitations of the study include the fact that it is nonblinded, which does allow for some bias in the subjective data recorded. However, utilizing 4 different operating surgeons, 3 of whom were not affiliated with the study, minimized this.

CLINICAL SIGNIFICANCE OF STUDY: This study demonstrates the safety and efficacy of a novel hemostatic sealant in children undergoing adenoidectomy. Floseal matrix hemostatic sealant can be used as a first-line hemostatic agent, and it is a good tool in the armamentarium of otolaryngologists who encounter significant bleeding following adenoidectomy.

OBJECTIVE: The efficacy of many of the noninvasive treatments for snoring has not been evaluated in controlled trials. This paper seeks to evaluate the efficacy of an oil-based spray in the treatment of snoring, in a double-blinded, placebo-controlled, crossover trial using objective acoustic analysis and subjective questionnaires.

STUDY DESIGN AND SETTING: Participants were randomized to use both oil-based oral spray (treatment) and water-based oral spray (placebo) during a two-night in-home study period. Questionnaires were completed by participant and bed-partner in addition to audio-tape recordings which were analyzed for frequency, duration, and mean energy of snoring.

RESULTS: Greatest snoring rate demonstrated 30% = benefit; 40% = no change; 30% = adverse effect (n = 20). Percent time snoring yielded: 30% benefit; 15% no change; 55% adverse effect (n = 20). Study data results for mean energy were (n = 12): benefit = 17%, no change = 33%, adverse effect = 50%. Bed-partner observations (n = 17) demonstrated 37% = benefit; 38% = no change; 25% = adverse effect.

CONCLUSION/SIGNIFICANCE: Objective and subjective evaluation of the performance of the oil-based Snoreless spray in comparison to placebo demonstrated a lack of efficacy in snoring reduction.

OBJECTIVE: To analyze patients with “normal” baseline quick intraoperative parathyroid hormone (QPTH) levels during parathyroidectomy and to determine the prevalence of this finding, the usefulness of the assay in this situation, and to explain the possible causes for this phenomenon.

STUDY DESIGN AND SETTING: Patients who underwent parathyroidectomy using QPTH in a tertiary hospital.

METHODS: Retrospective analysis of 39 patients treated surgically for primary hyperparathyroidism using QPTH.

RESULTS: Of the patients, 14 (36%) had normal baseline QPTH. 8 patients with localizing sestamibi scans had a single adenoma, and excision resulted in a mean decrease of 85.4% in QPTH. Six patients had nonlocalizing sestamibi scans, 1 patient had an 84% drop in QPTH level after removal of a single adenoma, and 5 patients had hyperplasia requiring ≥3 glands excision. At 11.36 months' mean follow-up, 13 patients (93%) were normocalcemic.

CONCLUSIONS: A “normal” baseline QPTH level was found in 36% of patients. A 50% decrease in QPTH remains predictive of biochemical cures in patients with localizing sestamibi scans. The likely explanation for this variability in “normal” levels between different assays is the variability in detection of the 7-84 PTH fragment, which results in an overestimation of the PTH level. Assays such as the QPTH, which are more sensitive for the biologically active PTH molecule [(1-84) PTH] than other laboratory PTH assays will tend to have lower PTH levels that can be within the normal range. EBM rating: B-3.

OBJECTIVE: To review a single surgeon's experience utilizing an intraoperative methylene blue infusion (IMBI) to identify parathyroid glands during neck exploration for primary hyperparathyroidism.

STUDY DESIGN AND SETTING: Retrospective review of 35 patients who underwent bilateral neck exploration utilizing an IMBI at a dose of 7.5 mg/kg following the induction of general anesthesia.

RESULTS: All patients reverted to normocalcemia with a mean follow-up of 17 months. IMBI facilitated the identification of abnormal parathyroid tissue in 34/35 patients (97%). A dark blue-purple staining was observed in 33/37 stained adenomas (89%). Four adenomas and four hyperplastic glands stained a lighter shade of blue-green. Among 89 normal glands, 41(46%) stained a pale green-grey color.

CONCLUSIONS: IMBI is a safe, readily available, cost-effective, and underutilized technique that facilitates rapid identification of parathyroid adenomas, helps distinguish normal glands from hyperplastic glands, and helps to locate ectopic glands. An overall reduction in operative time, especially for bilateral neck exploration, can be anticipated.

Since parathyroid glands are often inconspicuous, their identification can be a challenging problem when performing neck exploration for the treatment of hyperparathyroidism. Normal parathyroid glands can be a few millimeters in size (especially when suppressed by hypercalcemia), of variable color, and supernumerary. They may also be surrounded by or imbedded in adipose tissue or confused with small paratracheal lymph nodes. When thyroid surgery is performed by experienced surgeons, inadvertent parathyroidectomy may be as high as 9%. 1 Abnormal parathyroid glands may be concealed beneath the thyroid capsule, intrathyroid, intrathymic, or inside the carotid sheath. Other ectopic locations in the neck or anterior mediastinum are also encountered. Furthermore, the distinction between true double adenomas and asymmetric hyperplasia continues to challenge even the most seasoned endocrine surgeon.

It has been argued that with the exception of a mediastinal parathyroid adenoma, localizing studies (eg, technetium-99m-sestamibi [Tc-MIBI] imaging, MRI, CT, and ultrasound [US]) add little to the overall success of parathyroidectomy, especially for primary explorations in the hands of experienced endocrine surgeons. However, for the less experienced surgeon, preoperative localization studies have been helpful in directing the side of the neck for initial exploration, and for reducing operative times and frustration. Revision parathyroidectomy, after a failed initial neck exploration, can be an exercise in futility without some form of localizing study, the cost of which is then always justified. Recent extramural pressures to perform “minimally invasive surgery,” limiting both the scope and duration of parathyroidectomy and reducing hospital length of stay, have popularized the use of preoperative parathyroid localizing studies. Over the past decade, Tc-MIBI imaging has become the “gold standard” for preoperative localization because of its high sensitivity and specificity, and its use has become routine in many centers. Intraoperative procedures such as Tc-MIBI localization using a hand-held gamma probe, intraoperative circulating iPTH assay (Nichols Institute Diagnostics, San Juan Capistrano, CA, USA), have evolved to permit a more limited “minimally invasive” unilateral neck exploration. However, this approach is limited to patients for whom a preoperative Tc-MIBI strongly suggests the presence of a single adenoma. Even with this positive finding, Tc-MIBI will miss double adenomas and asymmetric four-gland hyperplasia in a significant number of patients. The additional radiation exposure to patient and personnel with radioguided surgery, the need for more than one scan, and complex scheduling issues for appropriate timing of the radiopharmaceutical administration may represent other disadvantages.

OBJECTIVE: To investigate the fluorescent characteristics of different thyroid tissues.

STUDY DESIGN: Fresh ex vivo thyroid tissue was surfaced scanned with a fluorescence spectrophotometer. Resultant spectra were evaluated via interpeak ratios.

RESULTS: Interpeak ratios of all histologies were found to be significantly different from each other (P < 0.001). The diagnostic sensitivity and specificity of fluorescent spectroscopy was 86% and 91% for thyroid nodule capsule, 78% and 59% for papillary thyroid carcinoma, and 82% and 63% for normal thyroid, respectively.

CONCLUSION: Fluorescent spectroscopy can been used to identify significant differences in the fluorescent characteristics of various thyroid histologies.

SIGNIFICANCE: This study is the first investigation of the fluorescence of thyroid tissue. The diagnostic ability of fluorescent spectrometry may allow it to be used as a localization aid for fine needle aspiration, using optical fiber probes. Further investigations may enhance the sensitivity and specificity of fluorescent spectrometry allowing it to replace or compliment fine needle aspiration. EBM rating: B-3.

OBJECTIVE: The purpose of this study was to compare the incidence of multiglandular disease and rate of treatment failure between younger and older patients with primary hyperparathyroidism.

STUDY DESIGN AND SETTING: The medical charts of patients who underwent surgery for primary hyperparathyroidism at our tertiary-care institution between 1995 and 2001 were reviewed.

RESULTS: Three hundred nineteen patients were identified, of whom 33 were aged 40 years or less. There were no statistically significant differences between the younger and older groups in the incidence of multiglandular disease (9.1% for both, P = 1.00) or in the treatment failure rate (12.1% and 8%, respectively, P = 0.43). Sonography was significantly more sensitive than technetium Tc-sestamibi in the younger group (96% vs 57%, P < 0.05). Parathyroid hormone level and gland weight were significantly higher in the older group (P = 0.004).

CONCLUSION: Our results suggest that the same treatment strategy should be applied to all patients with primary hyperparathyroidism. Ultrasound appears to be the localization procedure of choice in younger patients.

OBJECTIVES: While evaluating the validity of using normal human mucosal cells from the upper aerodigestive tract as diploid standards for DNA content studies of squamous cell cancer of head and neck by flow cytometry, pseudoaneuploidy was frequently detected. The purpose of this study was to further evaluate these DNA content abnormalities encountered in normal human mucosal cells and correlate them to physiological apoptosis.

STUDY DESIGN: Thirty-two specimens of upper areodigestive tract mucosa from 18 surgical resections, 11 fresh autopsies, and 3 buccal scrapings were examined for DNA content by flow cytometry.

RESULTS: Pseudoaneuploidy, which ranged from sub-G0/G1 peaks to hyperdiploid peaks with increased 90° light scattering properties was found in 60% of these specimens. Fluorescent microscopic examination of the sorted DNA pseudoaneuploid cells demonstrated cells undergoing apoptosis.

CONCLUSION: This unexpected pseudoaneuploidy in normal mucosal cells was a result of physiological apoptosis, a normal component of squamous differentiation. EBM rating: B-2.

OBJECTIVE: Determine staging characteristics and survival outcomes for primary malignancies of the trachea.

DESIGN: Cross-sectional analysis of national cancer database.

METHODS: Cases of primary tracheal malignancy were extracted from the Surveillance, Epidemiology, and End Results database for the time period 1988-2000. T-stage, N-stage, and overall stage of presentation were determined. Mean, median, and 5-year survival statistics were computed using Kaplan-Meier survival analysis for each tumor histology and for the overall cohort according to stage.

RESULTS: Ninety-two cases with adequate histologic information were identified. Mean age at presentation was 59.3 years with an equal sex distribution. Squamous cell carcinoma was the most common tumor type (41 cases) followed by adenoid cystic carcinoma (19 cases). Forty-nine cases (53%) presented with stage 3 or stage 4 disease. Squamous cell carcinoma exhibited poorer survival (mean survival, 44.0 month, 5-year survival, 34%) than adenoid cystic carcinoma (mean survival, 115 month, 5-year survival, 78%). Five-year unadjusted survival rates according to overall stage were 52.8%, 70.0%, 75.0%, 15.1%, respectively.

CONCLUSIONS: Primary tracheal malignancies often present with advanced stage. Patients with squamous cell carcinoma of the trachea have poorer prognoses when compared with adenoid cystic carcinoma and other tumor types. Staging tracheal cancer with a TNM-based system helps predict survival. EBM rating: C.

OBJECTIVE: Our goal was to evaluate our experience with radiation-induced malignancy (RIM), compare that experience to the literature, and review treatment modalities.

STUDY DESIGN AND SETTING: The setting is the University of Kansas Medical Center. A retrospective review was performed to identify patients with RIM. Patients were included if they met the criteria for RIM as delineated in the literature.

RESULTS: Thirteen patients met the criteria for RIM. The mean latency period was 22 years. Sarcomas were the most common type of RIM and the paranasal sinuses were the most common location. Surgical resection was our treatment of choice.

CONCLUSIONS: Our patient series differs from previous reports in that sarcomas were the predominating RIM and the paranasal sinuses were the most common location. We noted a shorter latency period than has been previously published. Surgical excision is the treatment of choice. EBM rating: C.

OBJECTIVE: To study the correlation between flow cytometrically measured DNA ploidy with prognostically important histopathologic groups and clinical outcome in patients with adenoid cystic carcinoma of the salivary glands.

STUDY DESIGN: 46 tumor specimens were analyzed flow cytometrically for DNA content and assessed for histological grade. Correlations were made between tumor DNA ploidy and histopathological grade, and disease-free and overall survival of these patients.

RESULTS: Of the 46 patients, 31 had a cribiform/tubular histologic pattern, and 15 had a solid pattern. 84% of the tumors with cribriform/tubular pattern were DNA diploid, compared with 33% of tumors that were graded solid. This difference proved to be statistically significant (χ 2 11.75, P = 0.0006). Overall and disease-free survival periods were longer for patients with DNA diploid tumors in both groups, 63% vs. 36% and 62% vs 38%, respectively.

CONCLUSIONS: Tumor DNA ploidy correlates with prognostically important tumor histopathology as well as overall and disease-free survival in patients with adenoid cystic carcinoma of the salivary gland. EBM rating: B-3.

OBJECTIVES: The aim of this study was to investigate the feasibility of molecular diagnosis of nasopharyngeal carcinoma (NPC) by combining nasopharyngeal swab and polymerase chain reaction (PCR) to detect Epstein-Barr virus (EBV) derived latent membrane protein-1 gene (LMP-1) and Epstein-Barr nuclear antigen gene (EBNA).

METHODS: 437 adults underwent nasopharyngoscopy, possible biopsy, and nasopharyngeal swab to obtain nasopharyngeal cells for the detection of LMP-1 and EBNA by PCR.

RESULTS: By detecting LMP-1 and EBNA in the nasopharyngeal swabs, NPC could be diagnosed with a false-positive rate of 1.7% (6/354), a false-negative rate of 8.6% (6/70), a sensitivity of 91.4% (64/70), a specificity of 98.3% (348/354), positive predictive value of 91.4% (64/70), and negative predictive value of 98.3% (348/354).

CONCLUSION: Detecting EBV genomic LMP-1 and EBNA by nasopharyngeal swab verifies NPC with a sensitivity of 91.4% and specificity of 98.3%. The nasopharyngeal swab coupled with PCR based EBV LMP-1 and EBNA detection could serve as a good supplement to pathological diagnosis of NPC.

The most common morbidity associated with selective neck dissection (SND; II–IV) is spinal accessory nerve dysfunction and related shoulder disability. Nerve dysfunction is usually attributed to stretching of the nerve during clearance of lymph nodes lying posterior and superior to the spinal accessory nerve (level IIb). If these lymph nodes were left in place and not removed, stretching of the spinal accessory nerve during neck dissection and postoperative shoulder disability could be avoided. 113 SNDs (II–IV) performed on clinically N0 necks of patients with laryngeal carcinoma were enrolled in this prospective study. During SND, level IIb was separately removed and processed. Mean number of lymph nodes in level IIb was 6.26 (range, 0-19). In none of the 113 SND (II-IV) specimens did level IIb contain metastases, thus providing an oncological basis that leaving these lymph nodes in place is an oncologically safe approach, probably avoiding postoperative shoulder disability.

OBJECTIVE: To review our experience with 2.0-mm locking reconstruction plate (LRP) system for patients requiring oromandibular reconstruction.

STUDY DESIGN: Retrospective case review of 43 consecutive patients who underwent mandibular composite resection with immediate reconstruction.

SETTING: Tertiary care center.

RESULTS: Forty-three patients underwent oromandibular reconstruction with the 2.0-mm mandibular LRP system and free flaps containing vascularized bone. Mean follow-up was 11 months. There were no intraoperative difficulties utilizing this system. Two (5%) patients had partial fasciocutaneous flap loss resulting in plate exposure. There were no instances of plate fracture or complications requiring plate removal to date.

CONCLUSION: 2.0-mm LRP mandibular system is reliable even in the setting of previous or adjuvant radiation therapy. Its technical ease of application, contouring malleability, and very low profile have proven to be advantageous in oromandibular reconstruction.

SIGNIFICANCE: No previous descriptions of use of the 2.0-mm LRP in combination with osteocutaneous free flaps for mandibular reconstruction are found in the literature. EBM rating: C.

OBJECTIVE: The objective of this study was to assess registration error due to fiducial configuration for the ENT headsets for the CBYON Suite (CBYON, Mountain View, CA) and InstaTrak (GEMS Navigation and Visualization, Waukesha, WI).

STUDY DESIGN: Axial CT scans (1-mm slice thickness) were obtained of for 24 cadaveric heads using the CBYON headset and for 23 cadaveric heads using the GEMS headset. The CBYON and GEMS NAV software were used to calculate the fiducial registration error (FRE). Fiducial localization error (FLE) was estimated from FRE. Theoretical target registration error (TRE) was calculated at 11 targets.

RESULTS: The FRE for CBYON and GEMS NAV was 0.69 mm and 0.27 mm, respectively. The theoretical TRE for CBYON and GEMS NAV was 0.41 mm and 0.30 mm, respectively. The theoretical TRE was greater at targets posterior in the sinus cavities.

CONCLUSION: Theoretical TRE values for both ENT headsets are less than clinically observed TRE. Clinically observed TRE is likely due to repositioning accuracy. EBM rating: B-2.

OBJECTIVE: This study was undertaken to demonstrate the safety and efficacy of in vitro, radioallergosorbent test (RAST)-based inhalant allergen immunotherapy.

STUDY DESIGN AND SETTING: Prospective 22 year single site clinical study, with outcome evaluations of 480 perennial allergic rhinitis patients, including 96 with concomitant asthma.

RESULTS: Rhinitis symptom control after 2 years of immunotherapy was excellent in 32.5% of patients, good in 45.6%, and fair in 14.2%. There was no improvement in 7.7%. For patients with asthma, 81% had good or excellent pulmonary symptom improvement, and no patient failed to improve. No severe reactions occurred, but there were 5 limited systemic reactions, or 0.008% of injections, during a 2.5-year mean immunotherapy treatment course.

CONCLUSION: RAST-based immunotherapy is safe and effective for patients with perennial allergic rhinitis, with or without concomitant asthma.

SIGNIFICANCE: This is the first large, multiyear study of safety and efficacy of RAST-based immunotherapy for treatment of perennial allergic rhinitis and asthma. EBM rating: C.

OBJECTIVE: To compare the effects of buffered hypertonic and buffered normal saline nasal spray on mucociliary clearance and nasal airway patency. STUDY DESIGN AND SETTING: Double-blind trial with subjects acting as their own controls. Tertiary care academic medical center.

RESULTS: Buffered hypertonic saline and buffered normal saline both improved saccharine clearance times (P < 0.0001 for buffered hypertonic and P = 0.002 for buffered normal saline). Buffered hypertonic saline improved saccharine clearance times more than buffered normal saline (39.6% vs 24.1%, P = 0.007). Neither buffered hypertonic nor buffered normal saline significantly affected nasal airway patency.

CONCLUSIONS: Both buffered hypertonic and buffered normal saline nasal spray significantly improved saccharine clearance times without affecting nasal airway patency. Buffered hypertonic saline affected saccharine clearance times to a greater degree than buffered normal saline.

CLINICAL SIGNIFICANCE: Buffered hypertonic and buffered normal saline sprays both improve mucociliary clearance and should therefore be beneficial in conditions such as rhinitis and sinusitis, which are associated with disruption of mucociliary clearance. However, these sprays do not appear to affect the nasal airway. Patients may therefore benefit from other treatments for “nasal congestion.” EBM rating: B-2.

OBJECTIVES: Transconjunctival and subciliary approaches to orbital floor blowout fractures (OBF) have known risks of postoperative eyelid malposition. This study evaluates the endoscopic transmaxillary repair of OBFs in a cadaveric model and clinical setting.

METHODS: Sixteen cadaveric and 10 clinical OBFs were repaired endoscopically. A Caldwell-Luc approach and modified sinus surgery instrumentation were used to repair each fracture. Variations in fracture pattern, instrumentation, and surgical technique were evaluated.

RESULTS: Endoscopic repair was achieved in all 16 cadaveric orbits and in 9 of 10 patients. Fracture patterns were classified as either medial or lateral to the infraorbital nerve. Average clinical operating time was 1:38. Of 9 postoperative CT scans, 5 were rated as excellent, 3 as good, and 1 as poor.

CONCLUSIONS: The endoscopic transmaxillary approach is a safe, viable technique for OBF repair. It offers improved visualization, anatomic fracture repair, no risk of postoperative eyelid complications, and good clinical results. EBM rating: C.

OBJECTIVES: To investigate the possible role of eosinophil peroxidase (EPO) in 3-nitrotyrosine (3NT) formation.

STUDY DESIGN AND SETTING: Observational study employing immunocytochemistry to assess the presence of 3NT, inducible nitric oxide synthase (iNOS), eosinophils, mast cells, neutrophils, and lymphocytes in ethmoid sinus mucosal biopsies from normal controls and subjects with allergic and nonallergic chronic sinusitis and nasal polyposis.

RESULTS: 3NT was more evident in biopsies from sinusitis patients (2.67 ± 0.14, n = 21) than in healthy mucosa (0.43 ± 0.2, n = 7, P < 0.01), but scores in atopic and nonatopic subjects were similar. Colocalization studies confirmed that 3NT was largely confined to eosinophils. No relationship was found between 3NT and other immune cells. 3NT detection was not correlated with the amount of immunostaining for iNOS.

SIGNIFICANCE: Chronic sinusitis is accompanied by 3NT formation, which is largely restricted to the eosinophils, and likely driven by the action of eosinophil peroxidase, rather than by nitric oxide levels. EBM rating: B-2.

OBJECTIVE: The goal of the present study was to find out if recurrence can be predicted in cases of allergic fungal sinusitis. We also studied the influence of postoperative corticosteroid therapy on recurrence following surgery.

STUDY DESIGN AND SETTING: This study was conducted at the ENT Department of Al Nahdha Hospital, which is a tertiary referral and teaching hospital in Muscat, Sultanate of Oman. The study is a retrospective analysis of 32 cases of allergic fungal sinusitis. Age, sex, extent of disease, and preoperative serum IgE levels were compared in patients who had recurrence with those who did not. We also studied the incidence, onset, and severity of recurrence in patients who received systemic corticosteroid as postoperative therapy and compared these values to those who received nasal corticosteroid spray only.

RESULTS: No statistically significant difference was noted in the parameters of age, sex, extent of disease, and preoperative serum IgE levels when these values were compared in the group of patients who had recurrence (8 patients) with the group of patients who did not (32 patients). No statistically significant difference was found in the incidence of recurrence in patients in whom systemic corticosteroids were used postoperatively (17 patients) compared with patients who used nasal corticosteroid spray only (15 patients). However, when the patient had a recurrence, when it occurred it was earlier and more severe in patients who used nasal corticosteroid spray only (4 patients).

CONCLUSIONS: At the present time, it is not possible to predict recurrence using parameters of age, sex, extent of disease, and serum IgE levels. Larger number of patients preferably in a prospective multicenter meta study are required to address this issue. Though use of systemic corticosteroid does not decrease the incidence of recurrence, it may delay the onset of recurrence and decrease the severity of recurrence.

OBJECTIVE: To determine whether oral dextromethorphan (1 mg/kg) given one hour prior to surgery decreases opioid administration in the perioperative period in children undergoing tympanomastoid surgery.

METHODS: This was a prospective randomized double-blinded and placebo-controlled study in which 20 male and 18 female children (age 11.5 ± 3.5 years) were enrolled. Nineteen children received dextromethorphan (DM), while the other 19 received placebos. Postoperative pain was assessed using a visual analogue scale and a pain score of ≥5 was treated with intravenous morphine sulfate. Patients were discharged home on oral oxycodone.

RESULTS: The total doses of fentanyl administered during surgery were higher in the placebo group compared to the DM group (4.1 ± 2 vs 2.6 ± 1.4 μg/kg, P = 0.02) and the total doses of intravenous morphine administered in the postoperative period were also higher in the placebo group compared to the DM group (150 ± 80 vs 73 ± 56 μg/kg, P = 0.004). The placebo group had a higher pain score at the time of admission to the Day Surgery Unit (DSU) and a higher maximum pain score, compared to the DM group, during their combined stay in the Post-Anesthesia Care Unit and DSU (7.3 ± 1.5 vs 3.1 ± 2.6, P = 0.001).

CONCLUSIONS: Premedication with DM reduces the need for opioid administration in the perioperative period in children undergoing tympanomastoid surgery. EBM rating: A.

OBJECTIVE: To determine the efficacy the “starplasty” pediatric tracheostomy technique in reducing the incidence of major complications and tracheotomy-related death.

METHODS: Retrospective chart analysis of all the cases of starplasty performed at 2 tertiary care centers between 1990 and 2002.

RESULTS: There were 94 children in our cohort ranging in age from 2 days to 14 years. Of the patients, 47 (50%) were females and 47 (50%) were males and 60 of the children (64%) were younger than 1 year of age. Forty-one patients (44%) had neurologically related airway problems as their primary indication for tracheostomy, 34 (36%) had upper airway obstruction, and the remainder had pulmonary diseases, prolonged intubation, or metabolic-related airway problems. There were 41 short-term complications including 5 cases of tracheal tube dislodgement. There were no instances of pneumothorax or tracheostomy-related death. There were 26 long-term complications. There were no cases of clinically relevant suprastomal collapse that compromised decannulation and no instances of tracheal stenosis. Twenty-six patients underwent decannulation, all of whom developed a tracheocutaneous fistula (TCF). Two patients had spontaneous closure of the TCF; 9 patients underwent surgical repair of their fistulas, 53 patients remain tracheostomy-dependent, and 8 patients died of their primary disease.

CONCLUSION: The need for pediatric tracheotomy has increased as a consequence of our success in treating chronically ill children. Starplasty reduces the incidence of major complications, including pneumothorax and death from accidental decannulation. Its major drawback is the need for secondary reconstruction of a tracheocutaneous fistula. EBM rating: C.

OBJECTIVE: Much has been written about the merits of various techniques of adenotonsillectomy. Proponents of each technique tout many virtues over one another. However, cost remains one variable that has not been thoroughly addressed. In this study, we compared the surgery time, anesthesia time, bleeding, and cost between 2 well-established techniques. Electrocautery tonsillectomy/adenoid ablation was compared against traditional cold knife dissection with adenoid curette.

STUDY DESIGN AND SETTING: A retrospective chart review of 275 patients in a large tertiary teaching hospital.

RESULTS: The electrocautery group had overall savings of 8, 8, and 9 minutes in surgery, anesthesia, and operating room times, respectively. In terms of cost, the variable cost of the electrocautery group was 19% less than the cold knife dissection group.

CONCLUSION/SIGNIFICANCE: This study demonstrated that cautery ablation of adenoids, when employed as part of adenotonsillectomy, enables the surgical team to save significant amount of time, and substantial cost for patients. EBM rating: B-3.

OBJECTIVE: Several studies suggest that a reliable diagnosis of childhood sleep-disordered breathing (SDB) requires polysomnography (PSG). We compared clinical and PSG-based diagnoses in children scheduled for adenotonsillectomy (AT). Parent responses on a validated Pediatric Sleep Questionnaire were used to determine which symptoms could help identify children with clinical diagnoses of SDB but normal PSG.

STUDY DESIGN AND SETTING: Thirty-four children aged 5.0 to 12.9 years and scheduled for AT to treat clinically diagnosed sleep-disordered breathing underwent laboratory-based PSG. Results were scored by 3 different criteria: 1) >1 obstructive apnea (2 breaths or longer) per hour of sleep; 2) >5 apneas or hypopneas per hour of sleep; or 3) >1 apnea, hypopnea, or respiratory event–related arousal per hour of sleep.

RESULTS: Depending on the criterion used, the PSG documented SDB from a minimum of 18/34 subjects (53%, for criterion I) to as many as 30/34 subjects (88%, for criterion III). Among symptoms studied, absence of daytime mouth breathing and habitual snoring were most helpful in identification of children who had no evidence of SDB on PSG, by criterion I (Chi-square, P < 0.05). The absence of other common symptoms, such as “loud snoring” or “trouble breathing” at night, were not helpful.

CONCLUSION: Children with clinical diagnoses of SDB may not consistently meet PSG criteria for this disorder. Questions about daytime mouth breathing and habitual snoring might help clinicians recognize children who would not have SDB on objective testing.

SIGNIFICANCE: Clinical identification of SDB confirmable on PSG could be improved. However, available outcome data do not yet clarify whether clinical or PSG criteria best identify children likely to suffer morbidity from SDB. EBM rating: C.

OBJECTIVE: To compare contact diode laser (CDL) tonsillectomy to monopolar cautery (MPC) with regard to pain and other morbidity during recovery.

STUDY DESIGN AND SETTING: Single-blind, randomized trial in a tertiary-care pediatric hospital. Tonsillectomy was performed by CDL in 30 children and by MPC in 28. Parents completed a daily questionnaire for 10 days after surgery.

RESULTS: There was significantly less pain in the CDL group than in the MPC group. The CDL group also required much less medication, and was much less likely to experience multiple awakenings (P < 0.001 for all comparisons).

CONCLUSION: Recovery after CDL tonsillectomy was associated with much less pain and discomfort than after MPC surgery.

SIGNIFICANCE: Postoperative pain is a major concern for surgeons, patients, and their parents. The long recovery period also has costs in school days missed for the child and work missed for the parents. CDL tonsillectomy may greatly mitigate these burdens.

OBJECTIVE: Migraine-related dizziness can present with or without headache, often making diagnosis difficult. Flow velocity and CO₂ reactivity testing using transcranial Doppler (TCD) measurement of intracranial blood flow has been described as abnormal in patients with classic or common migraine. This study sought to determine the utility, if any, of this noninvasive technique in the diagnosis of migraine-related dizziness.

STUDY DESIGN AND SETTING: A prospective, controlled study in academic neurotology and neurology practices was conducted. Nine patients with migraine-related dizziness and 10 patients with no history of migraine or dizziness were tested with transcranial Doppler ultrasound in a blinded fashion.

RESULTS: No statistically significant differences in intracranial blood flow velocities or in cerebrovascular reactivity to hypocapnia were found between patients and controls.

CONCLUSIONS: Assessment of intracranial blood flow velocity and CO₂ reactivity using TCD does not help in the diagnosis of migraine-related dizziness.

SIGNIFICANCE: A reliable objective test for the diagnosis of migraine-related dizziness remains elusive, and the diagnosis of this patient group continues to be suboptimal.

OBJECTIVES: To evaluate the efficacy of modifications to the standard canalith repositioning procedure (CRP) in the treatment of benign positional vertigo (BPV) of the horizontal semicircular canal (HSC).

STUDY DESIGN AND SETTING: Prospective trial of 72 patients with BPV of the HSC treated with a modified 360-degree CRP.

RESULTS: 51 of the 62 patients treated for canalolithiasis made a complete recovery (82.2%) after a single 360-degree CRP.

CONCLUSIONS AND SIGNIFICANCE: It is proposed a full 360-degree rotation of the HSC involved. It is essential to begin rotation of the patient departing from the affected side towards the healthy side, especially for canal side cupulolithiasis and for canalithiasis of the ampullar branch of the HSC. The head resting on the chest at angle of 30-degree during rotating encourages free-floating debris in the HSC to move into the utricle. Instead of using an oscillator for oscillation of the mastoid bone the head is shaken manually.

OBJECTIVE: To assess the use of titanium prostheses in tympanoplasty for reconstruction of the sound pressure and to evaluate the audiometric results obtained.

STUDY DESIGN AND SETTING AND PATIENTS: Retrospective chart review in a tertiary referral center. Between September 1998 and October 2000, 23 titanium middle ear implants (23 TORP) were used for reconstruction of the ossicular chain after tympanomastoidectomy. Preliminary functional results were obtained in 23 cases.

RESULTS: Average follow-up time was 18 months (range, 12-40) and no adverse reactions or extrusions occurred. Seven of 16 canal wall down tympanoplasties (43.7%), and 3 of 7 canal wall up tympanoplasties performed (42.9%) had a postoperative air-bone gap of between 0 and 10 dB.

CONCLUSIONS: Preliminary results show that titanium prosthesis provide a promising hearing result after total ossicular reconstruction, although long-term results are not yet available. The low weight of these prostheses may be the reason for the decrease in the air-bone gap.

OBJECTIVE: To further optimize the surgical technique with the CO₂ laser in stapes surgery a scanner system was used to obtain a footplate perforation of 0.5 to 0.6 mm with only 1 laser application (“one-shot” stapedotomy).

STUDY DESIGN: 188 patients with otosclerosis were submitted to a primary CO₂ laser stapedotomy with the SurgiTouch® scanner. This study surveys the surgical technique and clinical results.

RESULTS: An adequately large perforation diameter could be achieved with a single shot in 68% of the patients treated with the SurgiTouch® scanner. In 11% of the patients, a second laser application at the same site was necessary. In 21% of the patients, the perforation had to be enlarged by several slightly overlapping laser applications without scanner. The clinical data of this study clearly documents that there is no evidence of laser depending inner ear affections.

CONCLUSION: The CO₂ laser combined with modern scanner systems is well suited for application in stapes surgery.

OBJECTIVE: To document the etiology and successful treatment of severe recurrent pneumoparotid.

STUDY DESIGN: Computed tomography, ductal measurement by probe size, surgical treatment.

RESULTS: We performed a superficial parotidectomy for a 13-year-old with a history of recurrent parotitis. He subsequently developed recurrent pneumoparotid in the contralateral gland with subcutaneous dissection of air into the face, neck, and mediastinum. At surgery, Stensen's ducts were measured and found to be abnormally patent bilaterally compared to standardized norms. Parotid duct ligation, commonly used for sialorrhea, was employed as a novel treatment and was curative.

CONCLUSION: Insufflation of air into the parotid duct system can trouble woodwind instrument players, can complicate dental procedures, or can be self-induced. It is generally a benign condition requiring no therapy. Occasionally, pneumoparotid can be recurrent and lead to inflammation and infection of the parotid or subcutaneous emphysema.

SIGNIFICANCE: In selected cases of recurrent pneumoparotid, ductal ligation may be curative.

OBJECTIVES/HYPOTHESIS: To present the clinical manifestation of nasopharyngeal tuberculosis.

STUDY DESIGN: Clinical analysis of 23 patients with pathologically confirmed nasopharyngeal tuberculosis was carried out retrospectively.

SETTING: Srinagarind Hospital, Khon Kaen University. Thailand.

RESULTS: The most common presenting symptom was cervical lymphadenopathy (91.3%). The common locations of nodes were the superior and middle cervical. The abnormalities of the nasopharynx were found in 16 patients. The pathological findings were caseous granuloma with positive acid-fast bacilli (AFB) in 15 cases, caseous granuloma with negative AFB in 3 cases, and chronic granulomatous inflammation with negative AFB in 5 cases. Pulmonary tuberculosis was found in 8 of 18 patients. Sixteen patients who received complete treatment responded well.

CONCLUSION: Nasopharyngeal tuberculosis commonly presents with cervical lymphadenopathy. The differential diagnosis of tuberculosis from nasopharyngeal carcinoma is difficult. In the patients who have cervical lymphadenopathy and no other identified causes, biopsy of nasopharynx would give an additive information for diagnosis.

The variety and the confusion over the name of many medical terms, including otorhinolaryngological ones prompted us to search their etymology. The term “otorhinolaryngology” (combined form from the ancient Greek words: ous, rhina, larynx, and logos) and the term indicating the specialized doctor who practices “Otorhinolaryngology,” widely known as ENT in a brief version, are being examined. The investigation leads us to see which of these terms is the appropriate and etymologically correct one, and to support clearly the term “otorhinolaryngology” instead of “otolaryngology” and “otorhinolaryngologist” instead of “ENT.”

Cough is one of the atypical manifestations of gastroesophageal reflux disorder (GERD). The aim of this study was to evaluate the prevalence of GERD among patients presenting with persistent cough. The study included 80 patients over a period of 3 years. The inclusion criteria were nonsmoker adults with normal chest radiograph whose chief complaint was cough for at least 4 weeks duration. All patients included were subjected to nasal endoscopy, laryngoscopy, and 24-hour pH monitoring. Reflux was recorded in the different positions. Laryngeal signs of reflux were traced for and their significance was calculated. Patients who proved to have GERD received antireflux treatment with a follow-up of 3 months. The response to antireflux treatment was assessed according to subjective and objective improvement. Relapse in the follow-up period occurred in 9% of patients. It is concluded that laryngeal signs of GERD should be well known to diagnose and properly manage persistent cough.

OBJECTIVES: Surface electromyographic (EMG) studies were performed on 420 normal adults to establish normative database for muscle activity's amplitude during swallowing and drinking clinically useful for ENT department.

STUDY DESIGN: Prospective observational study of healthy volunteers.

METHODS: Parameters evaluated during swallowing include the EMG activity of the orbicularis oris, masseter, submental, and infrahyoid muscle groups covered by platysma (range, mean, SD). Four tests were examined including voluntary swallow of saliva (“dry” swallow), voluntary single water swallows as normal (variable volume of a bolus), voluntary single swallows of fixed amount of water (20 mL), and continuous drinking of 100 mL of water. Activity of the above-mentioned muscles during swallowing was measured for groups of adults of different age groups. Groups included volunteers and were separated into age groups as follows: ages 18-30, 31-40, 41-50, 51-60, 61-70, and 70+ years of age.

RESULTS: Normative data for electric muscle activity (mean ± SD; range, in μV) during single swallowing and continuous drinking are established for healthy adults. The range of submental group activity during swallows showed a significant decrease with the age, whereas the range of masseter activity changed insignificantly (1-dimensional analysis of variance, SPSS, Chi-square criterion, 95% confidence interval). There were no significant changes in mean muscle activity between different age groups. These parameters represent activities required for normal deglutition, and can be used to identify abnormalities in ENT patients, and provide a basis for comparison of swallowing performance both within and between patients. These measurements can be performed in a simple way, cause no discomfort, do not use radiation, and are noninvasive. The relevance and clinical utility of new and alternative measures, in particular, are discussed.

CONCLUSIONS: In single swallow tests range of electric activity of involved muscles is more informative than its mean. In the continuous drinking test, the mean electric activity is the only electric variance that can be evaluated. Orbicularis oris muscle activity is not important when reflex phase of a swallow is evaluated. Surface EMG of swallowing is a simple and reliable method for evaluation of swallowing with a low level of discomfort during the examination. The method can be easily used in outpatient ENT departments for quick evaluation of patients. The normative amplitude data can be used for comparison purposes in preoperaive and postoperative stages and in EMG monitoring during ENT treatment.

OBJECTIVES: To develop an immune-competent animal model for mucosally derived squamous cell carcinoma (SCCA).

STUDY DESIGN: Fifteen Fischer 344 rats were inoculated with 1, 2, 5, 10, or 20 × 10 6 FAT7 cells in their flanks. The animals were observed for tumor growth and metastasis.

RESULTS: All animals developed tumors that grew exponentially. Pulmonary metastases developed in all animals and 13% developed lymph node metastases.

CONCLUSION: The FAT7 flank tumor in Fischer 344 rats is a new animal model that closely resembles the behavior of human mucosal head and neck cancer.

SIGNIFICANCE: The existence of an immune-competent, mucosally derived, and reliable animal model of SCCA that somewhat resembles human head and neck SCCA gives the opportunity to perform immune-modulating experiments on head and neck cancer in these animals. EBM rating: B-3.

Lymphatic malformation is a benign vascular lesion resulting from lymphatic tissue being isolated from the remainder of the lymphatic system. They are present at birth and up to 90% are diagnosed by 2 years of age. More aggressive lesions are usually diagnosed earlier, with low-grade lesions presenting later with fewer complications. These lesions are hamartomas and not true neoplasms. The term hamartoma is used to describe an abnormally large mass of histologically normal tissue in a normal location. The lymphatic malformation is composed of lymph-filled channels lined with a single layer of flat endothelial cells on a basement membrane. They present with either generalized edema and poorly defined borders (microcystic) or a localized area of multilocular cysts (macrocystic). The term lymphatic malformation has replaced many other outdated terms, such as lymphangioma, cystic hygroma, lymphangioma circumscriptum, and lymphangiomatosis. In this study, we present a case report of a pediatric lymphatic malformation of the sphenoid sinus. To our knowledge, this lesion has not been described in the pediatric population and has been described only once in an adult in the German literature. 1 EBM rating: C.