This “Scary Cases” video features four unique surgeries performed by Mount Sinai Otolaryngology physicians, including: removal of a two-pound goiter; a mysterious cholesteatoma that failed to appear in an audio exam; a failed follow-up appointment leading to a massive carotid tumor, and a rhinoplasty that required precision re-crafting of the septum. For more information about our faculty and specialties, visit www.mountsinai.org/ent .
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Joshua Rosenberg, MD “Scared Straight: The Caudal Septal Deflection”
Hi everyone. My name is mara Cassetti and I'm a neuropsychologist at Mount Sinai. Um an associate professor in the Icahn School of Medicine. And also the director of the ear institute at new york eye and ear infirmary of Mount Sinai. And I have a scary case to share with you. So this case began with two weeks of slowly progressive facial process. So there was a woman who developed a pretty severe pain in her face and she went to her doctor who felt it could be of a dental origin. So in fact she had one root canal and then an additional extraction of some teeth. And actually didn't lead to any improvement as far as her teeth. I mean it didn't lead to any improvement as far as her pain. Approximately after the second tooth extraction she began to develop a facial process and over the subsequent two weeks this slowly slowly began became even more severe. They gave her some initial insides thinking it could be inflammation related to the dental procedure. And when it didn't improve she saw her primary doctor, he looked in her ear, didn't find anything abnormal and felt this could be consistent with Bell's palsy. So at that point he started her on the appropriate treatment for Bell's palsy which is high dose predniSONE. After only a few days on this she developed very severe vertigo. So severe. She really couldn't walk and she presented to the emergency room. This was an emergency room at an outside hospital And they took one look at her saw that she had official paris's was extremely dizzy and started to work her up for a stroke. So at that point they obtained an M. R. I. And this is a few cuts from this M. R. I. And I'm showing you a close up here of the left ear where they determined she had a brain tumor. In fact they really weren't sure what the ideology could be but they were very concerned with these neurologic compromise. She had developed specifically the severe vertigo and the facial paralysis so they decided to transfer her to Mount Sinai when we first had the opportunity to see her on the floor. This cartoon drawing represents a little bit of what we saw at the time which was a global facial paralysis on her left side. She did have some twitching in the area of her mid phase but she couldn't close her eye. She was globally asymmetric at rest, had a significant facial droop and was having a lot of time eating and drinking. We took a look in her ear and this is maybe not the best picture you've seen of the year but it's the one we had on the floor and it shows frankly a pretty normal ear exam, not a lot of fluids, certainly nothing in the external auditory canal. Maybe if you squint your eyes, you can see just a slight erosion of bone here in the superior area of the epidemic in um near the area of the scrotum but really no obvious debris there, no obvious redness or fluid. At this point, we decided we needed to get a hearing test because she told us some very important additional facts. She said that about five years ago was the last time she had really severe vertigo. And at that point her hearing went out, they told her, well sometimes this happens and they thought she might have B. B. B. V. In fact, over time, her vertigo seemed to get better. And although her hearing never did, she didn't really feel like it bothered her. She had a pretty severe hearing loss up to down to about 20% of word recognition on that sign. At this point we decided to get a cat scan and that's where we really had a sense of what could be going on. We're gonna highlight here what's going on in the area of the left temporal bone. And we're moving from superior. And as we go down, we see here in the area of the petrus apex, that's the portion of the temporal bone behind the interior. There's a scalloping out an erosion of this area of actually the capsule bone and extending into the petrus apex. And this is a pretty extensive area of erosion. In fact, it takes over multiple portions of the of the semicircular canals and here extends into the area of the of the labyrinthian portion of the facial nerve. And ultimately we're going to see into the area of the ganglion. Here's a close up of that same scalloped erosion in the area of that hard coded capsule bone with extension into the internal auditory canal, uh into portions of the um fungus of the internal auditory canal, the vestibule, and even a budding up into the cochlea. There were multiple areas where the facial nerve was involved. Here we have a corruptible image of that same sign showing us all the way medial to the semicircular canals and medial to the cochlea, where we see the scalloped erosion pretty significant down into the um extending deeply into the area of the petrus apex. And here we're getting a sense of how in intimately this pathology involved the facial nerve. It really looped around the entirety of the oda capsule bone, which is often not involved um because of how hard and difficult um how hard that bone is here. We see direct involvement in the area of the genetically ganglion. Some of our early scans, when we then had a chance to go back to these that had been done at the outside hospital, we started to make a differential diagnosis. One of the things we noted was that this did not enhance typically scary things actually enhance, but meningioma as cholesterol thomas and some Schwan omagh's may not enhance, including those of the facial nerve, interestingly, although this was not done for cholesterol toma. There were some signs of this diffusion weighted imaging that suggested she might have a cholesterol toma and in fact we decided we needed to approach this rather quickly. She had had a very rapid declination in her facial function. It was pretty severe at that point and the scans suggested she needed fairly urgent intervention. So at this point we performed a trans labyrinthine approach, not for a vestibular Schwann oma, but in fact for a cholesterol toma inter operatively we found cholesterol toma everywhere. It was in all the semicircular canals into the internal auditory canal, filling the vestibule and really covering the facial nerve all the way from the I. A. C. Down to its master segment. So we were able to remove that cholesterol toma. It was intense involved with the facial nerve. We dissected it off and decompressed the entirety. We were actually kind of optimistic in the O. R. Because we had um some some ability to stimulate the nerve at about two million amps which we thought was certainly not normal but perhaps optimistic. Of course this involved the internal auditory canal. So we encountered CSF and ultimately had to perform as planned uh over closure of your canal with a fat plugging up for you station tube to take care of that CSF leak and miraculously post operatively her facial nerve actually improved within about a week. Post operatively her facial nerve started to improve and she actually came back down to a house Brachman number two, she is still a symmetric at rest but importantly very happy because she has complete eye closure. So this scary case was a good reminder of how some often very common things can present in a really uncommon and frankly quite scary way. Thanks a lot. Hello everybody. My name is Diana Kirk and I'm an assistant professor in the department of otolaryngology, head and neck surgery at Mount Sinai Hospital. I'm going to be presenting today quite a scary case of the giant or perhaps as you'll see the ginormous thyroid. So this was a gentleman who's 68 who presented to me funnily enough last October. So quite a seasonal presentation. He presented to me with this quite scary giant thyroid which as you can see is quite prominent in his neck. And after a work up after we did ultrasound of the thyroid, checked his thyroid function tests. We also did a cat scan as well. We decided to book this gentleman for surgery because he was starting to get some compressive symptoms from this very large goiter. And if you got a little bit closer to it it looks quite ginormous. So as a surgeon, this is a little bit of a trick because you have to think about how you're going to approach this surgically and what needs to be done. But it's also a bit of a treat these large thyroids because you know, they sort of auto dissect a little bit. But you really do need to make sure that when you're planning your surgery that you absolutely get a cat scan of the neck because you want to really assess the inferior extent of this start and really understand how much of it goes retro internally, how much of it goes, retro trachea lee and whether you're going to need any other access maneuvers or assistance from your thoracic colleagues. So those things should really be planned before you go in. So we got the CT scan and as you can see here the mass has a para pharyngeal involvement. And then as you go down there's two big large masses in the neck here of each of the lobes are some calcification. There's also an isthmus component to this and it does dive down just a little bit retro sternal lee. But no retro trickle extension. If you look here at the corona, lol, you also want to take a look at this and I think this gives a nicer image and relationship to the a nominate artery and the next. I like also reviewing these before the surgery. And you can see here there's only a little bit of diving down behind the retros internal area and it's just a budding the a nominate artery there which is important important to see and plan for your surgery. But keeping in mind that when you get a ct neck, the patients obviously got their neck flexed rather. So it does over call the extent of retro sternal extension. So this is what the mass looks like. It becomes more ginormous, doesn't it? This is what the mass looks like when the patient was on the operative table as we're preparing for the surgery. And really this is something that you want to think about before you even get the patient in the operating room as to the maneuvers that you'll do. So those maneuvers include broad exposure. There's no minimally invasive approach for something like this at all. So you can see here, I've got the mass well exposed. I've split the strap muscles, I've split the eastern Oklahoma asteroid. I've got broad exposure and funnily enough, when I was putting this presentation together and there was some machine learning of the picture that the computer thought it was a pumpkin, which I thought was quite interesting and quite seasonal once again, but certainly it's not a pumpkin, pumpkin, it's just a very ginormous thyroid gland. So, as I've already mentioned, no incision is too big. You want to get broad exposure. You absolutely want to divide strap muscles for something like this. You do not want to be operating down a hole. And in this case I absolutely divided the stern Oklahoma asteroid and I utilized ligature or harmonic, whichever one you've got available to you in order to do that because you really want those muscle bellies to be nice and dry because you can get quite a little bit of bleeding from those. So this was the thyroid on the back table once again quite large. You know it does look a little bit smaller once you d vascular ISAT interestingly enough but it was still 15 cm wide and 15 cm high. So the final weight was £2. And the only reason I know this is because when I called the family to tell the tell them that the surgery went well they asked me how much it weighed because they themselves were having an internal competition Um in terms of going away because they all had their Goydos out in this particular family interestingly enough there is an Internet site that you can go to to see what £2 actually is in general terms and apparently it's the weight of a gray squirrel. So a seasonal animal for this time of year. You can see that post operatively at the end of the case it looked really well and completely different to what was presented to me. So this is the treat in the case um for something like this. Thank you for your time. I hope you enjoyed that scary case. If you have any questions please do not hesitate to reach out to me. This is my cell and my email address is here. It was a pleasure to present this to you. Thank you. Hi this is Nazir Khan. I'm one of the head and neck surgeon at Mount Sinai health system. I wanted to present one of my scary cases today. This is a story of a 44 year old man who was initially evaluated for a neck mass and was recommended to have a needle biopsy but was lost to follow up until uh the neck mass started to increase in size and started to become pretty pulse style. As you can see on this scan. He had a large left sided neck mass. And this was a carotid body tumor with the classic sign of displaying of the internal and external carotid arteries. And you can see here the external on the front and the internal on the back. This tumor actually went up pretty high into the power differential space. And you can see on this cut of the axial scan the top of the tumor here. And you can see that that's the left tonsils and these are the maxillary teeth. So this is up pretty high in the power differential space. So keys to this case for me are that collaboration is key here. Um I have the vascular surgeon see this patient and the interventional radiologist also involved in this case in order to perform an embolization of the tumor and uh perform a balloon occlusion test in order to evaluate the flow through the left internal carotid artery as well as the collaterals. And will this patient tolerate having the left internal carotid artery included for a period of time. On the day of surgery. I have the vascular surgeon in the room with me and we dissect this together. And you can see here this is intra operatively. Um You can see the hipaa glass cell nerve has been dissected. Here's the stump of the external carotid artery after it was litigated during the reception. The vessel loops are wrapped around the left internal carotid artery. And this is a large just under seven cm left sided frosted body tumor. And you can actually see the embolization coils in the back here. This is just about the size of a small pumpkin at the end of the case. You know there was enough damage to the advantage of the internal carotid artery that a group decision was made that we would reconstruct the internal carotid artery using a staff in this vein graft. And you can see in this video the pulse of the internal carotid artery running through the softness vein graft. Ultimately the patient did great and was um discharged on postoperative day three. Some of the keys to the surgery collaboration is key if without the help of great vascular surgeons and interventional radiologist this would this case would be very very difficult. We perform embolization for larger tumors and find it can be helpful. We don't always m belies smaller carotid body tumors but with this large tumor up into the power foreign jail space. I believe the embolization really helped with getting around the top of the tumor with a tumor going this high into the power differential space. You have to be very meticulous with your dissection and have patients due to the vascular charity on the superior side of the tumor. Um You know if without dropping the without dissecting the tumor slowly the only other approach would be to split the mandible and we wanted to avoid that approaching this patient. So meticulous dissection, cutting the styling mandibular ligament allowed us more access into the periphery real space and then getting control of critical neurovascular structures early before dissecting the tumor is very important. We get control of the internal and external carotid arteries as well as the common carotid artery. We dissect out the vagus nerve, the hipaa glassell nerve as well and have all these structures mobilized before we start dissection along the tumor. If you haven't referral or any questions about similar cases please feel free to contact me at (347) 880 6-94 or email me. Thank you. Happy Halloween. I'm Joshua Rosenberg, the chief of the division of facial plastic reconstructive surgery. A Mount Sinai today I'm talking about scared straight the concept of deflection. Trick or treat. We all know what it looks like when a patient has a severe central deflection. It can involve a lot more than just removing a little bit of septal cartilage and in some cases can really need basic reconstruction of the entire nasal framework and I'm here today to talk to you about what we do with a caudal simple deflection. So this patient walks in your office and you can see she has a bit of a crooked nose and you look at the base view, you can see the cartilage of receptor is clearly coming out the right side. When you look on interior in Oscar p. You can also clearly see that not only is the coddle septum here, but there's a full right angle, turn right on the caudal aspect of the septum and then in september also obstructing the left side. And so when we see this kind of anterior caudal septal deflection. We know that it involves a lot more than just your routine septa plastic because we can't simply remove some central septal cartilage and call it a day. We have to rebuild the entire anterior support mechanism the nasal septum that that key caudal portion of the l stripe. So when you look here traditional sep capacity versus what we do in anterior coddle or septal reconstruction and nutritional septa capacity for the majority of our patients. The sub construction is either sitting along the max awaited crest or further back in the nose. We know that we can safely remove the central portion of septal cartilage, leaving about a centimeter two centimeter half dorsal and caudal strut and that will provide more stability and integrity for the nose. But when a patient has a severe cottle deflection like what we saw here, where you can see the whole septum is crooked. We know there that we can't just simply remove the the deflected part that there is going to be. If we remove this area, they're gonna lose all the main support mechanisms of their nasal tip and really lose structural integrity of their nose and that certainly won't help their breathing. And so this calls really for a radically different approach. And this is what's been described as interior coddle septal reconstruction or modified extra portal septa plastic. And there are some key aspects of this one is this isn't just a septa plastic. This is really a total septa rhinoplasty. And this involves not only removing the deviated portions of the septum but rebuilding them and then rebuilding the nasal tip structures and the nasal valve structures around the new coddle septal strike number two is you generally will do this be an open approach and so that these patients will have wide exposure and our ability to see all of the key portions of the capitalizes framework of the nose. And so when we do this kind of capacity instead of just removing this central portion, we remove the coddle strut and the central portion, leaving only this dorsal l. Strut in the patient. Everything else comes out and then we're able to turn that around, rebuild it carve it out and create a new dorsal L. Strut and you can see here, this is a great example of this kind of septal cartilage being removed where the L. Street has come out. The coddle L. Street has come out along with the septal cartilage. And this is part of a larger septa rhinoplasty where where we're also rebuilding the strut and then redoing the entire nasal tip support mechanisms and also the nasal valve supports all of which are key parts of structural rhinoplasty, key parts of extracorporeal septa rhinoplasty and finally key parts of nasal breathing. And you can see here this is our patient. Three months after surgery, you're able to affect definitely a straighter nose. But also you can clearly see in her based on her nares that she's has a much much more wide open nose um and a better nasal airway to go along with the maintain maintenance of all her nasal tip uh and nasal framework support structures. And you can also see in her dorsal view there and finally happy Halloween and enjoy the holiday
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