This is an analysis of 1,024 primary cases of mastoid surgery for cholesteatoma operated upon during a ten-year period at the Otologic Medical Group, Inc. Our philosophy of management of the mastoid in these cases has been as follows: 1) avoid an open mastoid cavity when possible; 2) perform the operation in two stages if necessary; 3) reexplore the mastoid and middle ear for residual cholesteatoma when indicated. One-third of 380 revised cases had residual cholesteatoma, disease left by the surgeon. In 260 cases in which the surgeon felt it unlikely that there was residual disease he found it in 23%. In 4% this residual cholesteatoma was found in the mastoid. The incidence of residual cholesteatoma was higher in children and in planned, as opposed to unplanned, revisions. Residual cholesteatoma was detected in the middle ear more frequently than in the epitympanum, and in the epitympanum more frequently than the mastoid. Indications for, and timing of, the reexploration are discussed. Recurrent cholesteatoma refers to a retraction pocket and must be differentiated from residual cholesteatoma; the causes, prevention and treatment are different. Recurrent cholesteatoma was detected in 5%. The most common complication of the disease was a labyrinthine fistula (10%). Operative facial nerve damage occurred in one case. The most common postoperative complication was graft failure (3%). Intact canal wall tympanoplasty with mastoidectomy should be performed as a two-stage procedure in most cases when used in the treatment of aural cholesteatoma.
This study assesses the safety and effectiveness of balloon catheters used as instruments in sinus surgery in a "real-world" multicenter registry of 1,036 patients across 27 US otolaryngology practices.
Data were collected by standardized chart review with centralized database administration for all consecutive functional endoscopic sinus surgeries that included the use of balloon catheters across the 18-month time period from December 2005 to May 2007.
Balloon catheters were used in 3,276 peripheral (maxillary, frontal, and sphenoid) sinuses, for an average of 3.2 sinuses per patient. There were no major adverse events related to the use of balloon catheter instruments. The revision rate was 1.3% of sinuses treated with a balloon catheter after an average follow-up of 40.2 weeks. Sinus symptoms were improved in 95.2%, unchanged in 3.8%, and worse in 1.0% of patients. Postoperative sinus infections were significantly less frequent and less severe compared to infections before surgery. The results were consistent across all patient categories, including balloon-only patients and revision patients.
Use of balloon catheters as instruments in sinus surgery appears to be relatively safe and effective and to improve the patient's quality of life. The results are consistent and generalizable across a wide range of sinusitis patients and physician practices. The complication rates, revision rates, and patient symptom improvement rates all compare favorably with previously reported results of functional endoscopic sinus surgery.
We hypothesized that bisphosphates, a class of antiosteolytic drugs that affect bone cells, may block localized bone modeling in the middle ear. Prior studies have shown that transmitted pressure in the middle ear leads to osteoclastic bone resorption. Catheters were surgically implanted into the middle ear cavity (bulla) of 31 Mongolian gerbils. The animals were then divided into two groups, one subset receiving a bisphosphonate, and the other receiving no drug. Positive air pressure was applied to one middle ear, and the other side served as a control. At the end of the experimental period, tissue specimens were obtained, and histomorphometric evaluation of the ventral bullae was performed. Significant differences in osteoclast surface, osteoclast number, and mean individual osteoclast profile area led us to conclude that administration of the bisphosphonate used at the dose studied inhibits localized recruitment and activation of osteoclasts.
Flexible endoscopic evaluation of swallowing with sensory testing (FEESST) is a comprehensive endoscopic assessment of the sensory and motor components of a swallow. Previous studies addressing patient safety issues with respect to FEESST included relatively small numbers of patients and paid almost no attention to patient characteristics. The purpose of this study was to determine the incidence of FEESST-related complications in the outpatient and inpatient settings and to analyze patient diagnoses that led to the performance of FEESST. We performed a prospective study of FEESST complications in 1,340 consecutive evaluations performed over a 4 1/2-year period. The primary outcome variables were incidence of epistaxis and airway compromise. The secondary outcome variable was underlying patient diagnoses. The incidence of epistaxis was 1 in 1,340 (0.07%). There were no instances of airway compromise. Stroke was the most common reason for the performance of FEESST (343; 25.6%), followed by cardiac-related dysphagia (298; 22.2%) following open heart surgery (169/298; 56.7%), heart attack, congestive heart failure, or new arrhythmia. The remaining causes were head and neck cancer (207; 15.4%), pulmonary disease (141; 10.5%), chronic neurologic disease (124; 9.3%), and acid reflux disease (80; 6.0%). We conclude that FEESST is a relatively safe procedure for the sensory and motor assessment of dysphagia in a cohort of patients with a wide variety of underlying diagnoses. The emergence of cardiac surgery as a common cause of dysphagia warrants further study.
We retrospectively reviewed 1,465 stapes operations for facial canal dehiscences. The incidence of facial canal dehiscence was found to be 11.4%. A facial canal dehiscence with protrusion of the facial nerve is more common than a dehiscence without protrusion. In addition, 3 cases (0.2%) had a herniation of the facial nerve. Our data suggests that heredity could be one of the factors associated with a facial canal dehiscence. If an operated ear shows a dehiscent facial canal, there is a 29% possibility that the contralateral ear also has a dehiscence. Bilaterality of facial canal dehiscence is, therefore, exceptional.
We proved a 1,555 mutation of mitochondrial DNA in one member of each of three families with familial streptomycin hearing loss, and report the pedigrees and audiologic features. DNA was extracted by the standard method. The 1,555 A to G mutation was identified in all three patients and confirmed by direct sequencing of the polymerase chain reaction products by a cycle sequencing method. On audiograms, the hearing loss was sensorineural, bilateral, and symmetric, showing a high-tone loss or a profound loss particularly in the high-tone range, and the "symmetry law" of Langenbeck was applicable. The superimposed audiograms of members of one family did not cross themselves, proving the applicability of the "never-cross principle of audiograms."
Endoscopic diverticulotomy for the treatment of Zenker's diverticulum has been reported infrequently in the literature and has engendered considerable controversy. Between March 1992 and September 1996, we attempted to treat 102 patients with endoscopic treatment for pharyngoesophageal diverticula. In 98 patients, the endoscopic surgery was successfully completed. Conversion to open surgery was required in 4 patients (3.92%). One cartridge of staples in 16 patients (16.32%), 2 cartridges in 78 patients (79.59%), and 3 cartridges in 4 patients (4.08%) were used, according to the size of the diverticulum; the median duration of the procedure was 20 minutes (10 to 60 minutes). No postoperative morbidity or mortality was recorded. Oral feeding was started following radiologic control after a median of 2 days; the median hospital stay was 4 days. The median follow-up is 16 months (1 to 45 months). Four patients operated on before the introduction of the modified stapler showed a persistent diverticular pouch: 3 underwent repeat endoscopic operation, and 1 underwent conventional open surgery. All treated patients are asymptomatic. Manometric study performed in 15 patients showed a significant reduction of basal upper esophageal sphincter pressure compared to preoperative data (48.30+/-21.74 versus 29.38+/-5.68 mm Hg; p<.01). We therefore recommend endoscopic diverticulotomy, considering that the procedure is relatively safe and effective, with minimal patient discomfort, and the results are equal to those of the external approach. This procedure offers the advantages of short hospitalization, rapid convalescence, brief operative time, absence of skin incision. predictable resolution of symptoms, and reduced morbidity.
A new head and neck cancer cell line was developed from a highly aggressive HNSCC of the oral cavity diagnosed in a 26-year-old pregnant woman.
Cells from the primary tumor were passaged in culture and genotyped as a unique cell line. The resultant cell line was assessed for its ability to replicate the primary tumor.
The primary tumor and cell line contained 19.03% and 19.62% CD44(high) cells, respectively. CD44(high) cancer stem cells from UM-SCC-103 formed tumors after flank injections in mice that reconstituted the heterogeneity of the primary tumor. CD44 staining and histology in the primary tumor and tumors grown in vivo from the cell line were similar. CD44(high) cells from the primary tumor resulted in lung colony formation in 2 out of 2 tail vein injections in mice, whereas CD44(low) cells did not. Similarly, CD44(high) cells from UM-SCC-103 formed lung tumors in 2 out of 4 mice, whereas CD44(low) cells did not.
The similarity in marker expression and tumorigenic behavior between the primary tumor and the resulting cell line strongly suggests that the cell line resembles the primary tumor that it was derived from and provides an important new research tool for the study of head and neck carcinomas in young patients.
To acquire more insight into the results of treatment versus the "natural" course of glomus tumors, we studied the clinical data of 108 patients, in 58 of whom the disease was hereditary. During a period of 32 years (1956 to 1988), 175 tumors were diagnosed: 52 glomus jugulotympanic tumors, 32 vagal body tumors, and 91 carotid body tumors. The results of radical surgical treatment were disappointing for tumors located at the skull base, ie, nonradical in 59% (n = 23) of the cases, but very good for the carotid body tumors, for which 96% (n = 68) radical excision was achieved. Moreover, surgery at the level of the skull base dramatically increased morbidity, since it frequently induced cranial nerve palsy. During the follow-up period (maximal observation time 32 years, mean 13.5 years) none of the patients died of residual or recurrent tumor or developed distant metastases, irrespective of the mode and outcome of treatment. When these results are combined with the results of pedigree analysis, a realistic approximation of the "natural" course of the disease for both hereditary and nonfamilial tumors can be made. The results raise the question of whether this natural behavior is really improved by intervention. We conclude that removal of carotid body tumors and solitary vagal body tumors should be considered in order to prevent future morbidity. However, for skull base and bilateral glomus tumors a more conservative monitored "wait and see" policy can be sensible and should be considered in any proposal for treatment of head and neck paragangliomas.(ABSTRACT TRUNCATED AT 250 WORDS)
After the 9/11 terrorist attacks on the World Trade Center in New York in 2001, thousands of response workers were exposed to complex mixtures of toxins, pollutants, and carcinogens. Many developed illnesses involving the respiratory tract. We report unusual ultrastructural ciliary abnormalities in 3 response workers that corresponded to their respiratory and ciliary functional abnormalities. Each patient had respiratory cilia biopsies that were evaluated for motility and ultrastructural changes. Impaired ciliary motility was seen in 2 of the 3 patients. Each of the patients showed monomorphic ultrastructural abnormalities. Two of the patients showed identical triangular disarray of axonemal microtubules with peripheral doublets 1,4, and 7 forming the corners of the triangle and doublet 9 always more medially displaced than doublets 2, 3, 5, 6, and 8. Two workers had cilia in which axonemes were replaced by homogeneously dense cores. One of these also had cilia with triangular axonemes as previously described. The other had cilia with a geometric triangular to pentagonal shape. The ciliary abnormalities described here may represent a new class of primary ciliary dyskinesia in which abnormalities may have a genetic basis and a phenotypic expression that is prompted at the cellular level by local environmental conditions.
We investigated the cause of autosomal recessive nonsyndromic hearing loss (ARNSHL) that segregated in 2 consanguineous Iranian families.
Otologic and audiometric examinations were performed on affected members of each family. Genome-wide parametric multipoint linkage mapping using a recessive model was performed with Affymetrix 50K GeneChips or short tandem repeat polymorphisms. Direct sequencing was used to confirm the causative mutation in each family.
In 2 Iranian families, L-1651 and L-8600606, with ARNSHL that mapped to the DFNB7/11 locus, homozygosity for a reported splice site mutation (c.776+1G>A), and a novel deletion (c.1589_1590delCT; p.S530*) were identified in the TMC1 gene, respectively.
Consistent with the previously reported phenotype in DFNB7/11 families, the 2 Iranian families had segregated congenital, profound hearing impairment. However, in family L-1651, one affected family member (IV:3) has milder hearing impairment than expected, suggesting a potential genetic modifier effect. These results indicate that DFNB7/11 is a common form of genetic hearing loss in Iran, because this population is the source of 6 of the 29 TMC1 mutations reported worldwide.
We studied the clinical characteristics of an Australian family with an autosomal dominant sensorineural hearing impairment (DFNA9) caused by an I109N mutation in COCH.
Retrospective analyses of audiometric data from 8 mutation carriers of an Australian DFNA9 family with the I109N COCH mutation were performed. Cross-sectional hearing levels related to age, age-related typical audiograms, and speech recognition scores related to age and to the level of hearing impairment were investigated. Data were compared to those obtained in previously identified DFNA9 families with P51S, V66G, G87W, G88E, I109T, and C542F COCH mutations.
Deterioration of hearing in the I109N mutation carriers started before the age of 40 years. The audiometric characteristics of the I109N mutation carriers are essentially similar to those previously established in I109T mutation carriers and, to a lesser extent, in P51S, G87W, and G88E mutation carriers.
The phenotype associated with the I109N COCH mutation is largely similar to that associated with the I109T, P51S, G87W, and G88E mutation carriers. However, subtle differences seem to exist in terms of age of onset and rate of progression.
The field of otolaryngology-head and neck surgery has seen many advances in the treatment and prognosis of malignant external otitis (MEO). However, establishing the resolution of the infection remains problematic. A recent report suggests that indium 111-labeled white blood cell scintigraphy may be a reliable and timely indicator of resolution of infection. We present a case of a false-negative white blood cell scan in a patient with persistent MEO. A discussion of this case and a review of the literature illustrate that there continues to be no "gold standard" for establishing MEO resolution.
This retrospective study looked at the role of indium 111-labeled white blood cell (111In WBC) scintigraphy in head and neck infections. The efficacy of 111In WBCs was compared to gallium 67 citrate (67Ga) and technetium Tc99m methylene diphosphonate (99mTc MDP) scintigraphy in detecting and monitoring the resolution of infection. For 22 active infections, the sensitivities for 111In WBC, 67Ga, and 99mTc MDP scintigraphy were 94%, 56%, and 86%, respectively, and the specificities for 111In WBC, 67Ga, and 99mTc MDP scintigraphy were 100%, 43%, and 0%, respectively. For 8 successfully treated infections, all seven 111In WBC studies became negative after therapy, in as short an interval as 1 month. In contrast, all seven 99mTc MDP images remained positive for as long as 6 months after therapy. The seven 67Ga studies had variable results, with four (57%) remaining positive, including two (28%) positive at 6 months after therapy. These results suggest that 111In WBC scintigraphy should be the initial radionuclide imaging tool in detecting active head and neck infections because of its greater accuracy, and its ability to revert to normal much sooner than 67Ga or 99mTc MDP scintigraphs when applied to a subset of patients with resolved infections.
The medical charts and operative files of 112 patients (combined inception cohort) with well to moderately differentiated invasive glottic squamous cell carcinoma presenting fixation (22) or impaired motion (90) of the true vocal cord (TVC) consecutively treated with cricohyoidoepiglottopexy (CHEP) at our institutions from 1972 to 1989 were retrospectively reviewed. A minimum 5-year follow-up was always achieved. The Kaplan-Meier 5-year actuarial survival, local recurrence, nodal recurrence, distant metastasis, and metachronous second primary tumor estimate for the entire group of patients were 84.7%, 5.4%, 6.4%, 1.2%, and 10.8%, respectively. The 5-year absolute and cause-specific survival rates were 85.5% and 94.1% for patients with fixation of the TVC and 81.3% and 96% for patients with impaired motion of the TVC. The 5-year actuarial local control rates for patients with fixation or impaired motion of the TVC were 95.4% and 94.4%, respectively. Local recurrence was statistically more likely in patients with positive margins (p = .007). Nodal recurrence was statistically more likely in patients with local recurrence (p = .005). Permanent tracheostomy related to postoperative laryngeal stenosis was requested in 2 patients. Aspiration-related completion total laryngectomy and/or permanent gastrostomy were never requested. Overall, local control and laryngeal preservation were achieved in 97.3%, and 95.5% of patients, respectively. At our institutions, the change from the conservative treatment modalities of radiotherapy and vertical partial laryngectomy to CHEP has brought about an increase in long-term survival, local control, and laryngeal preservation rates when compared to historical controls using vertical partial laryngectomy or radiotherapy.
The purpose of this report is to promote early recognition, expeditious evaluation, and judicious management of acute external laryngeal trauma. A retrospective chart review was performed of 112 cases that were managed at a Medical College of Georgia tertiary care hospital by the senior author (E.S.P.). Patients were classified by the time of their presentation, the severity of their injury, and the treatment protocol followed. The clinical outcomes of airway, voice quality, and deglutition were retrospectively reviewed. For voice outcomes, in the delayed treatment group, only 27.7% of patients had a good result, as compared to a 78.3% good result in the early treatment group. Similar differences were demonstrated regarding the airway. In the delayed treatment group, only 73.3% had good airway function, as compared to 93.3% who had good airway function in the early treatment group. Ninety-nine percent of all patients had a good result for deglutition. We conclude that expeditious diagnosis and intervention reduce the incidence of suboptimal clinical outcomes, and with timely and appropriate application of diagnostic and management protocols, the majority of patients will be successfully decannulated (97%) with functional speech (100%) and normal deglutition (99%).
A review of 112 patients 5 years of age and younger with cervical abscesses is reported. Staphylococcus aureus and group A beta-hemolytic Streptococcus were cultured most often: in 39% and 17% of patients, respectively. Sixteen patients (14%) had unusual abscesses such as infected congenital cysts, cat-scratch disease, or myocobacterial abscesses. One patient had a necrotizing infection with group A streptococci and anaerobic streptococci. Intravenous antibiotic therapy was used in 104 patients, with 94% of these patients receiving a penicillin derivative, usually an antistaphylococcal penicillin. Ninety-six percent of the patients had incision and drainage of their abscesses; 8 patients required more than one incision and drainage. Two patients required airway intervention, 1 by intubation and 1 by trachetomy. Most pediatric cervical abscesses respond well to appropriate intravenous antibiotic therapy and incision and drainage.
From April 1987 to April 1992, 116 phonosurgical procedures were performed to treat glottal incompetence. The initial numbers of these surgical procedures included the following: 29 primary Silastic medializations, 3 primary Silastic medializations with arytenoid adduction, 53 secondary Silastic medializations, 4 secondary Silastic medializations with arytenoid adduction, and 11 bilateral Silastic medializations. These procedures are useful in treating unilateral true vocal cord paralysis, scarring, bowing, or paresis, as well as bilateral true vocal cord bowing. Of the initial 100 patients, 16 later underwent a revision with either a larger implant's being placed or an arytenoid adduction. Primary Silastic medialization is the placement of an implant under general anesthesia in the same surgical setting in which laryngeal innervation is sacrificed. Secondary Silastic medialization is the placement of an implant under local anesthesia for a preexistent vocal cord malfunction. In either case, overall voice results for unilateral paralysis are very good. Primary Silastic medialization significantly decreases the postoperative rehabilitation period in skull base patients because of the immediate postoperative glottal competence and decreased use of perioperative tracheotomy. Bilateral implants yielded good results in 6 patients with presbylaryngis, but 6 other patients with bowing from other causes experienced only moderate improvement in speech quality. There were no implant extrusions; however, 1 implant was removed secondary to a persistent laryngocutaneous fistula in a patient who had previously undergone laryngeal irradiation. This was the only complication in this series.
At present it is believed that the pharyngeal constrictor (PC) muscles are innervated by the vagus (X) nerve and are homogeneous in muscle fiber content. This study tested the hypothesis that adult human PCs are divided into 2 distinct and specialized layers: a slow inner layer (SIL), innervated by the glossopharyngeal (IX) nerve, and a fast outer layer (FOL), innervated by nerve X.
Eight normal adult human pharynges (16 sides) obtained from autopsies were studied to determine 1) their gross motor innervation by use of Sihler's stain; 2) their terminal axonal branching by use of acetylcholinesterase (AChE) and silver stain; and 3) their myosin heavy chain (MHC) expression in PC muscle fibers by use of immunocytochemical and immunoblotting techniques. In addition, the specialized nature of the 2 PC layers was also studied in developmental (newborn, neonate, and senescent humans), pathological (adult humans with idiopathic Parkinson's disease [IPD]), and comparative (nonhuman primate [adult macaque monkey]) specimens.
When nerves IX and X were traced from their cranial roots to their intramuscular termination in Sihler's-stained specimens, it was seen that nerve IX supplied the SIL, whereas branches of nerve X innervated the FOL in the adult human PCs. Use of AChE and silver stain confirmed that nerve IX branches supplying the SIL contained motor axons and innervated motor end plates. In addition to distinct motor innervation, the SIL contained muscle fibers expressing slow-tonic and alpha-cardiac MHC isoforms, whereas the FOL contained muscle fibers expressing developmental MHC isoforms. In contrast, the FOL became obscured in the elderly and in the adult humans with IPD because of an increased proportion of slow muscle fibers. Notably, distinct muscle fiber layers were not found in the human newborn and nonhuman primate (monkey), but were identified in the 2-year-old human.
Human PCs appear to be organized into functional fiber layers, as indicated by distinct motor innervation and specialized muscle fibers. The SIL appears to be a specialized layer unique to normal humans. The presence of the highly specialized slow-tonic and alpha-cardiac MHC isoforms, together with their absence in human newborns and nonhuman primates, suggests that the specialization of the SIL maybe related to speech and respiration. This specialization may reflect the sustained contraction needed in humans to maintain stiffness of the pharyngeal walls during respiration and to shape the walls for speech articulation. In contrast, the FOL is adapted for rapid movement as seen during swallowing. Senescent humans and patients with IPD are known to be susceptible to dysphagia; and this susceptibility may be related to the observed shift in muscle fiber content.
Injectable bovine collagen has been used for treatment of glottic insufficiency at the University of Wisconsin Clinical Science Center since 1983. This report reviews our experience in treating 119 patients with a variety of vocal fold disorders manifested by glottic insufficiency. Many of the patients were referred because of prior treatment failures or problems that were impossible to treat with other modalities. Results were assessed by comprehensive voice evaluations using subjective patient self-assessments, perceptual judgments made by a panel of experts who had no prior knowledge of the study, objective assessments, and videostroboscopy. Objective assessment included vocal function measures and acoustic analysis. Results indicate that collagen not only is comparable to other injection filler substances but also has unique advantages as a bioimplant. Collagen injection seems uniquely suited for treatment of several problems, including vocal fold atrophy, focal defects, minimal glottic insufficiency, and scarred vocal folds that are not managed optimally with Teflon injection. Overall there were no serious complications and treatment was effective for a broad spectrum of problems. In most instances the correction persisted, and in those instances in which injected collagen seemed improperly distributed, the vocal fold was recontoured or the implant removed without appreciable damage to the surrounding tissues. Injectable collagen has been extensively studied and deserves to be included in the armamentarium of the laryngeal surgeon.
Isolated sphenoid sinus disease (ISSD) is a relatively uncommon disease. The present study is a retrospective review of 122 patients with ISSD who were treated at the Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital at Shanghai Medical University over a 25-year period. The diagnosis of ISSD was made on the basis of history and physical examination, signs and symptoms, nasal endoscopy, and computed tomography (CT) and magnetic resonance imaging (MRI). The final diagnosis of ISSD was confirmed by histopathologic and microbiological examinations of the surgical specimens. The pathological findings in this study included sphenoid cyst (47 cases), sphenoid sinusitis (31 cases), fungal disease (19 cases), inverted papilloma (4 cases), sphenochoanal polyp (1 case), foreign body (8 cases), malignant tumors (8 cases), and others (4 cases). The most common initial symptom was headache, followed in decreasing order by visual changes, cranial nerve palsies, and nasal symptoms. The more frequent use of routine CT and MRI scanning, as well as endoscopy, in the diagnosis of sinus disease has led to an increase in the early diagnosis of ISSD. The recent advances in endoscopic sphenoidotomy has allowed for relatively safe and immediate treatment of ISSD, preventing late extension into adjacent vital structures, which is commonly fatal. Endoscopic surgery also enables the surgeon to make a precise pathological diagnosis.
We retrospectively reviewed our experience with 24 patients in the treatment of advanced recurrent squamous cell carcinoma of the head and neck, using salvage surgery and intraoperative iodine 125 (125I) implantation. Surgical complications and survival results were compiled and compared with those of other studies. The long-term effect of 125I on the carotid artery was evaluated by ultrasound. We had a major complication rate of 21% and an overall complication rate of 50%. Our 2-year overall and determinate survivals were 29% and 50%, respectively. Within the survival group, carotid ultrasounds were obtained to evaluate the long-term effect of 125I. All ultrasounds obtained at least 1 year from the time of treatment showed minimal or no change from the contralateral side. We conclude that intraoperative 125I and salvage surgery are an acceptable treatment for recurrent squamous cell carcinoma with minimal complication and effect on the carotid artery.
The records of 126 patients with recurrent pleomorphic adenoma of the parotid gland treated at our institution from 1965 to 1985 were retrospectively reviewed. Multiple variables were analyzed to determine tumor behavior and treatment results. Of the study patients, 61% were female and 39% male, with a mean age of 35.6 years at the time of treatment at our institution. The average follow-up period was 14.5 years. Tumor recurrence was 32.5% after one operation at our institution, 7.1% after two operations, and 1.6% after three. Malignant disease occurred in 9 (7.1%) patients. After all surgical procedures, partial facial nerve paralysis was noted in 13.5% and total paralysis in 5.5%. These results suggest low morbidity and good success in tumor eradication with an aggressive surgical approach.
This study reports the histopathological findings of 14 temporal bones from infants with trisomy 13 syndrome. The most primitive anomalies in the structures of the inner and middle ears in the present series are those of the semicircular canals, particularly of the horizontal canals: flattened horizontal canal cristae, absence or opening of the utricular endolymphatic valve, small facial nerve, and obtuse angle of the geniculate area of the facial nerve. Each ear demonstrated more than one of those anomalies. The anomalies present features similar to those found in the structures of the normal six to ten-week fetus. Many other mild anomalies observed appear to demonstrate features similar to those seen in the same structures in later fetal life. Reviewing these findings, most of the anomalies that were found in the inner and middle ears appear to be the result of poor development of the structures for reasons which are now unclear. In addition, middle ear infection was found in all cases.
Of 220 patients with sarcoidosis of the head and neck region, representing 9% of 2,319 patients with sarcoidosis seen at the Mayo Clinic from 1950 through 1981, we identified 12 who had laryngeal sarcoidosis. Edematous, pale, diffuse enlargement of the supraglottic structures was the most common laryngeal manifestation. The diagnosis is made by a group of clinical, radiologic, and laboratory findings, confirmed by the finding of noncaseating granuloma on biopsy. Sarcoidosis is a disease with frequent remissions and exacerbations and generally burns itself out; glucocorticoids may be indicated in particularly severe disease. When laryngeal sarcoidosis is suspected, the laryngologist should collaborate with other clinicians in a thorough evaluation of the patient.
Endoscopic sinus surgery (ESS) is today a common method for the treatment of chronic rhinosinusitis. Assessment of the results has been based mainly upon subjective evaluation, and only a few reports present objective measurements. In the present study, the 133-xenon washout technique was used for preoperative and postoperative evaluation of paranasal sinus ventilation in 12 patients selected for ESS. The postoperative half-times (T1/2) of 133-xenon washout were lower in the sinuses with abnormal preoperative half-times (T1/2), especially in the maxillary sinuses, where the postoperative T1/2 was 44 (22 to 150) minutes (median and quartiles, Q1-Q3) as compared with a preoperative T1/2 of 202 (94 to 278) minutes. The postoperative evaluation included a questionnaire and a follow-up visit with endoscopy and measurements of nasal nitric oxide. The results showed that patients who declared a marked reduction in symptoms exhibited significantly improved sinus ventilation. However, no direct correlation was found between improvement in ventilation and symptom improvement. Nine of the 12 patients showed improvement on endoscopy, and these patients also exhibited improved sinus ventilation. The postoperative nasal nitric oxide levels were within the normal range in 11 of the 12 patients; the other patient showed pathological T1/2 values for all paranasal sinuses. The 133-xenon washout technique is thus a method that can be used for objective evaluation of the ventilation of the paranasal sinuses before and after ESS procedures. However, the technique cannot be used to evaluate sinuses with totally obstructed ostia or postoperative sinuses with very wide neoostia, as rapid washout may lead to no activity remaining at the time of measurement.
Ventilation of the paranasal sinuses is of great importance in sinus pathophysiology. Therefore, methods of measuring sinus ventilation are important for the evaluation of patients with sinus disease. In the present study, a 133-xenon washout technique was used to evaluate the ventilation of the paranasal sinuses in 34 healthy subjects and in 13 subjects with sinus disease (5 patients with nasal polyposis and 8 patients with chronic sinusitis). For this purpose, a 133-xenon-air mixture was insufflated in each nostril and the washout of the radioactive gas from the paranasal sinuses was monitored with a dynamic single-photon-emission computed tomography camera. The half-time (+/-SD) was found to be 18 +/- 18 minutes for the maxillary sinus, 10 +/- 8 minutes for the frontal sinus, and 18 +/- 23 minutes for the posterior ethmoid and sphenoid sinuses in the healthy subjects. Repeated measurements in 18 of the healthy subjects indicated that the method had acceptable reproducibility according to a Bland-Altman plot. The 133-xenon washout was not influenced by insufflation pressure, nasal patency, or body position. The subjects with sinus disease exhibited half-times of 77 +/- 101 minutes for the maxillary sinus, 91 +/- 124 minutes for the frontal sinus, and 60 +/- 60 minutes for the posterior ethmoid and sphenoid sinuses. For patients with nasal polyposis, the half-time was significantly longer than that in healthy subjects, while patients with chronic sinusitis did not differ from healthy subjects in this respect.
In order to test the hypothesis that there is air streaming through the upper airways to the ipsilateral lung, and that reflex hypoventilation of the ipsilateral lung may occur in unilateral nasal obstruction, 11 volunteers and three patients were examined for these phenomena, employing Xenon-133 (133Xe) and a special mask permitting inhalation of the gas through one nostril at a time. Patients with deviated nasal septa were also examined, one of these before and after surgery. There was no difference in 133Xe distribution between right and left lungs when gas was inhaled through either normal nostril as compared to inhalation through the mouth, in patients with deviated septa or with cotton obstruction of the contralateral nostril. Furthermore, there was no evidence of delayed washout of 133Xe from either lung or any segment thereof under conditions of nasal obstruction. Thus acute or chronic nasal obstruction does not alter the distribution of inpired gas to the lungs. Neither air streaming nor reflex bronchoconstriction occurs with nasal obstruction.
The correction of paralytic dysphonia is primarily a mechanical problem requiring movement of the paralyzed vocal cord to the midline so that the functioning cord can meet it and effectively close the glottis. Intracordal Teflon® injection is now the treatment of choice. This paper reviews 135 patients who received Teflon® injections of the vocal cord during the last five years. Eighty-one percent of the patients with dysphonia recovered a normal solid phonatory voice and 96% were clinically improved at least one step. Pure laryngeal paralysis was virtually always improved, usually to a normal phonatory voice. Although some patients with hoarseness after surgical or blunt trauma were improved, the results were not as consistent. Aspiration was decreased or eliminated in the majority of patients unless there was too much laryngeal scarring to permit vocal cord repositionment or unless multiple cranial nerve or cerebellum deficits were present.
This presentation compares the preoperative voice recordings and the latest follow-up voice recordings, made 5 to 14 years postoperatively, of the first 300 patients with various degrees of spastic dysphonia whom we treated with recurrent laryngeal nerve (RLN) sections from 1975 to 1982. Voice therapy was usually given afterward and in some patients, when necessary, "fine tuning" surgery was performed later. The 243 patients who could be located were asked to answer a questionnaire regarding their voice production and communication abilities, and to make a voice recording. The preoperative and long-term postoperative voice recordings were analyzed by means of perceptual voice evaluation and acoustic analysis of the voice spectra. Fifteen percent developed recurrence of mild to moderate spasticity 6 to 24 months after the RLN section. This was curable with laser vocal cord thinning via direct laryngoscopy. Eighty-two percent of patients had little or no voice spasticity 5 to 14 years after their RLN section. The experimental alternative of injecting botulin directly into the vocal cord to temporarily paralyze it is discussed.
We reviewed 141 cases of paranasal sinus tumors treated at Karolinska Hospital from 1960 to 1980. Of these tumors, 100 were located in the maxillary sinus, 32 in the ethmoidal sinuses, 8 in both the ethmoidal and maxillary regions, and 1 in the sphenoidal sinus. The male-to-female ratio was 2.1 to 1. Squamous cell carcinoma and adenocarcinoma were the most frequent types of tumors (55% and 13%, respectively). Treatment included surgery, irradiation, or both. The 5-year survival rate was 34% for squamous cell carcinomas and 64% for adenocarcinomas. When compared to a previous material of patients treated at the same hospital from 1940 to 1950, the proportion of poorly differentiated squamous cell carcinomas had increased significantly. The age-adjusted incidence rate decreased from 1.2 to 0.4 for male patients and from 0.7 to 0.3 for female patients between 1960 and 1980. We conclude that the incidence of malignant paranasal sinus tumors has decreased, and that squamous cell tumors now seem to be generally less differentiated than they were 50 years ago.
The surgical findings in 144 successive ears operated on for congenital conductive hearing loss were analyzed, and the results were evaluated in terms of hearing gain. All the patients underwent middle ear surgery at the University Hospital Nijmegen between 1964 and 1990. A classification system was developed to analyze the findings. Class 1 comprises ears with congenital isolated stapes ankylosis. Class 2 comprises ears with congenital stapes ankylosis in combination with a congenital anomaly of the ossicular chain. Class 3 comprises ears with congenital anomalies of the ossicular chain and at least a mobile stapes footplate. Class 4 comprises ears with aplasia or severe dysplasia of the oval window or round window.
For the period 1974 to 1988, 148 patients undergoing 162 rhinotomies at The Mount Sinai Medical Center, New York, for a variety of benign and malignant neoplasms were reviewed with particular attention to postoperative complications. The effects of certain predisposing factors such as prior rhinotomy, lateral versus total rhinotomy, additional medial maxillectomy or craniofacial resection, and preoperative irradiation or nasal bone erosion are discussed. In addition, a surgical technique of rhinotomy with medial maxillectomy is presented that includes maneuvers designed to prevent these complications.
Over 486 people were massacred and buried communally at the Crow Creek Village Site, South Dakota, about 1350 AD. Osseous pathology in the craniofacial area of the victims' skeletons is reviewed and compared to data from other indigenous skeletal populations past and present. The Crow Creek mastoid x-rays are analyzed and compared to four other studies which span over 1000 years of Dakota Territory history. Findings regarding external auditory canal exostoses in the different groups are compared. Unusual findings in the craniofacial area are assessed. Insight into longitudinal epidemiology in one portion of the U.S. is possible through this study.
We describe and evaluate the process of fixation of the Digisonic SP cochlear implant with two titanium screws.
The characteristics of this implant allow cochlear implantation using a minimal incision, a subperiosteal pocket, and fixation with two titanium screws, without drilling a custom-fitted seat or creating suture-retaining holes in the skull. The fixation system relies on two tailfins for use of osseo-integratable screws, incorporated into the cochlear implant housing. The first version of this fixation system was modified after a case of device migration: the size of the titanium insert inside the silicone tailfin was increased. Data on 156 patients (8 months to 86 years of age) from a 4-year period in 6 cochlear implantation centers were retrospectively evaluated. Ten patients have undergone bilateral implantation.
Of 166 implantations, 4 postoperative infections and 1 device failure after head trauma were reported. No cerebrospinal fluid leaks or epidural hematomas were reported. One device migration was observed in the first series; no device migrations occurred in the second series.
The fixation system with screws embedded in the Digisonic SP involves a fast and simple surgical technique that seems to efficiently prevent implant migration.
This paper presents results of a histologic study of 16 temporal bones with cochlear implants from 13 subjects. Damage caused by electrode insertion in the basal turn of the cochlea was evaluated. Dendrite and spiral ganglion cell populations were compared to clinical performance scores to determine structures necessary for stimulation and the minimum number needed for electrical stimulation. Results show that damage from insertion of long electrodes was located mainly at the most anterior part of the basal turn; that despite total degeneration of dendrites in the area near the electrode, some spiral ganglion cells remained; and that spiral ganglion cells or possibly axons are the stimulated structures and that fewer of them than previously thought are necessary to achieve a hearing sensation from electrical stimulation.
Recurrent respiratory papillomatosis (RRP) is caused by human papillomavirus (HPV). Surgical excision is the mainstay of treatment; however, medical therapy including cidofovir, a cytosine analog, has been investigated. Human papillomavirus does not encode a viral DNA polymerase, which is the known target of cidofovir in cytomegalovirus infections.
In an effort to better understand the usefulness of cidofovir in the treatment of HPV-related disease, we tested cidofovir's ability to inhibit growth, alter gene expression, and inhibit genome replication.
With the use of carbon 14-labeled cidofovir in episomal HPV 16-containing keratinocytes, there was a minimal increase in cidofovir incorporation into episomal DNA versus genomic DNA. Cidofovir decreased the copies of episomal HPV 16 in keratinocytes; however, the copies per cell returned to baseline levels once cidofovir was removed. Expression of a viral oncogene (HPV 16 E6) in transformed keratinocytes with episomal HPV 16 was not decreased by cidofovir. Cytotoxicity in head and neck squamous cell carcinoma lines exposed to cidofovir correlated with cell doubling time, and not with HPV status. Also, tonsil keratinocytes transformed with episomal HPV 16 did not exhibit greater cidofovir-mediated toxicity than did telomerase-transformed keratinocytes.
These findings suggest that any potential in vivo benefit of cidofovir therapy results from non-viral-specific cell toxicity at the site of application.
A human middle ear epithelial cell line (HMEEC-1) was established using human papillomavirus E6/E7 genes. HMEEC-1 has remained morphologically and phenotypically stable, even after 50 passages. The cells are anchorage-dependent and nontumorigenic when injected into nude mice. This cell line thus provides a new tool for the study of normal cell biology and the pathological processes associated with the epithelial cells of the middle ear in otitis media. HMEEC-1 will also be useful in the search for new drugs and biological agents for the treatment of otitis media.
One hundred sixty patients affected by benign paroxysmal positional vertigo of the posterior semicircular canal were treated with Semont's maneuver. Complete recovery after only one session was achieved in more than 50% of cases. After a maximum of five sessions, almost all patients had recovered; only 8 needed another kind of rehabilitation. No drug therapy was required for any patient.
Most recent publications dealing with surgical repair following pharyngolaryngectomy or pharyngolaryngoesophagectomy appear to be based upon limited surgical experience of the most differing operations now available. An up to date review of 162 patients, including 68 gastric "pull up" procedures, has the advantage of being a personal series as well as a critical evaluation of each technique based upon personal evaluation.
The clinical concepts of electronystagmography (ENG) and vestibular testing are simple. They are not mysterious, complicated, nor time consuming. Every patient afflicted with dizziness deserves such a recording as part of the vestibular workup. No one would consider the evaluation of a patient with a hearing loss complete without an audiogram, and in 1975 no patient with a complaint of dysequilibrium has been properly or sufficiently evaluated without an ENG recording of balance function.