To evaluate the facial nerve outcome postoperatively of schwannoma vestibular surgery with a stimulation threshold (ST) lower than 0.05 mA.
Retrospective chart review.
A total of 106 patients had undergone schwannoma vestibular surgery between 2002 and 2008 in a tertiary center. The ST near the brainstem was obtained after the tumor removal. Facial nerve function was evaluated according to the House-Brackmann (HB) scale immediately postoperatively and at 1 year. The results were compared among the different STs used: <0.05 mA, 0.05 mA, and >0.05 mA.
There were 50 patients who had an ST <0.05 mA, 45 patients who had an ST of 0.05 mA, and 11 patients who had a ST >0.05 mA. Immediately postoperatively, for all of these groups we had a preservation of facial nerve function (HB I-II) in 94%, 80%, and 36% of patients, respectively (P < .0001). At 1 year in the same groups the preservation of the facial nerve function was 100%, 93%, and 82% of patients, respectively (P < .01).
A proximal ST of <0.05 mA is a better predictor of facial nerve function immediately postoperatively.
Two main purposes in the present study were: 1. to determine the feasibility of using the tissue adhesive isobutyl 2-cyanoacrylate in reconstructive middle ear surgery; and 2. to learn whether a potent topical corticosteroid (0.1 percent dexamethasone) would have beneficial anti-inflammatory effects when placed in the tympanic cavity at the time of middle ear surgery.
Tympanoplastic surgery was performed on 26 cat ears and six squirrel monkey ears; the animals were followed for six weeks to nine months postoperatively.
The conclusions to be drawn from this experimental study are that presently the tissue adhesive isobutyl cyanoacrylate appears too toxic for use on the delicate middle ear structures; likewise, corticosteroids placed in the middle ear do not appear to have any beneficial effects in tympanoplasty surgery.
There are conflicting reports regarding the effect of intranasal saline sprays on the various components of the mucociliary clearance system. This study evaluates the effect of normal saline and hypertonic saline on the ciliary beat frequency (CBF).
Eight healthy volunteers were randomized to receive 0.9% saline spray to one nostril and 3.0% saline spray to the other. Ciliated cells were collected, and the CBF was calculated using computerized microphotometry.
Although neither solution significantly altered the CBF from baseline measurements, there was a significant difference between the CBFs of the two solutions at 5 minutes postadministration (9.1 Hz with 0.9% saline, 10.1 Hz with 3.0% saline, P < .05). This was a transient effect and was not seen when cells were examined at 60 minutes postadministration.
The administration of hypertonic saline results in a significantly faster CBF 5 minutes after administration. This effect is not seen 60 minutes after administration.
The aims of the study were to determine: 1) how mucociliary activity in acute bacterial rhinosinusitis is affected; 2) how this activity is changed by therapy; 3) the effects of topical agents on mucociliary clearance, and 4) the most appropriate topical agent(s) to be used in the therapy of sinusitis.
Five groups of patients with acute bacterial rhinosinusitis were studied prospectively.
All patients had 500 mg oral amoxicillin and 125 mg oral clavulanic acid preparations given three times daily for 3 weeks. According to the topical agent applications, these groups included: group I (n = 12), no topical treatment was given; group II (n = 14), two puffs for each nostril once daily of 50 microg/100 mL fluticasone propionate was given; group III (n = 9), one puff for each nostril three times daily of 0.05% oxymetazoline was given; group IV (n =12), 3% sodium chloride (NaCl) (buffered to pH 6.5-7 at room temperature) was given; and group V (n =13), 10-mL solutions of 0.9% NaCl (buffered to pH 6.5--7 at room temperature) were given for nasal irrigations three times daily. All patients had medication for 3 weeks and were controlled each week. The saccharin method was used to measure nasal mucociliary clearance. To investigate the early effects of the topical agents for groups II to V, an additional test was repeated 20 minutes after the basal mucociliary clearance recordings. The test was repeated in the first, second, and third weeks of the treatment.
The mucociliary clearance was significantly slower in the acute bacterial rhinosinusitis group than in the control group. There was no significant difference between the basal mucociliary clearance and the 20th minute mucociliary clearance of the fluticasone propionate and 0.9% NaCl solution groups. The mean values of the basal and the 20 minute's mucociliary clearance of the oxymetazoline group were 24.72 +/- 6.16 and 15.5 +/- 7.45 minutes, respectively, which were statistically significant. The mean values of the basal and the 20th minute mucociliary clearance of the 3% NaCl solution groups were 19.45 +/- 9.35 and 15.45 +/- 8.20 minutes, respectively, which were also statistically significant. In the first group (without topical treatment), the basal mucociliary clearance became significantly shorter after the second week of treatment. In the first and second weeks of the treatment of the oxymetazoline group, the mucociliary clearance did not change significantly, but after the third week the mucociliary clearance was significantly shorter. In the 3% NaCl solution group, significant improvement began from the first week and continued through the third week. Comparing the basal and the third weeks' mucociliary clearance values among the groups, the oxymetazoline and 3% NaCl solution groups revealed more significant improvement than the other groups, but this improvement was not different from the improvement of group I. There was still a statistically significant difference in the mucociliary clearance of the post-treatment sinusitis groups from the control group.
The oxymetazoline and 3% NaCl solution groups seemed to be more effective in mucociliary clearance, but there was no significant difference in improvement among the groups. The improvement of acute bacterial rhinosinusitis takes more than 3 weeks, according to the mucociliary clearance values of the groups.
To determine whether smokers and former smokers have different outcomes of otologic surgery compared to nonsmokers. Smokers have been shown to have worse outcomes in other surgeries, including facial plastics procedures, and it is hypothesized that they will have worse outcomes after ear surgery. Former smokers benefit from reduced risk of heart disease and lung disease after quitting for a period of time. It is also hypothesized that former smokers' risk of ear disease will be reduced over time.
All patients undergoing otologic surgery are included in this study. Smoking status of all patients was determined and patients are classified as nonsmokers, current smokers, and former smokers. Final hearing is determined after a minimum 12 months follow-up. The rates of complications, subsequent surgery, extent of disease, and canal wall status were measured and compared between smokers and nonsmokers, and smokers and former smokers. The former smoker group was further divided into those that quit <5 years and those that quit >5 years. These groups were compared to nonsmokers.
A total of 1,531 surgeries were performed on 1,183 patients. Sixty-three percent of the population were nonsmokers, 21% of patients were current smokers, 5% were former smokers, and 11% unknown. Smokers had more cholesteatomas and required more canal wall down surgeries than nonsmokers. Smokers had a significantly higher incidence of ossicular chain involvement with cholesteatoma or discontinuity requiring reconstructions. They required more revision surgeries, and had overall worse final hearing than nonsmokers. Former smokers, regardless of how long they had quit, had significantly more ossicular chain reconstructions than nonsmokers. Former smokers who quit smoking <5 years had results similar to current smokers. Those former smokers who quit >5 years had results similar to nonsmokers.
Smokers have significantly worse chronic ear disease than nonsmokers. Surgery in smokers is more extensive and leads to worse hearing outcomes than nonsmokers. Subsequent surgeries are more common in smokers. Former smokers who quit <5 years are similar to current smokers, whereas those who quit >5 years were similar to nonsmokers.
To demonstrate the efficacy of the hedgehog pathway inhibitor GDC-0449 in the treatment of advanced basal cell carcinoma.
Three patients treated in a referral center for locally advanced basal cell carcinoma, one with metastases, were referred for treatment in a GDC-0449 phase I clinical trial. The treatment was once per day continuous therapy with oral GDC-0449.
Two patients showed complete clinical and radiologic resolution of disease, whereas one patient had significant reduction in tumor burden with radiologic evidence of slowly progressive local disease. Side effects were taste changes, mild to moderate hair loss, and muscle cramps in one patient.
GDC-0449 showed significant inhibitory activity in the treatment of advanced basal cell carcinoma.
In a series of 1502 patients seen in our Facial Paralysis Research Clinic 1048 were diagnosed as having Bell's palsy. Review of clinical, epidemiologic, and laboratory data, plus review of the literature, has led to the conclusion that Bell's palsy is an acute benign cranial polyneuritis probably caused by reactivation of the herpes-simplex virus, and the dysfunction of the motor cranial nerves (V, VII, X) may represent inflammation and demyelinization rather than ischemic compression. Spinal fluid analysis suggests that the disease is a phenomenon of the central nervous system with secondary peripheral neural manifestations. With our presently available information, treatment of a viral disease with an anti-inflammatory agent is rational. Prednisone treatment started within the first week of the disease can restore better function to the paralyzed face than is achieved without such therapy, and facial nerve decompression has been unnecessary.
The objective of this study was to analyze the safety and efficacy of botulinum toxin (BTX) therapy in a series of 1,000 treatments on 261 consecutive patients at the University Department of Otorhinolaryngology-Head and Neck Surgery, Cologne, Germany.
A prospective computer database was analyzed, and all patient charts were reviewed retrospectively. In doing so, the main focus was put on patient characteristics, treatment methods, efficacy, unwanted side effects, and reinjection rate.
A total of 16 different indications were treated with BTX belonging to the categories of focal dystonias, focal hyperhidrotic syndromes, and cosmetic dermatology. The overall morbidity was 1.3%, exclusively consisting of minor side effects. These were all reversible and mostly caused by paralysis of adjacent musculature. We did not observe any severe complications. Three (1.2%) patients developed a secondary nonresponse to BTX type A (BTX-A). Their treatment was continued with BTX type B. In 2.8% of treatments, patients thought the clinical effect was weak and returned for reinjection within 4 weeks after the first treatment.
The experience from the largest patient series known confirms that BTX-A injections are the therapy of choice for many forms of focal hyperhidrotic syndromes, focal dystonia, and hyperfunctional lines. It is an effective and safe treatment with only minor side effects. For optimal individual results, a thorough documentation of each treatment is necessary. Dosages should be as low as possible to reduce the probability of a patient developing a secondary nonresponse.
Vertigo and dizziness may be considered spatial disorientation. This disorientation follows malfunction (following disease or injury) of the computer-like action of the eyes, ears, proprioceptive sense, cervical spine, cerebrum, cerebellum, autonomic system or the master control in the reticular substance.
It is felt that changes in nystagmus would follow injury or disease to any of these components. Studies have been reported of the establishment of parameters of cristo ocular and cristo spinal reflexes in persons with good spatial orientation. The differential diagnosis of 1,000 cases of patients with vertigo will be compared with “normals,” establishing, where possible, a differential diagnosis.
The purpose of this study was to analyze the anatomical and audiologic results in more than 1,000 cartilage tympanoplasties that utilized a logical application of several techniques for the management of the difficult ear (cholesteatoma, recurrent perforation, atelectasis). Our hypothesis was that pathology and status of the ossicular chain should dictate the technique used to achieve optimal outcome.
Retrospective clinical study of patients undergoing cartilage tympanoplasty between July 1994 and July 2001. A computerized otologic database and patient charts were used to obtain the necessary data.
A modification of the perichondrium/cartilage island flap was utilized for tympanic membrane reconstruction in cases of the atelectatic ear, for high-risk perforation in the presence of an intact ossicular chain, and in association with ossiculoplasty when the malleus was absent. A modification of the palisade technique was utilized for TM reconstruction in cases of cholesteatoma and in association with ossiculoplasty when the malleus was present. Hearing results were reported using a four-frequency (500, 1,000, 2,000, 3,000 Hz) pure-tone average air-bone gap (PTA-ABG). The Student t test was used for statistical comparison. Postoperative complications were recorded.
During the study period, cartilage was used for TM reconstruction in more than 1,000 patients, of which 712 had sufficient data available for inclusion. Of these, 636 were available for outcomes analysis. In 220 cholesteatoma cases, the average pre- and postoperative PTA-ABGs were 26.5 +/- 12.6 dB and 14.6 +/- 8.8 dB, respectively (P <.05). Recurrence was seen in 8 cases (3.6%), conductive HL requiring revision in 4 (1.8%), perforation in 3 (1.4%), and post- and intraoperative tube insertion in 11 (5.0%) and 18 ears (8.2%), respectively. In 215 cases of high-risk perforation, the average pre- and postoperative PTA-ABGs were 21.7 +/- 13.5 dB and 11.9 +/- 9.3 dB, respectively (P <.05). Complications included recurrent perforation in 9 ears (4.2%), conductive HL requiring revision in 4 (1.9%), postoperative and intraoperative tube insertion in 4 (1.9%) and 6 ears (2.8%), respectively. In 98 cases of atelectasis, the average pre- and postoperative PTA-ABGs were 20.2 +/- 10.9 dB and 14.2 +/- 10.2 dB, respectively (P <.05). Complications included 1 perforation (1.0%), conductive loss requiring revision in 2 cases (2.0%), and post- and intraoperative tube insertion in 7 (7.1%) and 12 ears (12%), respectively. In 103 cases to improve hearing (audiologic), the average pre- and postoperative PTA-ABGs were 33.6 +/- 9.6 dB and 14.6 +/- 10.1 dB, respectively (P <.05). Complications included 1 perforation (1.0%), conductive loss requiring revision in 11 (11%), and post- and intraoperative tube insertion in 6 (5.8%) and 2 (1.9%), respectively.
Cartilage tympanoplasty achieves good anatomical and audiologic results when pathology and status of the ossicular chain dictate the technique utilized. Significant hearing improvement was realized in each pathological group. In the atelectatic ear, cartilage allowed us to reconstruct the TM with good anatomic results compared to traditional reconstructions, which have shown high rates of retraction and failure. In cholesteatoma, cartilage tympanoplasty using the palisade technique resulted in precise reconstruction of the TM and helped reduce recurrence. In cases of high-risk perforation, reconstruction with cartilage yielded anatomical and functional results that compared favorably to primary tympanoplasty using traditional techniques. We believe the indications for cartilage tympanoplasty (atelectatic ear, cholesteatoma, high-risk perforation) were validated by these results.
A series of 1,000 consecutive intranasal ethmoidectomies performed on 565 patients was reviewed. There were 28 complications (2.8%) in 26 patients. No patient died, and none became blind. This experience suggests that, in experienced hands, intranasal ethmoidectomy for polypoid disease and chronic ethmoid sinusitis can be a safe operation.
A series of 1,077 intranasal ethmoidectomies (825 with sphenoid sinusotomies) was performed in 600 patients over a 15-year period at The Mount Sinai Medical Center. The technique is a modification of the classical operation originally proposed by Yankauer. The rate of significant complications was 1.1%. A subset of 90 patients underwent 166 procedures and were followed an average of 3.5 years. The patients were analyzed according to whether the disease was focal or diffuse, infectious or polypoid, and whether asthma was present. The surgical success rate was 88% in nonasthmatics, but dropped to 50% in asthmatic patients despite total sphenoethmoidectomy. This underscores the importance of this condition as a biological modifier of surgical prognosis. Accordingly, a system of classification of sinus diseases is proposed based upon disease extent and type and whether asthma is present.
We reviewed the records of all patients who had a myringotomy and insertion of a ventilation tube at Otologic Medical Group during a 6-year period; there were 2,266 intubations on 1,568 ears.
Uncomplicated serous otitis media was the indication in 1,055 ears; 19% developed brief episodes of otorrhea. Persistent otorrhea necessitated tube removal in 9 ears, all but 2 of which became dry. These 2 patients required mastoid surgery.
We conclude that myringotomy and insertion of a ventilation tube in serous otitis media is associated with infrequent complications, and these complications are probably related more to the underlying disease process than to the ventilation tube.
On the basis of survey results of the Acoustic Neuroma Association (ANA), we report patient ratings of postoperative headache (POH) symptoms, determine its effect on quality of life (QOL), and review the literature regarding POH after acoustic neuroma (AN) treatment.
In this cohort study, 1,657 patients who underwent surgical treatment of AN reported their experiences of POH.
A detailed questionnaire was mailed to members of the ANA to identify preoperative and postoperative headache symptoms, complications, and long-term effects on physical and psychosocial function. Questions were answered by 1657 (85.4%) respondents that were intended to qualify and quantify the effects of POH, including QOL issues. Responses were analyzed by tumor size, surgical approach, and patient age and sex. Statistical analysis was performed with the SPSS software.
Preoperative headache was reported in approximately one third of respondents. Typical POHs occurred more than once daily (46%), lasted 1 to 4 hours in duration (43.1%), and were of moderate intensity (62.6%). The worst headaches were rated as "severe" by 77% of respondents. Treatment most often reported for typical headaches were nonprescription medications including nonsteroidal anti-inflammatory drugs in 61.3% (P < .01) and regular use of narcotics in 15%. Patients who underwent the retrosigmoid approach were significantly more likely to report their worst POH as "severe" (82.3%) compared with the translabyrinthine (75.2%) and middle fossa approaches (63.3%). Women and younger patients tended to have poorer outcomes with regard to POHs.
In this large cohort study of AN patients, POH was a significant morbidity among AN patients with persistent headaches. Treating physicians should be aware of the risk factors identified and the effect POH has on the QOL when counseling patients regarding optimal treatment management.
A prospective study of 1,713 patients with squamous cell carcinoma of the head and neck submitted to neck dissection between 1957 and 1973 is presented. We confirm the prognostic significance of the histological analysis of the nodal metastasis. Capsular rupture is the most important factor regardless of the primary site or tumor size. The presence of tumor emboli within lymphatics, the number of invaded nodes, and the number of nodes with capsular rupture are of significance though to a lesser extent. Classification of the clinical characteristics or the nodes provided, in 70% of the patients, a good prediction of histological involvement. In the clinical estimation of histological invasion, an important parameter is the size of the largest node detected, and we suggest this characteristic should be included in the TNM classification of UICC.
We developed the largest paranasal sinus computed tomography (CT) scan study so far by including 1,889 cases to investigate the prevalence, localization, age distribution, and the secondary complications of paranasal sinus osteomas.
A prospective study was performed on 1,889 consecutive adult individuals who underwent paranasal sinus CT examinations with suspected sinus disease.
The prevalence of paranasal sinus osteomas was determined to be 3%. Osteomas were located most frequently in the ethmoid sinuses. The size of the osteomas varied from approximately from 2 to 30 mm. Of the osteomas found, 37%were accompanied by pathological sinonasal findings.
The prevalence of sinonasal osteoma in the paranasal sinus region detected by CT scan is supporting the literature, whereas the localization pattern challenges it.
To evaluate the long-term performance of adult Clarion 1.0 cochlear implant users.
This was a retrospective, longitudinal study evaluating word discrimination in quiet for 31 adult cochlear implant patients with preimplantation sentence scores of less than 10%.
The length of the study was 135 months with a mean follow-up length of 93 (median, 96) months. For the duration of the study, all subjects used the Clarion 1.0 cochlear implant with speech processors programmed for the use of the continuous interleaved sampling strategy.
There was no significant growth or decline in speech perception after 24 months postimplantation unless adverse medical events were experienced. Age at implantation was significantly and substantially negatively correlated (-11% word score per decade, r = 0.68) with most recent score, maximum score, time to maximum score, range of performance, 24- to 130-month mean score, and for any longitudinal data point tested: 3 to 6 months, 6 months, 1 year, 2 years, 5 years, and 10 years. There were no age-related declines in performance. There were no observed correlations between duration of deafness and any of the variables listed above.
The lack of correlation between duration of deafness and performance in a cohort without residual hearing suggests the presence of a strong correlation between age and speech performance with a cochlear implant. That the cochlear implant is a safe therapy for the treatment of profound deafness is supported by the stability of scores through the 10-year study period as well as a zero rate of device failures or explantation.
To review the repair of larger nasal defects (> 1.5 cm in diameter) and the vascular supply to the forehead flap.
Retrospective chart review (1994-1999) and cadaver analysis of forehead flap vasculature.
Chart review was made of patients with cutaneous nasal defects greater than 1.5 cm in diameter. An intravascular silicone cast was used to detail the arterial supply to forehead flaps focusing on contribution from the supratrochlear and angular vessels.
In 127 patients with nasal defects, 76 defects were greater than 1.5 cm in diameter and were repaired with a midline forehead flap (44 [58%]), paramedian forehead flap (3 [4%]), single-stage midline forehead flap (8 [11%]), interpolated melolabial flap (5 [7%]), local nasal flap (7 [9%]), or skin graft (9 [12%]). All original defects were modified to some degree with an aggressive application of the nasal esthetic subunit principle. Forty-three patients (57%) had cartilage grafts, 18 (24%) had a full-thickness defect requiring repair of the internal lining, and 11 (14%) had some degree of complication, although no patient had full-thickness necrosis of a flap or required a second flap. Analysis of the vascular pedicle to the midline and paramedian forehead flaps demonstrated significant contributions from the angular artery. Skin paddles from a midline and paramedian forehead flap had similar vascular arcades.
Nasal reconstruction has reached a standard of consistent esthetic results with restoration of nasal function. The midline forehead flap is dependable and robust and leaves a donor site scar consistent with the principle of esthetic units.
To evaluate the effect of the 1.5 Tesla magnetic resonance imager (MRI) on the Cochlear Nucleus 24 Device without removing the internal magnet. To determine whether device fixation using a compression dressing could prevent internal magnet displacement in the MRI scanner and potentially obviate the need for surgical removal of the internal magnet.
Prospective cadaveric study.
Four cadaver heads were implanted bilaterally with the Nucleus device with the internal magnet in place and placed into the 1.5 Tesla MRI scanner. The devices were then explanted after interaction with the MRI and evaluated for displacement of the internal magnet. Conditions tested include device fixation with a commercially available compression dressing and no fixation (worst-case scenario). Magnet strength was measured before and after each of the test conditions.
Moderate to severe displacement of the magnet from the internal device occurred in 14 of 16 (87%) implants when no compression dressing was placed. Displacement occurred in 0 of 16 (0%) implants when the compression dressing was applied. No decrease in the strength of the implant magnet was found with the initial or subsequent MRI/implant interactions.
Use of the 1.5 Tesla MRI on subjects with Cochlear Nucleus 24 implants did not result in any significant demagnetization of the internal magnet and did not cause displacement of the magnet when an external compression dressing was applied. Surgical removal of the internal magnet before scanning with the 1.5 Tesla MRI may not be necessary if a compression dressing is applied.
The aim of this study was to investigate the effects of a 1.8 GHz continuous electromagnetic fields (EMF) on human nasal mucociliary transport, and to determine the pathophysiology of ciliary beat frequency (CBF) during an EMF-induced change.
Human nasal mucosa cells were exposed to a 1.8 GHz EMF (SAR=1.0 W/kg), and CBF was analyzed using an optical flow technique with the peak detection method.
The 1.8 GHz-exposed group showed a decreased CBF when compared to the control group. In the cytotoxicity assay, difference in survival rates was not found between the two groups. In the EMF-exposed group, protein kinase C (PKC) activity was increased during a PKC activity assay. The broad PKC inhibitor, Calphostin C abolished the EMF-induced decrease of CBF. The EMF-induced decrease of CBF was abolished by GF 109203X, a novel PKC (nPKC) isoform inhibitor, whereas the decrease was not attenuated by Gö-6976, a specific inhibitor of conventional PKC (cPKC) isoform.
EMF may inhibit CBF via an nPKC-dependent mechanism. Therefore, we have confirmed that EMF could decrease CBF by increasing PKC activity. Laryngoscope, 2012
The wound healing characteristics of incisions made with the short pulsed CO2 laser tuned to 9.55 microm versus the traditional 10.6 microm were investigated. Previous studies have shown that at 9.55 microm, collagen is targeted more selectively than at 10.6 microm, which results in decreased acute thermal injury patterns. This study investigates the difference in wound healing over time between lasers and compares laser incisions with cold knife techniques.
Randomized controlled trial using a porcine model.
Tissue from 10.6-microm and 9.55-microm incisions of 10 piglets was evaluated with histological analysis and tensiometry at 3, 7, 14, and 21 days postoperatively. A Bonferroni-Dunn corrected analysis of variance analysis at a 95% significance level was used to compare the effect of wavelength.
The results demonstrate that although knife incisions are consistently stronger than laser incisions, the 9.55-microm CO2 laser incisions are no stronger than incisions made with the conventional 10.6-microm laser. Furthermore, histological analysis shows no difference in lateral thermal damage between lasers at 3, 7, 14, and 21 days postoperatively. The progression of collagen formation and inflammation does not differ over time.
This study of wound healing using a porcine model demonstrates that the 9.55-microm CO2 laser does not demonstrate an improvement in wound healing over the traditional 10.6-microm CO2 laser. These results may be secondary to the common explosive vaporization mechanism produced by both lasers in the infrared spectrum.
A total of 1000 human temporal bones were used to study the prevalence of carotid canal dehiscence, microdehiscence, and thin bony coverage. Additionally, this study compares the prevalence according to sex and temporal bone age. A carotid canal dehiscence was detected in 77 (7.7%) bones. It was present bilaterally in 23.2% of the paired temporal bones. The prevalence of carotid canal dehiscence decreases with increasing temporal bone age. It was found in 10 (15.9%) bones in the younger than 2 age group, as opposed to 43 (6.3%) bones from the 40 and older group.
The concept of microdehiscence of the carotid canal is introduced. A carotid canal microdehiscence was found in 74 (7.4%) bones. Microdehiscences were noted to occur bilaterally in 12.3% of the paired bones. The prevalence of carotid canal microdehiscence also decreases with increasing temporal bone age. It was detected in 7 (11.1%) bones in the younger than 2 age group, in contrast to 51 (7.5%) bones in the 40 and older group.
A total of 134 (15.5%) temporal bones were found to have a thin bony coverage, without the presence of a dehiscence or microdehiscence. The prevalence of thin coverage was noted to increase linearly with age. A thin carotid canal was found in 2 (8.3%) bones from the younger than 2 age group, whereas 113 (17.3%) temporal bones from the 40 and older group exhibited this entity.
To the best of our knowledge, this is the first systematic study of histologic sections of a large number of temporal bones that looks at these entities.
Recurrent laryngeal nerve palsy (RLNP) is a major obstacle in thyroid and parathyroid surgery. Therefore, methods that reduce the number of temporary and, especially, permanent recurrent laryngeal nerve palsies are of great interest. One promising way to ensure the integrity of the recurrent laryngeal nerve (RLN) is to identify the nerve always. The first question raised in the present study was whether RLN preparation reduces the number of recurrent laryngeal nerve palsies or whether it introduces additional risks. Second, from former cases we know that the absence of postoperative hoarseness does not exclude RLNP, nor does postoperative hoarseness exclusively imply RLNP. Besides, misdiagnosis is not uncommon. Therefore, preoperative and postoperative laryngoscopic examination was given attention.
Patients were investigated 1 to 7 days before and 3 to 7 days after surgery. When an RLNP was identified, patients were followed up in a 2-week rhythm the first few times and every 6 to 8 weeks thereafter until RLNP resolved or it was considered permanent after 2 years.
We prospectively investigated 608 surgical patients with 1080 nerves at risk. Because different diseases might have different rates of postoperative RLNP, we analyzed benign thyroid disease (680 nerves at risk), thyroid malignoma (321 nerves at risk), and hyperparathyroidism (79 nerves at risk) separately. Patients undergoing primary surgery (no prior thyroid surgery) and secondary interventions (there were one or more thyroid operations before this intervention) were evaluated separately.
We found 3.4%, 7.2%, and 2.5% of temporary recurrent laryngeal nerve palsies per nerve in the benign thyroid disease, thyroid malignoma, and hyperparathyroidism groups, respectively. The prevalence of recurrent laryngeal nerve palsies in these groups was 0.3%, 1.2%, and 0%, respectively. Conforming with other studies, the total number of recurrent laryngeal nerve palsies (temporary and permanent) was not increased compared with cases with no RLN preparation, whereas the number of permanent recurrent laryngeal nerve palsies was markedly reduced. An RLN was always identifiable. Astonishingly, the restitution of an RLNP was up to 2 years in duration; however, most restitutions occurred within the first 6 months. Thirty cases of hoarseness appeared or were intensified after surgery and were not caused by RLNP. Eleven cases of postoperative RLNP had no detectable hoarseness.
Besides indirect laryngoscopy, videostroboscopy should be performed in all cases with no evident bilateral normal laryngeal function or normal voice. Otherwise, the incidence of false-positive or false-negative diagnosis of RLNP is likely to be increased.
The treatment of 102 patients with squamous cell carcinoma of the pyriform sinus seen at the University of Virginia Medical Center from 1958 through 1977 is reviewed. Eight-seven cases form the basis for this report. Surgery alone, radiation alone and combination of the two were the treatment modalities utilized for the patients in this study. The overall 3 year, no evidence of disease determinate survival was (37%). Recent literature has suggested that preoperative radiation obscures tumor margins with a decrease in survivals as compared to postoperative irradiation. Though the number of patients in both the preoperative (27) and postoperative (7) groups are small, our data suggests similar survivals. In addition, when pathology was examined, no tumor margins were transected in the preoperative irradiation group and only 5/23 patients had margins classified as close. The incidence of postoperative complications was not significantly difference between the combination therapy and surgery only groups. It is concluded that preoperative irradiation does not compromise the resection of adequate tumor margins nor significantly increase postoperative complications.
To describe in a retrospective study our experience in endoscopic management of tracheobronchial stenosis with 145 stents (11 different models).
We analyzed the medical records of 103 patients (67 males and 36 females) who underwent the placement of prosthesis for any causes of tracheobronchial stenoses between 1990 and 2005.
A total of 145 prostheses were placed. Of these, 96.1% of the patients had a relief of dyspnea, and 73.8% had only one prosthesis. Stent removal and replacement were significantly linked with etiologies (more frequently in patients with an inflammatory component), but not with the type of stent.
Endostenting is a safe and effective treatment for tracheobronchial stenoses. Removal and replacements were due to etiologies of the strictures, but not to the type of stent. Stenoses with an inflammatory component were prone to iterative stenting. Only benign diseases that are a contra-indication to open surgery should be treated by endoscopic stenting.
This study is a review of the treatment outcomes of juvenile nasopharyngeal angiofibroma (JNA) specifically comparing endoscopic, endoscopic-assisted, and open surgical approaches.
Systematic review of studies using the MEDLINE database.
A systematic review of studies on JNA from 1990 to 2012 was conducted. A search for articles related to JNA, along with bibliographies of those articles, was performed. Articles were examined for individual patient data (IPD) and aggregate patient data (APD). Demographics, presenting symptoms, surgical approach, follow-up, and outcome were analyzed.
Eighty-five articles were included, with IPD reported in 57 articles (345 cases) and APD in 28 articles (702 cases). For the IPD cohort, average follow-up was 33.4 months (range, 0.5–264 months). Average blood loss was 544.0 mL, 490.0 mL, and 1579.5 mL for endoscopic, endoscopic-assisted, and open surgical cases, respectively (P < .05). Recurrence rate following endoscopic surgery and open surgery were significantly less than endoscopic-assisted surgery (P < .05). In the APD cohort, the recurrence rate following endoscopic surgery was 4.7% compared to 20.6% in the endoscopic-assisted group and 22.6% in the open surgery group (P < .05). Among studies that reported Radkowski/Sessions grading, there was no significant difference in recurrence rates for both the IPD and APD cohorts across each stage between open and endoscopic surgery (P > .05).
In this study, endoscopic resection had a significantly lower intraoperative blood loss and lower recurrence rate when compared to open resection. However, there was no difference in recurrence rate when analyzing the IPD and controlling for Radkowski/Sessions grading. Therefore, further large-scale studies may be required to fully elucidate treatment options.
In Memphis, TN, we have treated surgically 105 patients with cerebellopontine angle tumors. In reporting that experience here, we place major emphasis on the use of two surgical aids: a combined surgical approach and the CO2 laser. Diagnostic techniques are also discussed, along with data management, postoperative results, and complications.
The objectives of this prospective series were to present our results in 106 sequential cases of lymphatic mapping and sentinel lymph node biopsy (SLNB) in the head and neck region and contrast the experience in oral cancer with that for cutaneous lesions.
SLNB has an acceptably low complication rate in the head and neck. Lymphatic mapping and gamma probe-guided lymphadenectomy can improve the management of malignancies of the head and neck by more accurate identification of the nodal basins at risk and more accurate staging of the lymphatics. For appropriately selected patients, radionuclide lymphatic mapping may safely allow for minimally invasive sentinel lymphadenectomy without formal completion selective lymphadenectomy.
One hundred six patients underwent intralesional radionuclide injection and radiologic lymphoscintigraphy (LS) on Institutional Review Board-approved protocols and 103 of these underwent successful SLNB. These included 35 patients with malignant melanoma, 10 cutaneous squamous cell carcinomas, four lip cancers, eight Merkel cell carcinomas, two rare cutaneous lesions, and 43 oral cancers. Mean follow up was 24 months. Patients with oral cavity malignancy underwent concurrent selective neck dissection after narrow-exposure sentinel lymph node excision. In this group, the SLNB histopathology could be correlated with the completion neck specimen histopathology. Patients with cutaneous malignancy underwent SLNB alone and only received regional lymphadenectomy based on positive histology or clinical indications. Data were tabulated for anatomic drainage patterns, complications, histopathology, and patterns of cancer recurrence.
Surgical complications were rare. No temporary or permanent dysfunction of facial or spinal accessory nerves occurred with sentinel node biopsy. Lymphatic drainage to areas dramatically outside of the expected lymphatic basins occurred in 13.6%. Predictive value of a negative sentinel node was 98.2% for cutaneous malignancies (based on regional recurrence) and 92% with oral cancer (based on pathologic correlation). Gross tumor replacement of lymph nodes and redirection of lymphatic flow represented a significant technical issue in oral squamous cell carcinoma. Sixteen percent of patients with oral cancer were upstaged from N0 to N1 after extended sectioning and immunohistochemistry of the sentinel node.
LS and SLNB can be performed with technical success in the head and neck region. Complications are minimal. More accurate staging and mapping of lymphatic drainage may improve the quality of standard lymphadenectomy. The potential for minimally invasive surgery based on this technology exists, but there is a small risk of missing positive disease. Whether the failure rate is greater than that of standard lymphadenectomy without gamma probe guidance is not known. New studies need to focus on refinements of technique and validation of accuracy as well as biologic correlates for the prediction of metastases.
Although the middle cranial fossa approach has been used less frequently in recent years than in the past, it continues to be a useful technique for the removal of small acoustic tumors with possible hearing preservation. The approach provides complete exposure of the contents of the internal auditory canal, thus allowing positive facial nerve identification and facilitating total tumor removal.
This paper reports the results of 106 middle fossa acoustic tumor removals over a 25-year period. Measurable postoperative hearing remained in 59% of cases. In 89% of cases, normal or near-normal postoperative facial nerve function was obtained. Total tumor removal was achieved in 98% of cases. Preoperative selection criteria are discussed, and postoperative complications are reported.
Development of new therapeutic interventions in head and neck squamous cell carcinoma (HNSCC) will be facilitated by a model system that incorporates the ease of manipulation found in current tissue culture systems while retaining the three dimensional architecture that defines these malignancies.
Original scientific investigation.
We describe a modification of a normal respiratory mucosa model system which recreates premalignant mucosal histology. Grossly normal appearing human mucosa is harvested from laryngectomy specimens, the mucosal epithelium selectively removed by protease treatment and placed in conventional tissue culture. After 7 days, the cells are seeded into denuded rat tracheas, which are in turn implanted in flank pockets of athymic nu/nu mice. The tracheas are incubated for three weeks, removed and the mucosa examined histologically.
As originally described, normal pseudostratified squamous epithelium can be re-established in this system. Using human dysplastic mucosa as a starting material, mucosal histologies of respiratory dysplasia, squamous metaplasia, squamous dysplasia and squamous carcinoma in situ can be established.
This system will provide a paradigm for future therapeutic interventions to modify the progression of squamous metaplasia to dysplasia, carcinoma in situ and invasive squamous cell carcinoma.
Traditional teaching has emphasized the need for complete removal of sinus mucoceles to achieve a cure. However, with the introduction of endoscopic sinus surgical instruments and techniques, there has been a trend toward transnasal endoscopic management of sinus mucoceles. The aim of this study is to establish the efficacy of endoscopic management of sinus mucoceles.
Between 1988 and 2000, 103 patients with 108 paranasal sinus mucoceles were treated endoscopically. This series includes 66 frontal and frontoethmoid, 17 ethmoid, 7 sphenoethmoid, 12 sphenoid, and 6 maxillary mucoceles. Ninety patients (83.3%) had intraorbital extension and 85 of them presented with some degree of proptosis or eye displacement. Sixty patients (55.5%) had erosion of the skull base with varying degrees of intracranial extension of the mucocele. Follow- up ranged from 1 to 131/2 years with a median of 4.6 years.
All patients underwent endoscopic-wide marsupialization of the mucocele cavity. Stents were used in frontal mucoceles only.
Recurrence of a frontal mucocele was seen in 1 patient (0.9%). In 5 patients, out of 23 patients who presented with massive pansinus polyposis in addition to the mucocele, recurrent polyposis required revision surgery. However, the mucoceles did not recur in those patients.
There is increasing evidence in the literature that endoscopic management of sinus mucoceles results in long-term control with recurrence rates at or close to 0%. Rhinologic surgeons should consider the endoscopic technique as the surgical treatment of choice.
Mycetomas of paranasal sinuses are more frequently diagnosed with the widespread use of nasal endoscopy and computed tomography (CT). We present a series of 109 cases treated by functional endoscopic sinus surgery (FESS) with a mean follow-up of 29 months. All localizations were seen, and contrary to what was initially thought, seven cases presented in multiple sites. Several clinical presentations were found, from a pansinusal involvement to a simple mycetoma hanging in a superior meatus. A heterogeneous sinus opacity with microcalcifications on CT scan is very suggestive of the diagnosis, but a homogeneous opacity may be encountered even with bone lysis. FESS was performed in all cases to obtain a wide opening of the affected sinuses, permitting a careful extraction of all fungal material. In the postoperative period, no medical treatment is prescribed. With a mean follow-up of 29 months, only four recurrences were seen. This study reinforces the interest in FESS for cases of mycetoma of the paranasal sinuses.
Elective neck dissection for the N0 neck in head and neck surgery is still controversial. This prospective nonrandomized study of N0 supraglottic carcinoma was designed to find an appropriate method of neck management.
Anatomical studies show that the first echelon of lymphatic drainage from the supraglottic larynx is toward the upper jugular nodes (level II). An upper neck dissection (UND) was applied and all the lymph nodes were sent for frozen section. If the subclinical metastasis was found, a modified neck dissection was performed. If the nodes harbored no foci of cancer, the patients were observed after surgery on the supraglottic lesions.
Patient records of 142 patients with supraglottic laryngeal cancer (T1-4N0M0) were reviewed, with special attention paid to neck recurrences and survival rates. The cases were treated between 1976 and 1990 and all were observed for at least 5 years after the operation or until the time of death.
The UND specimens of 142 patients were negative for metastasis. The 5-year survival rate for this group after surgery was 80.8%, according to the life table analysis. Fifteen of the 142 patients (10.6%) had neck recurrences during the period of observation within 5 years. The recurrence rate of this series with limited dissection on the neck was comparable with those reported in the literature after neck dissection, either radical or modified.
There is no need for a comprehensive neck dissection for N0 supraglottic laryngeal cancer. A selective neck dissection such as UND (level II) or a supraomohyoid neck dissection (sparing the submandibular region) of level II and III will serve the purpose of radical neck treatment for the supraglottic cancer.
At our institution, any liver transplant candidate with a recent history of smoking combined with daily use of alcohol prior to a 6-month sobriety period warrants formal evaluation by otolaryngology. Given the significant resource consumption and lack of evidence in support of this strategy, we sought to determine the effectiveness of these guidelines in detecting head and neck cancer.
Retrospective review of clinical database and patient billing records.
Under an institutional review board-approved protocol, a search was performed for patients seen at our institution's otolaryngology office from 1999 to 2010. This patient list was cross-matched with the patients evaluated for transplant at the University of Pittsburgh Starzl Transplantation Institute during the same timeframe. A search for the diagnosis of head and neck squamous cell carcinoma of the head and neck (HNC) among these patients was carried out through both a National Cancer Institute-affiliated clinical research registry and ICD-9 codes from billing records. Otolaryngology attending physicians were also asked to recall detection of HNC upon screening of this patient population.
Of 581 patient evaluations performed by the otolaryngologist for HNC screening prior to liver transplantation from 1999 to 2009, one (0.17% of evaluations) case of HNC was detected.
Given the consumption of resources required for this screening strategy and the limited yield, it appears that current screening guidelines are ineffective and need to be reconsidered.
Human papillomavirus (HPV) types 6 and 11 have been associated with benign laryngeal papilloma, while HPV-16 is occasionally associated with laryngeal carcinoma. In this study, a case of laryngeal squamous papillomas with severe dysplasia was evaluated for the presence of HPV infection. The biopsy specimens were taken from a 58-year-old female patient at two different time points 3 months apart. Architecturally, the tumor showed papillary configuration reminiscent of squamous papilloma. Cytologically, the lesion showed morphologic features characteristic of severe squamous epithelial dysplasia. HPV infection was determined by DNA in situ hybridization using type-specific HPV-DNA probes. HPV-11 probes demonstrated homogeneous nuclear staining, suggesting productive viral replication. In contrast, HPV-16 probe produced a speckled pattern, suggesting HPV-16 DNA integration. Normal laryngeal epithelium did not yield specific hybridization. The presence of HPV-11 and HPV-16 was confirmed by PCR using HPV type-specific primers. Immunocytochemical staining was performed to detect Ki-67, a proliferation marker, and p53. Ki-67 expression was demonstrated throughout the whole thickness of epithelium. Staining for p53 was negative. This study suggests that multiple HPV infections can occur in the same lesion and that HPV-16 infection and its DNA integration may contribute to the occurrence of severe dysplasia in the lesion described.
The main objective was to demonstrate that human papillomavirus (HPV) type 11 is an aggressive virus that plays a significant role in the development of laryngeal cancer in patients with a history of recurrent respiratory papillomatosis (RRP). We have done so by preliminary investigation into the molecular mechanism underlying the malignant transformation of RRP to invasive squamous cell carcinoma.
An experimental, nonrandomized, retrospective study using tissue specimens from nine patients with a history of RRP that progressed to laryngeal or bronchogenic cancer was performed.
DNA and RNA were extracted from 20 formalin-fixed, paraffin-embedded specimens from six patients with a history of early onset RRP and laryngeal cancer and from three patients with early onset RRP and bronchogenic cancer. Polymerase chain reaction (PCR) was performed on DNA to determine the HPV type in each specimen. Reverse-transcriptase PCR specific for virus transcripts was performed on RNA to determine whether the viral genome was integrated into the host genome.
HPV-11 but not HPV-6, 16, or 18 was found in all of the laryngeal and bronchogenic cancers in patients with a history of early onset RRP in this study. RNA, sufficiently intact for examination, was obtained from seven patients. Analysis of HPV 11 transcripts revealed integration of the viral genome in three of seven patients.
HPV type 6 and 11 are considered "low-risk" viruses and are not associated with genital cancers, as are HPV types 16 and 18. However, our data suggests that HPV type 11 is an aggressive virus in laryngeal papilloma that should be monitored in patients with RRP.
Most nasopharyngeal carcinomas (NPCs) are of the nonkeratinizing or undifferentiated types, which are consistently associated with Epstein-Barr virus (EBV). The smaller group of highly differentiated, keratinizing NPCs seems to be only infrequently associated with EBV. In order to examine whether these rare tumors were related to another oncogenic virus, the authors used the polymerase chain reaction to examine paraffin-embedded sections of 15 keratinizing NPCs for human papillomavirus (HPV) types 6, 11, 16, and 18 genomic sequences. HPV DNA was found in 4 tumors (1 HPV-11-positive, and 3 HPV-16–positive tumors). None of 23 undifferentiated or nonkeratinizing NPCs harbored HPV DNA.
The putatively oncogenic HPV type 16 may thus be involved in the carcinogenesis of some EBV-negative keratinizing squamous cell nasopharyngeal carcinomas.
In this report, 11 cases of angiosarcoma of the head and neck are reviewed. The patients ranged in age from newborn to 78 years; mean age was 64 years. There were eight men and three women. Sites of involvement included the scalp and forehead, cheek, nose and ethmoid sinuses, neck, and mandible. Surgery was the primary method of treatment. The 2-year survival rate was 50% (5/10) and the 5-year survival rate was 22% (2/9). Regional metastases were seen in 18% (2/11). We found that the tumors were poorly circumscribed and spread horizontally within the dermis for considerable distances, especially in the scalp. Total surgical excision using frozen section control before reconstruction may offer the best chance for control of disease.
The environmental complexity that sounds are presented in, as well as the stimulus presentation rate, influences how sound intensity is centrally encoded with differences between children and adults.
Cortical auditory evoked potential (CAEP) comparison study in children and adults examining two stimulus rates and three different stimulus contexts.
Twelve 10 and 11 year olds and 11 adults were studied in two experiments examining the CAEP to a 1-KHz, 50-ms tone. A Slow-Rate experiment at 750-ms stimulus onset asynchrony (SOA) compared the CAEPs of 78 dB to 86 dB SPL in 2 complexity conditions. A Fast-Rate experiment was performed at 125 ms SOA with the same conditions plus an additional complexity condition. Repeated measures and mixed-model analysis of variance (ANOVA) was used to examine the latency and amplitude of the CAEP components.
CAEP amplitudes and latencies were significantly affected by rate, intensity, and age with complexity interacting in multiple mixed-mode ANOVAs. P1 was the only CAEP component present at the Fast Rate. There were main effects of rate, age, and stimulus intensity level on the CAEP amplitudes and latencies. Maturational differences were seen in the interactions of intensity with complexity for the different CAEP components.
Complexity of the sound environment was reflected in the relative amplitude of the CAEPs evoked by sound intensity. The effect of stimulus intensity depended on the complexity of the surrounding environment. Effects of the surrounding sounds were different in children than in adults.
A database was developed for prospective, longitudinal study of recurrent respiratory papillomatosis (RRP) in a large population of pediatric patients. Data recorded for each patient included epidemiological factors, human papilloma virus (HPV) type, clinical course, staged severity of disease at each surgical intervention, and frequency of surgical intervention. The study hypothesizes that patients with HPV type 11 (HPV-11) and patients younger than 3 years of age at diagnosis are at risk for more aggressive and extensive disease.
The 10-year prospective epidemiological study used disease staging for each patient with an original scoring system. Severity scores were updated at each surgical procedure.
Parents of children with RRP referred to the authors' hospital completed a detailed epidemiological questionnaire at the initial visit or at the first return visit after the study began. At the first endoscopic debridement after study enrollment, tissue was obtained and submitted for HPV typing using polymerase chain reaction techniques and in situ hybridization. Staging of disease severity was performed in real time at each endoscopic procedure using an RRP scoring system developed by one of the authors (B.J.W.). The frequency of endoscopic operative debridement was recorded for each patient. Information in the database was analyzed to identify statistically significant relationships between extent of disease and/or HPV type, patient age at diagnosis, and selected epidemiological factors.
The study may represent the first longitudinal prospective analysis of a large pediatric RRP population. Fifty-eight of the 73 patients in the study underwent HPV typing. Patients infected with HPV-11 were significantly more likely to have higher severity scores, require more frequent surgical intervention, and require adjuvant therapy to control disease progression. In addition, patients with HPV-11 RRP were significantly more likely to develop tracheal disease, to require tracheotomy, and to develop pulmonary disease. Patients receiving a diagnosis of RRP before 3 years of age had significantly higher severity scores, higher frequencies of surgical intervention, and greater likelihood of requiring adjuvant medical therapy. Patients with Medicaid insurance had significantly higher severity scores and required more frequent surgical debridement. Birth by cesarean section appeared to be a significant risk factor for more severe disease and necessity of more frequent surgical intervention.
Statistical analysis of the relationships among epidemiological factors, HPV type, and clinical course revealed that patients with HPV-11 and patients younger than 3 years of age at RRP diagnosis are prone to develop more aggressive disease as represented by higher severity scores at endoscopic debridement, more frequent operative debridement procedures per year, a greater requirement for adjuvant therapy, and greater likelihood of tracheal disease with tracheotomy.