Ear,Nose & Throat Journal

Exposure of the facial nerve from the brainstem to the parotid can be accomplished without injury to the nerve, tympanic membrane, external auditory canal, ossicular chain, inner ear or structures within the cerebello-pontine angle. The procedure has reliably provided good results for patients who have had the proper indications with facial paralysis from Bell's palsy, herpes zoster oticus, infection, hemifacial spasm, temporal bone fracture and tumors. The current technique for exposure through the mastoid, middle cranial fossa and retrolabyrinthine combined approaches are described. This technique, properly performed, is a valuable treatment for facial nerve lesions.

Seventeen percent of all vertiginous patients have benign paroxysmal positional vertigo. Treatment can include occlusion of the posterior semicircular canal for control of these positional vertigo symptoms. More recently, use of an argon laser technique to occlude the posterior membranous semicircular canal has been proposed. However, this laser technique was not tolerated by a diabetic patient.³ This report describes a new technique using the argon laser to ablate the utricular macula in the affected ear in patients with benign paroxysmal positional vertigo. This procedure is done as outpatient surgery under local anesthesia. The procedure successfully resolved benign paroxysmal positional vertigo in 14 patients. Symptoms in these patients improved from 20-100% (median 87%; mean 80%) as measured by the Dizziness Handicap Inventory.

Salivary gland choristoma (heterotopic salivary gland tissue) is a rare condition that occurs at various locations within the head and neck. We present a 10-year-old boy with a salivary gland choristoma of the middle ear and compare findings with the 15 similar cases published in the English and German languages. Patients typically have a long-standing conductive hearing loss and visible middle ear mass. Operative findings include a lobulated middle ear mass of histologically normal salivary gland tissue attached posteriorly in the region of the oval window, together with absent or malformed ossicles. Frequently the mass is intimately associated with the facial nerve. The constancy of these findings has led to the proposal of an abnormal developmental syndrome. This syndrome will be described and possible explanations for its cause will be discussed.

Cholesterol granuloma cyst of the petrous apex is an uncommon lesion and often presents a diagnostic and management dilemma to the otolaryngologist. Patients usually demonstrate signs and symptoms referable to a mass lesion of the cerebellopontine angle or brainstem. We present two cases of cholesterol granuloma cyst that were treated at our institution and discuss our diagnostic and management algorithms. Also included is a thorough review of the literature.

Forty-four children who underwent adenotonsillectomy for obstructive sleep apnea (OSA) were studied. The diagnosis was confirmed polysomnographically. Patients with other medical problems or complications of OSA were excluded. The overall complication rate was 32%. Significant airway complications occurred in 16%. Factors associated with development of statistically significant airway complications were acute airway compromise, age <3 years, thin body habitus, and both oxygen (O₂) desaturation and carbon dioxide (CO₂) retention seen polysomnographically. Although many OSA patients can safely have outpatient adenotonsillectomy, perioperative monitoring of patients with these risk factors is needed.

A total of 220 patients have undergone cervical exploration for hyperparathyroidism by the author. A review of 125 cases was published in 1991. An additional 95 patients have been explored in the subsequent four years. Subtotal parathyroidectomy was performed in 39 patients with chronic renal failure. Exploration was successful in over 97% of the 181 patients diagnosed with primary hyperparathyroidism. Single adenomas were found in 146, double adenomas in 11, and multiple gland hyperplasia in 19 patients. Two of the five patients in whom cervical exploration failed were ultimately diagnosed with benign familial hypocalciuric hypercalcemia. Twenty-four adenomas were ectopic. Preoperative thallium-technetium scans and ultrasound correctly localized only 61% of the adenomas. Technetium sestamibi scans were correct in two of four adenomas. Only 47% of ectopic adenomas were correctly localized by isotope scanning and 29% by ultrasound.

All four glands should be examined at initial exploration. Because of the occurrence of double adenomas, contralateral exploration is always indicated regardless of whether an enlarged gland and a normal one are found on the first side. All enlarged parathyroids should be removed when dealing with single or multiple adenomas; subtotal parathyroidectomy (3-1/2 glands) should be performed in multiple gland hyperplasia. Frozen section confirmation of excised parathyroid tissue is essential. If exploration is unsuccessful, ectopic locations, such as the retroesophageal areas, thymus, anterior and posterior mediastinum, carotid sheath and thyroid lobe, must be examined carefully.

Preoperative localization studies are not as reliable as an experienced parathyroid surgeon.