Otolaryngology–Head and Neck Surgery

The history of rhinology is the story of the efforts of men and women who have tried to help patients who have nasal and sinus disorders or other conditions thought to be related to the nose or sinuses. Woven through this story are the subplots of the progress of surgical technology, the understanding of anatomy and physiology, and the hit-or-miss relationship between them. Through the last half of the nineteenth century, great strides were made in understanding nasal and sinus anatomy and physiology. As that century ended and as the twentieth century began, there was a surge of technology that allowed a marked increase in the type and number of surgeries performed. Unfortunately, nasal and sinus surgery holds the awesome potential to promote health or to severely hurt someone. The knowledge of nasal physiology and anatomy had been exceeded, and often those operations were not in the patient's best interest. Through the middle of the twentieth century the basic science knowledge seems to have caught up with the care being provided, but as the end of the century approaches, another tide of surgical activity seems to be upon us. Perhaps in no other area of surgery has this disparity between biologic knowledge and surgical activity been so well demonstrated. Perhaps the next 100 years will witness a better coordination of these activities. (Otolaryngol Head Neck Surg 1996; 115:283-97.)

Human temporal bones provide an irreplaceable resource for study of the pathology and pathophysiology of disorders of hearing, balance, taste, and facial nerve function. Additional specimens are needed to study disorders for which there are few human specimens; to increase the number of specimens for a given disorder to understand the natural variability and expression of the disease entity; to evaluate the accuracy of otologic diagnoses and the efficacy of otologic treatment modalities; to apply newly available scientific methods, including immunohistochemistry and molecular biologic or molecular genetic techniques; and to teach the anatomy of the human ear and modern otologic surgical techniques. This article provides information for the scientific community concerning techniques for temporal bone and auditory brain stem removal, including intracranial and extracranial approaches and methods to minimize postmortem autolysis and cosmetic defects. Close collaboration between physicians and funeral directors will maximize the yield and utility of these valuable specimens for scientific inquiry and training. (Otolaryngol Head Neck Surg 1996;115:298-305.)

The role of immunoglobulin E-mediated food allergy in subjects with allergic disorders, especially in patients with rhinitis and sinusitis, is underestimated by clinicians because of the initial attribution of these disorders to immediate-type hypersensitivity reactions. The difficulties of diagnosing food-related reactions have caused further delay in their recognition and incorporation into the daily practice of diagnosing food allergy. Two of the diagnostic methods for food allergy are the in vitro assay of total immunoglobulin E and the measurement of food-specific immunoglobulin E levels in serum with the radioallergosorbent test. Measurement of specific immunoglobulin E level is the most commonly used but also one of the most controversial techniques. We examined 123 patients with rhinitis who were referred to our otolaryngology/allergy clinic between January and April 1995. All patients received an initial radioallergosorbent test screen, which included milk. We determined the positive predictive value of this positive screen and, in particular, of a positive test for milk in the diagnosis of immunoglobulin E-mediated food allergies in these patients. Conclusions were based on comparison with the result of an additional radioallergosorbent test food panel consisting of eight common and two investigational food allergens. (Otolaryngol Head Neck Surg 1996;115:312-8.)

Recent case reports have challenged the notion that tonsillectomy is contraindicated in patients with or at risk for velopharyngeal insufficiency. The purpose of this study was to quantify the effects of tonsillectomy (with or without adenoidectomy) on perceptual speech characteristics, aerodynamic measures, and endoscopic descriptions of velopharyngeal function in a clinical population. Fifteen children 4 to 10 years of age received preoperative and postoperative evaluations. Perceptual speech characteristics improved or remained the same for most variables. There was no statistically significant difference between preoperative and postoperative ratings of hypernasality or frequency and severity of nasal emission. However, ratings of voice quality (pitch and breathiness) were significantly improved after surgery. Aerodynamic measures showed improvement or no change in velopharyngeal function for 12 of 15 children. Endoscopic assessment showed improvement or no change in velopharyngeal closure for 7 of 11 children tested. Cross-method analysis indicated that no single subject showed deterioration in velopharyngeal function in all three measures. The data from this investigation do not support the assumption that tonsillectomy is contraindicated for all children with or at risk for velopharyngeal insufficiency. (Otolaryngol Head Neck Surg 1996;115:319-23.)

During a 10-year period (1984–1994) 1229 stapes operations for otosclerosis were performed at our respective institutions by experienced surgeons well trained in the various techniques. Procedures included 691 stapedectomies, 234 small-fenestrae stapedotomies, and 304 revision operations. These primary and revision cases resulted in 20 ears with severe sensorineural hearing loss or anacusis noted during the immediate postoperative period. This article will critically evaluate those procedures that resulted in profound hearing loss and attempt to determine possible reasons for this occurrence. It is hoped that these data will allow surgeons to identify before and/or during surgery patients at risk for development of this complication and therefore decrease the overall morbidity rate of this exacting procedure. (Otolaryngol Head Neck Surg 1996;115:324–8.)

The mucosal upheaval where the mucosal wave starts and propagates upward appears on the lower surface of the canine vocal fold during vibration. We investigated the vibratory behavior of the in vivo human vocal fold viewed from the tracheal side. Subjects consisted of 14 men and 6 women who had undergone tracheostomy for various head and neck diseases; their ages ranged from 22 to 70 years, with a mean of 53.9 years. The inferior aspect of the vocal fold during phonation was observed with the aid of a rigid oblique-view endoscope inserted through a tracheostome (inferior glottoscopy). Each subject was asked to sustain the vowel /a/ at a comfortable pitch and loudness (easy phonation) and then at a higher pitch. Inferior glottoscopy could be performed during easy phonation in 19 subjects and during high-pitched phonation in 10 subjects. During easy phonation, the mucosal upheaval appeared on the lower surface of the vocal fold between the anterior commissure and the vocal process in all 19 subjects. During high-pitched phonation, the vocal fold became longer, and the subglottic vault surrounded by the bilateral mucosal upheavals became narrower compared with those during easy phonation. Use of a dilated blood vessel as a landmark in one subject showed the location of the mucosal upheaval on the vocal fold mucosa to actually shift medially toward the oral side during high-pitched phonation. Despite structural differences between the human and canine vocal folds, the infraglottic aspect of the vocal fold vibration observed in the living human larynx was quite similar to that observed in the excised canine larynx (Otolaryngol Head Neck Surg 1996;115:329-34.)

The number of valuable resources for otolaryngologist-head and neck surgeons on the Internet continues to grow at a rapid pace. This article is a comprehensive guide to resources currently available. (Otolaryngol Head Neck Surg 1996;115:335–41.)

The treatment of chronic suppurative otitis media caused by Pseudomonas aeruginosa remains a challenging problem. The virulence of Pseudomonas is related to its secretion of two matrix metalloproteinases, alkaline protease and elastase. This experiment examines the effects of a synthetic inhibitor of matrix metalloproteinases GM 6001, or N-(2(R)-2-(hydroxyamido carbonylmethyl)-4-methylpentanoyl)-L-tryptophane methylamide), in a chinchilla Pseudomonas otitis media model. Thirty chinchillas underwent bilateral subtotal tympanic membrane perforations. Twenty-four chinchillas underwent bilateral middle ear inoculation with P. aeruginosa. Chinchillas were divided into four groups of six animals after the establishment of otitis media. Animals in one group were controls; the other three groups received either gentamicin, GM 6001, or gentamicin plus GM 6001 into the external auditory canal three times daily for 4 weeks. Clearance of Pseudomonas infection occurred in three ears of three animals, all in gentamicin groups, with or without GM 6001. Otorrhea (p = 0.0014) and external canal erythema (p = 0.025) were mild in the two gentamicin groups and moderate in the GM 6001 group when compared with bacterial controls. Animals in the GM 6001 group had the highest survival rate, less severe facial paralysis, and less vestibular toxicity than the gentamicin, gentamicin plus GM 6001, or control groups, although these differences were not statistically significant. This pilot study showed encouraging results for a role of ototopical protease inhibitors in the treatment of Pseudomonas otitis media. (Otolaryngol Head Neck Surg 1996;115:342–51.)

Controversy exists regarding voice recovery after the use of laser vs. microforceps techniques in the removal of benign vocal fold lesions. The purpose of this study is to compare recovery of voice and healing between groups of cats undergoing vocal fold epithelium removal by CO₂ laser and those having vocal fold stripping. Fourteen adult female cats underwent standardized unilateral vocal fold injuries by CO₂ laser ablation or stripping. After a 6-week recovery period, phonations were evoked by electrical stimulation of the midbrain periaqueductal gray area. Phonations were recorded for acoustic analysis. The larynges were harvested, fixed, and sectioned for histologic correlation. Acoustic analysis showed the mean signal-to-noise ratios in the laser group (19.72) to be significantly higher than those in the stripped group (13.51) (p = 0.04). The stripped group showed significantly greater amplitude perturbation (8.68% vs. 2.43%, p = 0.02). No between-group difference was found for period perturbation. Histologically, the laser group showed minimal Reinke's space scarring and near-normal epithelial regeneration, and the stripped group showed marked subepithelial scarring, often involving the vocalis muscle. These results demonstrate superior recovery of voice and healing in animals undergoing vocal fold epithelium removal with the CO₂ laser. Inferior outcomes seen in the stripped group may be related to difficulty in preserving Reinke's space during epithelium removal. (Otolaryngol Head Neck Surg 1996; 115: 352–9.)

Although hyperbaric oxygen has been shown to improve the survival rate of ischemic grafts and flaps of many types, it has not been studied extensively in free tissue transfer. This study was designed to evaluate the effect of hyperbaric oxygen on flap survival when exposed to critical combinations of primary ischemia, reperfusion, and secondary ischemia times. Unilateral abdominal adipocutaneous island flaps based on the superficial inferior epigastric vessels were raised in 133 Sprague-Dawley rats. Primary normothermic ischemia was induced by applying a microvascular clamp to the vascular pedicle for 6 hours. The clamp was removed for 2 hours of reperfusion and then reapplied for a 6-, 10-, or 14-hour period of secondary ischemia. After completion of the secondary ischemia time, the clamp was removed, and the animals were randomly assigned to one of three treatment regimens. The control animals breathed normobaric air, and the others breathed normobaric 100% oxygen or hyperbaric oxygen (100% oxygen at the equivalent of 33 feet of seawater, 2.0 atmospheres absolute), respectively, for two periods of 90 minutes for 7 days. Flap survival was assessed at postoperative day 7 and was found to be an all-or-none phenomenon. Maximum likelihood-derived survival curves were fitted to the data and used to calculate the secondary ischemic time at which 50% of the flaps survived (D50). The D50 for the air and 100% oxygen groups was 6 hours, whereas that for the hyperbaric oxygen group was 10 hours. This difference in D50 was found to be statistically significant (analysis of variance, p >0.05). Chi-squared statistical evaluation of pooled data reaffirmed a statistically significant increase in flap survival of the animals treated with hyperbaric oxygen vs. those treated with air or 100% oxygen (p >0.03 and p >0.01, respectively). Hyperbaric oxygen enhances the tolerance of normothermic, microvascular flaps to prolonged secondary ischemia. A similar effect was not noted in the 100% oxygen group; therefore the additional expense and technology of a hyperbaric chamber system is necessary to achieve this effect. (Otolaryngol Head Neck Surg 1996; 115:360–4.)

This study uses stereology to determine the volume fraction distribution of chondrocytes throughout septal cartilage. En bloc submucous resection of septal cartilage from four different age groups was performed. Each age group contained three pigs. The weight, volume, and dimensions of the septi were determined. The septi were fixed, embedded in plastic, sectioned vertically at regular intervals along their anterior-posterior axis, and stained with toluidine blue. Each section was further stratified horizontally to allow chondrocyte volume fraction changes to be observed as a function of the two-dimensional location within the septum. The volume fraction of the chondrocytes within the septal cartilage was obtained through light microscopy and stereologic technique. Nested analysis of variance for age groups, individuals within age groups, and locations on the septum was performed. Additionally, unequal number-comparison tests for age groups were calculated. Gross septal parameter changes regarding weight, volume, and length all increased with advancing age. Overall, chondrocyte volume fraction decreased with advancing age. Chondrocyte volume fraction was not found to vary along the anterior-posterior axis or along the vertical axis. Stereologic methodology is an unbiased, simple, and efficient technique to understand the distribution of cells within a tissue. (Otolaryngol Head Neck Surg 1996;115:365–9.)