Otolaryngology–Head and Neck Surgery

Effective data interpretation is a habit, not a random event. By applying the seven habits outlined in this article, any otolaryngologist—regardless of the level of statistical knowledge or lack thereof—will be able to use data effectively. The seven habits are (1) check quality before quantity, (2) describe before you analyze, (3) accept the uncertainty of all data, (4) measure error with the right statistical test, (5) put clinical importance before statistical significance, (6) seek the sample source, and (7) view science as a cumulative process. The same habits apply whether interpreting one's own data, interpreting someone else's data, reviewing an unpublished manuscript for a journal, or reviewing a grant application for a funding agency. The basic principles that underlie these habits provide a systematic process for moving from observations to generalizations with predictable degrees of certainty—and uncertainty.

Products of arachidonic acid metabolism can influence normal and malignant cell growth. In vivo, inhibitors of arachidonic acid metabolism have been associated with inhibition of tumor growth, including head and neck squamous cell carcinoma (HNSCC). This has not been evaluated extensively in vitro in an HNSCC model. Therefore we investigated the effects of several arachidonic acid cascade inhibitors (AACIs) (indomethacin, curcumin, phenidone, nordihydroguaiaretic acid, 5,8,11,14-eicosatetraynoic acid, and 13-cisretinoic acid) on the growth of two HNSCC cell lines (MDA 886Ln and 1483). We found that AACIs caused dose-dependent growth inhibition of both cell lines. In an effort to inhibit HNSCC cell growth at lower concentrations of these drugs, we evaluated the effects of a variety of AACIs in combination with 13-cis retinoic acid. We observed synergistic growth inhibition when the drugs were used in all combinations, with the exception of indomethacin. These results suggest that AACIs may have some utility in the direct treatment of HNSCC, and a strategy combining 13-cis retinoic acid with other AACIs may prove to be even more effective.

CT scans of eight nonsmoking patients with chronic sinusitis and two controls were graded for their disease severity (from 0 to IV) with the classification system proposed by May. Subsequently, endoscopically harvested middle turbinate specimens from these patients (16 diseased turbinates, 4 controls) were evaluated both by scanning and by transmission electron microscopy. As the severity of the disease increased as demonstrated by CT scan, electron microscopy of 5 × 3 × 0.05 mm mucosal specimens demonstrated that the number of ciliated cells decreased whereas the number of goblet and squamous cells increased. As the disease progressed to stages III and IV, scanning and transmission electron microscopy demonstrated areas of squamous metaplasia and areas completely denuded of epithelium. The increased goblet cell population, the loss of cilia and ciliated cells, and the patches of denuded epithelium may account for the recurrent bacterial infections and chronic nasal drainage seen in patients with chronic sinusitis. The extensive mucosal changes that occur in grade III and IV disease are similar to those occurring in cigarette smokers, and it takes years to recover after discontinuation of smoking. Delayed recovery of the mucosal epithelium may account for both the recurrent infections and the slower response to treatment on the part of patients with extensive grade III and IV changes on the CT scan.

The surgical management of subglottic stenosis may be complicated by reformation of strictures. A slow-release combination of 5-fluorouracil, which has an antiproliferative effect on fibroblasts, and the corticosteroid triamcinolone acetonide has been used experimentally to control scar production in ophthalmic operations. This study was performed to determine if this material also can be used to reduce formation of subglottic stenosis. Subglottic stenosis was induced in rabbits by means of injury to the subglottic mucosa and submucosa. A suspension of the compound at a concentration of 2.5 mg/ml or 12.5 mg/ml was injected into the adjacent soft tissues. A control group of rabbits received the same volume of the suspension fluid but no compound. Two rabbits from each group were killed 1,2, and 12 weeks postoperatively. No stenosis was seen at 1 or 2 weeks, but at 12 weeks the rate of formation of subglottic stenosis was decreased to a mean of 15.20% in the experimental groups compared with 47.37% in the control group. There were no indications of local or systemic toxicity. The promising results from this preliminary study suggest that use of this compound may reduce restenosis among patients treated surgically for subglottic stenosis. Further studies are being conducted.

Neural regeneration after grafting can be unpredictable. In an effort to enhance the return of function after cable grafting, we studied the effects of an angiogenic factor, endothelial cell growth factor (ECGF), on regenerating nerves. Cable grafts on the sciatic nerve were established in 18 rats and treated with ECGF or a control saline solution. At 5 weeks, nerve conduction studies were performed, and the animals were killed for histologic measurements of graft vascularity and axon counts. A significant increase in vascularity was noted in the treated group versus the control group; neither the axon counts nor the nerve conduction velocities differed significantly between the two groups, although the treated group appeared to show improved neural conduction compared with the control group.

Symptom questionnaires were obtained from 106 patients immediately before nasal and sinus computed tomography scans at the Johns Hopkins Outpatient Center. Their scans were analyzed by two otolaryngologists and three neuroradiologists by using a semiob-jective rating system of the size and opacity of 36 anatomic areas. Patients estimated their own left and right sense of smell as excellent, diminished, or absent. Results of the data are as follows: (1) There is no correlation between smell ability and size of the nasal and sinus structures. This indicates that there is no gross effect of the bulging of sinuses into the nasal airway; (2) As a rule, opacity of only left-sided anatomic structures was correlated with both left and right sense of smell (p < 0.01). This suggests that our subjects were using their left smell receptors preferentially, to the exclusion of and in place of the right smell receptors; and (3) Total, not partial, opacity of the left olfactory cleft, frontal recess, or ethmoidal infundibulum was correlated with decreased sense of smell. This suggests that these anterior structures in the region of the olfactory cleft do affect airflow, but complete obstruction of these spaces is needed. Possible explanations for the effect of opacified sinuses on the sense of smell include (1) The presence of fluid or thickened mucosa in the sinuses may interfere with perceived olfactory ability by changing nasal airflow patterns or odorant access to receptors; (2) There may be olfactory receptors inside the sinuses; and (3) There may be a relation between the trigeminal receptors in the sinuses and the olfactory system.

Collagen is a functionally essential component of the five-layered structure of the vocal fold. Soluble bovine collagen has previously been shown to be an effective injectable bioimplant for vocal fold defects, paralysis, and, especially, scarred larynges. Although bovine collagen appears to be well tolerated, the concern for possible adverse immunologic responses has deterred approval from the Food and Drug Administration for its clinical use in the larynx. Currently we are investigating the use of injectable autologous collagen for vocal fold augmentation. The purpose of this study is to examine the histologic fate of autologous collagen injected into the canine vocal fold at multiple intervals after injection. An ellipse of skin measuring 3 × 6cm was harvested from each of three dogs and processed into a naturally cross-linked injectable solution of collagen (Autologen). This autologous collagen was injected into one vocal fold and a control injection of buffer solution was injected contralaterally. The injections were well tolerated and no dog appeared to suffer any immediate or delayed ill effects. The dog larynges were harvested 1, 3, and 6 months after collagen injection and examined grossly and histologically. Injected autologous collagen material persisted in these experimental animals and appeared to be well tolerated. Based on this preliminary study, we anticipate autologous collagen to be at least as suitable as bovine chemically cross-linked collagen as an injectable bioimplant for vocal fold augmentation. It may also have the advantage of added safety and stability.

OBJECTIVE: Advances in imaging resolution have resulted in superior visualization of intracranial anatomy. Because of the inherent complexity of the surgical exposure of these lesions, intraoperative localizing techniques are required. Currently, C-arm fluoroscopy provides only two-dimensional localization for these anatomic structures. The recently described ACUSTAR I system, developed in conjunction with Codman and Shurtleff, Inc. (Randolph, Mass.), is an interactive, image-guided device that allows three-dimensional localization with a degree of accuracy previously unattainable. We assessed the clinical utility of the ACUSTAR I system for intraoperative spatial confirmation during transsphenoidal approaches to pituitary lesions.

METHODS: Eight patients underwent transsphenoidal approaches to pituitary lesions with the assistance of the ACUSTAR I system. The spatial relationships were clinically judged intraoperatively by the surgeon and by use of traditional C-arm fluoroscopy and then were compared with the ACUSTAR I system results.

RESULTS: In all eight patients, the ACUSTAR I system correctly displayed the surgical orientation and provided localization to within less than 1 mm. In two patients, this facilitated the redirection of an errant approach. No complications were associated with the use of this image-guided device.

CONCLUSIONS: The ACUSTAR I system is useful in displaying accurate, three-dimensional anatomic relationships during transsphenoidal approaches to pituitary lesions. This system provides critical information intraoperatively to redirect errant approaches and prevent significant morbidity.

BACKGROUND: Salivary gland cancer (SGC) is a rare disease with a largely unknown origin. Because cancer of the tongue and mouth floor is caused primarily by smoking and alcohol consumption, we investigated the role of tobacco, alcohol, and other possible risk factors in the development of SGC in a hospital-based study.

METHODS: Interviews were obtained from 128 patients with newly diagnosed histologically confirmed SGC and from 114 age- and gender-matched controls by using a structured questionnaire. All patients were interviewed at bedside by a trained interviewer.

RESULTS: No differences in levels of education were found between the two groups. Cigarette smoking and alcohol consumption did not independently or jointly increase the risk of SGC. Chewing tobacco and snuff use were also unrelated factors. The odds ratio for low body mass in men was 0.46 (p = 0.05). There was no relation with body mass in women. An examination of employment history and job-related exposures revealed no occupational risk factors.

CONCLUSION: These findings show that smoking, alcohol consumption, and most occupational exposures are unrelated to SGC.

Unilateral vocal cord paralysis (UVCP) is relatively common, and previously, thyroidectomy used to be the leading cause. We retrospectively reviewed 98 cases of UVCP. The left vocal cord was involved in 70% of the cases and the right vocal cord in 30%. The cause was neoplastic in 32%, surgical in 30%, idiopathic in 16%, traumatic in 11%, central in 8%, and infectious in 3% of the cases. Only 4 cases were the result of thyroid surgery. Evaluation consisted of a review of the history, a physical examination, and computerized scanning or magnetic resonance imaging, as needed. The functional recovery rate as related to the cause was as follows: surgery 31%, idiopathic 19%, traumatic 18%, and neoplastic 0%. Thirty-five percent of patients required medialization Iaryngoplasty or Teflon injection. Lung and skull base tumors and their surgical treatment are the most common causes of UVCP.

The lateral thigh free flap is a fasciocutaneous flap based on the cutaneous perforators of the deep femoral vessels. Although originally described in 1983, it has had very few reports in the literature. This article describes the flap and reports our findings and outcomes in nine cadavers (18 thighs) and 33 clinical cases. The position of the vascular pedicle may vary in each case but has always been found to be present. Successful transfer occurred in 30 of 33 cases. Flap loss was attributable to infection, fistula, and hematoma in three of four cases. The flap was especially useful in large defects, most commonly total and base-of-tongue defects. We have found this flap to be reliable and to result in minimal morbidity.

The objectives of this study were to investigate potential relationships between pretreatment patient-mix characteristics, treatment modalities, and costs generated during the pretreatment work-up, treatment, and 1-year follow-up periods for patients with oral cavity cancer (OCC). Another objective was to identify potential areas for cost reduction and improved resource allocation in the management of OCC patients. Using a retrospective cohort of 73 patients with OCC, pretreatment patient-mix characteristics and treatment modalities were evaluated in relation to university-based charges incurred during the pretreatment evaluation, treatment, and 1 -year follow-up periods. Simple regression and stepwise multiple regression analyses were used to develop predictive models for cost based on independent variables, including age, AJCC TNM clinical stage, smoking history, American Society of Anesthesiologists (ASA) class, comorbidity as defined by the Kaplan-Feinstein grade and treatment modality. The dependent measurements included all physician, office, and hospital charges incurred at the University of Iowa Hospitals and Clinics during the pretreatment evaluation, treatment, and follow-up periods, as well as the total pretreatment through 1-year follow-up management costs. Independent variables that were identified as being significantly associated with treatment costs included T classification, N classification, TNM stage, unimodality versus multimodality treatment, and the Kaplan-Feinstein comorbidity grade. Age, smoking status, and ASA class were not significantly associated with costs. The majority of the OCC management costs were incurred during the treatment period. The most substantial decreases in management costs for OCC will be realized through measures that allow identification and treatment of disease at an early stage, in which single-modality treatment may effectively be used. Resource allocation for OCC should support the investigation of measures through which the diagnosis and treatment of OCC at the earliest possible stage is facilitated. The presence of comorbid illness is a significant component in the determination of management costs for OCC and should be included in analyses of resource allocation for OCC. The singular diagnosis of OCC encompasses a wide range of patient illness severity, and diagnosis-related reimbursement schemes for OCC treatment should optimally differentiate between early and advanced stage disease.

As part of a large-scale study of presbyacusis, responses to a medicinal drug questionnaire from 85 female and 126 male human subjects were analyzed. Medicinal drugs were divided into 35 categories based on their pharmacologic effects. Subjects' ages ranged from 60 to 82 years. At least 10% of subjects reported taking drugs in 14 of 35 categories. Results were significantly different between female and male subjects. In men, none of the 14 categories showed a statistically significant relation to the pure-tone average (PTA) of 500, 1000, 2000, and 4000 Hz. In women, 3 of the 14 categories showed a statistically significant relation to the PTA. First, the average PTA of female subjects taking β-adrenergic medication was 20 dB higher (poorer) than those not taking β-adrenergic medication. Second, women taking antihistamine/cold preparations had an average PTA 9 dB higher (poorer) than those not taking antihistamine/cold preparations. Third, the average PTA of women taking calcium-channel blockers (CCBs) was 12 dB lower (better) than those not taking CCBs. In men, however, these drugs produced effects on the PTA of less than 3 dB. Differences between women and men were not explainable by differences in age or hearing level.

Automobile airbag safety systems have successfully reduced the number of occupant injuries from motor vehicle accidents. Unfortunately, airbags are also associated with some inherent risk, including a high-amplitude, short-duration noise from airbag deployment. A review of the available research in the automobile industry indicates that the peak amplitude of this noise may exceed 170 dB sound pressure level. Despite the increasingly wide application of airbags in automobiles, there have been no previous reports of airbag-related otologic injuries. We have encountered six patients with otologic symptoms that appear to be related to airbag impulse noise. Five of these patients have documented hearing loss, one patient reported persistent tinnitus, and two patients have significant dysequilibrium. Although permanent hearing loss from airbag noise appears to be rare, temporary threshold shifts are probably much more common. It is important, therefore, that the clinician be aware of the noise associated with airbag inflation and the possibility of acoustic trauma from these safety devices.

Widespread application of cochlear implants is limited by cost, especially in developing countries. In this article we present a design for a low-cost but effective cochlear implant system. The system includes a speech processor, four pairs of transmitting and receiving coils, and an electrode array with four monopolar electrodes. All implanted components are passive, reducing to a minimum the complexity of manufacture and allowing high reliability. A four-channel continuous interleaved sampling strategy is used for the speech processor. The processor and transmission link have been evaluated in tests with a subject previously implanted with the Ineraid electrode array and percutaneous connector. A prototype of the link, consisting of four pairs of transmitting and external receiving coils, was used, with the outputs of the receiving coils directed to four intracochlear electrodes through the percutaneous connector. The subject achieved speech reception scores with the prototype system that were equivalent to those achieved with a standard laboratory implementation of a continuous interleaved sampling processor with current-controlled stimuli.

A randomized, double-blind clinical trial was conducted on 41 adult patients to compare the efficacy and safety of the combination of terfenadine and pseudoephedrine with that of terfenadine alone. Efficacy of treatment evaluated by the physician and patients showed an excellent rating in 45.45% patients in the combination treatment group compared with an excellent rating in 10.53% in the single treatment group. The difference between both treatments was statistically significant, with a z value of 1.660 (p < 0.05). The combination of terfenadine and pseudoephedrine was found to result in faster relief in a greater number of patients than terfenadine alone. However, both drugs were well tolerated.

The insertion of intraluminal stents is an effective method of relieving the distressing symptom of asphyxia in patients with obstructive lesions in the trachea and main-stem bronchi. We report our experience in the use of the studded Dumon silicone stent (Endoxane prosthesis' Axion, Aubagne, France). Between February 1994 and August 1996, 42 stents were placed in 30 patients. Of the 27 patients with a malignant stricture, 10 had carcinoma of the bronchus, 13 carcinoma of the esophagus, and 4 metastatic carcinoma involving the tracheobronchial tree. The benign lesions were made up of two tuberculous strictures and one suprastomal stenosis after tracheostomy. Stents were placed through a rigid bronchoscope with patients under general anesthesia. Postplacement assessment was performed with a 10-point, symptom-based visual analog scale. In eight less urgent cases, forced expiratory volume in 1 second and forced vital capacity were determined before and after surgery. The mean symptomatic improvement on the 10-point scale was 6.1 points, whereas the forced expiratory volume in 1 second (in the eight patients tested) improved by 75%, and the forced vital capacity improved by 54%. The median survival was 2 months for patients with carcinoma of the bronchus and 3 months for patients with carcinoma of the esophagus. Two patients with metastatic carcinoma and all of the patients with the benign lesions were alive and well after 12 months of follow-up. Insertion of the Dumon stent is a simple, safe, and effective method of countering the distressing symptoms arising from obstructive tracheobronchial lesions.

As soon as the use of streptomycin was started for the treatment of tuberculosis, its ototoxic effect was discovered. Initial reports demonstrated that streptomycin was successful in reducing vestibular responses while preserving cochlear activity. Streptomycin sulfate has been used for almost half a century for the treatment of vertigo in patients with Meniere's disease. At the Gruppo Otologico, Piacenza, Italy, between 1987 and 1995 we treated 16 patients with either bilateral Meniere's disease or with Meniere's disease in their only hearing ear, adopting the titration streptomycin therapy protocol of Graham et al. Three patients with follow-up periods of less than 2 years were not included in this study. The ages of the patients ranged from 36 to 64 years with a mean of 49.2 years. The patients were observed for 2 to 8.8 years. The dose of administered streptomycin varied from 14 to 49 gm. Episodic vertigo was totally relieved in all of the patients after initial treatment, whereas hearing remained the same or was improved when compared with the pretreatment levels. Five of the patients experienced recurring vertigo during a period of 4 to 24 months after initial treatment. Oscillopsia persisted in two patients and ataxia in darkness persisted in another two patients. Hearing was unchanged in 14 ears, improved in 2 ears, and worsened in 4 ears at the last follow-up evaluation. The overall outcome indicated that intramuscular titration streptomycin therapy seems to be one of the most important therapeutic options in the treatment of disabling vertigo in patients with either bilateral Meniere's disease or Meniere's disease in an only hearing ear.

We evaluated the use of a novel three-dimensional ultrasound imaging device in patients with various head and neck lesions. The investigated system was found to be a valuable adjunct to conventional ultrasound in head and neck evaluations. A disadvantage of the three-dimensional system was the need for expensive technical equipment.

The prognostic significance of wound infections after surgery for squamous cell carcinoma of the head and neck is controversial. We retrospectively studied the relationship between wound infection, tumor recurrence, and survival rates in 158 patients operated on for supraglottic cancer. All patients had 3-year follow-up. Wound infection developed in 14 patients (8.8%). The overall recurrence rate was 29.7%. For those in whom a wound infection developed the recurrence rate was 57%, compared with 27% for those in whom no such infection developed (p = 0.041). Disease-free survival was also adversely affected in the group of patients with infections, although because of the limited number of patients the differences did not reach statistical significance. We conclude that postoperative wound infection may have an adverse effect on prognosis in squamous cell carcinomas of the head and neck.