Otolaryngology–Head and Neck Surgery

The search for a safe, effective treatment for the vertigo associated with Meniere's disease has long been an important topic in otolaryngology. In recent years many groups have begun using intratympanic gentamicin to treat this vertigo. Although reported cure rates are as high as 90%, many questions remain regarding this type of treatment. Current limitations are the necessity for repeated treatments and a lack of clear dosing guidelines. In addition, the gentamicin must be delivered in a manner that allows maximal vestibulotoxic effect without injury to hearing. Until investigators can control the exact amount of medicine that is placed in the ear and have an understanding of the kinetics of gentamicin absorption, adequate dosing guidelines will be difficult to establish, and therapy will continue to rely on empiric data. We describe the use of a fibrin-based sustained-release vehicle, impregnated with gentamicin, injected into the middle ear of chinchillas. This allows for a prolonged effect without repeated dosing. Using this model, we studied the absorption kinetics of gentamicin at time points ranging from 8 hours to 1 week after injection. We used our findings to create a kinetics curve of gentamicin absorption. We discuss the shape and characteristics of this kinetics curve and examine the effects of the fibrin-based sustained-release vehicle and gentamicin on the middle ear. We noted no absorption in the contralateral (untreated ear) or blood. Through better understanding of the actions of gentamicin in this animal model, we hope to facilitate safer use of intratympanic medicines in our patient population and initiate programs for the use of this sustained-release vehicle in human beings.

Hearing results were studied in pediatric patients after canal-wall-up and canal-wall-down mastoid surgery in a private practice setting. A retrospective chart review was performed on 69 patients who underwent surgery from 1991–1995. Twenty-six patients underwent canal-wall-up mastoidectomies, and 43 patients underwent canal-wall-down mastoidectomies. Various types of ossicular reconstruction were performed in patients in both groups. Hearing was evaluated for preoperative and postoperative pure-tone averages, speech-reception thresholds, and air-bone gaps for the various types of ossicular reconstruction. Patients with canal-wall-up mastoidectomies and an intact ossicular chain had an average postoperative air-bone gap of 15 dB, whereas reconstruction of the ossicular chain (regardless of technique) resulted in an average postoperative air-bone gap of 19 dB. Patients with canal-wall-down mastoidectomies and an intact ossicular chain had an average air-bone gap of 15 dB, while all techniques of ossicular reconstruction had an average air-bone gap of 29 dB. Canal-wall-up and canal-wall-down mastoid surgeries in pediatric patients have similar hearing results. Variables other than hearing should be used to make treatment decisions regarding the canal wall in pediatric candidates for mastoid surgery.

We reviewed our experience with 100 children admitted to Children's Hospital of Pittsburgh between 1980 and 1995 with an intratemporal complication of acute otitis media. Seventy-two patients were treated for acute mastoiditis. Of these 72 children, 54 (75.0%) were treated conservatively with broad-spectrum intravenous antibiotics and myringotomy. Eighteen (25.0%) required mastoidectomy for treatment of a subperiosteal or Bezold's abscess or cholesteatoma, or because of poor response to conservative therapy. Twenty-two children presented with facial paralysis, complete in 5 (22.7%) and incomplete in 17 (77.3%). Eighteen (81.8%) were treated conservatively, but four required mastoid surgery. Nineteen patients had adequate follow-up; of these, 15 recovered normal facial function but 4 were left with partial paralysis. Three patients presented with serous labyrinthitis and recovered completely with conservative therapy. Of the two patients who presented with suppurative labyrinthitis, one was treated conservatively, but the other required tympanomastoidectomy with cochleotomy; both patients had permanent, profound sensorineural hearing loss in the affected ear. Four patients presented with acute petrositis, and in all four it resolved with mastoidectomy. In the antibiotic era, intratemporal complications of acute otitis media still occur in otherwise healthy children, often after inadequate treatment of acute otitis media.

Samples of tumor, tumor stroma, and mixed tumor and stroma were microdissected from three squamous cell carcinomas, as well as from adjacent nontumor tissue and assayed for malate dehydrogenase or lactate dehydrogenase activity as indicators of the relative contribution of aerobic and anaerobic processes, respectively, to energy metabolism. Malate and lactate dehydrogenase activities were greater in tumor tissue than in tumor stroma in all three tumors. However, the magnitudes of malate and lactate dehydrogenase activities were different among the tumors, suggesting that tumors vary in the degree to which aerobic and anaerobic reactions contribute to energy production. These results indicate that a quantitative assessment of enzymes involved in energy production may be a useful probe in the understanding of tumor metabolism.

Screening programs show promise in increasing the rate of early detection of head and neck cancers in high-risk populations. Prout et al (Otolaryngol Head Neck Surg 1997;116:201–8) examined the usefulness of a large-scale screening program for head and neck cancer in an inner city population by primary care physicians. Symptom assessment was based on the American Cancer Society's “Seven Warning Signs for Cancer,” (Cancer manual. 8th ed. Boston: American Cancer Society, Massachusetts Division; 1990. p. 40–64) 4 of which are relevant to the head and neck. However, these signs may be insufficient for detection of early head and neck cancer. We analyzed these and other typical symptoms to determine their role in early detection. Coincident medical problems, tobacco abuse, and alcohol abuse were also analyzed. Our findings indicate that no symptom or symptom complex is strongly correlated with early head and neck cancer for any subsite except the glottis. Symptom duration is an unreliable indicator of the duration of disease. However, patients under medical supervision are more likely to have their cancers detected early, supporting the value of surveillance by the primary care physician. The absence of definite early warning signs for most head and neck cancers suggests the need to develop essential screening criteria. Defining the population that is at high risk for head and neck cancer and subjecting it to an aggressive screening protocol is essential.

Recent reports have suggested that the incidence of permanent facial nerve paralysis or paresis after surgery for benign parotid tumors is between 3% and 5%. The intraoperative use of nerve-integrity monitors has been advocated to reduce the incidence of facial nerve paralysis. The purpose of this study was to compare postoperative facial nerve function after monitored and unmonitored parotid surgical procedures. The charts of 69 consecutive patients with parotid lesions who underwent surgery from 1987 to 1996 were retrospectively surveyed. Sixteen high-risk patients were excluded from the study. The study group consisted of 53 patients (33 unmonitored and 20 monitored) who underwent lateral parotidectomy for mobile tumors of the superficial lobe of the parotid gland. No patient demonstrated permanent facial paralysis. In 9 patients (17%), transient nerve paralysis developed: 5 (15%) of the 33 patients who underwent lateral parotidectomy without the use of a nerve-integrity monitor and 4 (20%) of the 20 patients who underwent lateral parotidectomy with the use of a nerve-integrity monitor. Nerve-integrity monitoring is optional for mobile parotid tumors of the superficial lobe.

Basaloid squamous carcinoma (BSC) of the head and neck has been shown to have a poor prognosis when compared with conventional squamous cell carcinoma (SCC). Pathologically, specimens determined to be BSC can have nearly pure basaloid features (group 1) or a mixture of basaloid and squamous features (group 2). The clinical behavior in these 2 subgroups has not been compared previously. BSC is also commonly confused histologically with poorly differentiated SCC (PDSCC). A retrospective comparison of disease stage at presentation, rate of distant metastasis, rate of local recurrence in those offered surgical resection, and rate of survival is made to compare outcomes of the 2 BSC groups and the PDSCC group. The presence of particular histologic features may be associated with poorer outcomes. Patients with BSC have advanced disease at presentation. Survival in the BSC group was less than half that in the PDSCC groups. Statistical analysis shows the 2 groups to be well matched with regard to stage and site of disease. Presence of neck nodal disease on presentation predicts poor survival. In this study distant metastases occurred in 52% of patients with BSC and in 13% of patients in the PDSCC group. The local recurrence rate is comparable for BSC and conventional SCC, with even early tumors in the BSC group recurring distantly rather than locally or regionally. Considering the high distant metastatic rate of BSC and poorer overall survival rate, a more extensive metastatic survey is indicated in these patients before surgery is recommended. We recommend that patients with a diagnosis of BSC not be included with conventional SCC groups in prospective randomized cancer protocols.

Twenty consecutive children, ranging in age from 6 days to 18 years, were treated with skeletal expansion, in addition to soft-tissue reduction, for medically refractory obstructive sleep apnea. The underlying diagnoses were craniofacial microsomia (n = 6), Down syndrome (n = 3), Pierre Robin syndrome (n = 3), cerebral palsy (n = 3), Nager's syndrome (n= 1), Treacher Collins syndrome (n= 1), cri du chat syndrome (n = 1), juvenile rheumatoid arthritis (n= 1), and temporomandibular joint ankylosis (n= 1). Fourteen children had severe medically refractory sleep apnea and were tracheostomy candidates; in the remaining six, tracheostomies were placed shortly after birth and could not be decannulated. Overnight, 12-channel polysomnography was obtained before and after surgery. The mean apnea index improved from 7.42 to 1.26, the mean respiratory disturbance index improved from 25.24 to 1.72, and the mean lowest apnea-related oxygen saturation improved from 68% to 88%. Of the 14 children with medically refractory obstructive sleep apnea, two required tracheostomies. Of the six patients with tracheostomies, five have been decannulated at the time of this writing. Skeletal expansion in conjunction with soft-tissue reduction in the pediatric population permits substantial increases in the volume of both the nasopharynx and oropharynx. Creative use of conventional osteotomies and the application of distraction osteogenesis have enabled surgeons to apply maxillofacial and craniofacial techniques in treating children with obstructive sleep apnea.

The Medical Outcome Study Short-Form 36-item Health Survey (SF-36) was used to prospectively assess outcomes after endoscopic sinus surgery. Our study found that chronic rhinosinusitis has a significant adverse impact on patient-perceived functional status and quality of life. Endoscopic sinus surgery resulted in statistically significant improvement in both disease-specific symptoms and patient-perceived global health status at 6 and 12 months of follow-up. The SF-36 is recommended for use as the global health monitor in outcomes evaluation for chronic rhinosinusitis.

We designed a prospective, randomized, double-blind study to test the efficacy and safety of ibuprofen compared with acetaminophen with codeine for pediatric posttonsillectomy/adenotonsillectomy patients. Twenty-seven children, aged 6 to 16 years, were enrolled. We collected information on pain control, return to normal sleep pattern, return to normal diet, and duration for which medication was required. Coagulation profiles were measured before surgery and on postoperative day 3. Acetaminophen with codeine was more effective in controlling pain on days 1 and 3 (p = 0.0475 and 0.0328, respectively). However, we detected no difference between the treatment groups (p = 0.2216) with regard to pain control on day 5. The ibuprofen group required medication for a longer period (p = 0.0464). We detected no statistically significant differences between groups with regard to return to normal diet (p = 0.2346) and return to normal sleep pattern (p = 0.9554). The postoperative hemorrhage rate was 0% in the acetaminophen-with-codeine group and 12.5% in the ibuprofen group. The ibuprofen group demonstrated a mean increase in bleeding time of 2.07 minutes on the third postoperative day (p = 0.0379). The mean change in postoperative bleeding time between the two groups was statistically significant (p = 0.0140). We found no statistically significant differences in prothrombin time and partial thromboplastin time between groups. On the basis of the findings of this pilot study, we conclude that acetaminophen with codeine is safer and more efficacious than ibuprofen in the management of posttonsillectomy/adenotonsillectomy pain in children.

Obstructive sleep apnea is a complex disorder characterized by periodic cessation of breathing during sleep. Classically, men exclusively have been evaluated for mode of presentation or associated morbidity that accompanies obstructive sleep apnea; minimal investigation has been undertaken with regard to the female population. Recent literature indicates that obstructive sleep apnea is much more prevalent in women than previously recognized and is increasingly underdiagnosed. We present a review of a large cohort of women with obstructive sleep apnea, with specific attention to presenting symptoms, coexisting medical problems, and surgical efficacy. The study group comprised 58 women with the diagnosis of obstructive sleep apnea; we analyzed the group for presentation, polysomnographic findings, and therapeutic management. We reviewed cases for medical management or surgical intervention. In the surgery group, each patient was evaluated with polysomnography before and after surgery. Significant coexisting medical problems were identified in both groups. We address the success of surgical intervention.

The American Academy of Otolaryngology–Head and Neck Surgery has concerns about the effects of our environment on human health. In this review we evaluate waterborne biologic organisms, microorganisms, and other disease-causing agents that might pollute our drinking water. Next, we evaluate chemical toxins that might pollute our drinking water. Then we examine our drinking water and wastewater treatment systems. Finally, we discuss management strategies.

In this study, we attempted to determine which method was the best for reinnervating the laryngeal adductor muscles by comparing nerve suture, nerve implantation, and nerve-muscular pedicle (NMP) transfer, as well as the length of time that could elapse after denervation and still allow for successful reinnervation with the ansa cervicalis. Reinnervation was performed in 36 dogs, at 6-, 8-, 10-, 12- and 18-month intervals after denervation via the three methods of muscle reinnervation described above. We noted some return of adduction in the cases using nerve suture before a 10-month interval after denervation, and with nerve implantation and NMP transfer before the 8-month intervals. The variable adduction was caused by reinnervation of the adductor muscles from the ansa cervicalis, as demonstrated by laryngeal spontaneous and evoked electromyography, the strength of muscle contraction, and histologic findings. Adduction was not observed in the cases after the above-mentioned intervals but partial improvement of the bulk and strength of the reinnervated vocal cord was still achieved. An analysis of the experimental results showed that nerve suture was superior to nerve implantation and the NMP technique. Little difference was noted between nerve implantation and the NMP technique.

We carried out a retrospective study of patients with supraglottic carcinomas who were treated surgically at the Marques de Valdecilla Hospital (Santander, Spain) between 1978 and 1987 and who were followed up for at least 5 years. The Kaplan-Meier survival curves were calculated for 24 clinical, histologic, and morphometric parameters. Multivariate analysis was then performed by means of the Cox regression model. In the univariate analysis, survival was related to presence of capsule rupture of the involved lymph nodes (p = 0.00001), number of metastatic lymph nodes (p = 0.0002), postoperative TNM stage (p = 0.004), grade of cell differentiation (p = 0.001), presence of intratumoral necrosis (p = 0.01), and type of invasion (p = 0.04). The nuclear area did not have an influence on survival. Only the presence or absence of capsule rupture of the metastatic lymph nodes and the grade of cell differentiation were included in the final Cox model and proved to be parameters with independent prognostic significance. (Otolaryngol Head Neck Surg 1998;119:548–53.)