Otolaryngology–Head and Neck Surgery

OBJECTIVE: This study addresses the interaction of bacterial antigens, specifically peptidoglycan-polysaccharide (PG-PS) and lipopolysaccharide (LPS), in the induction and reactivation of mucoid middle ear effusions.

METHODS: Twenty-seven rats underwent eustachian tube obstruction before inoculation of the middle ear bulla with PG-PS. Three weeks later, after resolution of all middle ear effusions, 6 rats were randomly selected and euthanized as the first control group (control I). The remaining 21 animals were randomly assigned to 3 groups that received intravenous injections of Krebs Ringer (control II), PG-PS, and LPS, respectively. These rats were euthanized 2 days after intravenous injection. Middle ear mucin production and histologic changes were measured in all animals.

RESULTS: The mean concentrations of mucin were 0.94 ± 0.52 mg/mL, 0.41 ± 0.87 mg/mL, 16.33 ± 3.67 mg/mL, and 1.15 ± 0.41 mg/mL in the control I, control II, PG-PS, and LPS groups, respectively. Thus the mean concentration of mucin in the middle ear lavage samples was significantly greater in rats that were injected intravenously with PG-PS than in rats in other groups (P < 0.05). Histologic analyses demonstrated a greater degree of goblet cell hyperplasia in the PG-PS group than in other groups.

CONCLUSIONS: This is the first animal model of recurring otitis media with effusion in which a systemic injection of PG-PS was used to reactivate a middle ear effusion in rats previously primed with a transtympanic injection of PG-PS. This study suggests that after otitis media with effusion has resolved, it may be reactivated by the presence of bacterial antigens and/or cytokines in the systemic circulation. (Otolaryngol Head Neck Surg 1999;121:7-12.)

OBJECTIVES: To learn about the impact of dizziness on driving from a patient perspective and to present an approach to the vestibular patient and driving.

DESIGN: An anonymous questionnaire completed by 265 dizzy patients at 3 different centers.

RESULTS: The participants were experienced drivers who needed to drive to function normally (83%). Those with constant or severe dizziness comprised a higher risk group of drivers. Although few had ever been warned not to drive, 52% said that if they were warned to stop driving, they would not. Most thought that it was the doctor's role to report unsafe drivers to the authorities (P < 0.001, χ² = 87.2670).

CONCLUSIONS: The diagnosis of a vestibular disorder should not alone be grounds to suspend a patient's driver's license. Legislation should be amended to better reflect the views of doctors and patients alike. (Otolaryngol Head Neck Surg 1999;121:13-7.)

OBJECTIVE: To determine the proportion of children with acute otitis media (AOM) presenting in our catchment area in New York City who were infected with nonsusceptible Streptococcus pneumoniae and to determine the susceptibility of these organisms to penicillins and other antibiotics commonly used to treat AOM.

SETTING: Ambulatory clinics and the emergency department of a tertiary care, inner-city medical center.

PATIENTS: During a 2-year period from 1993 to 1995, 115 children (aged 6 months to 12 years) with AOM underwent tympanocentesis. Patients did not receive antibiotics for at least 1 week before tympanocentesis.

RESULTS: Thirty-one children were infected with S pneumoniae, and 83.9% of isolates were susceptible to penicillin. Of the 16.1% strains that were nonsusceptible, most (4 of 5 strains) were intermediately resistant, and only 1 exhibited high-level resistance to penicillin. Of all the cephalosporins tested, only cefotaxime had consistent activity against the intermediately resistant strains. Notably, all nonsusceptible pneumococci were inhibited by macrolides.

CONCLUSIONS: This study provides unique reference data for nonsusceptible Streptococcus pneumoniae in children with AOM and documents that newer cephalosporin agents are not active against all of these strains. (Otolaryngol Head Neck Surg 1999;121:27-30.)

BACKGROUND: Appropriate management of the clinically negative (N0) neck in supraglottic laryngeal cancer continues to be an area of controversy in head and neck surgery. Our treatment policy has been aggressive surgical management even in the clinically N0 neck.

METHODS: Between 1971 and 1991, 104 patients had the primary diagnosis of supraglottic laryngeal cancer. Ninety of these patients received their treatment at Roswell Park Cancer Institute and are the subject of this retrospective review.

RESULTS: All neoplasms included in this study were squamous cell cancers. The most common subsite involved with tumor in our series was the epiglottis, followed by the aryepiglottic folds and false cords. Supraglottic laryngectomy was performed of 29% of the cases; the remainder received total laryngectomy. Thirty-six percent of the patients had pathologic stage I/II disease, and 64% had stage III/IV. The 5-year survival rates were 100%, 81%, 73%, and 63% for stages I through IV, respectively. Fifty-seven patients had clinically N0 disease at presentation; of these 34 underwent elective neck dissection, and the remaining 23 patients were observed. Of those patients receiving neck dissection, 30% (n = 10) were found to have histologically positive disease, and of the 23 patients observed, 30% (n = 7) had histologically positive regional (neck) disease. Of the 17 clinically N0 and pathologically N+ patients, 82% (14 of 17) had involvement of level I (submandibular triangle), and 100% had involvement of level II. The incidence of bilateral disease in the clinically N0 patient was 44%. There were no local failures.

CONCLUSIONS: There is a high incidence of occult regional disease even in early-stage supraglottic squamous cell carcinoma of the larynx. In the surgical management the clinically N0 neck, we presently recommend bilateral neck dissection of levels I through IV to adequately address those regions at highest risk for occult disease. (Otolaryngol Head Neck Surg 1999;121:57-61.)

OBJECTIVE: Abnormalities in the mucosal lining of the vocal folds may interfere with the normal vibratory patterns and result in vocal limitations, especially for singers whose demands are great. A prospective, longitudinal study was undertaken to investigate the incidence of laryngeal abnormalities in asymptomatic singing students.

METHODS: Sixty-five singing students at the school of music underwent videostroboscopic evaluation and completed a comprehensive questionnaire. Videos were rated by 3 experienced clinicians, and interrater reliability was calculated. Results were correlated with demographic factors, background medical history, and singing history.

RESULTS: Five students (8.3%) exhibited early signs of benign vocal fold lesions (2 with nodules and 3 with cysts). A high incidence of posterior erythema (n = 44; 73.4%), suggesting possible reflux, was found.

CONCLUSIONS: A surprisingly high number of otherwise asymptomatic singing students demonstrated abnormal laryngeal findings. Their relationship with vocal performance will be addressed as well as implications for preventative measures. (Otolaryngol Head Neck Surg 1999;121:69-77.)

OBJECTIVE: The lateral pharyngeal walls contribute to obstruction in obstructive sleep apnea. These structures may be unaffected by uvulopalatopharyngoplasty. This was evaluated by retrospective review of upper airway observations after palatopharyngoplasty.

METHODS AND PATIENTS: The retropalatal airway was endoscopically observed intraoperatively after each procedure in 7 patients. The airway was dilated with nasal continuous positive airway pressure.

RESULTS: Transpalatal advancement pharyngoplasty increased the area 120% (P = 0.001), and closing pressure decreased 9.2 cm H₂O (P < 0.01). The maximal anteroposterior length (MAX-AP) and maximal lateral radius increased 90% (P = 0.01) and 60% (P < 0.001), respectively. MAX-AP changed in 2, both increased in 4, and maximal lateral radius increased in 1 patient. The closing pressure change correlated with airway size (r ² = 0.44, P < 0.05); airway shape was associated with change in MAX-AP (r ² = 0.51, P < 0.07).

CONCLUSIONS: Both the anteroposterior and lateral wall dimensions are altered by palatopharyngoplasty techniques, which increase retropalatal airway size. This is not limited to facial advancement surgery. (Otolaryngol Head Neck Surg 1999;121:82-6.)

A target-matching paradigm was developed to assess the vocal equivalents of reaction and movement time in Parkinson's disease. Six patients with Parkinson's disease and 6 age- and gender-matched control subjects were asked to enunciate /pa/ to reach a target frequency and intensity level in response to a light stimulus. The stimulus and acoustic responses were simultaneously recorded. Measures included laryngeal reaction time, time between stimulus and phonation onset; frequency voice target time, time from phonation onset to target level of frequency; and amplitude voice target time, time from phonation onset to target level of intensity. The 2 subject groups were significantly differentiated by laryngeal reaction time (t = −299.67, df = 10, P = 0.005) and frequency voice target time (t = −148, df = 10, P = 0.014). These data suggest voice target time is a viable tool for assessing the effects of neurologic disorders on voice execution in Parkinson's disease.

Endoscopically placed airway stents offer a viable option in primary or adjunctive treatment of severe pediatric tracheobronchial stenoses. Optimistic clinical reports substantiate the need for experimental studies to more effectively evaluate their clinical role. Development of an animal model comparable with the pediatric airway, amenable to endoscopic instrumentation, and capable of assessing effect on growth was the purpose of this pilot project. Nine 4-week-old piglets underwent endoscopic midtracheal placement of the balloon-expandable Palmaz metallic stent. Initial expansion and stent position were verified fluoroscopically and by direct videobronchoscopy. Serial endoscopic examination and stent reexpansion were performed 2 and 4 weeks after stent insertion. Animal weight, clinical tolerance, tracheal growth, and stent integrity were observed. Tracheal inflammation was evaluated grossly and by objective histopathologic criteria. Successful endotracheal stent placement and expansion were accomplished in all piglets. One pig died of anesthesia complications less than 24 hours after stent insertion. The remaining pigs exhibited excellent clinical tolerance through experiment completion. No detrimental effect on growth was noted, and effective dilatation of the stented tracheal region was observed. Stent incorporation was evident with significant mucosal ingrowth. Inflammation in the form of nonobstructing granulation tissue was present, and no evidence of necrosis or cartilage invasion was evident. The piglet trachea appears to be an excellent model for evaluation of expandable metallic airway stents in management of congenital and acquired tracheobronchial stenoses. (Otolaryngol Head Neck Surg 1999;121:92-7.)

Recent clinical trials have renewed interest in middle ear inflation as a treatment for otitis media with effusion. However, air inflation in human beings with significant negative middle ear pressures was shown to be followed by a rapid pressure decrease to approach the preinflation values. In this experiment, the middle ears of anesthetized rhesus monkeys with unilateral inflammation were inflated at different times with air or N₂, and pressures were recorded by tympanometry until they had stabilized or the animal had recovered from anesthesia. The results for air inflations reproduced those reported for human beings with negative pressures. Similarly, after N₂ inflation a significantly greater rate of pressure decrease and significantly lesser terminal pressures were observed for inflamed ears when compared with the contralateral control ears. However, the rate of pressure decrease and the magnitude of the pressure drop were dampened by sequential N₂ inflations. These observations have clinical implications with respect to the efficacy of inflation as a treatment for otitis media with effusion. (Otolaryngol Head Neck Surg 1999;121:98-102.)

OBJECTIVES: Posterior epistaxis is a common otolaryngologic emergency. Management is controversial because of the many treatment options available. These options vary in efficacy, rates of complications, and cost. Posterior nasal packing is the medical management most frequently used to control posterior epistaxis. It is associated with major complications, including stroke, myocardial infarction, arrhythmias, and death. Because of these potential complications, many otolaryngologists monitor patients with posterior nasal packing in the intensive care unit (ICU). However, the level of care used to monitor these patients is variable, and standards have not been established.

METHODS: From 1991 to 1997, 46 patients had posterior nasal packing placed to control epistaxis. Management, complications, and hospital charges were analyzed.

RESULTS: Six patients (13%) were admitted to the ICU, 2 (4%) were admitted for telemetry monitoring, and 38 (83%) were sent to the ENT ward for continuous pulse oximetry. Four major complications occurred (1 episode of syncope [emergency department], 2 arrhythmias [ICU], and 1 death [hospice]). Twenty-six patients were treated with posterior packing in the ENT ward, at a mean cost of $2988. Fourteen patients underwent intervention (5 ligations, 6 endoscopic cauterizations, and 3 angiograms), with a mean cost of $5482. Six patients spent time in the ICU, with a mean cost of $8242. Patients treated in the ENT ward had significantly lower costs than those undergoing intervention (P = 0.017) or those admitted to the ICU (P = 0.020).

CONCLUSION: We propose that most patients with posterior epistaxis can be treated in specialized ENT wards. This can be done without increasing complications and with significantly decreased costs.

New advances in anterior cranial base surgery have dictated the need for a comprehensive, multidisciplinary approach in the treatment of lesions of this area, necessitating multiple modes of diagnostic and surgical techniques. Traditional consideration of the complex problems presented by neoplastic involvement of the anterior cranial base predicated on isolated syndrome analysis is no longer sufficient to adequately assess tumor pathology. To address these complex problems, we discuss a method of localization of pathology based on anatomic structure and function as well as the corresponding surgical approach to the anterior cranial base. (Otolaryngol Head Neck Surg 1999;121:113-8.)

Smoke and blood can limit visibility during electrosurgical tonsillectomy. Although some surgeons use a suction coagulator to perform tonsillectomy, 1 1 find that the large circumference of the suction electrode leaves a more diffuse thermal injury than the fine tip of the electrosurgical pencil. I therefore adopted the technique of placing a suction catheter through one nostril into the oropharynx. 2 Other methods of attaching suction catheters to the electrosurgical pencil have also been described. 3 These techniques allow continuous smoke evacuation but are less effective at clearing blood from the operative site. Furthermore, it is often necessary to use suction cautery when more difficult bleeding is not easily addressed with the electrosurgical pencil. An instrument that provides pinpoint electrosurgical dissection in combination with effective smoke and blood evacuation would facilitate the performance of tonsillectomy and adenoidectomy.

A universally held axiom in otologic surgery is that a widely patent external auditory canal is essential for the postoperative success of canal wall down mastoid surgery. A sufficiently large meatus facilitates postoperative office evaluation and debridement of the mastoid cavity. A large meatoplasty supports the rapid epithelialization and overall exteriorization of mastoid bowl size. Failure to perform an adequate meatoplasty may lead to cholesteatoma formation, chronic secretion, and postoperative canal stenosis.

Lymphomas account for 13% of all newly diagnosed cancers in children and adolescents. Non-Hodgkin's lymphoma (NHL) represents approximately 60%, with Hodgkin's disease accounting for the remainder. 1 , 2 NHL of the sinonasal tract is relatively rare and accounts for only 1.5% of all NHLs in the United States. 3 NHLs are among the most rapidly growing of all malignancies and often result in progressive mass effect and facial asymmetry. Tumors of the sinonasal tract can give rise to rhinorrhea, sinus infection, epistaxis, nasal obstruction, and proptosis. Sinonasal NHL has often been confused with a number of infectious, autoimmune, and inflammatory diseases. Because NHL is one of the fastest growing tumors, the expeditious diagnosis of NHL is crucial. We report an unusual case of a girl with nasal airway obstruction and facial swelling as the only symptoms of the underlying disease process. This case demonstrates a rare, extranodal lymphocytic lymphoma of the maxillary sinuses and soft tissues of the face.

Sudden hearing loss is a clinical diagnosis describing hearing losses of sensorineural origin. The time period before onset is usually 72 hours. Many also characterize the loss by a decrement of at least 30 dB in 3 contiguous test frequencies. 1 , 2 The causes are numerous, but one of the most frequent causes is a viral infection. 3 – 6 One strong indication of a viral cause is an acute antibody titer elevation with a subsequent 4-fold reduction in titer during the next 2 months. 3 – 6 Articles in the radiologic literature have chronicled the findings of enhancement of the inner ear with gadolinium MRI scans in cases of presumed viral infections. 7 , 8 This is the first article to report the MRI enhancement of the cochlea in 2 patients with seroconversion evidence of a viral cochleitis.

The aim of this article is to describe the safety and quality of the osseointegrated implant technique for the retention of craniofacial prostheses, to present a protocol for collection of clinical data, and to discuss the impact of the procedure on the patient quality of life. A protocol was designed and used to study patients who had received auricular prostheses consecutively since 1979 at our department. The patients were asked to answer a questionnaire designed to describe symptoms and problems specific for someone wearing an auricular prosthesis. In total, 99 patients received 107 prosthetic ears (8 patients had bilateral defects) retained on 309 implants (2 to 4 implants/ear). Patients of all ages were represented, and only 9 discontinuities were reported. Most patients (95%) wear their prosthesis every day, in most cases more than 10 hours/day. The follow-up period ranged from 1 to 12 years, giving a total of 2624 postoperative observations of implants, with a 3% incidence of significant skin reaction. We conclude that the surgical technique for auricular prostheses retained on osseointegrated implants is simple and associated with a low rate of peroperative and long-term complications. It offers a high degree of stability and aesthetic satisfaction. (Otolaryngol Head Neck Surg 1999;121: 133-43.)

MRI is widely used for postoperative surveillance of patients undergoing surgery for removal of acoustic neuroma. The purpose of this study was to investigate the frequency and pattern of postoperative changes in the cerebellum and brain stem on MRI after removal of acoustic neuroma. A retrospective study was conducted in 30 consecutive patients who underwent postoperative MRI between 1994 and 1995. The timing of the scans after surgery ranged from 12 months to 10 years. T₂-weighted turbo spin-echo images revealed cerebellar encephalomalacia in 17 of 30 cases. Cerebellar encephalomalacia was found more consistently in patients who had large tumors and was more frequent after the suboccipital approach. Encephalomalacia is largely caused by gliotic changes in the adjacent cerebellar tissues after tumor removal.

Postoperative arterial blood pressures were monitored in 43 patients who had undergone bilateral neck dissection during a 6-week period at Ankara Numune Hospital's Ilnd Otorhinolaryngology Department. During the first operations, all cases received carotid sinus denervation, whereas no denervation was done for the opposite side dissections held 6 weeks later. Study and control groups were composed of the same patients to achieve an objective outcome for the risk of postoperative hypertension. Hypertension was observed in 10 (23%) of 43 patients after the first operations and 12 (28%) of 43 patients after the opposite side dissections, for which no carotid denervation was done. The difference between the rates was insignificant statistically. (Otolaryngol Head Neck Surg 1999;121: 150-2.)

Posterior glottic stenosis most commonly results from prolonged endotracheal intubation. The tube causes decubitus and perichondritis with a consequent scar tissue formation in the posterior commissure that often limits the abduction of the vocal cords. Many different surgical methods are known for the treatment, but in most cases temporary tracheostomy is required. We recommend a minimally invasive method to avoid tracheostomy, which is a very inconvenient state for the patient. The scar of the posterior commissure is excised endoscopically with the CO₂ laser, and a modification of the endoextralaryngeal vocal cord laterofixation—described by Lichtenberger—is used to lateralize 1 or both vocal cords until the posterior commissure is completely reepithelialized. In this article we report on the first 5 cases. All patients had satisfactory airways immediately after the laterofixation procedure, which proved to be stable later on as well. In the cases of moderate stenosis, further scarring was prevented, and after the healing of the mucosa in the posterior glottic area, the laterofixation sutures were removed. The vocal cord mobility was recovered in the cases in which the cricoarytenoid joint was not fixed. In 1 case of severe stenosis (bilateral cricoarytenoid joint fixation), the procedure yielded only partial improvement.

Pseudoaneurysm is a rare complication after trauma. A true aneurysm is a dilatation of the vessel wall, whereas a pseudoaneurysm is a weakening or rent in a vessel wall with contained rupture into the surrounding tissues. The cause of a true aneurysm is often an arteriosclerotic or inflammatory process and congenital malformations. Pseudoaneurysms are usually posttraumatic. 1 Causes of pseudoaneurysm of the carotid artery include deep neck infection, 2 blunt or penetrating trauma of the cervicofacial region, 3 , 4 and radiation therapy. 5 Injury to the carotid artery, by either direct or indirect forces, is rare but may produce either dissection of the vessel wall or formation of a pseudoaneurysm. Although pseudoaneurysm of the superficial temporal artery after trauma has been reported 6 occasionally, traumatic pseudoaneurysm of the external carotid artery between the internal maxillary and facial arteries associated with a parotid mass and subsequent facial palsy is an uncommon event.

Deep neck infections and abscesses may still occur despite the widespread use of antibiotics. Approximately 50% of deep neck infections occur in the lateral pharyngeal space, which offers minimal resistance to infection. Complications of parapharyngeal abscesses—such as jugular thrombophlebitis, cavernous sinus thrombosis, mediastinitis, and hemorrhage from the carotid artery—are well known to otolaryngologists and can be life threatening. 1 Surgical intervention is often required to manage these infections, but 10% to 15% of all the patients with lateral pharyngeal space infections can be treated with medicine alone. 2

A 9-year-old girl with a history of left cerebral hemiatrophy and seizure disorder had a generalized seizure after 2 weeks of mild intermittent hoarseness and inspiratory stridor. She required urgent intubation for 48 hours because of episodes of status epilepticus 5 and 3 months before this admission. Our service was asked to evaluate her for postictal inspiratory stridor, hoarseness progressing to aphonia, and mild respiratory distress.