Otolaryngology–Head and Neck Surgery

OBJECTIVE: Determine the possible role of oxidants and antioxidants in the pathogenesis of otitis media with effusion in children.

STUDY DESIGN AND SETTING: Randomized controlled trial, tertiary referral center. The study group was made up of children with otitis media with effusion who were to undergo bilateral ventilation tube insertion and adenoidectomy. The control group was comprised of otherwise healthy children. The blood levels of antioxidants (retinol, β-carotene, (α-tocopherol, laycopene, ascorbic acid, superoxide dismutase, glutathione peroxidase, GSH) and oxidation products (malondialdehyde) were determined before and 1 month after the operation in the study group and once only in the control group. These substances were also measured in the adenoid tissue and middle ear fluids.

RESULTS: In the study group, the blood levels of antioxidants and oxidants before and after the operation were significantly different when compared with the control group (P < 0.05). In the study group, the blood antioxidant levels increased and oxidant levels decreased significantly after the operation (P < 0.05). The levels after the operation never reached those of the control group.

CONCLUSIONS AND SIGNIFICANCE: Oxidants and antioxidants played a significant role in the pathogenesis of otitis media with effusion in children. These children are under significant oxidative stress. Insertion of a ventilation tube and adenoidectomy significantly decreased the oxidative stress in these patients, but could not normalize it completely. Additional studies are necessary in the clinical use of antioxidants in otitis media with effusion.

OBJECTIVE: Our objective was to determine the diagnostic yield of laboratory testing, radiological imaging, and GJB2 mutation screening in a large cohort of patients with differing severities of idiopathic sensorineural hearing loss (SNHL).

DESIGN AND SETTING: We undertook a retrospective study of patients presenting with SNHL at our institution from 1993 to 2002.

RESULTS: Laboratory testing had an extremely low yield. Patients with unilateral SNHL had a significantly higher imaging yield than those with bilateral. The diagnostic yield of GJB2 screening was significantly higher in patients with severe to profound SNHL than in those with less severe SNHL. However, a relatively large number of patients with mild to moderate SNHL had positive GJB2 screens.

CONCLUSIONS: Based on diagnostic yields, we propose a cost-effective stepwise diagnostic paradigm to replace the more commonly used and costly simultaneous testing approach. EBM rating: C. (Otolaryngol Head Neck Surg 2004;131: 804–9.)

OBJECTIVE: Study the complication rate of tracheostomy in premature infants and identify contributing factors.

SETTING: Two university-based tertiary care children's hospitals.

METHODS: The charts of 55 neonates who underwent tracheostomy between January 1997 and December 2002 were reviewed. Group 1 included 32 infants born weighing < 1000 grams. Group 2 included 23 infants born weighing ≥ 1000 grams.

RESULTS: Group 1 infants had a higher incidence of comorbidities related to prematurity. Thirty-eight infants underwent tracheostomy due to ventilatory dependence, 13 for airway obstruction, and 4 for neurologic debilitation. Sixteen infants (29%) had a complication related to tracheostomy. There was no tracheostomy-related mortality.

CONCLUSIONS: Tracheostomy in the preterm infant has the potential for significant morbidity. Meticulous technique, surgeon experience and specialized care may play a role in reducing the complication rate. Complications are usually minor and do not require additional surgical intervention. EBM rating: C.

OBJECTIVES: The goal of this review is to provide a synthesis of the current literature addressing the effects of sleep-disordered breathing on cognition and behavior in children aged 2–18.

STUDY DESIGN AND SETTING: A computerized search was performed to include studies between 1966 and 2001. Studies were assessed based on research question, sampling, intervention, outcomes, confounding, and statistical methods. Sensitivity analyses were performed for quantitative assessments of selection bias, misclassification, and confounding.

RESULTS: Seventeen reports with 5312 patients were reviewed. The majority of these studies demonstrated poor sampling, insufficient consideration of confounders, and imprecise use of statistical tools. However, there was little evidence of bias in two studies when scrutinized using a sensitivity analysis.

CONCLUSIONS: Despite suggested links between daytime behavior problems and neurocognitive deficits, there is little certainty for causality based on the quality of the evidence.

SIGNIFICANCE: By discussing the quality of the current evidence, we hope to improve study design and contribute to the development of an understanding of this complex topic.

OBJECTIVE: Using an evidence-based technique, systematically review the literature to evaluate the accuracy of routine clinical history and physical examination in the diagnosis of obstructive sleep apnea/hypopnea syndrome (OSAHS) in the pediatric patient.

STUDY DESIGN AND SETTING: The biomedical literature was systematically reviewed. Articles comparing the results of clinical evaluation to polysomnography (PSG) were selected. The level of evidence was assessed using established evidence-based medicine (EBM) guidelines.

RESULTS: Twelve articles were identified using the search criteria. Eleven of 12 articles concluded that clinical evaluation is inaccurate in the diagnosis of OSAHS. The level of evidence was good to very good (Grade B/B+).

CONCLUSION/SIGNIFICANCE: Clinical history and physical examination are not reliable for diagnosing OSAHS compared with overnight PSG. Complicating the interpretation of this work is the lack of a validated PSG threshold of clinically significant disease. There is an urgent need for the development of adequate screening tests with validated clinical outcomes. EBM rating: B-3.

OBJECTIVE: The aim of our study was to assess the rate of reactionary and secondary posttonsillectomy hemorrhage using “cold” dissection and bipolar diathermy and to determine whether there was any difference in the postoperative hemorrhage rate between the 2 methods.

METHODS: This was a prospective study of all patients undergoing tonsillectomy between November 8, 1999 and November 7, 2000 in a tertiary medical centre. The data collected included patient identity, age, gender, date of surgery, method of operation, and complications (if any). The timing of reactionary or secondary posttonsillectomy hemorrhage and the treatment were recorded. We hypothesized no difference in posttonsillectomy hemorrhage rates using the 2 methods. X 2 test was used for statistical analysis.

RESULTS: A total of 349 patients underwent tonsillectomy in the period (134 males, 215 females, mean age was 16.7 years). Of these, 337 were bilateral procedures, 145 patients had tonsillectomy using cold dissection, and 192 patients had bipolar diathermy. Reactionary hemorrhage occurred in 1 patient (0.3%) and 31 patients (9.2%) developed secondary hemorrhage. The hemorrhage rates using cold dissection (n = 8) and bipolar diathermy (n = 24) were 5.5% and 12.5%, respectively (P < 0.05).

CONCLUSIONS: The primary and secondary posttonsillectomy hemorrhage rates were 0.3 and 9.2%, respectively. Tonsillectomy using bipolar diathermy has a statistically significant higher secondary hemorrhage rate than using cold dissection (12.5% vs. 5.5%, P < 0.05). (Otolaryngol Head Neck Surg 2004;131:833–6.)

OBJECTIVE: To examine the nightly variability of sleep-disordered breathing (SDB) as measured by the apnea-hypopnea index (AHI).

STUDY DESIGN AND SETTING: Retrospective comparison of 3 sequential nights of testing performed in the home in 1091 patients who were referred for diagnostic testing of SDB.

RESULTS: The Pearson and Intraclass correlation coefficients ranged between 0.88 and 0.90 for each pair of nights. Based on night 1, approximately 90% of patients were classified consistently with “AHI-high” (the highest AHI measured across the 3 nights) using an AHI threshold of 5. However, 10% were misclassified on night 1 relative to the highest AHI level.

CONCLUSION AND SIGNIFICANCE: These findings suggest that (1) 1 night of diagnostic testing for SDB is not sufficient to diagnosis SDB in approximately 1 of every 10 cases, and (2) there is little, if any, significant nightly change in SDB in the home environment. EBM rating: D. (Otolaryngol Head Neck Surg 2004;131:837–43.)

OBJECTIVE: To validate the role of a portable sleep monitor device (SNAP) in the diagnosis of obstructive sleep apnea syndrome (OSAS). Inter-reader variability was also assessed for both PSG and SNAP.

STUDY DESIGN AND SETTING: Sixty consecutive adults referred for PSG at The University of Chicago Sleep Disorder Clinic were prospectively enrolled.

RESULTS: There was no significant difference between total number of apnea and hypopnea, respiratory disturbance index (RDI), and minimum oxygen obtained by PSG and SNAP, but there was a significant difference between sleep time and mean oxygen. Pearson's correlation coefficient for RDI ≥ 15 was 0.92.

CONCLUSION: There was a significant correlation of RDIs between SNAP and PSG. SNAP has good sensitivity, specificity, positive and negative predictive values. Differences between SNAP and PSG could be attributed to inter-reader variability and not necessarily due to technical limitations of SNAP. SNAP is an excellent tool for the diagnosis of OSAS in the laboratory setting. Future studies should be performed to evaluate SNAP's accuracy in the home setting in the diagnosis of OSAS. EBM rating: B-2. (Otolaryngol Head Neck Surg 2004;131:844–50.)

OBJECTIVE: This study evaluates the use of high-frequency ultrasound in the measurement of the material nature of the pediatric craniofacial skeleton.

STUDY DESIGN AND SETTING: Three desiccated human skulls, aged 1 year, 5 years, and adult, underwent ultrasonic evaluation at 6 sites on each hemicranium.

RESULTS: The overall mean signal reflection coefficients for the infant, child, and adult skulls are 98.8 mV (13.75 mV SD), 172mV (24.5 mV SD), and 230 mV (23.5 mV SD), respectively. The mean signal reflection coefficient is positively correlated with increasing chronological age. Comparison of intra-subject signal patterns suggests bone density fields, which vary as a function of growth.

CONCLUSION: High-frequency ultrasound provides accurate measurements of the osseous impedance of the craniofacial skeleton. Pattern analysis suggests increases in skull density with greater growth and age.

SIGNIFICANCE: Although further testing must be performed in vivo, high-frequency ultrasound may accurately measure the osseous impedance of the pediatric craniofacial skeleton. EBM rating: C.

PURPOSE: This study evaluated the feasibility of fiberoptic CO₂ laser soldering for the repair of esophageal injuries under tight temperature feedback control in an animal model. Healing was compared to conventional suture closure.

MATERIALS AND METHODS: A CO₂ soldering system equipped with infrared transmitting silver halide fibers was used. The soldered tissue temperature was monitored continuously, and laser power was adjusted to provide constant temperature. The procedure was done with 50% bovine serum albumin solder. Longitudinal incisions measuring 8 to 10 mm were made under general anesthesia in the cervical esophagus of 25 rats. Twenty rats (group I) underwent laser tissue bonding; 8 of which were tested in a preliminary study to determine optimal laser parameters. In the remaining 5 rats (group II, controls), closure was performed with 1 layer of 6/0 Vicryl sutures. The rats were sacrificed 2, 3, 4, and 6 weeks postoperatively, and the esophagus was examined histologically.

RESULTS: Optimal temperature was found to be 65 to 70° C and optimal exposure time, 150 to 200 seconds. Laser soldering was successful in 9 of the 12 rats (75%) treated under optimal settings; suturing was successful in 4 of the 5 control rats (80%). There were no significant differences between the groups in healing or complication rates.

CONCLUSIONS: These results indicate that the CO₂ laser soldering technique is a valid option for the correction of esophageal tears or incisions in rats. The confirmation and extension of these findings in further studies with larger animals may ultimately lead to the routine in vivo use of temperature-controlled laser repair for the esophagus and other organs. This method lends itself to endoscopic bonding of tissues.

OBJECTIVE: The effects of viscosity, taste, and nectar-thick liquid bolus volume on swallowing apnea duration (SAD) were examined.

STUDY DESIGN AND SETTING: Twenty-two adults, comprised of 10 males and 12 females, participated. SAD was assessed via nasal airflow during swallow conditions of viscosity (thin liquid, thick liquid, and puree), taste (water, apple juice, lemon concentrate), and nectar-thick liquid bolus volumes (5, 10, 15, and 20 mL) across three trials.

RESULTS: A significant main effect of nectar-thick liquid bolus volume was found (P < 0.05). Viscosity and taste were not significant.

CONCLUSIONS: SAD increased with increases in bolus volume; however, neither changes in bolus viscosity nor changes in taste affected SAD.

SIGNIFICANCE: These findings indicate that since viscosity was not significant, the normative data previously published (by this PI) with 60 healthy adults stratified by age and gender can be utilized for comparison to disordered swallowing without regard to the bolus viscosity being used. EBM rating: D. (Otolaryngol Head Neck Surg 2004;131:860–3.)

OBJECTIVES: To develop a canine model of vocal fold scar and to evaluate its treatment with lamina propria replacement therapy using autologous cultured fibroblasts.

MATERIALS AND METHODS: Full thickness of the lamina propria layer in canine vocal folds was injured with a laser. Fibroblasts were cultured and expanded in the laboratory from a buccal mucosal biopsy. The scarred vocal folds were treated with 3 weekly injections of fourth, fifth, and sixth passage autologous fibroblasts. Mucosal waves and acoustic parameters were measured at baseline, after scarification, and several months after injection therapy. Histologic evaluation of the vocal folds for fibroblasts, collagen, elastin, reticulin, and hyaluronic acid was performed.

RESULTS: Nine beagle dogs were used, and 1 animal served as control. Vocal fold scarring resulted in absent or severely limited mucosal waves and significantly worse acoustic parameters. Significant improvements in mucosal waves and acoustic parameters were obtained after lamina propria replacement therapy. After therapy, mucosal waves became normal in 4 animals and near normal in the other 4. No statistical difference was found in mucosal waves between baseline and post-therapy. All animals tolerated therapy without complications. The treated vocal folds demonstrated an increased density of fibroblasts, collagen, and reticulin, a decreased density of elastin, and no change in hyaluronic acid.

CONCLUSIONS AND SIGNIFICANCE: Therapeutic options for vocal fold scars are limited. Lamina propria replacement therapy in the form of autologous cultured fibroblasts improves mucosal pliability and returns normal or near normal mucosal waves in experimentally scarred vocal folds. This novel therapeutic modality may hold new promise for treating vocal fold scars.

OBJECTIVE: Bacterial tracheitis (BT) is a condition that can cause fatal airway obstruction. We evaluated our experience with BT over a 10-year period.

STUDY DESIGN: Retrospective review of patients treated for BT between 1991 and 2001. RESULTS: Ninety-four cases were evaluated. The mean patient age was 7.9 years. At presentation, 60% were afebrile, and the mean WBC count was 10.8 × 10³/mm³. Only 53% of patients required intubation. Younger children were more likely to require this intervention. S. aureus was the most commonly cultured bacteria, while isolation of M. catarrhalis was associated with a higher intubation rate. A pathologic virus was isolated in 64% of the 34 cultures performed. Only 9 patients were described as “toxic,” and 6 presented in respiratory extremis. There were no deaths.

CONCLUSION AND SIGNIFICANCE: A subset of patients with tracheal membranes has a less severe clinical appearance. Nonetheless, these patients require debridement and aggressive medical treatment. We propose that the term “exudative tracheitis” (ET) better describes this entity. Older patients who are less systemically ill and rapidly respond to local and systemic therapy are characteristic of ET. EBM rating: C.

OBJECTIVE: To conduct a clinical trial of famciclovir for symptom control in Ménière's disease.

STUDY DESIGN AND SETTING: Randomized, double-blinded placebo-controlled clinical trial in a tertiary referral center, with 12 subjects in the active treatment arm and 11 subjects in the placebo arm.

RESULTS: There were no serious adverse events. Twenty-five percent of the famciclovir group and 18% of the placebo group showed a reduction in number of vertigo spells, the primary efficacy endpoint. This difference was not statistically significant. All subjects improved in dizziness and health-related quality of life. There was a trend for the famciclovir arm to have less fluctuation in hearing relative to the placebo arm.

CONCLUSION: No dramatic effects of famciclovir were found on vertigo or dizziness. Some promising effects on reduction of the fluctuation in hearing were observed.

SIGNIFICANCE: Famciclovir may suppress the fluctuation of hearing in Ménière's disease, but had a minimal effect on vertigo or dizziness symptoms in this study. The probable multifactorial etiology in Ménière's disease requires that further studies be conducted to determine the effects of antiviral medications. EBM rating: A.

OBJECTIVE: Although successful cochlear implantation of patients with deafness following meningitis is expected, long-term stability of electrical current requirements has not been systematically evaluated. This study evaluated changes in programming for patients deafened by bacterial meningitis and stability of auditory performance over time.

STUDY DESIGN AND SETTING: In this retrospective descriptive study, cochlear implant (CI) stimulation mode and performance of 14 patients deafened by meningitis were compared with those of an age-matched control group of patients deafened by other causes.

RESULTS: There were no significant differences in mean performance between the meningitis group and control group (P > 0.05). However, the postmeningitis group required progressively higher stimulation levels and higher programming modes over time as compared to the control group.

CONCLUSIONS: Even with deafness accompanied by labyrinthine ossification attributed to meningitis, neural elements were present and could be stimulated. Because increasing levels of stimulation were required over time, postmeningitic children with CIs, and those with cochlear ossification in particular, may need frequent programming adjustments to maintain performance.

SIGNIFICANCE: These patients need close follow-up of stimulation levels and programming modes post-operatively in order to perform optimally with CIs. EBM rating: B-3.

OBJECTIVE: To evaluate patterns of ototoxic damage sustained from gentamicin applied directly to the round window in varying delivery vehicles.

SETTING: The search for a reliable method of drug delivery to the inner ear continues. Vehicles such as Gelfoam, hyaluronic acid, and fibrin may allow for a more reproducible pattern of ototoxic damage.

STUDY DESIGN: Histological evaluation of vestibular and cochlear damage was performed on Mongolian gerbils after a known dosage of gentamicin in different delivery vehicles.

RESULTS: Variable ototoxic damage was caused by Gelfoam and fibrin-based vehicles. No ototoxic damage was found in the Healon vehicle. The vehicle of fibrin and Gelfoam combined resulted in severe damage. There was no evidence of selective cochlear or vestibular ototoxicity in any of the vehicles tested.

CONCLUSIONS AND SIGNIFICANCE: The fibrin/Gelfoam vehicle was the only delivery system to produce reliable damage. Ototoxic damage depended on the vehicle. We found no evidence for selective vestibular ototoxicity with gentamicin.

OBJECTIVES: Previous reports on aging of human cochlea included subjects with ear diseases or ototoxic drugs. We studied spiral ganglion cells, hair cells, and lateral wall of cochlea from subjects without ear disease or ototoxic drugs.

STUDY DESIGN: This study included 39 temporal bones from 24 subjects aged 1 day to 86 years. We assessed standard cytocochleograms, mean loss of fibrocytes in spiral ligament, and areas of stria vascularis.

RESULTS: Losses of outer hair cells and fibrocytes were significantly greater in childern, adults, and the elderly compared with infants. Spiral ganglion cell loss was significantly greater in adults and elderly compared with infants and children. Areas of stria vascularis of infants were significantly larger than the elderly.

CONCLUSIONS: Degenerative changes of outer hair cells occur in children but spiral ganglion cells remain the same until around 20 years. Degeneration of stria vascularis due to aging appears to be slower than spiral ligament. EBM rating: C.

OBJECTIVES: This report will present the results of the USA Phase 1 clinical trials for the Envoy System (St. Croix Medical): A totally implantable middle ear hearing system for sensorineural loss.

STUDY DESIGN: A prospective, single-subject, repeated-measures, multicenter study was performed to evaluate safety and functionality of the Envoy System. Data collected included Abbreviated Profile of Hearing Aid Benefit, bone conduction threshold, speech reception threshold, functional gain, word recognition, and adverse events. Testing was performed unaided, with the patient's best-fit hearing aid, and post device activation at 2 (trial endpoint) and 4 months.

RESULTS: Five of 7 patients at the 2-month postactivation period had working systems. All 5 patients perceived benefit increases with the Envoy System over their best-fit hearing aid, including communication in high background noise levels. Word recognition was improved over hearing aids. Functional gain and speech reception thresholds were similar for the Envoy device and hearing aids.

CONCLUSIONS: The feasibility trial has shown the Envoy device, a totally implantable middle ear device, can safely sense and drive the ossicular chain. EBM rating: B-2.

OBJECTIVE: The study investigates the ability of physicians with different levels of training to accurately identify middle ear (ME) pathology using tympanograms and tympanic membrane (TM) digital photographs.

STUDY DESIGN AND SETTING: Groups of medical students, internal medicine residents, and attending and resident otolaryngologists were presented with a set of 50 matched tympanograms and photographs of TMs. The physicians were asked to differentiate between a normal and an abnormal-appearing TM. The sensitivity and specificity of diagnosis of ME pathology by physicians were compared with the gold standard, examining the ME cavity for pathology during myringotomy.

RESULTS: The sensitivity did not vary among physicians with different levels of training; however, specificity improved with an increase in physician experience.

CONCLUSIONS AND SIGNIFICANCE: This study establishes a baseline for accuracy of diagnosis of ME pathology using tympanograms and photographs of TMs as compared with binocular otomicroscopy and the gold standard, myringotomy. EBM rating: B-2.

OBJECTIVES: Determine the resorption rate and biocompatibility characteristics of 2 polyester ventilation tubes, and to determine whether soap and water exposure accelerates polyester tube degradation.

STUDY DESIGN AND SETTING: 50/50 poly (D, L-lactide-co-glycolide; PLGA-50) and poly (L-lactide; PLA) polymers were placed into the tympanic membranes of Hartley pigmented guinea pigs. Integrity of the tubes was determined by weekly otoscopic examination. Biocompatibility was assessed by comparing auditory brainstem response (ABR) thresholds and by examining tympanic membrane changes following tube resorption. Shah minigrommet ventilation tubes were used as controls. In the second portion of this study, implanted PLGA-50 and PLA tubes were exposed weekly to a mixture of soap and water (1:5) until complete resorption was observed. Biocompatibility was assessed by periodic ABR testing and tympanic membrane examination.

RESULTS: The PLA tubes remained in the tympanic membrane for a longer period (63.2 ± 19.3 days) than the PLGA-50 (18.8 ± 8.1 days). The tympanic membrane and resorbable tube interface demonstrated equivalent findings for auditory thresholds and tissue histopathology at the implant site compared to nonresorbable controls. The resorption behavior was not altered by exposure to soap and water. Tympanic membranes of all animals following tube degradation and soap water exposure were intact with minimal scarring and no signs of persistent foreign body response. The histological analysis showed that implantation of resorbable tubes was not accompanied by secondary infection with otorrhea through the tube, did not result in a permanent perforation or dislocation of the tube into the middle ear cavity, and was not followed by excess tympanosclerosis or localized or diffuse membrane atrophy.

CONCLUSIONS AND SIGNIFICANCE: Resorbable polyester pressure equalization tubes demonstrate predictable resorption behavior and similar bio-compatibility characteristics when compared with nonresorbable Shah minigrommet ventilation tubes. Exposure to soap water does not accelerate polyester tube degradation nor change the host tissue response during the indwelling period or after complete resorption. The data suggests that resorbable ventilation tubes are substantially equivalent to other FDA-approved tympanostomy devices with regard to safety and biocompatibility in the guinea pig model examined and may provide improved clinical performance by combining this approach with sustained release technology. EBM rating: B-2.

OBJECTIVE: To overcome the limitations of monaural hearing resulting from a subtotal petrosectomy and blind sac closure by fitting of a behind-the-ear hearing aid.

STUDY DESIGN: Three patients were fitted with aids. Patient satisfaction and the decision to buy the aids were recorded.

RESULTS: Three patients reported good hearing result despite the absence of the middle ear structures.

CONCLUSION: For patients troubled by the limitations imposed on hearing with a unilateral conductive loss following a subtotal petrosectomy and blind sac closure, a behind-the-ear aid is a simple and easy option to try, if the residual canal allows fitting of the aid.

OBJECTIVE: MRI and MRA are accepted as valuable methods for diagnosing vertigo, although they are costly and time-consuming. Thus, some indicator of the necessity of a detailed evaluation by MRI and MRA is desirable.

STUDY DESIGN AND SETTING: To assess the usefulness of an impairment of the visual suppression (VS) as an indicator, the relation between abnormal findings on MRI and/or MRA and impairment of the VS of manually rotated vestibuloocular reflex (VOR) was retrospectively examined in 40 consecutive patients suffering from vertigo.

RESULTS: 12 of 23 patients with a low VS% were found to have a pathologic condition on MRI and/or MRA, however, no abnormality was found in any of the patients with a normal VS%. The rates of abnormality on MRI and/or MRA significantly differed between the 2 groups (X ², P = 0.0004).

CONCLUSION: The VS% is thought to be a good indicator of the need for further evaluation by MRI and MRA in vertiginous patients.

BACKGROUND: Medicinal leeches have been demonstrated to be extremely useful and safe in the salvage of venous outflow compromised tissue, particularly in digit replants and various forms of flaps.

OBJECTIVE: To demonstrate the utility of medicinal leeches in the salvage of venous outflow-compromised traumatic soft tissue avulsions in key facial structures.

METHODS: A retrospective review of 4 cases involving the external ear, nose, lip, and scalp in which apparent venous outflow compromise was present. Medicinal leeches were applied acutely in each of these 4 cases, salvaging each of the partially avulsed soft tissue segments.

RESULTS: Complete or near complete salvage of each soft tissue segment after using medicinal leeches.

CONCLUSIONS: Although it is unusual for a partial soft tissue avulsion of the face to require medicinal leech therapy, situations may occur in which there is adequate arterial inflow but inadequate venous outflow. In such cases, medicinal leeches may play a very important role in salvaging the soft tissue segment. This is particularly important in vital structures such as the ear, nose, lip, and eyelid in which acute or secondary reconstruction is complex. EBM rating: C.

OBJECTIVE: Delineate the relationships among the optic nerve (CN II), the sphenoid sinus, and the sphenoethmoid cell.

STUDY DESIGN: High-resolution CT scans of 64 frozen human cadavers were obtained on a Siemens VolumeZoom CT scanner (Munich, Germany) and transferred to a CBYON Suite Doctor Station version 2.6 (CBYON, Mountain View CA) for standardized review.

RESULTS: Pneumatization around CN II was categorized into 5 types: no adjacent pneumatization (type 0), pneumatization adjacent to CN II (type 1), adjacent pneumatization with indentation (type 2), pneumatization of <50% CN II circumference (type 3), and pneumatization of >50% CN II circumference (type 4). The prevalence of types 0 to 4 CN II position relative to the sphenoid sinus was 4.7%, 25.8%, 39.8%, 14.1%, and 15.6%, respectively. The prevalence of sphenoethmoid cells was 28.1%. The prevalences of types 0, 1, 2, 3, and 4 CN II positions relative to the sphenoethmoid cell was 5.6%, 58.3%, 25%, 2.8%, and 8.3% respectively.

CONCLUSIONS: Software-enabled CT review facilitated precise study of the anatomic relationships of CN II. Caution must be exercised during sinonasal surgery to minimize the risk of inadvertent CN II injury. EBM rating: D.

OBJECTIVE: Rhinosinusitis is the sixth most common chronic condition of the elderly. Functional endoscopic sinus surgery (FESS) has developed over the last 20 to 30 years into a widely accepted treatment modality for chronic rhinosinusitis in adults who have failed maximal medical management. The aim of this study was investigate the safety and efficacy of FESS in the geriatric population as compared to that of the adult population.

METHODS: Retrospective review of prospective measurement of outcomes in consecutive patients over 60 years of age who underwent FESS. Fifty-six patients over 60 years of age underwent FESS and were evaluated preoperatively and postoperatively at 3, 6, and 12 months with the Sino-Nasal Outcome Test-20 (SNOT-20) questionnaire, and a rigid nasal endoscopy scoring system. Data analysis was performed using the Student's t test to compare mean scores. Any complications were noted.

RESULTS: Patients evaluated by the SNOT-20 scoring system experienced 64% improvement of symptom scores at 3 months, 73% improvement at 6 months, and 75% improvement at 12 months. Rigid nasal endoscopy scores improved by 76% at 3 months, 65% at 6 months, and 76% at 12 months. There were very few minor complications and no major complications of the surgery. These results are comparable to those of the literature that address outcomes in the adult population undergoing FESS.

CONCLUSIONS: FESS in the geriatric population is a safe and effective treatment modality for rhinosinusitis that is refractory to medical therapy. EBM rating: C.

OBJECTIVE: To study functional outcomes following concurrent chemoradiotherapy of head and neck cancer.

METHODS: A retrospective chart review assessed diet, feeding tube use, and tracheotomy pretreatment and 3, 6, 12, and 24 months posttreatment.

RESULTS: Of 196 patients who underwent chemoradiotherapy between 1990 and 2002, 148 (76%) required feeding tubes immediately posttreatment; 150 (77%) required nutritional support at 3 months. By 12 months, 92% were tube-free and 83% resumed near-normal diet. Of 17 patients (9%) with tracheotomy posttreatment, 71% were decannulated by 6 months. Stage IV disease strongly predicted prolonged feeding tube use and slow recovery of diet; age ≥60 also predicted slow recovery. Primary site, gender, and radiotherapy schedule did not predict functional recovery after adjusting for stage and age.

CONCLUSION: Few patients required tracheotomy before or during chemoradiotherapy. Many patients required feeding tubes and nutritional support for several months following therapy, but most were tube-free and eating near-normal diets within 1 year. EBM rating: C.

OBJECTIVE: Patients who undergo skull base resection after prior surgery or radiation may be at high risk for complications when local flaps alone are used for reconstruction. To determine whether the complication rate could be reduced, fasciocutaneous free tissue transfer was used to reinforce the dural closure in patients who had prior skull base surgery or radiation.

METHODS: This study is a case series of 20 patients (14 males, 6 females, aged 8–79 years of age with a mean of 47.7 years) from 1997 to 2001 who had prior skull base surgery or radiation, and underwent salvage skull base resection without large volume defects. All patients had a radial forearm free tissue transfer to reinforce the dural closure. Six patients had an osseous component to the forearm flap to provide vascularized bone to the orbital rim.

RESULTS: The overall local complication rate was 35%. Three patients (15%) had major complications including 1 case of meningitis, 1 case of cerebrospinal fluid leak, and 1 case of a flap requiring venous salvage. There were no flap failures, 1 idiopathic median nerve palsy, and no pathologic radius bone fractures.

CONCLUSION: Reconstruction with fasciocutaneous free tissue transfer for high-risk patients with low-volume dural defects following skull base resection can minimize the risk of major postoperative complications. EBM rating: C.

OBJECTIVE: To compare thyroid fine-needle aspiration (FNA) using monolayer (MT) versus conventional smear (CS) cytopreparatory techniques with final histology.

STUDY DESIGN: Retrospective review of 100 consecutive thyroidectomies.

SETTING: Tertiary care university affiliated medical center.

RESULTS: 26% of MT aspirates were inadequate compared with 3% of CS aspirates (P < 0.05). The negative predictive values for MT and CS were 86% and 100%, respectively. The positive predictive values for MT and CS were 69% and 90%, respectively.

CONCLUSIONS: Fewer inadequate specimens will be obtained with CS than with MT. A clinician performing FNA can obtain adequate specimens at a rate comparable to that of a hospital-based cytopathologist.

SIGNIFICANCE: CS provides greater assurance to the patient and the surgeon that a thyroid nodule with a FNA interpreted as benign can be observed. A higher percentage of patients with malignant tumor will receive thyroidectomy with the use of CS technique for FNA. EBM rating: B-3. (Otolaryngol Head Neck Surg 2004;131:964–7.)

The hypothesis that jugular thrombosis (JT) may cause a mass in the cervical region is usually overlooked. The objective of the present study was to identify the characteristics of neck masses resulting from JT in cancer patients and to analyze the possible reasons for their formation. A retrospective study was conducted on 8 patients with JT affected by 3 types of neoplasia, ie, carcinomas (3 cases), adenocarcinomas (3 cases), and lymphomas (2 cases) located in the breast, digestive apparatus, lymphatic system (2 cases each), lung and an undetermined site (1 case each), diagnosed over the last 12 years. The most frequent symptom of JT was the presence of a mass in the supraclavicular space (62.5% of cases) deeply located on the anterior margin of the sternocleidomastoid muscle and diagnosed by computed tomography and ultrasound. The masses were slightly hardened, with a clearly defined upper limit and an imprecise lower limit and with an irregular surface. The patients also presented with cough, hoarseness, pain during movements, facial edema, and collateral circulation. In one of the patients with a lung cancer, JT symptoms preceded the symptoms of cancer by 2 months. Hypercoagulation, compression, and invasion of a vessel possibly explain the occurrence of JT in these patients.

We reviewed our experience with sinonasal cancer patients to assess the prognostic factors. Between 1974 and 1995, we enrolled 125 patients (58 + 16 years [mean age + SD]; 94 males and 31 females). Tumor stage distribution was: T1, 64 patients; T2, 36 patients; and T3, 25 patients. Surgery as a primary treatment was selected for 106 patients (55 cases of surgery alone, 40 cases of surgery plus radiotherapy, and 11 cases of surgery plus chemotherapy with/ without radiotherapy). The 1-, 5-, and 10-year overall survival was 75.0%, 37.2%, and 24.7%, respectively. The parameters with statistical prognostic significance were nodal stage, locoregional failure, and tumor stage. Histological type and primary site had no prognostic value. There were no significant survival differences between surgery alone and surgery plus radiotherapy. Sinonasal tumors have a poor survival, despite early diagnosis, radical surgical resection, and strict follow-up. Radiotherapy seems not to be clearly necessary in stage T1.

OBJECTIVE: Surface electromyographic studies were performed on 440 normal adults to describe and evaluate different types of normal swallows clinically useful for ENT department.

STUDY DESIGN: Prospective observational study of healthy volunteers.

METHODS: EMG recordings were made using stick-on surface electrodes. Rectified and filtered EMG signals were evaluated. Parameters evaluated include the graphic configuration of activity of the orbicularis oris, masseter, submental group, and infrahyoid muscles, the last 2 covered by platysma, during single swallowing and continuous drinking. Four tests were examined: voluntary saliva swallows, voluntary separate swallows as normal, voluntary separate swallows of excessive amount of water (20 mL), drinking of 100 mL of water. Graphic recording of activity of the above-mentioned muscles during swallowing and drinking were evaluated for groups of adults of different ages.

RESULTS: There are several types of normal swallows as seen at the surface EMG records. There was no difference between EMG recordings of male and female swallows. Only group of elderly patients (age 70+) shows age-induced differences in recorded swallows. There are two main types of normal swallow: single-share and double-share swallows. The oral phase of swallowing, being under conscious control, is very variable and should not be taken into consideration during evaluation of records. Final oral, pharyngeal, and initial esophageal stages of swallowing can be defined and evaluated at the rectified and filtered surface EMG record.

CONCLUSION: The normal muscle activity during swallows and drinking has several graphic patterns which can be identified and described similar to EKG records when surface EMG is rectified and filtered. The method of EMG recording is quick and simple, and can be used for screening and evaluation purposes in outpatient and inpatient ENT departments. These parameters represent activities required for normal deglutition, and can be used to identify abnormalities in ENT patients, and provide a basis for comparison of swallowing performance both within and between patients. These normal data form a valuable basis for future comparison with patients in pre- and postoperative stages and in EMG monitoring during ENT treatment.

Chronic tobacco smoking and alcohol consumption are well-established risk factors for the development of squamous cell carcinoma (SCC) of the head and neck. There are, however, a variety of other habitual and culturally based activities that are less commonly seen in the Western world and that are also risks factors for the development of this type of cancer. In this era of globalization, many of these habits have now crossed borders and appear in various areas throughout the world. This article reviews habitual and social risk factors for cancer of the head and neck, excluding smoking and alcohol consumption. These factors include chewing tobacco and snuff, areca nut in its various forms, Khat leaves, and the drinking of Maté. EBM rating: D. (Otolaryngol Head Neck Surg 2004;131: 986–93.)

OBJECTIVES: To evaluate the treatment results of adenoid cystic carcinoma (ACC) of the submandibular gland at a single institution during a 35-year period.

STUDY DESIGN & SETTING: A retrospective review was performed by examining the records and reviewing the pathology of 22 patients with ACC of the submandibular gland treated at UCLA Medical Center from June 1963 to December 1997.

RESULTS: Seven men and 15 women with an age range of 23 to 85 years (median, 48 years) were treated. Surgical intervention was performed in 21 patients. All patients with advanced tumor size, perineural invasion, microscopically positive surgical margins, or regional neck metastases received postoperative adjunctive therapy, primarily radiotherapy. Follow-up varied from 6 months to 181 months (median, 67 months). Disease-free survival at 3, 5, and 10 years was 66%, 57%, and 41% respectively, whereas overall survival was 76%, 70%, and 37%, respectively (note: 5- and 10-year survival rates are not statistically conclusive due to the small sample size).

CONCLUSIONS: We report fairly high disease-free survival rates in this patient population and a number of prognostic trends are evident. Early diagnosis, wide surgical intervention, and postoperative radiation are associated with a favorable prognosis. Advanced tumor size, positive surgical margins, perineural invasion, and local recurrence of the tumor are associated with an unfavorable prognosis. EBM rating: C.

Paranasal sinus fungus balls occur usually in single sinus, most frequently the maxillary sinus. 1 Multisinus localization was found only 6% in the largest review of this disease entity. 2 Even multiple sinuses involved, these sinuses were mostly contiguous. Bilateral involvement was rare in the literature. 2–4 Nevertheless, there has never been a report of three discrete sinus fungus balls in the same patient. This report represents the first case of the paranasal sinus fungus balls presenting in triple discrete sinuses at once.

The first successful composite human laryngeal transplantation was performed by a team led by the senior author on January 4, 1998. The recipient was a 40-year-old male who had sustained a crush injury to his larynx 20 years prior, rendering him aphonic. Multiple previous attempts for reconstruction at an outside hospital were unsuccessful. The donor was a 40-year-old male who had died from a ruptured cerebral aneurysm. The specifics of the procedure have been detailed elsewhere. 1 Throughout the patient's postoperative course, serial fiberoptic evaluations and voice testing were performed to evaluate laryngeal reinnervation reflected in phonatory function. We herein report the results of these exams, as well as the results of electromyographic recordings of the laryngeal musculature 4 years posttransplantation.