Otolaryngology–Head and Neck Surgery

Most patients with neurofibromatosis type 2 (NF2) are totally deaf after removal of their bilateral acoustic neuromas. Twenty-five patients with neurofibromatosis type 2 have been implanted with a brainstem electrode during surgery to remove an acoustic neuroma. The electrode is positioned in the lateral recess of the fourth ventricle, adjacent to the cochlear nuclei. The present electrode consists of three platinum plates mounted on a Dacron mesh backing, a design that has been demonstrated to be biocompatible and positionally stable in an animal model. Correct electrode placement depends on accurate identification of anatomic landmarks from the translabyrinthine surgical approach and also on Intrasurglcal electrophysiologic monitoring. Some tumors and their removal can result in significant distortion of the brainstem and surrounding structures. Even in the absence of Identifiable anatomic landmarks, electrode location can be adjusted during surgical placement to find the location that maximizes the auditory evoked response and minimizes activation of other monitored cranial nerves. Stimulation of the electrodes produces auditory sensations in most patients, with results similar to those of single-channel cochlear Implants. A coordinated multldlscipllnary team is essential for successful application of an auditory brainstem implant.

The auditory brainstem Implant (ABI) restores some hearing sensations to patients deafened by bilateral acoustic tumors. Electrodes are stable for more than 10 years. In most cases nonaudltory side effects can be avoided by judicious selection of the stimulating waveform and electrode configuration. Most perceptual measurements demonstrate that the ABI produces psychophysical and speech performance similar to that of single-channel cochlear implants. ABI patients receive suprasegmental Information in speech and significant enhancement of speech understanding when the sound from the ABI is combined with Ilpreading.

A review is given of the experience obtained over 6 years of having a psychiatric consultant available as part of the staff of the Voice Clinic, to which more than a thousand patients have been referred. The presenting features in a case that should alert the otolaryngologist to the need for psychiatric consultation and possible treatment are noted. Suggestions are made as to how to prepare the patient for the referral to a psychiatrist with the appropriate Interests and willingness to collaborate closely with the otolaryngologist and the speech pathologist.

Health care costs have risen dramatically in recent years. Cost-containment strategies have become necessary to ensure that adequate medical care is accessible to all who need it. These strategies Include choosing the least costly of several treatment modalities with equal efficacy. Radiotherapy has been considered by some as the treatment of choice for early glottic tumors. Rationale for this is based on two major assumptions: That cure rates are equal for radiotherapy and surgery, and that voice preservation and quality is superior with radiotherapy. Implicit In these assumptions is the idea that cost of therapy should not be a factor in selecting an alternative. This study presents a literature review of cure rates for laser cordectomy and radiotherapy for T₁ glottic cancers. An objective voice analysis was performed on 14 patients with T₁ glottic cancers treated with laser cordectomy and the results were compared to a group of 20 patients treated with radiotherapy for similar early tumors. Finally, the average total cost of each modality was calculated and compared. Our findings indicate that: (1) cure rates are equivalent; (2) voice quality after laser cordectomy is as good as that noted after radiotherapy; and (3) total cost of therapy is much less for laser cordectomy than for radiotherapy. We advocate laser cordectomy rather than radiotherapy for most early glottic tumors.

Laser cordectomy offers the same cure rate and quality of voice as radiotherapy for early T₁ glottic carcinomas, and at our institution laser surgery is significantly less expensive.

Poor oral hygiene is believed to play a role as a risk factor for head and neck cancer, especially for oral cancer. Only few epidemiologic data exist about dental status and oral hygiene in these patients. We performed a case-control study involving 100 patients with squamous cell carcinoma of the upper aerodigestlve tract and 214 age- and sex-matched control subjects with no known tumorous disease. In the tumor patients, oral hygiene and dental status proved to be significantly worse: The majority of the tumor patients seldom or never brushed their teeth and the frequency of dental visits was significantly lower. Tartar of 3 mm or more was found in 40.9% of the tumor patients and in 22% of the control subjects. In the tumor group, the incidence of decayed teeth was significantly higher compared with the control subjects. Chronic Inflammation of the gingiva was observed in 28% of the tumor patients vs. 13.5% in the control gorup. Oral hygiene was negatively correlated with alcohol as well as with tobacco consumption. The social status of subjects also correlated with oral hygiene, which was found to be worst in subjects from the lower social strata. The present study revealed a poor dental status and oral hygiene in patients with head and neck cancer. The pathogenetic mechanism being associated with this suspected risk factor remains to be investigated.

Removal of the globe and associated structures has been advocated for tumors Invading the periorbital bone and periosteum, orbital fat, or extraocular muscles. In some patients with cancerous tumors encroaching on the globe, however, it may be possible to remove the tumor and save the eye. Tenon's fascia is a firm fibrous sheath surrounding the entire globe except the cornea. If the neoplasm spreads along fascial planes rather than through them, and If this layer remains free of tumor Involvement, preservation of the globe can be considered. Oculoplastic reconstructive techniques may limit exposure and diplopia, allowing the eye to be “banked” in vivo, and saved as a spare for the future. Six patients with malignant tumors encroaching on the globe have had definitive surgical extirpation with preservation of the eye. Three patients have had the globe uncovered successfully. Five of six patients remain disease-free, with followup from 6 months to 6 years. No globes have been removed. These techniques appear to be therapeutically sound, preserve function and appearance, and Improve patient morale. The indications and limitations of this approach to certain cases of periorbital cancer are discussed.

Removal of an acoustic neuroma using the translabyrinthine approach has previously been considered “Incompatible” with hearing preservation. By modifying the approach and preventing the loss of endolymph, we have successfully removed two Intracanallcular acoustic neuromas that originated from the inferior vestibular nerves, and preserved serviceable hearing in the ears operated on. This report represents the preliminary findings using this particular technique in the management of Intracanallcular acoustic neuromas.

Human Immunodeficiency virus (HIV), the causative agent of acquired immunodeficiency syndrome (AIDS), has reached worldwide epidemic proportions and is Increasing. Otologists, neurotologlsts, and audiologists practicing in metropolitan centers in North America can expect to encounter patients with HIV-related illnesses, including patients with AIDS-related complex (ARC) and AIDS. Five representative cases are presented: Chronic otitis media, facial palsy, Gradenigo's syndrome with facial paralysis, otosyphilis, and Kaposi sarcoma of the mastoid. The common link in all cases was HIV Infection. This presentation discusses the management of several HIV-infected patients with otologic and neurotologic findings. HIV Infection has extended to all parts of North America. The worldwide incidence is Increasing. As the epidemic continues to unfold, new challenges to both the diagnosis and treatment of otologic and neurotologic disease in HIV-positive patients will confront the audiologist and otolaryngologist. Recommendations for the safety of the examining audiologist and treating physician are given.

Functional endoscopic sinus surgery (FESS) is a new and exciting treatment for chronic sinus disease. Our knowledge of the surgery continues to expand. A retrospective and prospective review of 200 patients undergoing FESS was undertaken at the Houston Ear, Nose, and Throat Clinic. Parameters studied included patient symptoms, medical history, medical therapy, and radiologic findings. Also reviewed were length of hospitalization, complications, and postoperative symptoms. Nasal obstruction was the most common preoperative symptom. Anterior ethmoid and ostiomeatal complex disease were the most common preoperative CT scan findings. More than 84% of the surgeries were performed on an outpatient basis. Minor complications developed in 8% of the patients, and only one major complication occurred (0.05%). With a mean followup of 17 months, 88% of the patients were symptom-free or Improved; however, 41.5% still required some medical therapy. FESS can safely be performed while the patient is under general anesthesia. Partial middle turblnectomy is a safe and recommended procedure; no cases of atrophic rhinitis occurred. We conclude that FESS is a highly successful treatment for chronic sinus disease (p < 0.01) and that a strong patient history for sinus symptoms is the most Important Indication for FESS.

In 1987, we published a case series of a newly-described, highly malignant neoplasm, termed sinonasal undifferentiated carcinoma, in which treatment results were poor. In this updated study, we report the followup for the original three surviving patients and for six additional cases whose tumors were diagnosed between January 1987 and October 1991. These data suggest that the prognosis for patients with localized disease may be better than originally described.

Thirty HydroxylVent tubes were implanted in twenty-seven patients. The chief Indications were unresolving eustachian tube dysfunction, with either collapse or perforation of the tympanic membrane. Every patient had undergone a lengthy course of treatment with conventional ventilation tubes. Twenty ears (66%) showed good results, with prolonged ventilation and restoration of middle ear function. Two tubes appeared to be open, with the development of a pinpoint perforation of the drum. Eight tubes occluded as a result of displacement of the tube, middle ear pathology, or debris. Indications and techniques of management are discussed, along with an analysis of complications.

DNA analysis by flow cytometry is considered to be of prognostic value in epidermoid carcinoma of the head and neck. However, few and contradictory studies have been made on laryngeal carcinomas. We studied 48 epidermoid carcinomas in patients subjected to horizontal supraglottic laryngectomy with a 5-year- followup. The technique described by Hedley for fixated and paraffin-embedded tumors was used. Thirteen tumors were excluded on the grounds of presenting variation coefficients in excess of 10. Of the 35 cases analyzed, 28 (80%) were diploid and seven (20%) aneuploid. No correlation was observed between tumor ploldy and patient survival, recurrence, or any of the histopathological variables studied.

Eosinophil cationic protein (ECP) is probably responsible for the underlying Inflammatory mechanisms seen in asthma. It can be modulated in vivo by immunotherapy or steroids, with an appropriate reduction in symptoms of respiratory tract diseases. ECP is an identifiable mediator in additional target organs involved in allergic reactions, making it of potential interest in the study of otitis media with effusion. A qualitative prospective study was designed to discover the relationship of ECP and serum IgE in patients with middle ear effusion and allergy, as demonstrated by RAST and skin testing. The concentrations of ECP in the middle ear fluid from 23 consecutive patients with otitis media with effusion undergoing the placement of tympanostomy tubes ranged from 2 to 1248 μg (normal serum ECP, 5 to 15 μg), with 87% being abnormally elevated. There was no correlation between an individual's ear and serum levels of ECP (r = 0.1672; p = 0.6232), suggesting a more localized process. There was no relation between effusion ECP and serum IgE (p = 0.0040). ECP from middle ear effusion did correlate with a patient's having allergy, as confirmed by RAST and skin testing (p = 0.0095). Mechanisms involving Immune mediated disease in the middle ear, of which the eosinophil may be one participant, are presented.

Antihistamines are believed to reduce the sneezing and rhlnorrhea associated with allergic rhinitis, primarily by competitive antagonism of histamine for H₁ cellular receptors, but additional mechanisms of action may contribute to their clinical efficacy. To Improve our understanding of H₁ antihistamine action, we studied the effects of pretreatment with terfenadine, cetirizine, ketotifen, azatadine, diphenhydramine, and azelastine on increases in vascular permeability, mast cell activation, and sneezing Induced by nasal challenge with antigen. All studied antihistamines reduced sneezing, Indicating that they all effectively antagonize histamine after its release. In addition, terfenadine and topically administered azatadine blocked the release of histamine. Studies with cetlrizine and azelastine revealed that these antihistamines significantly reduced sulfldopeptide leukotriene levels. Terfenadine and azelastine also reduced klnin production. These results confirm that antihistamines are effective in reducing sneezing and, in some cases, vascular permeability. The findings of these studies also Illustrate that the various antihistamines have multiple and different mechanisms of action that may have Implications for their clinical uses.

Recent results indicate that the adjusted DNA Index (aDI), a measure of nuclear DNA content, is a significant prognostic factor for patients with advanced laryngeal cancer treated with surgery and radiation therapy. Because DNA aneuploidy is an indirect measure of the proliferative activity of a cell population, a study was conducted to examine differences in tumor response to induction chemotherapy based on aDI values. Pretreatment tumor specimens were obtained from 50 patients with stage III and IV laryngeal squamous cell carcinoma who underwent Induction chemotherapy (cis-platin/5-FU). With the use of computerized cytomorphometry, DNA content and nuclear area were measured and associations with tumor site, stage, chemotherapy response, tumor recurrence, and survival were examined. An elevated aDI was more frequent in patients with a chemotherapeutic response (p = 0.08), and mean aDI was higher among the complete responders. There were no complete responders among patients with a low aDI value (< 0.024). Neither aDI nor nuclear area correlated significantly with organ preservation or patient survival. Our results indicate that a complete response is more likely for patients with tumors with an elevated aDI and that pretreatment aDI may be useful in selecting high-risk patients who might benefit from chemotherapy.

Postoperative pharyngocutaneous fistula is not an uncommon complication. Although the frequency of postoperative flstulae has decreased with the use of perioperative broad-spectrum antibiotics, It remains a complication with significant morbidity and expense. We present an animal model for postoperative pharyngocutaneous flstulae based on Increasing wound tension. The New Zealand white rabbit was used to assess the rate of wound breakdown in the thyrohyoid membrane. The animals were assigned to one of seven groups according to the width of tissue resected. After tissue resection, the pharyngeal wounds were repaired, as were the overlying skin wounds. Animals were monitored postoperatively up to 14 days, at which time they were killed and underwent autopsy. Statistically significant results were achieved that demonstrate an Increasing incidence of pharyngeal wound breakdown associated with Increasing width of tissue resected and, therefore, closure tension. The procedure and results will be presented in detail. We propose that this model may be used to assess postoperative wounds as well as substances or methods touted as promoters of wound healing.