Otolaryngology–Head and Neck Surgery

Aminoglycoside antibiotics can be used successfully in the treatment of otologic infections caused by gram-negative bacteria. They can be particularly valuable, sometimes in combination with a β-lactam antibiotic such as carbenicillin, in malignant external otitis, acute middle ear infections caused by gram-negative organisms, and central nervous system complications of cholesteatomas. On the basis of susceptibility tests and of the pharmacology of these drugs, we administer appropriate therapeutic doses of one of the following antibiotics: Kanamycin, gentamicin, tobramycin, or amikacin. All of these drugs may be ototoxic and nephrotoxic.

Although inverting papillomas originating from the paranasal sinuses have been reported, inverting papillomas emanating from the sphenoid sinus are exceedingly rare. The following is a case report and one year follow-up of a 57-year-old white man who underwent a radical sphenoidostomy for recurrent inverting papilloma of the sphenoid sinus. The patient, to date, is free of disease.

A 51-year-old woman complained of intermittent nasal obstruction and rhinorrhea. Sinus roentgenograms and polytomograms revealed a small mucocele of the right sphenoid sinus. There was no encroachment of the orbital apex or intracranial contents. The mucocele was marsupialized via an external ethmoidectomy, and the scant tissue present inside the sinus was examined histologically. The pathologic diagnosis was hemangiopericytoma. The small tumor had apparently originated at the sinus ostium, thus creating the mucocele. Several months postoperatively, a small, vascular tumor nodule was noted in the incision. No recurrence was evident intranasally. A course of 5,040 rads of external beam radiation therapy was given to the right ethmoid labyrinth and right sphenoid. Since completing her radiation therapy, there has been no recurrence. This case is of interest because the tumor occurred as a mucocele of the sphenoid sinus.

Fibro-osseous lesions of the paranasal sinuses, especially those that contain multinucleated giant cells, demonstrate a significant histopathologic overlap although they manifest themselves throughout a wide range of clinical behavior. They routinely require a critical clinical and pathologic interpretation. Often, the clinical course of the disease is the only guide to diagnosis and mode of treatment.

This study presents the case of a 4-year-old boy with an osteoid-producing tumor of the ethmoid sinus. Despite an original diagnosis of fibrous dysplasia, the lesion followed a relentless course. Eventually, maxillectomy, orbital exenteration, and craniotomy were required to control the disease. The literature of fibro-osseous lesions of the paranasal sinuses is reviewed and an attempt is made to classify these lesions according to their clinical behavior.

Cervical thymic cysts are extremely unusual neoplasms that only rarely produce signs and symptoms of upper airway tract compromise. Less than 7% of patients initially have dyspnea or hoarseness. We report the first known case of progressive neonatal airway obstruction secondary to a rapidly enlarging cervical thymic cyst. Because one half of these benign tumors may demonstrate mediastinal extension, computed axial tomography or B-mode ultrasonography or both is recommended prior to surgical excision. Review of the literature confirms that the majority are successfully removed via a transcervical approach without recurrence.

This report presents six cases of obstructive sleep apnea associated with discrete anatomic abnormalities of the upper airway tract. All patients were relieved of their sleep apnea by surgical correction of the airway obstruction, and therefore permanent tracheotomy was avoided. The obstructive causative factors were nasal septal deformity, adenoidal hypertrophy, nasopharyngeal stenosis, lingual cyst, lingual tonsillar hypertrophy, and laryngeal cyst. The last-named four conditions have not previously been reported as correctable causes of sleep apnea.

Jet ventilation via the Sanders injector during intravenous general anesthesia provides excellent operative conditions for CO₂ laser microsurgery of the larynx. This technique, which includes complete muscle relaxation, is superior to traditional methods of anesthesia because the endotracheal tube is eliminated, thus improving the surgical field and reducing burn hazards owing to ignition of the tube.

The laryngoscope has been modified to carry multiple ports into which a 14-gauge needle is inserted and the tip advanced just distal to the vocal cords. This needle is securely attached to the injector and pressure from the oxygen source is adjusted according to the patient's build and total compliance.

Satisfactory arterial blood gases, superb operating conditions, safety, and rapid awakening make this the method of choice for most patients.

Thymic cysts are unusual neck masses in adults and children and are rarely differentiated from other neck masses by physical examination. This is a case report of a thymic cyst producing airway obstruction in a neonate. The embryogenesis and differential diagnosis of thymic cysts are reviewed.

Immunopathologic studies classify lymphoma under the T-cell or B-cell groups. Such a classification gives a better indication for prognosis and treatment of lymphomas, with the T-cell group having the worse prognosis.

A patient with a T-cell lymphoma of the oral cavity is presented. The diagnostic features and management are discussed.

The mucosa covering the lingual and laryngeal surfaces of the epiglottis offers excellent and readily accessible material for reconstruction of the pharyngoesophagus where large pharyngeal defects need to be repaired. Such defects are often encountered following radical surgery for cancer involving the pyriform sinus, postcricoid area, or cervical esophagus.

A case report is presented with illustrations demonstrating this technique.

The work of several investigators suggests that anemia may increase the survival length of skin flaps in the dog and the rabbit. The following experiment was designed to study the survival of standardized skin flaps of varying lengths in normocythemic, polycythemic, and anemic pigs. The pig was chosen because of the similarity of its skin to that of human skin.

Twenty-nine standardized random-pattern flaps and six standardized arterial flaps were studied in pigs with varying hematocrits. A statistically significant increase was found in the survival lengths of skin flaps in the polycythemic animal as compared with the anemic one. No significant difference was found when the flap survival lengths of the normocythemic control animal were compared with those of the polycythemic animal or with those of the anemic animal. These findings suggest that relative polycythemia may allow improved flap length-survival and, in contradistinction to the findings of previous investigators, that anemia does not result in improved survival length.

Mucoepidermoid carcinoma is most commonly found in the parotid gland. It rarely occurs in the larynx and hypopharynx. There are only 32 reported cases from these areas. A case of a mucoepidermoid carcinoma of the hypopharynx is presented. Although the initial impression was squamous cell carcinoma, glandular structures were found in metastatic lymph nodes in the neck specimen, and after mucicarmine stains were positive, the final diagnosis was changed to mucoepidermoid carcinoma. This case illustrates the difficulty in diagnosing mucoepidermoid carcinoma, especially in unexpected locations. Differentiating mucoepidermoid carcinoma from other neoplasms is important because treatment may differ depending on the diagnosis. The pathologic spectrum of mucoepidermoid carcinoma is presented, and the management of these tumors with respect to the histologic grade is discussed.

There is a 1% incidence of congenital internal carotid tortuosity, which places this vessel into apposition with the superior pharyngeal constrictor instead of its usual location 2 to 3 cm lateral to it. Two angiographically documented cases are reported and the embryologic cause of this anomaly is discussed. Palpation of the pharyngeal wall prior to tonsillectomy or adenoidectomy is recommended.

A 55-year-old woman had a right-sided neck mass overlying the angle of the mandible, which proved to be a chemodectoma. The occurrence, differential diagnosis, and relatively high frequency of incorrect preoperative diagnosis of carotid body tumors is reviewed. The essential role of angiography to substantiate the diagnosis is discussed.

A previous study by the authors compared pathologic changes in the mouse sciatic nerve following prolonged continuous stimulation with either pulsed or direct current. The pulsed current stimulator was found as equally effective yet far safer than the direct current (DC) stimulator. In an attempt to reproduce more accurately the clinical setting, the Ear, Nose, and Throat Device Classification Panel of the Food and Drug Administration requested a prospective, controlled study of repeated DC stimulation at one or more sites along a peripheral motor nerve. Again, repetitive DC stimulation both at one site and at multiple sites of the same nerve produced significant myelin and axon degeneration. The authors conclude that even routine use of the DC stimulator carries with it the potential for permanent nerve damage and muscle paralysis.

This study explores the interrelationships of certain characteristics associated with the elective surgeon's personality. Findings indicate that the very characteristics that distinguish the surgeon's expertise also make it difficult for him to accept the changes that have occurred in the spectrum of modern medicine and the resulting role confusion. Rather than reacting defensively or negatively, this work recommends that the surgeon take an affirmative, assertive approach to the problem.

It has been discovered that many of the vague throat symptoms designated as globus are due to gastroesophageal reflux. Several illustrative cases are reported to demonstrate the gamut of symptoms that may be encountered and their means of control.

From 1950 through 1975, 54 patients with mucoepidermoid carcinoma of the oral cavity were treated at the Mayo Clinic. Metastatic disease occurred in 13 patients; nine patients died of their disease. Mucoepidermoid tumors of the hard palate should be treated by partial maxillectomy. Complete neck dissection is necessary for tumors larger than 2 cm in the base of the tongue. Other intraoral mucoepidermoid carcinomas are treated by wide surgical excision.

The technique discussed in this paper enables the surgeon to perform extensive excision of large cavernous hemangiomas with minimal blood loss, thus increasing the safety of surgical treatment. The method consists of using through and through 2-0 silk mattress sutures surrounding the hemangioma, thus cutting off the blood supply.

An extremely rare laryngeal hamartoma causing inspiratory stridor in a 6-week-old infant is reported and the histology discussed. The tumor is benign and responds to simple excision. No other cases have been found in the 20th century American literature.

Regeneration of cilia after injury has been assumed but not proved. Using scanning electron microscopy, the presence of many organelles shorter and thinner than cilia on topical decongestant damaged nasal mucosa was noted. Their similarity to microvilli and the failure to demonstrate any cilia except those of standard length, would appear to make it unlikely that cilia regrowth occurs after chronic use of topical decongestants.

The purpose of this study was to determine the effect of acute nasal obstruction on sleep and breathing in eight normal persons. The subjects were randomized into two groups. One night the subject was studied with the nose open and a second night with the nose obstructed. The electroencephalogram, electrocardiogram, inspiratory effort, nasal and oral airflow, and oxygen saturation were monitored. Sleep proved to be both subjectively and objectively disturbed. The subjects with the nose obstructed awoke more often, had a greater number of changes in sleep stage, had a prolongation of rapid-eye-movement (REM) latency, and spent a greater amount of time in stage I non-REM sleep (light sleep). Acute nasal obstruction caused a statistically significant increase in the number of partial and total obstructive respiratory events (obstructive hypopnea and obstructive apnea). Sleep apnea developed in one subject during this study merely on the basis of acute nasal obstruction.

A comparison of a newly developed vestibulospinal screening test and two vestibulo-ocular screening tests (caloric and rotation) was performed on two groups of patients, one with Meniere's disease (MD) the other with benign paroxysmal positional nystagmus (BPPN) and vertigo. Vestibulospinal screening tests were slightly more sensitive (not statistically significant) than caloric tests for detection of a peripheral vestibular disorder. Caloric, rotation, and vestibulospinal screening tests were specific neither for MD nor BPPN groups. The caloric test false-positive rate for the involved ear was unacceptably high for the BPPN group. The rotation test false-positive rate was the highest of the three tests for both groups. The vestibulospinal test combined with either the caloric or the rotational tests increased the sensitivity for detection of a peripheral vestibular disturbance, particularly for the MD patients.

Forty-three infants, treated with aminoglycosides during the neonatal period, were tested repeatedly over a period of two to five years for neurovestibular responses. Results of testing were compared with those obtained from a group of 276 healthy newborns followed simultaneously. No abnormalities were found in the untreated group. Among the treated infants, three had a sensorineural hearing loss and eight had laboratory evidence of vestibular dysfunction and delay of head and postural control.

Horseradish peroxidase was injected into the foramen magnum and oval window of guinea pigs to determine perilymphatic communication routes and boundaries. The primary route to the auditory system appeared to be through the cochlear aqueduct. Perineural spaces of the eighth nerve contributed to this communication and provided the principal perilymphatic communication routes to the vestibular system. Light and electron microscopic examination were used to identify membrane permeability and define boundaries in the epithelial lining of the auditory and vestibular endorgans.

A case report is presented of an unusual occurrence of peripheral facial nerve paresis owing to isolated perineurial extension from a cutaneous squamous cell carcinoma.

Current evidence dispels the previously held belief that perineural invasion and extension occurs in lymphatic spaces. The clinical importance of recognizing this route of spread by tumors of the head and neck is discussed.

Despite a great deal of anatomic and physiologic data in animals, controversy still exists over whether or not the perilymphatic space in man is directly connected to the intracranial space via a patent cochlear aqueduct or other fluid channel. Human physiologic data are limited, indirect, and conflicting. Anatomic and pathologic data have heretofor been inadequate for answering the question convincingly. The temporal bones of a 19-year-old woman with central nervous system lymphoblastic leukemia are discussed. The passive-appearing movement of lymphoblasts between cerebrospinal fluid and perilymphatic spaces suggests both a functionally patent cochlear aqueduct and alternate pathways.

The differential diagnosis in 170 patients between birth and 18 years of age is reviewed. There are a number of obvious physical findings and historical features that allow one to make a diagnosis rather quickly. Pain, vesicles, a red pinna, vertigo, and sensorineural hearing loss suggest herpes zoster oticus. Slow progression beyond three weeks, recurrent facial paralysis involving the same side, facial twitching, weakness, or no return of function after six months indicate a neoplasm. Bilateral simultaneous facial paralysis indicates a cause other than Bell's palsy, such as Guillain-Barré syndrome, pseudobulbar palsy, sarcoidosis, and leukemia. Recurrent facial paralysis associated with a fissured tongue, facial edema, and a positive family history should suggest Melkersson-Rosenthal syndrome.

Two patients complained of severe vertigo following eructation or hiccup. One patient was poststapedectomy; the other had idiopathic cochlear degeneration. The symptoms were reproduced by Hennebert's test in the pathologic ear. The tensor tympani was transected in both patients. An endolymphatic sac procedure was performed concomitantly in the second patient. Both patients had immediate relief of symptoms. It is hypothesized that these reflex phenomena, which elicited vertigo, were accompanied by tensor tympani contraction, which resulted in medial movement of the stapes or prothesis, and that this movement was transmitted via adhesions to vestibular endorgans to produce the described symptoms.

The electronic probe provides a simple means to detect eustachian tube patency, and can be used as a sensitive probe of objective tinnitus. The basic unit consists of a battery-operated, electronic amplifier connected by 18-in leads to a sensitive microphone and to a small speaker (Fig 1). These transducers are each connected to rubber nipples of the type used for impedance audiometry (Fig 2).

The relation between middle ear admittance measured at the tympanic membrane and middle ear volume was studied in adult hamsters. A modified tympanometric procedure was used to measure complex admittance at eight test frequencies. Middle ear volume was varied by injecting small amounts of water into the bulla cavity. As bulla volume decreased, the value of admittance magnitude also decreased. The measured values of admittance magnitude could be accurately predicted by the equation for admittance magnitude until the bulla was about 70% filled. The results confirm that measures of middle ear admittance reflect the volume of the middle ear cavity as would be expected of a pure compliance. Where such measures are available in man, they might be used to predict the degree of fluid intrusion into the middle ear cavity.

Computerized tomographic (CT) scanning for intracanalicular tumors requires air as a contrast agent within the internal auditory canal and special computer manipulations of the image to visualize small tumors. The same computer manipulations of CT scans provide detail of the middle and inner ear structures not available by non-CT tomographic techniques. The demonstration of horizontal semicircular canal fistula is one area in which CT scanning is clearly superior. Some pitfalls of the technique and interpretation of it will be discussed.

The charts of 22 patients with an onset of laryngeal papillomatosis after age 18 were reviewed retrospectively. The typical patient had hoarseness. Airway obstruction did not occur in this series. One half of the patients had one recurrence or less of their papilloma. The remainder of the patients encountered multiple recurrences.

The histologic criteria of mitosis and dysplasia reflected recent past activity and correlated poorly with subsequent clinical behavior.

Malignancy did not occur in the larynx of any of these adult onset laryngeal papilloma patients followed from 1 to 20 years.

Forty-one children with recurrent otitis media with effusion (OME) were evaluated for IgE mediated allergy by critical analysis of history, physical findings, skin testing for selected antigens, and laboratory determination of total IgE and radioallergosorbent testing (RAST) for six inhalant and two food allergens. The children were divided into an allergic and nonallergic group. The allergic group clearly had higher total IgE in their serum. There was an elevation of middle ear effusion (MEE) IgE in 5 of 20 allergic cases. In three of these five patients or 15% of the allergic group, the IgE/mg protein was higher in the MEE than in the corresponding serum, suggesting the possibility of local production of IgE.

Specific IgE antibody as measured by RAST was noted in 9 of 20 MEE and 5 of 20 nasal washings in the allergic group and in only 2 of 21 MEE and in 10 nasal washings of the nonallergic group.

Nasal IgE was substantially increased in three patients of the allergic group; however, the corresponding MEE IgE was not increased in proportion to the nasal IgE. The MEE RAST was positive in 22% of the allergic group and in less than 1% of the nonallergic group. Nasal RAST was positive in 20% of the allergic group and in none of the nonallergic group.

We conclude that IgE-mediated allergic reactions may play a role in the pathogenesis of OME in only about 15% of children defined as allergic on the basis of clinical and laboratory evidence. Allergy investigation as a diagnostic procedure in children with recurrent OME, but without a history of allergy on the basis of history, family history, or laboratory testing is likely to be nonproductive.

Autogenous mandibular grafts that have been cryosurgically devitalized and reimplanted have been studied in the canine. Initial investigations have lent impetus to further application in human cancer surgery. Six patients underwent immediate autogenous mandibular graft reconstruction. All failed because of intraoral complications and decreased vascularization in the midportion of the bone graft. None evidenced recurrence of tumor in bone, although two patient's grafts failed on the basis of tumor recurrence in the adjacent soft tissue.

We present a new complication: Transient pupillary dilatation in an eye that sustained a posterior orbital floor blow-out fracture. By reviewing the neural pathways involved with pupillary motor function, we surmise the causes of this complication to include trauma to the ciliary ganglion, short ciliary nerves, or the parasympathetic motor root. This type of injury has only recently been reported in the ophthalmologic literature, and has not, prior to this report, been included in the otolaryngologic literature.