bluuebunny/crossref_metadata_2025 huggingface dataset:
Selective Indications for the Management of Extensive Anterior Epitympanic Cholesteatoma via Combined Transmastoid/Middle Fossa Approach
Authors: Steward David L. , Choo Daniel I. , Pensak Myles L.
Published: November 2003

Objectives/Hypothesis Cholesteatoma that is present in the anterior epitympanic space may extend medially along the supralabyrinthine route to the geniculate ganglion, labyrinth, and cochlea and medially toward Kawase's triangle and the anterior petrous apex. Superiorly it may erode into the middle fossa. Contemporary microsurgical techniques allow for optimal management of these lesions with minimal morbidity, provided that the irregular and complex osteology of the petrous base is understood. The objective of the study was to review the relevant regional anatomy, pathobiology, and current algorithm used in treatment of this select patient population using a combined transmastoid/middle fossa (TM/MF) approach.

Methods A retrospective review was performed of all clinical and radiographic data from patients undergoing combined TM/MF management of extensive anterior epitympanic cholesteatoma between July 1984 and June 1998. Data from physical examinations, preoperative imaging studies, and operative findings and other relevant data were tabulated and analyzed for patients undergoing TM/MF management of cholesteatoma.

Results Of 488 patients with cholesteatoma treated by the otological service between 1984 and 1998, 11 patients underwent TM/MF exposure and removal of anterior epitympanic cholesteatoma. Total cholesteatoma removal was accomplished in six patients. In three patients, because of facial nerve involvement, labyrinthine fistulae, or internal carotid artery involvement, open‐cavity surgery was performed. In two patients, residual or recurrent cholesteatoma was exteriorized at “second‐look” procedures. In this small cohort of patients the majority had extension to the arcuate eminence, geniculate ganglion, or Kawase's triangle or had “blue‐lining” of the cochlea or labyrinth. To a lesser degree, the middle ear and mastoid contents were involved. Further facial nerve dysfunction or sensorineural hearing loss was not noted after surgery.

Conclusions Selective TM/MF removal of cholesteatoma provides an optimal route for removing complex cholesteatoma in patients with intact sensorineural function and medial cholesteatoma extension.
Otolaryngology Consultation for Peritonsillar Abscess in the Pediatric Population
Authors: Blotter James W. , Yin Leopold , Glynn Matthew , Wiet Gregory J.
Published: November 2003

Objective To assess clinical outcomes of children seen in consultation for peritonsillar abscess treated without the routine use of computed tomography or needle aspiration.

Study Design Retrospective review of patients evaluated in the emergency department for possible peritonsillar abscess. Patient outcomes are reviewed with a statistical analysis of children grouped according to age.

Methods A series of 102 patients, ages 8 months to 19 years, who were evaluated by the emergency department with otolaryngology consultation for possible peritonsillar abscess. All patients were admitted and given intravenous fluid replacement, antibiotics, and analgesia. Patients who responded to 24 hours of medical treatment were discharged, whereas patients who did not respond underwent elective tonsillectomy.

Main Outcome Measure Outcome of patients evaluated for peritonsillar abscess treated without immediate surgery, needle aspiration, or computed tomography. Outcomes are correlated with age and clinical findings.

Results Fifty‐two patients were discharged after initial medical therapy. Fifty patients underwent elective tonsillectomy; 40 of these patients were found to have abscesses at the time of surgery. When analyzed according to age, patients ages 8 months to 6 years were more likely to respond to medical treatment than children ages 7 to 12 and 12 to 19 (P = .023). Significant differences in the mean age of children requiring surgery (11.0 y) compared with those who responded to medical treatment (7.9 y) were observed (P = .003). Younger children who underwent tonsillectomy had a lower incidence of surgically confirmed abscess.

Conclusions A significant number of children presenting with odynophagia, malaise, pharyngotonsillar bulge, and decreased oral intake respond to medical therapy without radiological evaluation or surgical intervention. Additionally, younger children (1–6 y) are more likely to respond to medical treatment than older children. Pertinent clinical data, as well as advantages and disadvantages of this approach, are discussed.
Influence of Serum Lipids on Auditory Function
Authors: Suzuki Kensaku , Kaneko Mitsuru , Murai Kazuo
Published: November 2003

Objective To evaluate the influence of serum lipids on auditory function.

Study Design The study group comprised 607 men and 317 women who underwent medical examination at our hospital. Eligibility criteria included 1) age of 40 to 59 years; 2) normal ear drums; 3) no history of noise exposure or of diseases associated with hearing loss; 4) normal results of a glucose tolerance test; and 5) normal hearing or sensorineural hearing loss with a flat‐form or high‐tone gradual‐form audiogram. We investigated the relation between the hearing level of the better‐hearing ear and serum concentrations of total cholesterol, triglyceride, and high‐density lipoprotein cholesterol.

Methods For each variable, the subjects were divided into two groups—a high‐level group (serum lipid concentration ≥ 1 SD higher than the mean) and a low‐level group (serum lipid concentration ≤ 1 SD lower than the mean). Differences in hearing level between the two groups were compared according to sex with the t test.

Results For total cholesterol and total triglyceride, there was no significant difference in hearing level between the high‐level group and the low‐level group in either sex. As for high‐density lipoprotein cholesterol, hearing levels at 2000 Hz (P < .05) and 4000 Hz (P < .01) in the high‐level group were significantly better than those in the low‐level group in men.

Conclusion A low high‐density lipoprotein cholesterol concentration is associated with hearing loss. Arteriopathy may play a role in auditory dysfunction.
Combined Radiotherapy With Planned Neck Dissection for Small Head and Neck Cancers With Advanced Cervical Metastases
Authors: Wang Steven J. , Wang Marilene B. , Yip Helena , Calcaterra Thomas C.
Published: November 2003

Background We have previously described our treatment algorithm for patients with small head and neck cancers with advanced cervical metastases (stage N2 or greater). Primary radiotherapy is given to the primary site and neck, followed 6 weeks later with endoscopy and biopsy of the primary site. If biopsy of the primary site is negative by frozen section, an immediate neck dissection is performed even when no clinical residual neck disease is present. Our initial review found that 36% of patients with a complete clinical response to radiotherapy had positive nodes on histological examination.

Study Design Retrospective.

Methods The medical records of 71 patients treated at UCLA Medical Center from 1986 to 1999 by this algorithm were reviewed.

Results After radiotherapy, 69 of 71 patients had a complete response at their primary site. Forty‐two patients had a complete clinical response in the neck. Seventy‐one neck dissections were performed. Overall, 31 of 71 neck dissections (44%) had positive nodes. Among the 42 patients with a complete response to radiotherapy, 13 (31%) had positive histological nodes. Among the 29 patients with a partial response to radiotherapy, 17 (59%) had positive nodes. Follow‐up and incidence of neck recurrence are discussed.

Conclusion Planned neck dissection for advanced cervical metastases remains controversial for patients with a complete clinical response to radiotherapy. However, our results suggest that clinical assessment after radiotherapy cannot assure the absence of neck disease. Until there are reliable methods to distinguish which patients are truly free of neck disease, we believe the benefits of a planned neck dissection outweigh the low morbidity of this procedure.
Role of Middle Turbinate Biopsy in the Diagnosis of Fulminant Invasive Fungal Rhinosinusitis
Authors: Boyd Gillespie M. , Huchton David M. , O'Malley Bert W.
Published: November 2003

Objective To determine the efficacy of middle turbinate biopsy in the diagnosis of fulminant invasive fungal rhinosinusitis.

Study Design Nonrandomized prospective study.

Methods Directed middle turbinate biopsy was performed in 25 patients suspected of having fulminant invasive fungal rhinosinusitis. All patients were immunocompromised and had fever of unknown origin, symptoms of rhinosinusitis, or both.

Results Six patients were found to have fungal invasion on histopathological review (6 true‐positive findings), disease developed in 2 patients with negative results on biopsy (2 false‐negative findings), and disease never developed in 17 patients with negative results on biopsy (17 true‐negative findings), resulting in an overall sensitivity of 75% and a specificity of 100%.

Conclusions Middle turbinate biopsy is a safe and effective method of making a timely diagnosis of fulminant invasive fungal rhinosinusitis. The added morbidity and cost of surgery can be avoided in the patient with a negative finding on biopsy. However, the effect of earlier diagnosis on overall patient survival is unclear at present.
A Meta‐analysis Comparing Outcomes of Microsurgery and Gamma Knife Radiosurgery
Authors: Kaylie David M. , Horgan Michael J. , Delashaw Johnny B. , McMenomey Sean O.
Published: November 2003

Objectives/Hypothesis Surgery has been the most common treatment for acoustic neuromas, but gamma knife radiosurgery has emerged as a safe and efficacious alternative to microsurgery. This meta‐analysis compares the outcomes of the two modalities.

Study Design A retrospective MEDLINE search was used to find all surgical and gamma knife studies published from 1990 to 1998 and strict inclusion criteria were applied.

Results For tumors less than 4 cm in diameter, there is no difference in hearing preservation (P = .82) or facial nerve outcome (P = .2). Surgery on all sized tumors has a significantly lower complication rate than radiosurgery performed on tumors smaller than 4 cm (P = 3.2 × 10−14). Surgery also has a lower major morbidity rate than gamma knife radiosurgery (P = 2.4 × 10−14). Tumor control was defined as no tumor recurrence or no tumor re‐growth. Surgery has superior tumor control when tumors are totally resected (P = 9.02 × 10−11). Assuming that all partially resected tumors will recur, surgery still retains a significant advantage over radiosurgery for tumor control (P = .028).

Conclusion Data from these studies date back to the late 1960s and do not completely reflect outcomes using current imaging and procedures. A major difficulty encountered in this study is inconsistent data reporting. Future surgical and radiation reports should use standardized outcomes scales to allow valid statistical comparisons. In addition, long‐term results from gamma knife radiosurgery using lower dosimetry have not been reported. Surgery should remain the therapy of choice for acoustic neuromas until tumor control rates can be established.
Clinical Indicators Useful in Predicting Response to the Medical Management of Meniere's Disease
Authors: Devaiah Anand K. , Ator Gregory A.
Published: November 2003

Objectives To identify factors that may correlate with responsiveness to medical management of Meniere's disease.

Study Design Retrospective chart review.

Methods The 1995 guidelines of the American Academy of Otolaryngology—Head and Neck Surgery (AAOHNS) Committee on Hearing and Equilibrium were used for data acquisition and measuring clinical response. New patients with 2 years' follow‐up were evaluated and grouped as either medically or surgically treated. Patients were e‐cluded for inadequate follow‐up or prior otological surgery. Dietary sodium restriction (<1500 mg/d) and a diuretic were employed initially. A compliance rating system was devised to evaluate diet adherence. Patients whose medical management failed were offered surgery.

Results Of 65 patients reviewed, 29 patients qualified for analysis. Seventeen patients were treated medically (patients had either definite or possible Meniere's disease), and 12 patients required surgery. Patients with definite Meniere's disease were at a higher stage (based on audiogram) than patients with possible Meniere's disease (P = .002). Patients who required surgery for Meniere's disease were at a higher stage than patients with either definite or possible disease (P < .001). Patients with definite disease had lower compliance than patients with possible disease (P = .004), but both groups showed symptom improvement. Patients with possible disease had better control than patients with definite disease (P < .001). Hearing was stabilized in patients with possible disease and improved at 500 Hz in patients with definite disease (P = .04).

Conclusions Sodium restriction and diuretic treatment response are correlated to clinical measures of Meniere's disease. Patients with possible Meniere's disease should be treated with aggressive medical therapy to prevent disease progression.
Role of Angiography in the Evaluation of Patients With Pulsatile Tinnitus
Authors: Shin Edward J. , Lalwani Anil K. , Dowd Christopher F.
Published: November 2003

Objectives/HypothesisPulsatile tinnitus in the face of normal findings on otoscopy is a common otological diagnostic dilemma and can be due to serious vascular malformations such as transverse or sigmoid sinus dural arteriovenous fistula (transverse or sigmoid sinus [TS] DAVF). Left untreated, TS DAVF may result in significant morbidity and mortality. TS DAVF can be suspected or diagnosed with computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA), with the gold standard being angiography. Our objective was to assess the utility of these various diagnostic modalities in the diagnosis of dural arteriovenous fistula.

Study DesignRetrospective clinical review.

MethodsBetween 1986 and 1996, 54 patients were evaluated and treated for TS DAVF. Between 1996 and 1999, an additional 33 patients underwent MRI combined with MRA for the evaluation of pulsatile tinnitus. A retrospective review of the medical records for both groups, with special attention to clinical presentation, diagnostic evaluation, therapy, and outcome, was performed.

ResultsAll patients had pulsatile tinnitus with normal findings on otoscopy. CT scan was relatively insensitive in the detection of TS DAVF. MRI and MRI/MRA were significantly more sensitive than CT. In the evaluation of patients with subjective pulsatile tinnitus, MRI/MRA defined anatomical abnormalities that may contribute to pulsatile tinnitus in 63% of patients.

ConclusionsIn the absence of objective pulsatile tinnitus, MRI/MRA is an appropriate initial diagnostic step. When a patient has an objective bruit, the clinician may choose to proceed directly to angiography to make certain that a TS DAVF is not missed.
Absence of Bacterial Infection in the Mucosal Secretion in Chronic Laryngitis
Authors: Ebenfelt Anders , Finizia Caterina
Published: November 2003

Objectives To examine whether an infectious process is present in the laryngeal secretion in patients with chronic laryngitis.

Study Design Mucosal secretion from vocal cords and ventricular folds from 14 patients with chronic laryngitis was examined. Twelve patients with healthy larynxes served as control subjects.

Methods Secretion from the laryngeal mucosa was sampled with an imprint technique during general anesthetic. The samples were stained and examined by light and fluorescence microscopy. The numbers of leukocytes and bacteria and the extension of phagocytosis were estimated.

Results In the secretion from eight of the patients with chronic laryngitis we could observe huge numbers of bacteria, whereas only few bacteria were seen in the secretion from the control subjects. However, in both groups, only a few neutrophils were observed and phagocytosis was not present, indicating that the bacteria were present as colonizers.

Conclusions No infectious process is present in the secretion in chronic laryngitis. Further studies concerning the pathogenesis should focus on the pathological processes or conditions of the mucosa.
Acute Sinusitis: A Histopathological and Immunohistochemical Study
Authors: Berger Gilead , Kattan Avi , Bernheim Joelle , Ophir Dov , Finkelstein Yehuda
Published: November 2003

Objective To provide data on the histopathological and immunohistochemical characteristics of acute sinusitis in humans.

Study Design A nonrandomized, retrospective, controlled, qualitative and quantitative study.

Methods Inflamed sinus mucosal tissues were removed during functional endoscopic sinus surgery from 11 patients with acute sinusitis, of whom 6 had complications with extension of inflammation to the orbit (4) or the meninges (2), 3 had recurrent sinusitis, and 2 had acute exacerbation of chronic sinusitis. Normal sinus mucosal tissues were retrieved from four patients with various nasal tumors and served as controls. All specimens underwent routine histological processing. Representative sections from each region were stained with hematoxylin and eosin, periodic acid‐Schiff, and toluidine blue. Immunohistochemical staining for T and B lymphocytes was also applied. A two‐phase examination was designed: low‐magnification microscopic assessment (×40) to yield the typical pathological features and high‐magnification assessment (×400) to count various inflammatory cells.

Results The lamina propria displayed the most significant changes with edema, extensive infiltration of neutrophils and mononuclear cells, formation of microabscesses, thrombophlebitis, and necrotic foci, whereas the involvement of the epithelial layer in the inflammatory reaction was relatively modest. Immunohistochemistry revealed an increase in the population of T and B lymphocytes. The former were diffusely scattered, whereas the latter also formed distinct clusters: around small venules, adjacent to seromucous glands, and under the epithelium.

Conclusions The inflammatory reaction of the lamina propria exceeded that of the epithelial layer. It is assumed that the clusters of B lymphocytes around blood vessels may point to the fact that these cells were recruited from the blood during acute sinusitis.
Age‐Related Mitochondrial DNA Mutations in the Human Larynx
Authors: Manaligod Jose M. , Milam Michael , Hill Sarah Ann , Sanders Tammy , Skaggs Jennifer , Smith Richard J. H.
Published: November 2003

Objective To determine whether age‐related mitochondrial DNA mutations occur in the human larynx.

Study Design Genetic study of cadaveric larynx specimens.

Methods Vocal fold mucosa, thyroarytenoid muscle, and cricoarytenoid joint tissue were harvested from 13 fresh postmortem larynges (age range, 2 d–82 y). DNA was extracted from each sample, and the polymerase chain reaction (PCR) was used to amplify a target DNA sequence resulting from the common age‐associated, 4977–base‐pair (bp) mitochondrial DNA deletion. PCR products were visualized by agarose gel electrophoresis. Automated sequencing determined the sequence of identified PCR products.

Subjects Thirteen cadaveric larynges were obtained through the University of Kentucky Medical Center (Lexington, KY). Specimens from patients with a history of head and neck cancer, previous laryngeal trauma, or surgery were excluded.

Results Strongly positive bands were identified in samples from three individuals. Weaker bands were seen in samples from four other samples. No band was noted from the two pediatric larynges. Different band patterns were seen among the three different tissue sites in the larynges with positive PCR products, but no consistent pattern was seen. Sequencing of the identified PCR products from selected samples confirmed that they were products of the age‐associated, 4977‐bp mitochondrial DNA deletion.

Conclusions An age‐associated mitochondrial DNA deletion was detected in several postmortem human larynges. Its presence seemed to increase in appearance with age. In the larynges in which the deletion occurred, there were individual regional differences in the occurrence of the deletion, but no consistent pattern was noted across all individuals who carried the deletion.
Neonatal Subglottic Stenosis—Incidence and Trends
Authors: Walner David L. , Loewen Mark S. , Kimura Robert E.
Published: November 2003

Objective/Hypothesis Neonatal subglottic stenosis is a known entity arising from endotracheal tube intubation. In the 1970s and 1980s, estimates of the incidence of subglottic stenosis were in the range of 0.9% to 8.3% of intubated neonates. Because of improved techniques of handling neonates who require ventilatory support, we thought the actual incidence of neonatal subglottic stenosis in the late 1990s was much lower.

Study Design We retrospectively reviewed all neonatal intensive‐care unit (NICU) admissions from 1997 at our institution, which serves as a level 3 NICU. We also performed a MEDLINE search of the reported incidence of neonatal subglottic stenosis between 1960 and 1999.

Methods Analysis was performed to identify all children who developed subglottic stenosis at our institution. Data were also collected and analyzed with regard to average gestational age, average birth weight, average duration of intubation, and the number of children requiring tracheostomy. The reports identified in the literature were reviewed as to the incidence of subglottic stenosis.

Results A total of 544 neonates were admitted to the unit. Of these, 281 were intubated for an average of 11 days. No patients developed subglottic stenosis. Three patients required tracheostomies for other reasons. All studies published after 1983 reported an incidence of neonatal subglottic stenosis as less than 4.0%, and all studies published after 1990 reported an incidence of neonatal subglottic stenosis as less than 0.63%.

Conclusions Although our report applies to only a single institution in a single year, after reviewing the literature we think a downward trend exists in the incidence of neonatal subglottic stenosis in the late 1990s. The current incidence of neonatal subglottic stenosis is likely between 0.0% and 2.0%.
Electroporation Therapy for Head and Neck Cancer Including Carotid Artery Involvement
Authors: Allegretti Joseph P. , Panje William R.
Published: November 2003

Objectives Electroporation therapy with intralesional bleomycin (EPT) is a novel, technically simple outpatient technique in which high‐voltage electric impulses delivered into a neoplasm transiently increase cell membrane permeability to large molecules, including cytotoxic agents, causing localized progressive necrosis. Unlike many laser ablation methods, EPT can treat bulky tumors (>2 cm) with complete penetration. Our recent publication confirms an excellent response rate in the use of EPT in a clinical trial.

Study Design, Patients, and Methods Following our initial prospective study report in 1998, we have followed our entire initial cohort (10 patients) of patients with head and neck cancer beyond 24‐months follow‐up. Additionally, we have used this approach to treat four additional patients (total: 9 males/5 females) with upper aerodigestive tract squamous cell carcinoma, including three with internal carotid artery (ICA) involvement up to or within the skull base. Two patients underwent preoperative balloon test occlusion with cerebral perfusion studies followed by carotid embolization. EPT was then done safely at least 2 weeks later to avoid the temporary hypercoagulable state.

Results Within the overall cohort (14 patients) 6 patients had a complete response, 6 had a partial response, and 2 did not respond (overall 85.7% response rate). Both patients with ICA involvement had a partial or complete response to treatment; neither patient had a hemorrhagic or neurologic complication. Overall, 13 of the 14 patients were treated for persistent or recurrent head and neck cancer. Two of the four patients with early recurrent stage tumors had no evidence of recurrence after EPT with an average follow‐up of 31.5 months. The overall early stage tumor group had four complete responders out of five (80%). On the contrary, only 2 of 9 patients with advanced recurrent stage tumors were disease‐free at 18 months. Morbidity was low for early stage tumors, but higher for advanced tumors with complications, including poor wound healing, dysphagia, and osteomyelitis. There were no treatment‐related deaths.

Conclusion We found EPT to be safe and efficacious in patients with head and neck cancer, even with internal carotid artery involvement. Patients with early stage recurrences have the potential for prolonged survival beyond 2 years without the morbidity of surgery and radiation or toxicity of systemic chemotherapy. Because of its superb access qualities even for bulky tumors, EPT is a potential method of delivery for other tumoricidal agents such as in genetic‐altering schemes.
Changes of Nasal Function After Temperature‐Controlled Radiofrequency Tissue Volume Reduction for the Turbinate
Authors: Rhee Chae‐Seo , Kim Dong‐Young , Won Tae‐Bin , Lee Hyo‐Jung , Park Seok‐Won , Kwon Tae‐Young , Lee Chul Hee , Min Yang‐Gi
Published: November 2003

Objectives Temperature‐controlled and temper‐ature‐monitored radiofrequency tissue volume reduction (RFTVR) for the turbinate is a new treatment modality for nasal obstruction secondary to turbinate hypertrophy. We compared the nasal functions after the treatment of RFTVR and laser vaporizing turbinoplasty (LVT) using subjective symptom scores and objective tests.

Study Design Prospective, randomized clinical trial.

Methods Twenty‐four patients with nasal obstruction secondary to inferior turbinate hypertrophy were prospectively evaluated from March 1999 to October 1999 at Seoul National University Hospital (Seoul, Korea). Si‐teen patients were treated with RFTVR, and eight patients with LVT. The preoperative and postoperative nasal functions were investigated by visual analogue scale of symptoms, butanol threshold test, saccharine test, acoustic rhinometry, rhinomanometry, and ciliary beat frequency.

Results At 8 weeks postoperatively, the severity and the frequency of nasal obstruction improved subjectively in 81.3% and 93.8% of RFTVR group and in 87.5% and 87.5% of LVT group, respectively. Significant improvement of nasal symptoms began from 2 to 3 days after the operation in the RFTVR group, whereas there was significant improvement of nasal symptoms at 8 weeks after operation in the LVT group. However, objective nasal functions including nasal volume and total nasal resistance were significantly improved at 8 weeks after surgery in both groups. Among patients reporting symptoms of hyposmia, 55.6% of RFTVR group and 63.6% of LVT group showed improved olfaction. Saccharin transit time and ciliary beat frequency were preserved after RFTVR.

Conclusion RFTVR for the turbinate may be useful as an alternative approach for the treatment of chronic turbinate hypertrophy.
Facial Purpura
Authors: Goldman Andrew C. , Govindaraj Satish , Franco Ramon A. , Lim Jessica
Published: November 2003

Objectives Patients with facial purpura can have acute and dramatic illnesses. For this reason, the clinician must be aware of certain diagnoses that can present as facial purpura and know how to initiate treatment efficiently. According to our review of the literature, no paradigm currently exists for the diagnosis and management of facial purpura. Our goal is to develop a schema for the identification and management of facial purpura.

Study Design Case series.

Methods A case series of five cases is presented followed by a systematic development of a differential diagnosis based on etiology of the lesion.

Results Facial purpura can be classified into conditions that are primarily or secondarily vasculitic, thrombocytopenic, neoplastic, infectious, toxic, and miscellaneous, which encompasses episodic reports that do not fit into the other categories. A paradigm to diagnose patients with facial purpura is developed based on clinical presentation and etiology. To demonstrate the utility of our algorithm, the five cases presented are re‐examined using the algorithm. To our knowledge, this represents the first reported series of facial purpura in the modern English literature. A flow chart based on our diagnostic paradigm is presented.

Conclusion Clinicians caring for patients with facial purpura must recognize the acute conditions that require emergent medical intervention. Once these diagnoses have been considered, the clinician can employ a systematic approach to the diagnosis based on etiology. This study provides a useful reference for the otolaryngologist when encountering a patient with facial purpura.
Mucosal Immunity of the Middle Ear: Analysis at the Single Cell Level
Authors: Suenaga Satoshi , Kodama Satoru , Ueyama Shigehiro , Suzuki Masashi , Mogi Goro
Published: November 2003

Objective Studies have suggested that the middle ear is a potential site of immunological regulation and that the middle ear mucosa constitutes a part of the mucosal immune system. We clarify the characteristics of the middle ear mucosa with respect to immune potential.

Study Design We investigated lymphocyte subsets, mRNA of cytokines, and induction of antigen‐specific IgA‐producing cells in the middle ear mucosa in specific pathogen‐free C57BL/6 mice.

Results Flow cytometric analysis showed a certain amount (10%–15%) of γδ T cells among CD3+ T cells. P6‐specific IgA‐producing cells were induced by intranasal immunization with P6 together with cholera toxin. RT‐PCR assay of mucosal T cells detected mRNA of Th2 type cytokines such as IL‐5 and IL‐10.

Conclusion These findings support the fact that the middle ear is potentially an effector site of the mucosal immunity.
Excision of the Preauricular Sinus: A Comparison of Two Surgical Techniques
Authors: Lam Henry Chuen Kwong , Soo Gordon , Wormald Peter John , Van Hasselt Charles Andrew
Published: November 2003

Objectives To compare the long‐term recurrence rate of the standard technique (simple sinectomy) and the supra‐auricular approach (wide local excision) for the surgical management of preauricular sinuses.

Study Design Retrospective cohort.

Methods Fifty‐four patients with a preauricular sinus excised between May 1986 and December 1996 were included in this study. All patients were categorized into one of two groups based on the type of surgery performed: the standard technique or the supra‐auricular approach. The medical records were then reviewed and the latest information concerning the recurrence of a preauricular sinus were updated by phone interview. The recurrence rate of these two groups was statistically analyzed by the Fisher exact test.

Results Forty‐nine of 54 patients were successfully contacted with data updated and analyzed. The 32% recurrence rate of the standard excision (n = 25) was significantly higher than the 3.7% recurrence rate of the supra‐auricular approach (n = 27; two‐tailed test, P = .01).

Conclusion The supra‐auricular approach for excision of a preauricular sinus has a statistically lower recurrence rate in comparison to the standard technique.
External Osteotomy in Rhinoplasty
Authors: Giacomarra Vittorio , Russolo M. , Arnez Z. M. , Tirelli G.
Published: November 2003

Objectives To compare external and internal lateral osteotomy in rhinoplasty.

Study Design Retrospective review and study on cadavers.

Methods One hundred forty‐two patients who underwent aesthetic rhinoplasty were examined. The following criteria were taken into consideration: edema and ecchymosis around the eyes, the degree of closure of the roof, symmetry and level of fractures, solidity of the bone pyramid, and any scarring at the access point of the osteotome. In the last 25 patients who had surgery, a nasal endoscopy with optical fibers was carried out to evaluate any damage to the mucosa caused by the 2‐mm osteotome. Furthermore, to compare the two routes in vivo, for five of these patients a lateral osteotomy was carried out externally for one side and internally for the other. Lateral osteotomy were performed on five cadavers by an external route on one side and by an internal one on the other. A midface degloving procedure was performed to expose the osteotomy sites.

Results Edema and ecchymosis were always much less severe in patients who were treated with external osteotomy. The control of the fracture line was always excellent. Endoscopic evaluation and study on cadavers revealed damages to the mucosa caused from the internal osteotomy and a better control of fracture line in external osteotomy.

Conclusions External osteotomy is an easy and precise approach. Because the fracture is of a greenstick type, the bone stumps are stable. The reduced bleeding reduces the formation of edemas and ecchymosis around the eyes. The damage to the nasal mucosa is minimal, and the cutaneous scars are virtually invisible a month after surgery.
Esthesioneuroblastoma: The University of Iowa Experience 1978–1998
Authors: Simon James H. , Zhen Weining , McCulloch Timothy M. , Hoffman Henry T. , Paulino Arnold C. , Mayr Nina A. , Buatti John M.
Published: November 2003

Objective Esthesioneuroblastoma is rare and the best treatment has yet to be defined. The purpose of this study is to analyze the natural history, treatment, and patterns of failure of esthesioneuroblastoma treated at one institution.

Methods Between 1978 and 1998, 13 patients with esthesioneuroblastoma were identified using the University of Iowa Tumor Registry. All patients were staged according to Kadish criteria. Mean follow‐up was 6.3 years. Six patients had 5 or more years of follow‐up and four had follow‐up exceeding 9.5 years. One patient was lost to follow‐up at 36 months.

Results No patients had Kadish stage A disease, five were stage B, and eight stage C. Overall actuarial 5‐ and 10‐year survival rate was 61% and 24%, respectively. Disease‐free survival rate at 5 and 10 years was 56% and 42%, respectively. Seven patients have died, three of intercurrent disease and three of disease progression, one with an unknown disease status. Six patients remain alive, three without evidence of disease and three have experienced a local or regional recurrence. Five patients who were initially controlled developed recurrence, three local only, one locoregional, and one regional and distant. Median time to failure was 96 months. All patients with follow‐up exceeding 12 years have experienced either a local or regional recurrence. Survival after salvage therapy in these patients ranged from 3 to 12 years.

Conclusion Esthesioneuroblastoma has a long natural history characterized by frequent local or regional recurrence after conventional treatment. Successful retreatment can lead to prolonged survival.
Effect of Anemia on the Fasciocutaneous Flap Survival in a Rat Model
Authors: Desyatnikova Stella , Winslow Catherine , Cohen James I. , Wax Mark K.
Published: November 2003

Objective/Hypothesis Ablative surgery for head and neck cancer that creates large composite defects often results in a significant decrease in the hematocrit level. These defects are best reconstructed with a microvascular free tissue transfer. Effect of the decreased hematocrit on microvascular flap survival is controversial. The purpose of this study was to assess the effect of isovolemic anemia on flap survival in a rat model.

Study Design Prospective analysis.

Methods Ninety rats were used (30 control and 60 experimental animals). Experimental animals were rendered anemic by blood draw and volume resuscitated with either a colloid (30 animals) or crystalloid (30 animals) solution. In all animals a ventral fasciocutaneous flap was raised. A vascular clamp was applied to the arteriovenous pedicle, and different ischemic times were allowed to elapse before clamp removal. Flap survival was assessed at 5 days. Probit analysis was performed for the three animal groups.

Results A significantly increased probability of the flap survival was found in the anemic animals compared with the control group (P ≤.05). No difference was found between the colloid and crystalloid resuscitation groups.

Conclusions A decreased hematocrit level increases fasciocutaneous flap tolerance to ischemia and significantly increases the primary ischemic time in the ventral flap clamp model in rats. Fluid replacement with either crystalloid or colloid produces identical results.
Thyroplasty for Adductor Spasmodic Dysphonia: Further Experiences
Authors: Isshiki Nobuhiko , Haji Tomoyuki , Yamamoto Yukiko , Mahieu Hans F.
Published: November 2003

Objectives Two different surgical techniques for midline lateralization thyroplasty (type 2 thyroplasty) for adductor spasmodic dysphonia (SD) have been described, one using a composite graft and the other without. Indications and results for each method among different types of SD were compared, together with the theoretical background for the surgery.

Study Design Retrospective.

Methods The medical records of six patients with SD together with the fiberscopic video recording of laryngeal findings before, during, and after surgery were reviewed. The intraoperative video recordings of the surgical procedures were compared with the postoperative findings.

Results The vocal features of SD, diverse preoperatively, disappeared postoperatively and a normal, or almost normal, voice was attained in 5 of 6 cases. The failure in one patient was attributed to combined focal dystonia of the neck muscles and difficulty in lateralization. Type 2 thyroplasty without a graft, which causes bowing of both vocal folds, is simple to perform and effective enough for most SD cases. No recurrence has been noted so far over postoperative periods ranging from 6 months to more than 3 years.

Conclusion The results suggest that thyroplasty is an effective therapeutic approach for SD.
Juvenile Nasopharyngeal Angiofibroma: Management and Therapy
Authors: Scholtz Arne W. , Appenroth Elisabeth , Kammen‐Jolly Keren , Scholtz Lars U. , Thumfart Walter F.
Published: November 2003

ObjectiveTo conduct a review of contemporary approaches on the diagnostic‐preoperative, operative, and postoperative methods in the management of juvenile nasopharyngeal angiofibroma (JNA).

Study DesignRetrospective study of 14 cases of JNA resection at the Department of Otorhinolaryngology, University of Innsbruck (Innsbruck, Austria) between 1987 and 1998.

MethodsData was obtained for each patient regarding age, presenting symptoms, duration of symptoms, biopsy findings, tumor location, administration of preoperative angiography and embolization, and surgical approach. The follow‐up period ranged from 1 to 13 years.

ResultsBased on the histological evaluation by the preoperative biopsy and the tumor location, several surgical approaches were applied. A transnasal endoscopic procedure was employed in seven cases. The preoperative embolization and the intranasal approach with the potassium titanyl phosphate laser minimized blood loss. The recurrence rate was at a low of 15%.

ConclusionThe surgical approach should be determined by tumor location, tumor size, and effectiveness of tumor embolization. For patients with JNA with tumor extension involving the nasopharynx, the nasal cavity, the paranasal sinuses, and the pterygopalatine fossa, the transnasal endoscopic technique offers a minimally invasive resection of the entire tumor mass with minimal morphological disturbance.
The Role of Copper Suppression as an Antiangiogenic Strategy in Head and Neck Squamous Cell Carcinoma
Authors: Cox Claudell , Teknos Theodoros N. , Barrios Marty , Brewer George J. , Dick Robert D. , Merajver Sofia D.
Published: November 2003

Objective To determine whether tetrathiomolybdate (TM), a powerful chelator of copper, is capable of lowering the body stores of copper and suppressing the growth of head and neck squamous cell carcinoma in an orthotopic murine model.

Study Design In vivo, murine model.

Methods Twelve 8‐week‐old male C3H/HeJ mice were assigned to either a TM treatment group (n = 7) or a control group (n = 5). Serum samples were obtained from a single mouse in each group to measure the level of ceruloplasmin as a surrogate marker of total body copper on days 0, 4, and 7. Mice in both groups received a floor‐of‐mouth injection of 1.5 × 105 SCC VII/SF cells. After 7 to 10 days of tumor growth the treatment group received fresh water daily, to which TM was added to achieve an oral intake of 50 mg per mouse. The control group received only fresh drinking water daily. Tumor volume measurements were obtained every other day. Microvessel density counts were assessed in the tumors by Factor VIII analysis.

Results Measurable tumor growth was achieved in 100% of the mice by the tenth day. Total body copper was reduced by 28% from baseline levels in mice in the treatment group. The difference in mean tumor volume in the control group was 4.7 times greater than the TM‐treated group at the completion of treatment (3004 mm3 and 633mm3, respectively). This accounted for an overall suppression rate of 79% (P = .008; two‐tailed Student t test). In addition, microvessel density was reduced by 50% in the TM‐treated group.

Conclusion In this initial study, the first of its kind in head and neck squamous cell carcinoma, we have demonstrated the ability of TM to significantly suppress both the growth of squamous cell carcinoma and tumor vascularity in this orthotopic murine model, suggesting its potential for efficacy in the treatment of this disease in humans.
Homologous Collagen Substances for Vocal Fold Augmentation
Authors: Courey Mark S.
Published: November 2003

Objectives/Hypothesis Dysphonia resulting from failure of glottic closure during voicing is a difficult clinical problem. Recently developed homologous collagen compounds may be beneficial in treating this problem. The objectives of this thesis are to: 1) evaluate the potential site(s) of collagen graft placement in the human vocal fold, quantify the amount of graft material that can be injected into these sites, and determine how these sites are accessed by the currently available surgical tools for injection; 2) determine the effects of the superficial vocal fold implant on laryngeal vibratory patterns and characterize how the implant affects the forces required to bring vocal folds into an adducted position for vibration; and 3) evaluate the host response to two different forms of cadaveric collagen.

Study Design Prospective laboratory.

Methods Three separate experiments were undertaken: 1) Eight cadaver larynges were injected with collagen compounds through a 27‐gauge needle. The amount of substance required to medialize the vocal fold and potential positions for graft placement were evaluated. 2) Six cadaver larynges were mounted on a stabilizing stand while airflow, vocal fold length, adduction forces, and abduction forces on the vocal folds were manipulated. Vibratory patterns before and after the injection of the vocal folds with solubilized collagen were assessed. 3) A nude mouse model was used to study the host response to two different exogenous collagen compounds.

Results Solubilized collagen compounds could be injected reliably into the superficial layer of the lamina propria (SLLP), medial portion of the thyroarytenoid muscle, or lateral portion of the thyroarytenoid muscle. When injected superficially, significantly less material was required to displace the medial edge of the vocal fold to midline (P = .0001). When graft material was placed into the medial portion of the thyroarytenoid (TA) muscle, the forces required to bring the vocal fold into a position suitable for vibration were significantly reduced (P = .0106) and the vibratory patterns of the vocal folds were not impaired. Both AlloDerm® and Dermalogen® solubilized preparations of human dermal tissue were well tolerated in the nude‐mouse model. Minimal inflammatory reaction occurred. Small amounts of graft material were identified histologically at the end of the 6‐month study period. The graft material appeared organized and had been infiltrated with fibroblasts of host origin.

Conclusions Homologous collagen compounds can be reliably injected into the cadaveric human larynx. When the substances are injected into the medial portion of the TA muscle, immediately deep to the vocal ligament, they decrease the force of contraction needed to bring the vocal folds into a position adequate for phonation and have minimal affect on the vibratory patterns. These forms of homologous collagen are well tolerated. A small amount persists over a 6‐month interval. These materials warrant further clinical trials in human subjects.
Safety and Patient Experience With Transtympanic Electrocochleography
Authors: Ng Matthew , Srireddy Sharmila , Horlbeck Drew M. , Niparko John K.
Published: November 2003

Objectives/Hypothesis Transtympanic electrocochleography (t‐ECOG) is a sensitive diagnostic instrument used for Meniere's disease. It is sensitive by virtue of the recording electrode's position on the promontory of the cochlea where the signals are generated. There is concern about the invasive nature of t‐ECOG in comparison to extratympanic recording techniques. The purpose of this study was to examine the safety issues, complications, and patient experience with t‐ECOG.

Study Design Observational study utilizing retrospective chart review and patient survey.

Methods The medical records of 205 patients who underwent t‐ECOG were reviewed for complications. Complications included persistent tympanic membrane perforation, hearing loss, otitis media, otitis externa, ear canal injury, hemotympanum, and pain. An additional 36 patients undergoing t‐ECOG were surveyed on subjective measures such as pain during topical anesthesia of the tympanic membrane, during transtympanic placement of the needle electrode, and during the test procedure and overall experience with t‐ECOG.

Results There was one case of a nonhealed, persistent perforation in the setting of acute otitis media directly as a result of t‐ECOG. Two patients developed otitis media, and three patients had ear pain for up to 5 days. All 36 patients felt the procedure to be tolerable with minimal discomfort.

Conclusions Transtympanic electrocochleography may be performed with good patient acceptance and infrequent complications.
Granulocyte‐Macrophage Colony‐Stimulating Factor in a Combination Gene Therapy Strategy for Head and Neck Cancer
Authors: Day Katherine V. , Li Daqing , Liu Shixi , Guo Ming , O'Malley Bert W.
Published: November 2003

Objectives/Hypothesis Gene therapy offers a new approach for treatment of head and neck squamous cell carcinoma (HNSCC). This study examined the effectiveness of granulocyte‐macrophage colony‐stimulating factor (GM‐CSF) in combination gene therapy strategy against HNSCC in an orthotopic mouse model.

Study Design Experimental animal research.

Methods Established tumors were treated with recombinant adenovirus constructs containing the genes for murine granulocyte‐macrophage colony‐stimulating factor (Ad‐mGM‐CSF), murine interleukin 2 (Ad‐mIL‐2), or herpes simplex virus thymidine kinase (Ad‐tk).

Results The combination of Ad‐mGM‐CSF or Ad‐mIL‐2 and Ad‐tk resulted in significantly greater reduction in tumor size versus other treatment groups or control subjects. There was no statistical significance between the triple combination of Ad‐mGM‐CSF, Ad‐mIL‐2, and Ad‐tk versus Ad‐mIL‐2 and Ad‐tk at 1 to 2 weeks after treatment. There was no tumor reduction seen from Ad‐mGM‐CSF alone and no additional benefit seen from Ad‐mGM‐CSF combinations in long‐term follow‐up studies. The greatest cytotoxic T‐lymphocyte and natural killer cell activity occurred in the combination Ad‐mIL‐2 and Ad‐tk groups with and without Ad‐mGM‐CSF.

Conclusion Results suggest that the additional mGM‐CSF did not enhance the immunogenicity of the HNSCC. Optimal activation of T lymphocytes may require additional co‐stimulatory molecules to stabilize the interaction of the T lymphocyte and antigen presenting cell. The presence of major histocompatibility complex Class II may increase CD4+ T‐cell mediated immunogenicity and augment therapeutic antitumor immune responses in combination with tk, mIL‐2, and mGM‐CSF.