bluuebunny/crossref_metadata_2025 huggingface dataset:
High‐Precision Measurement of the Vocal Fold Length and Vibratory Amplitudes
Authors: Schuberth Stefan , Hoppe Ulrich , Döllinger Michael , Lohscheller Jörg , Eysholdt Ulrich
Published: November 2003

Objective/Hypothesis Standard laryngoscopy suffers from a lack of information about the actual size of the observed objects (i.e., vocal fold length and oscillating amplitudes). However, there is much interest in absolute measures for both clinical and research purposes. Therefore, a laser projection device has been developed that enables the precise determination of absolute units in endoscopic investigation during respiration and phonation.

Study Design An experimental study in which 9 adults underwent high‐speed endoscopy combined with a laser projection device.

Methods The projection system consists of two parallel laser beams with a distance of 3.8 mm. It is mounted on the tip of a rigid endoscope, which is attached to a digital high‐speed camera. During development and design, examination situations were taken into account. Two laser spots are projected onto the vocal folds and enable the definition of a metric scale within the endoscopic image. Knowledge‐based image processing algorithms were used for evaluation.

Results First measurements of the vocal fold length during phonation were performed in a group of nine healthy male students. The determination of glottal length during phonation agrees with former results. Quantifying vocal fold velocities in absolute units makes it possible to estimate the initial collision forces.

Conclusions The presented laser projection system allows the determination of absolute measures in the larynx. Because of the simple functional principle, the system is open for use without digital high‐speed recording as well. Absolute units may also be helpful in voice diagnosis and in monitoring during voice therapy.
Benign Paroxysmal Positional Vertigo in Patients With Ménière's Disease Treated With Intratympanic Gentamycin
Authors: Perez Nicolas , Martin Eduardo , Zubieta Jose Luis , Romero Maria Dolores , Garcia‐Tapia Rafael
Published: November 2003

Objectives To analyze the incidence and characteristics of benign paroxysmal positional vertigo (BPPV) in patients with Ménière's disease who did not respond to medical treatment and to whom intratympanic gentamycin treatment was proposed.

Study Design This is a retrospective analysis of the patients in our database. A complete otoneurologic bedside examination of each patient, including assessment of positional nystagmus, was performed at the time of diagnosis and during the follow‐up.

Results Nine of 90 patients with Ménière's disease also had BPPV, which manifested in different ways. In 3 patients, BPPV preceded the onset of Ménière's symptomatology in the same ear; in 1, BPPV manifested after treatment for Ménière's disease had ended and the patient was in complete control of the spontaneous spells of vertigo; in 5 cases, recurrences of both Ménière's disease and the positioning symptomatology coincided. Treatment for each condition was conducted independently and favorable results were obtained after long‐term follow‐up when Ménière's disease and BPPV did not coincide simultaneously. In the group manifesting symptoms of both disorders at the same time, gentamycin treatment with the Canalith Repositioning Procedure and/or Semont maneuver partially resolved the symptoms.

Conclusions In the context of Ménière's disease, the sequence of appearance of BPPV relative to the spontaneous episodes must be taken into account when planning the treatment for each of the disorders, which should be considered independently. This pattern could also influence the prognosis for each disorder.
Safety of Completion Thyroidectomy Following Unilateral Lobectomy for Well‐Differentiated Thyroid Cancer
Authors: Kupferman Michael E. , Mandel Susan J. , DiDonato Liesje , Wolf Pat , Weber Randal S.
Published: November 2003

Objectives When a diagnosis of thyroid cancer is returned following unilateral lobectomy, removal of the contralateral lobe is frequently necessary. Morbidity for completion thyroidectomy includes a reported 2% to 5% risk of recurrent laryngeal nerve (RLN) injury and an 8% to 15% incidence of hypoparathyroidism. In this study, to determine morbidity following completion thyroidectomy, we reviewed our results of reoperative surgery among patients with thyroid cancer.

Study Design Retrospective chart review.

Methods Between 1997 and 2000, 36 consecutive patients, 32 females and 4 males, with a mean age of 43.6 years (range, 19–59 y), underwent completion thyroidectomy. Preoperative fine‐needle aspiration revealed follicular derived neoplasm in 32 patients (88.9%), indeterminate in 3 patients (8.3%), and Hürthle cell neoplasm in 1 patient (2.8%). The interval between the first and second operation was a mean of 43.3 days (range, 2–103 d).

Results At the primary surgery, 29 patients (80.6%) had a follicular variant of papillary carcinoma, 6 (16.7%) had follicular carcinoma, and 1 (2.8%) had Hürthle cell carcinoma. Of these, 14 had multifocal disease. In the completion lobe, 20 patients (55.6%) had evidence of thyroid carcinoma. There was a 0% incidence of RLN injury, and the mean pre‐ and post‐completion thyroidectomy serum calcium was 8.9 mg/dL and 8.6 mg/dL, respectively. There was one postoperative hematoma, requiring re‐exploration. Five patients (13.9%) had a transient postoperative serum calcium (Ca) <8.0 mg/dL, with one being symptomatic. None required vitamin D or prolonged calcium supplementation.

Conclusions When completion thyroidectomy is necessary for the treatment of thyroid malignancy, the procedure can be performed safely with low morbidity and is effective for diagnosing and removing occult disease in the remaining thyroid.
Laryngeal Electromyography in the Management of Vocal Cord Mobility Problems in Children
Authors: Jacobs Ian N. , Finkel Richard S.
Published: November 2003

Objectives To evaluate the efficacy and clinical usefulness of laryngeal electromyography (EMG) in the evaluation and management of vocal cord mobility problems in children; and to determine the ability of laryngeal EMG to differentiate vocal fold fixation versus paralysis.

Study Design Case‐series review of 8 children with vocal cord immobility who underwent laryngeal EMG.

Methods Eight children with bilateral vocal fold immobility underwent microlaryngoscopy and electromyography. Bipolar concentric needle electrodes were used and implanted separately into both posterior cricoarytenoid (PCA) and both thyroarytenoid (TA) muscles. EMG activity was recorded during spontaneous ventilation under a light plane of anesthesia with propofol. EMG activity was correlated with the phases of the respiratory cycle.

Results Three patients had evidence of normal EMG activity with PCA activity peaking during early inspiration. Maximal TA activity occurred expiration. These patients were assumed to have vocal fold fixation. Two of these 3 patients underwent laryngotracheoplasty (LTP) with posterior glottic expansion with costal cartilage. One is being considered for LTP in the future. Five patients had abnormal EMG activity and remain tracheotomy‐dependent. Four patients exhibited synkinetic activity with peak PCA activity during expiration and peak TA activity during expiration. Two patients had both fixation and unilateral vocal cord paralysis. One was successfully decannulated after posterior graft LTP and the other is planned for the future.

Conclusions Electromyography, which differentiates paralysis from fixation, is a useful diagnostic tool in the evaluation of children with vocal cord immobility.
Orbital Preservation in Surgical Management of Sinonasal Malignancy
Authors: Imola Mario J. , Schramm Victor L.
Published: November 2003

Objective To determine the oncological and functional outcome when applying defined criteria for orbital preservation during surgical treatment of sinonasal malignancy encroaching on the orbital structures.

Study Design Retrospective consecutive review of patients in tertiary care center setting.

Methods Analysis of 66 patients undergoing surgical treatment for sinonasal malignancy encroaching on the orbit. Orbital preservation was performed in all patients with tumor extension up to and including resectable periorbital involvement. Minimum follow‐up was 2 years. Detailed analysis of oncological and functional outcomes is included.

Results Of 66 tumors abutting or invading into the orbit, 54 were amenable for surgical treatment with orbital preservation and the remaining 12 underwent orbital exenteration. Histopathological findings were divided into five subgroups: squamous cell carcinoma, adenomatous carcinomas, sinonasal undifferentiated carcinoma, sarcoma, and other. Squamous cell carcinoma represented the largest subgroup (24 patients), and 5‐year overall actuarial survival was not statistically different (P = 1.4; relative risk, 0.713) between patients treated with orbital preservation (53%) versus those undergoing exenteration (46%). Similarly, no difference in survival was found in the adenomatous carcinoma subgroup. Within the orbital preservation group as a whole, local recurrence occurred in 30% patients (16 of 54) compared with 33% patients (4 of 12) treated with orbital exenteration. Of note, eye‐sparing surgery was associated with local recurrence at the original site of orbital involvement in only 7.8% of cases (4 of 54). Overall eye function was graded as functional without impairment in 54% of patients (29 of 54), functional with impairment in 37% (20 of 54), and nonfunctional in 9% (5 of 54). The most common abnormality was globe malposition (enophthalmos or hypophthalmos) that was seen in 34 patients (63%) and was associated with the lack of adequate rigid reconstruction of subtotal or total orbital floor or multisegment orbital defects. However, enophthalmos was asymptomatic in the majority of cases, and persistent diplopia occurred in only five patients (9%). Various ocular sequelae were present in 20 of the 49 patients (41%) with functional eyes. Radiation therapy increased the risk of ocular complications, in particular, optic atrophy, cataract formation, excessive dryness, and ectropion.

Conclusions Selective orbital preservation is oncologically safe and is a worthwhile undertaking in attempting to maintain a functionally useful eye with surgical management of sinonasal malignancy encroaching on the orbit. Consideration should be given to rigid orbital reconstruction in larger defects resulting from subtotal or total orbital floor resection or resections involving two or more orbital walls.
Perspectives in Laryngopharyngeal Reflux: An International Survey
Authors: Book David T. , Rhee John S. , Toohill Robert J. , Smith Timothy L.
Published: November 2003

Objectives Although data exists to support the relationship between laryngopharyngeal reflux (LPR) and laryngitis, there is variability among otolaryngologists regarding the methods and criteria used to make the diagnosis. This study was undertaken to discern the current attitudes and practices of a select cohort of otolaryngologists in regards to LPR.

Methods Four hundred fifteen surveys were mailed to members of the American Broncho‐Esophagological Association. Survey recipients were asked to rate patient symptomatology and physical examination findings in terms of their relationship to LPR and their preferred laryngeal visualization procedure in terms of clinical use and diagnostic accuracy. The role and validity of adjunctive diagnostic tests were also surveyed.

Results Survey response rate was 38%. Symptoms felt to be most related to reflux were: throat clearing (98.3%), persistent cough (96.6%), heartburn/dyspepsia (95.7%), globus sensation (94.9%), and voice quality change (94.9%). The physical examination findings felt to be most related to reflux included: arytenoid erythema (97.5%), vocal cord erythema (95.7%) and edema (95.7%), posterior commissure hypertrophy (94.9%), and arytenoid edema (94.0%). Fiberoptic laryngoscopy was the most commonly performed diagnostic visualization procedure (75.7%) and was also considered to be most sensitive and specific (45.0%). The most commonly ordered adjunctive test was a double pH probe (37.2%), which was also felt to be the most sensitive and specific adjunctive test (75.9%).

Conclusion A polling of a select group of otolaryngologists demonstrated agreement in the criteria used to diagnose reflux laryngitis, although some variability exists. The development of objective guidelines for the diagnosis of LPR is a critical initial step toward evaluating the manifestations and therapeutic interventions for this disease process.
Laryngeal Collagen Injection as an Adjunct to Medialization Laryngoplasty
Authors: Hoffman Henry , McCabe Daniel , McCulloch Timothy , Jin Sung M. , Karnell Michael
Published: November 2003

Objectives/Hypothesis Dysphonia associated with laryngeal paralysis may be identified in the short term postoperatively or may develop years after successful medialization laryngoplasty. In selected cases, laryngeal collagen injection permits further medialization of one or both vocal folds by small increments to improve phonation after medialization thyroplasty. The study seeks to determine whether collagen injections result in measurable improvements in voice quality and vocal function when offered to select patients who have received medialization thyroplasty.

Study Design Retrospective review of patient charts and voice database.

Methods Seven patients were treated with Zyderm II collagen using indirect mirror laryngoscopy and a curved injection apparatus. Changes in voice quality and function were assessed by comparing measures obtained before treatment (mean period, 5.6 d), shortly after treatment (mean period, 38.1 d), and in the long term after treatment (mean period, 226 d).

Results Mean self‐ratings of the patient, clinician's ratings, and objective measures demonstrated measurable improvement in vocal function after collagen injection.

Conclusions The office‐based procedure offers a simple, efficient adjunct to open techniques of medialization laryngoplasty. Techniques of anesthesia, injection, and patient selection are discussed.
Endoscopic CO2 Laser Management of Laryngocele
Authors: Devesa Pablo Martinez , Ghufoor Khalid , Lloyd Simon , Howard David
Published: November 2003

Objective To report on the management of laryngoceles by CO2 laser‐assisted endoscopic excision.

Study Design A 15‐year retrospective study of 12 adult patients (7 men and 5 women) who presented with a laryngocele. Nine patients had an internal laryngocele, one patient had an external laryngocele, and two patients had combined internal‐external components. Two laryngoceles were right‐sided, six were left‐sided, and four were bilateral.

Methods An endoscopic examination of the laryngocele was carried out for both diagnostic and therapeutic purposes. Once identified the air‐ or mucus‐filled cyst (extending from the laryngeal ventricle into the paraglottic space and beyond the thyrohyoid membrane in some cases), the laryngocele was excised in toto, with its surrounding capsule, via endoscopic approach using the CO2 laser.

Results The main presenting symptom was dysphonia in seven patients, visible or palpable mass in the neck in three, and upper airway obstruction in the remaining two. All laryngoceles were treated with endoscopic laser excision of the internal and external components when required. The average postoperative stay in hospital was 1.8 days. Only two of the patients treated had a tracheotomy; both cases presented elsewhere with an emergency airway obstruction, which necessitated tracheotomy. In these two cases, decannulation was subsequently performed. There were no significant complications. The follow‐up ranged from 6 months to 5 years.

Conclusion CO2 laser‐assisted endoscopic excision of a laryngocele is a quick, precise, and safe alternative to an external approach excision (lateral thyroidotomy, laryngofissure) with fewer complications than its external counterparts, resulting in speedier rehabilitation of both the patient and his or her voice.
Surgical Management of Posterior Epistaxis: A Changing Paradigm
Authors: Klotz Darrell A. , Winkle Mark R. , Richmon Jeremy , Hengerer Arthur S.
Published: November 2003

Objective To demonstrate that surgery, as the initial treatment option for posterior epistaxis, can provide comparable success and complication rates to nonsurgical management with fewer associated costs.

Study Design A retrospective chart review and cost analysis.

Methods Two hundred three consecutive charts were reviewed for patient outcome, complications, and hospitalization time. Average costs were calculated from hospital department and physician fee schedules.

Results Average success rate of all surgical procedures performed for posterior epistaxis was 90%, anterior–posterior packing success was 62%, and embolization success was 75%. The packing‐only group had a significantly greater mean hospitalization time (5.29 d) than patients who were treated either surgically (2.1 d) or with embolization (2.6 d). The average per‐patient admission charges were, for successful posterior packing, $5136 per patient; for surgical treatment, $3851 per patient; and for embolization, $5697 per patient. Surgery offered a cost savings of $1846 per patient over traditional packing. There was no significant difference in complication rates between the groups.

Conclusion The review suggests that a better success rate, a comparable complication rate, and a cost savings can be achieved with surgical intervention as the first‐line treatment for intractable epistaxis when compared with traditional anterior–posterior packing and embolization.
Laryngeal Mask Anesthesia With Intraoperative Laryngoscopy for Identification of the Recurrent Laryngeal Nerve During Thyroidectomy
Authors: Scheuller Michael C. , Ellison David
Published: November 2003

Objectives/Hypothesis A critical step in thyroidectomy involves definitive identification of the recurrent laryngeal nerve (RLN). Using the laryngeal mask airway, identification of the RLN can be facilitated by stimulation of the nerve while monitoring vocal cord movement with a fiberoptic laryngoscope. We present this technique as an effective and safe means to identify the RLN during thyroid surgery, with significant advantages over existing techniques in appropriately selected patients.

Study Design Retrospective case series.

Methods We performed thyroidectomy on 8 patients (13 RLN identifications) in which laryngeal mask airway anesthesia with fiberoptic laryngoscopy was used to identify the RLN. Results are reviewed with regard to postoperative vocal cord function, as well as intraoperative and postoperative courses with laryngeal mask airway anesthesia.

Results In all 13 cases in which the RLN was sought, it was definitively identified by witnessing brisk vocal cord movement on a video screen with stimulation of the RLN. No patient had postoperative vocal cord paresis or paralysis. Overall recovery from laryngeal mask airway anesthesia was uneventful and had advantages when compared with general anesthesia with endotracheal intubation.

Conclusions Laryngeal mask airway anesthesia with intraoperative fiberoptic laryngoscopy to identify the RLN is effective and safe in carefully selected patients. Advantages include decreased postoperative throat discomfort, absence of coughing during emergence from anesthesia, and elimination of the possibility of vocal cord mobility impairment secondary to RLN ischemia from the endotracheal tube balloon. In addition, this technique is applicable in operations besides thyroid surgery, in which definitive identification of the RLN is indicated.
Prevalence of Esophagitis in Patients With pH‐Documented Laryngopharyngeal Reflux
Authors: Koufman James A. , Belafsky Peter C. , Bach Kevin K. , Daniel Elena , Postma Gregory N.
Published: November 2003

Objective To report the prevalence of esophagitis in patients with pH‐documented laryngopharyngeal reflux.

Study Design Prospective study of 58 consecutive patients with documented laryngopharyngeal reflux, all of whom underwent transnasal esophagoscopy as part of their reflux evaluations.

Methods All patients with a diagnosis of laryngopharyngeal reflux confirmed by abnormal pharyngeal pH monitoring over a 5‐month period were included, and all subjects completed a self‐administered reflux symptom index and underwent transnasal esophagoscopy with directed biopsy.

Results Of the 58 study patients with pH‐documented laryngopharyngeal reflux, the mean age was 49 years (± 13 y), and 53% (31 of 58) were women. Of the study group, 40% (23 of 58) had heartburn and 48% (28 of 58) had abnormal esophageal reflux (by pH monitoring criteria); by transnasal esophagoscopy with biopsy, 12% (7 of 58) had esophagitis and another 7% (4 of 58) had Barrett's metaplasia. Thus, 60% of the study cohort had no heartburn, and 81% (47 of 58) had normal esophageal epithelium (i.e., no esophagitis or Barrett's metaplasia).

Conclusions In the present series of patients with documented laryngopharyngeal reflux the prevalence of esophagitis and Barrett's metaplasia was only 19%. These data confirm the clinical impression that the patterns, mechanisms, and manifestations of laryngopharyngeal reflux differ from those of classic gastroesophageal reflux disease. Unlike gastroesophageal reflux disease, patients with laryngopharyngeal reflux uncommonly have esophagitis. Thus, although esophagoscopy may be an excellent method for screening the esophagus, it is not the method of choice for diagnosing laryngopharyngeal reflux.
Evolving Resistant Pseudomonas to Ciprofloxacin in Malignant Otitis Externa
Authors: Berenholz Leonard , Katzenell Udi , Harell Moshe
Published: November 2003

ObjectiveTo determine whether there has been an increase in ciprofloxacin‐resistant pseudomonas malignant otitis externa, and if this has increased the morbidity of the disease.

Study DesignRetrospective.

SettingTertiary referral center.

PatientsTwenty‐eight patients over 13 years.

ResultsThe records of a total of 28 patients who were admitted between 1988 and 2001 with the diagnosis of malignant otitis externa were reviewed. Seven patients had ciprofloxacin‐resistant pseudomonas on their hospital culture and sensitivity test. Five of the 7 resistant cases appeared in the last 3 years, as opposed to 2 of the 7 who appeared in the 10 years before that period. In our series, there is a significant trend developing over time of pseudomonas resistant to treatment with ciprofloxacin. No increased morbidity or mortality was found in the ciprofloxacin‐resistant pseudomonas group compared with the remaining patients who were sensitive to ciprofloxacin.

ConclusionsIn our series, resistance to ciprofloxacin in patients with malignant otitis externa is increasing over time. This may have an impact on the relatively successful outpatient treatment of these patients in the past decade. A return to inpatient or outpatient intravenous treatment with third‐generation cephalosporins/antipseudomonal penicillins and more frequent debridement will be required in these patients.
Otologic Manifestations of Wegener's Granulomatosis
Authors: Takagi Dai , Nakamaru Yuji , Maguchi Shiroh , Furuta Yasushi , Fukuda Satoshi
Published: November 2003

Objective/Hypothesis To evaluate the clinical features, treatment, and outcomes of otologic manifestations in Wegener's granulomatosis (WG) treated at Hokkaido University Graduate School of Medicine, Sapporo, Japan.

Study Design We retrospectively reviewed 15 cases of WG with ear involvement.

Methods Twenty‐five patients with WG were treated at Hokkaido University Graduate School of Medicine between 1992 and 2001. Fifteen of these patients had otologic symptoms. We evaluated the clinical course, method of therapy, and outcomes in all cases. Diagnosis of WG was made when the patients had clinical findings and a positive titer of cytoplasmic pattern antineutrophil cytoplasmic antibodies (c‐ANCA), or when there were clear histologic findings. We also present three case reports.

Results In 15 cases, the most frequent finding was chronic otitis media. Sensorineural hearing loss was present in 2 patients. In 7 patients whose otologic manifestations were the primary involvement of WG, all were confirmed positive for c‐ANCA and were treated with glucocorticoids and immunosuppressive drugs. Three patients who could be treated within 1 month of symptom onset showed marked improvement.

Conclusions In localized cases, biopsy specimens are often small, and it is frequently difficult to make a histologic diagnosis. The prognosis for hearing was poor when appropriate treatment was not given in the early stages of the disease. Therefore, WG should be included in the differential diagnosis in cases of atypical inflammatory states of the ear. Early diagnosis and appropriate treatment are important to prevent irreversible changes in the middle ear and inner ear.
Nissen Fundoplication Surgery for Extraesophageal Manifestations of Gastroesophageal Reflux (EER)
Authors: Lindstrom Dean R. , Wallace James , Loehrl Todd A. , Merati Albert L. , Toohill Robert J.
Published: November 2003

Objective To determine the outcome of Nissen fundoplication surgery for the treatment of patients with chronic extraesophageal manifestations of reflux (EER).

Methods A retrospective medical record analysis was performed. Patient demographics, extraesophageal disease secondary to gastroesophageal reflux (GER), methods of GER diagnosis, acid suppression therapy before antireflux surgery, and response to surgical intervention were evaluated.

Results The charts of 29 patients who underwent Nissen fundoplication surgery for EER were included in the study. Hoarseness was present in 17 patients; laryngopharyngeal reflux (LPR) was the most common diagnosis (n = 20). Barium esophagram was done in all patients and revealed abnormalities indicative of GER in 26 patients. Twenty‐four‐hour ambulatory pH study was done in 27 patients and pharyngeal reflux was present in 19. Preoperative esophageal endoscopy was performed in 22 patients. This study revealed evidence of gastroesophageal reflux disease (GERD) in 14 patients with 8 having evidence of Barrett's esophagus. Sixteen of the 29 patients had symptoms or findings of GERD. Twenty‐eight patients had laparoscopic Nissen fundoplication (LNF) and 1 had an open procedure. Twenty‐five of the 29 patients (follow‐up ranging from 6–108 mo) had excellent results with near‐total freedom from symptoms and are taking no acid‐suppressive medications.

Conclusions GER has an important role in the cause of many otolaryngologic and pulmonary disorders. Nissen fundoplication is an effective modality to treat EER in selected cases.
The Effect of Age on Vestibular Rehabilitation Outcomes
Authors: Whitney Susan L. , Wrisley Diane M. , Marchetti Gregory F. , Furman Joseph M.
Published: November 2003

ObjectiveThe purpose of the retrospective chart review was to compare vestibular rehabilitation outcomes in young versus older adults.

Study DesignRetrospective matched design.

MethodsTwenty‐three persons with vestibular disorders aged 20 to 40 years were matched by gender, vestibular diagnosis, and vestibular function test results to 23 older adults aged 60 to 80 years. The patients were treated with a custom‐designed physical therapy exercise program. Patients completed the Dizziness Handicap Inventory, the Activities‐Specific Balance Confidence (ABC) scale, and the Dynamic Gait Index; number of falls; and rated the severity of their dizziness. The two‐samplettest, the Mann‐WhitneyUtest, and McNemar's test for correlated proportions were used to determine whether there was a difference in scores between the two age groups at the beginning and end of physical therapy.

ResultsDuring the initial evaluation, older adults reported having statistically greater space and motion discomfort and more severe symptoms on a scale of 0 to 100. Younger adults had more impaired DGI scores and a higher proportion of caloric testing abnormalities. After rehabilitation, overall improvement was seen in both the younger and older populations. There were no statistical differences between the two groups on the DHI, the DGI, reported symptoms at discharge, or number of falls. When only the complete matched‐pair data were analyzed, there were no statistically significant differences between the age groups in the proportion of patients demonstrating clinical improvement.

ConclusionAge does not significantly influence the beneficial effects of vestibular rehabilitation for persons with vestibular disorders.
The Muscular Compliance of the Auditory Tube: A Model‐Based Survey
Authors: Leuwer Rudolf , Schubert Rainer , Kucinski Thomas , Liebig Thomas , Maier Hannes
Published: November 2003

Objectives The role of the paratubal muscles, especially the medial pterygoid muscle, still is unclear. The aim of this study was to define the function of the medial pterygoid muscle concerning the muscular compliance of the auditory tube.

Methods High‐resolution cross‐sectional T1 magnetic resonance imaging data of one of the authors' paratubal structures were used, a new functional 3‐D model of the auditory tube and its related structures visualized by the Hamburg VOXEL‐MAN digital image system.

Results Functional 3‐D reconstructions of the paratubal structures reveal that the medial pterygoid muscle is acting as a movable hypomochlion of the tensor veli palatini muscle. Contraction of the medial pterygoid muscle increases and relaxation decreases the force of the tensor veli palatini muscle on the distal part of the auditory tube. Hence, the opening pressure of the auditory tube is moderated by the action of the medial pterygoid muscle.

Conclusion The influence of the medial pterygoid muscle on the opening pressure of the auditory tube may have an impact on the diagnosis and therapy in patients with patent auditory tube as well as the middle ear pathology in patients with cleft palate.
Hearing Results With a Hydroxylapatite/Titanium Bell Partial Ossicular Replacement Prosthesis
Authors: Smith Jason , Gardner Edward , Dornhoffer John L.
Published: November 2003

Objectives/Hypothesis To study the preliminary hearing results in patients receiving a hybrid hydroxylapatite/titanium bell partial ossicular replacement prosthesis (PORP) and compare these with a cohort of patients receiving a HAPEX PORP. We hypothesized that the design of the hybrid PORP would enhance its acoustic properties. In particular, the titanium bell, which allows the prosthesis to be freestanding, would obviate the need for Gelfoam, preventing fibrosis.

Study Design A retrospective study was made of two cohorts of patients.

Methods A computerized otologic database was used to identify all patients implanted with either PORP. The four‐frequency (500, 1000, 2000, and 3000 Hz) pure‐tone average air–bone gap (PTA‐ABG) and ABG values for individual frequencies were compared using the Student t test.

Results The PTA‐ABG for the titanium bell prosthesis was 9.8 ± 5.7 dB, compared with 13.2 ± 8.3 dB for the HAPEX PORP, which was statistically significant (P <.05). The average ABG values at 500 and 1000 Hz were also statistically significantly improved with the titanium bell PORP (P <.05).

Conclusions The titanium bell PORP showed improved postoperative results for the PTA‐ABG and at 500 Hz and 1000 Hz. The prosthesis is freestanding and may provide better coupling with the capitulum, factors which may lead to improved hearing results in the lower frequencies.
Surgical Anatomy of the Sphenopalatine Artery in Lateral Nasal Wall
Authors: Lee Hye Yeon , Kim Hyun‐Ung , Kim Sung‐Shik , Son Eun Jin , Kim Ji Woo , Cho Nam Hoon , Kim Kyung‐Su , Lee Jeung‐Gweon , Chung In Hyuk , Yoon Joo‐Heon
Published: November 2003

Objective We investigated the surgical anatomy of the sphenopalatine artery. First, the location of the sphenopalatine foramen on the lateral nasal wall and the pattern of the main branches of the sphenopalatine artery from the sphenopalatine artery were studied. Second, the course of the posterior lateral nasal artery with respect to the posterior wall of the maxillary sinus, the perpendicular plate of the palatine bone, and the pattern of distribution of its branches on the fontanelle was determined. Third, the distribution pattern on the inferior turbinate was analyzed.

Study Design Fifty midsagittal sections of randomly selected Korean adult cadaver heads with intact sphenoid sinus and surrounding structures were used in the study.

Methods The mucosa on the sphenopalatine foramen and its surrounding mucosa were removed with a microscissors, a fine forceps, and a pick to expose the sphenopalatine artery under an operating microscope (original magnification ×6).

Results The feeding vessels of the superior turbinate were from the septal artery in 36 cases (72%). The feeding vessels to the middle turbinate branch originated from the proximal portion of the posterior lateral nasal artery just after exiting the sphenopalatine foramen in 44 cases (88%). Some portion of the posterior lateral nasal artery ran anterior to the posterior wall of the maxillary sinus in 38%. The major feeding arteries to the fontanelle were from the inferior turbinate branch in 25 cases (50%). In most cases, the inferior turbinate branch was the end artery of the posterior lateral nasal artery (98%).

Conclusions The study provides detailed information concerning the sphenopalatine artery, which we hope will help explain the arterial bleeding that may occur during ethmoidectomy, middle meatal antrostomy, conchotomy, and endoscopic ligation of the sphenopalatine artery.
Clarithromycin and Prednisolone Inhibit Cytokine Production in Chronic Rhinosinusitis
Authors: Wallwork Ben , Coman William , Feron Francois , Mackay‐Sim Alan , Cervin Anders
Published: November 2003

Objectives Long‐term, low‐dose macrolide therapy is effective in the treatment of chronic rhinosinusitis. The mechanism of its anti‐inflammatory effect and how this differs from corticosteroids remains unclear. The effect of clarithromycin and prednisolone on interleukin‐5, interleukin‐8, and granulocyte‐macrophage colony‐stimulating factor production by cultured chronic sinusitis nasal mucosa was examined in the study.

Study Design and Methods Nasal mucosa was obtained from 11 patients with chronic sinusitis. This tissue was cultured for 24 hours in the presence of clarithromycin or prednisolone at a variety of concentrations. Cytokine levels were determined by enzyme‐linked immunoassay.

Results Clarithromycin and prednisolone each produced significant reductions in interleukin‐5, interleukin‐8, and granulocyte‐macrophage colony‐stimulating factor production. There was no significant difference between the effects of clarithromycin and prednisolone.

Conclusion Macrolide antibiotics are capable of inhibiting pro‐inflammatory cytokine production in vitro and are as potent as prednisolone. This mechanism is likely to be at least partly responsible for the clinical efficacy of macrolide antibiotics in chronic rhinosinusitis.
Patterns of Swallowing Failure Following Medialization in Unilateral Vocal Fold Immobility
Authors: Nayak Vijay K. , Bhattacharyya Neil , Kotz Tamar , Shapiro Jo
Published: November 2003

Objective To quantify the incidence of penetration and aspiration following medialization for unilateral vocal cord immobility (UVCI) and determine patterns of failure.

Study Design Blinded analysis consecutive case series.

Methods Prospective blinded analysis of videofluoroscopic swallowing studies of patients who had received a medialization procedure was conducted, determining the incidence of penetration and aspiration by using the Penetration‐Aspiration Scale. Pharyngeal transport measures were also assessed. Associations between clinical factors and penetration‐aspiration were statistically determined.

Results Sixty‐seven videofluoroscopic swallowing studies were reviewed in patients (mean age, 63.3 y) who had undergone vocal fold medialization (14 laryngoplasties and 53 vocal cord injections) for UVCI. Unilateral vocal cord immobility was left‐sided in 56 patients (83.6%), and 50 patients (74.6%) had a postsurgical etiologic factor for their immobility. Thirty (44.8%) and 16 (23.9%) patients demonstrated penetration and aspiration, respectively. Penetration most often occurred during the swallow, but aspiration was equally likely to occur during or after the swallow. No differences in the incidence of penetration or aspiration were noted according to the side of vocal fold paralysis (P = .20, χ2 test) or etiologic factor (P = .69). Further analysis found that swallow factors significantly associated with penetration and aspiration were swallow delay (P = .001, Wilcoxon ranked pairs test) and reduced laryngeal elevation (P = .001), as well as bolus residues in the valleculae (P = .002), piriform sinus (P = .001), or posterior pharynx (P = .008).

Conclusions Many patients demonstrate significant radiographic aspiration even after medialization procedures for UVCI. Although glottal incompetence is a known risk factor for aspiration, other factors including pharyngeal bolus transport are important in determining an effective swallow in UVCI.
Myocardial Infarction After Microvascular Head and Neck Reconstruction
Authors: Chiang Scott , Cohen Benjamin , Blackwell Keith
Published: November 2003

Objective/Hypothesis Microvascular flap transfer is a popular method for immediate reconstruction of defects in the head and neck resulting after the treatment of head and neck cancer. Head and neck cancer occurs most commonly in elderly patients with a high prevalence of heavy smoking. Surgery in this patient population is frequently prolonged and is associated with significant intraoperative blood loss. The present study seeks to identify factors contributing to perioperative myocardial infarction and to determine the best course of management.

Study Design Retrospective analysis of 193 consecutive free flap surgeries.

Methods A series of 193 microvascular free flaps performed over a 5‐year period for reconstruction of defects in the head and neck was retrospectively analyzed to identify the incidence, management, and outcome of perioperative myocardial infarction in this patient population.

Results Myocardial infarctions occurred in seven patients, for an overall incidence of 3.6%. Statistical analysis using logistic regression failed to demonstrate any significant relationship between age, sex, total operative time, operative blood loss, net intraoperative fluid shifts, tumor stage, American Society of Anesthesiology (ASA) preoperative classification, type of free flap, and the occurrence of perioperative myocardial infarction. Hemodynamic instability manifested by hypotension occurred in four patients who had perioperative myocardial infarction. Three of these patients underwent urgent coronary artery bypass surgery, whereas one patient underwent urgent endovascular therapy with subsequent stabilization of the hemodynamic instability. All free flaps survived despite myocardial infarction and hemodynamic instability. Two patients (29%) died after postoperative intervals of 74 and 99 days, never having left the hospital.

Conclusions Systemic hypotension is a well‐recognized risk factor for free flap failure. Our experience suggests that aggressive intervention to reverse coronary ischemia associated with hemodynamic instability has a favorable outcome on free flap survival, and free flap thrombosis is not an inevitable outcome of the low‐flow state associated with perioperative cardiopulmonary bypass. Although the overall incidence of perioperative myocardial infarction in patients undergoing microvascular head and neck reconstruction is low, patient mortality is high, so emphasis should be placed on preoperative identification of patients with coronary artery disease.
Laryngopharyngeal Reflux and Laryngeal Web Formation in Patients With Pediatric Recurrent Respiratory Papillomas
Authors: Holland Bradford W. , Koufman James A. , Postma Gregory N. , McGuirt William F.
Published: November 2003

Objective To determine whether treatment of laryngopharyngeal reflux reduces the laryngeal soft tissue complications encountered in surgery for recurrent respiratory papillomas.

Study Design Retrospective chart review.

Methods Retrospective chart review of all pediatric patients treated for laryngeal recurrent respiratory papillomas between 1984 and 1999 was performed. Thirty‐one such patients were identified. Twenty‐four were at “high risk” for developing complications based on the number of operating suite visits and the presence of disease at the anterior commissure. Twelve patients underwent 24‐hour double pH probe testing.

Results Overall, 13 of 31 patients (42%) developed laryngeal webs. No other soft tissue complications were encountered. Of the patients who had pH probe testing, 12 of 12 (100%) had at least one pharyngeal episode of acid exposure. Of the “high‐risk” patients, 10 were treated for reflux and only 2 of 10 (20%) developed webs. Eleven of 14 (79%) of the “high‐risk” patients who were not treated for reflux developed webs. The difference in rate of web formation between patients treated for reflux and those not treated for reflux was statistically significant (P = .011).

Conclusions Antireflux treatments for patients undergoing surgery for laryngeal recurrent respiratory papillomas may reduce the soft tissue complications, especially scarring and web formation. Prophylactic antireflux therapy may be warranted in any patient undergoing surgery during which laryngeal mucosal disruption is anticipated.
Is Gastric Reflux a Cause of Otitis Media With Effusion in Children?
Authors: Tasker Andrea , Dettmar Peter W. , Panetti Marguerite , Koufman James A. , P. Birchall John , Pearson Jeffrey P.
Published: November 2003

Objectives/Hypothesis Otitis media with effusion is the most common cause of childhood deafness. Gastroesophageal reflux has been implicated in the disease pathogenesis; therefore, it is necessary to identify the presence or absence of gastric juice in the middle ear.

Study Design Middle ear effusions were collected from children undergoing myringotomy. If gastric reflux has occurred, effusions should contain pepsin protein.

Methods Total pepsin/pepsinogen protein, fibrinogen, and albumin content of effusions were measured in enzyme‐linked immunosorbent assays using antibodies to porcine pepsin, human albumin, and human fibrinogen. Proteolytic activity of each effusion was measured at pH 2. The pH of effusions was measured.

Results Fifty‐nine of 65 effusion samples gave a positive result with the antipepsin antibody, which also recognized pepsinogen. Pepsin/pepsinogen levels ranged from 0.8 to 213.9 μg/mL (serum reference levels, 49.8–86.6 ng/mL). All effusions contained albumin and fibrinogen with respective ranges of 1.77 to 95.75 and 0.30 to 2.30 mg/mL (serum reference levels, 35–45 and 2.2 to 4.6 mg/mL, respectively). Acidic protease activity occurred in 19 of 65 effusion samples. The pH of effusion samples was 7 to 9.

Conclusions The majority of effusion samples contained pepsin/pepsinogen protein; only 29% were active. The pepsin level in effusion samples based on activity is substantially lower than levels based on antibody detection; however, the pH present would irreversibly inhibit pepsin, which would explain the low levels of active enzyme. Pepsin/pepsinogen levels in the effusion samples were up to 1000 times higher than serum levels, whereas albumin and fibrinogen levels were of the same magnitude. The pepsin in middle ear effusions is almost certainly due to reflux of gastric contents, and there may be a role for antireflux therapy in the treatment of otitis media with effusion.
Paranasal Sinus Malignancies: An 18‐Year Single Institution Experience
Authors: Myers Larry L. , Nussenbaum Brian , Bradford Carol R. , Teknos Theodoros N. , Esclamado Ramon M. , Wolf Gregory T.
Published: November 2003

Objectives To characterize a single institution experience with management of paranasal sinus malignancies during an 18‐year time period, report long‐term survival rates, and identify prognostic factors.

Study Design Retrospective chart review.

Methods Studied were 141 patients treated for a paranasal sinus malignancy at a single institution from 1980 to 1997 with a minimum 3‐year follow‐up. Gender, age, TNM stage, anatomic site, pathology, treatment, and recurrence rates were reviewed. Multivariate analysis was performed to determine factors affecting survival.

Results The male to female ratio was 1.6:1, and the median patient age was 60 years. Most patients presented with T3/T4 or locally advanced disease (88%), N0 status (96%), and M0 status (96%). The maxillary sinus was the most commonly affected site (70%), followed by the ethmoid sinus (26%). The most common malignancy was squamous cell carcinoma (51%), followed by adenoid cystic carcinoma (12%) and adenocarcinoma (11%). Sixty‐two percent of this study group underwent surgery as part of a multimodality curative treatment plan or alone as curative treatment. Eighteen patients (13%) had unresectable local disease and received non‐surgical palliative treatment. Kaplan‐Meier analysis revealed the 5‐year and 10‐year disease‐specific survival was 52% and 35%, respectively. Multivariate analysis revealed T4 stage (P = .005), N‐positive stage (P = .009), and M‐positive stage (P = .018) negatively impacted survival. Seventy‐two patients (51%) developed recurrent disease at a median time of 336 days after initial treatment.

Conclusions Most patients with paranasal sinus malignancies presented with locally advanced disease. Advanced T stage, regional, and distant metastasis are highly predictive of poor survival. Recurrence rate is high and typically occurs within the first year after treatment.
External Auditory Canal Stenosis After Radiation Therapy
Authors: Carls J. Lauren , Mendenhall William M. , Morris Chris G. , Antonelli Patrick J.
Published: November 2003

Objectives To determine whether the risk of external auditory canal stenosis from external‐beam radiation therapy is dose dependent.

Study Design Retrospective chart review.

Methods The presence of external auditory canal disease was recorded for patients who received low‐dose (e.g., lymphoma [20–40 Gy]), medium‐dose (e.g., chemodectoma [40–55 Gy]), or high‐dose (e.g., parotid and nasopharyngeal neoplasms [55–75 Gy]) external‐beam radiation therapy from 6 months to over 8 years following treatment. The incidence of external auditory canal disease was compared between groups.

Results None of 13 low‐dose, none of 19 medium‐dose, and 8 of 91 (8.7%) high‐dose external‐beam radiation therapy subjects developed ipsilateral external auditory canal stenosis. No external auditory canal stenosis developed in patients treated with high‐dose external‐beam radiation therapy in the absence of parotid surgery. External auditory canal stenosis developed only in patients treated with parotidectomy and high‐dose external‐beam radiation therapy (P = .0059), and all of these cases of external auditory canal stenosis developed within 3 years of radiation therapy.

Conclusions High dose external‐beam radiation therapy alone does not significantly predispose patients to external auditory canal stenosis. However, combined high‐dose external‐beam radiation therapy and surgery around the external auditory canal do significantly increase the risk of external auditory canal stenosis.