bluuebunny/crossref_metadata_2025 huggingface dataset:
Endoscopic Sinus Surgery Using Intraoperative Computed Tomography Imaging for Updating a Three‐Dimensional Navigation System
Authors: Cartellieri Monika , Vorbeck Fritz
Published: November 2003

Objectives: The use of three‐dimensional navigation systems provides information on the structures surrounding the field of operation and thereby reduces the risk of iatrogenic damage. The computed tomography (CT) data conventionally used are provided by preoperative scanning procedures, which means that tissue changes coming about during surgery are not seen on the screen. An intraoperative CT scanning procedure being able to update the CT data could provide a solution.

Study Design: Endoscopic sinus operations using an intraoperative CT updating the three‐dimensional navigation system were performed on six persons to find out, whether the above is true.

Methods: Different parameters, advantages, and disadvantages in the cases of these six patients were compared with a group of 22 patients who underwent conventional endoscopic sinus surgery with different three‐dimensional navigation systems without updating the CT data set.

Results: The intraoperative CT for updating the three‐dimensional navigation system provides useful information for the surgeon.

Conclusion: Balancing its advantages against its disadvantages, the updating of the CT data set with intraoperative CT cannot be recommended for conventional standard endoscopic sinus surgery.
Increased Female Authorship in Otolaryngology Over the Past Three Decades
Authors: Bhattacharyya Neil , Shapiro Nina L.
Published: November 2003

Objective To identify changing trends in female authorship and publication in the otolaryngology literature.

Methods All articles published in the four major otolaryngology journals in each of the years 1978, 1988, and 1998 were reviewed. The authorship panel of each article was examined for number of authors, gender, educational degree category, and subspecialty area of publication. Data were analyzed for trends in female authorship and the association of gender with the other design variables.

Results A total of 2,463 articles were analyzed. The average percentage of female authorship increased from 4.1% in 1978 to 8.7% in 1988 and 12.4% in 1998, and the percentage of articles with a female “first author” increased from 3.2% to 7.4% and 11.4% for the same years, respectively. Each of these increases was statistically significant (P < .001). The weighted rank of female authorship also increased from 0.063 to 0.164 and 0.243 for the same years, respectively (P < .001). With respect to subspecialty publication, women were first authors of 14.7% of articles concerning pediatric otolaryngology but accounted for 9.9% or less of the first authors in the other subspecialty areas (P < .001). Female authors were also much more likely to be nonphysicians (P < .001) than men.

Conclusions There has been a significant trend toward increased female authorship in the otolaryngology literature. A significant portion of this is accounted for by nonphysician female authors, and female authorship tends to be concentrated in pediatric otolaryngology.
Hypoxia Depresses Nitric Oxide Output in the Human Nasal Airways
Authors: Haight James S. J. , Qian Wei , Daya Hamid , Chalmers Patsy , Zamel Noe
Published: November 2003

Objectives The role of oxygen in the nasal air on nasal nitric oxide (NO) output was studied in 13 adult volunteers.

Methods Nasal NO was measured while air containing oxygen (0%–100% in nitrogen) was aspirated through the nasal airway before and after the topical application of xylometazoline.

Results The mean nasal NO output of the untreated nose was 507.8 ± 161.9 nL/min (mean ± SD) when 21% oxygen was aspirated through the nasal cavities in series and remained unaltered by 100% O2 (P = .79). Below 10% oxygen the reduction in nasal NO output correlated positively and significantly with the decrease in oxygen concentration (r2 = 0.14). NO output was 245.2 ± 153.4 nL/min at 0% oxygen, a significant decline from 21% oxygen (P < .0001). Nasal vasoconstriction induced by xylometazoline and alterations in the blood oxygen content by a maximal breath‐holding or breathing 100% oxygen did not alter nasal NO in hypoxia (P = .41).

Conclusions Nasal NO output is markedly depressed in hypoxia and is oxygen dependent at concentrations of less than 10%. Approximately 50% of nasally generated NO is produced from oxygen in nasal air or regulated by it.
Clinical Outcomes in Patients With Chronic Sinusitis
Authors: Metson Ralph B. , Gliklich Richard E.
Published: November 2003

Although sinusitis is one of the most common chronic illnesses in this country, relatively little is known about the effect of this disease or its treatment on quality of life. In a series of studies utilizing both disease‐specific and general health instruments, patients with chronic sinusitis were found to have significant decrements in several subscales of general health, including bodily pain and social functioning (P < .05), compared with the general US population. Surgery for sinus disease was shown to result in significant reduction in both symptoms and medication usage (P < .05) after 12 months. These same outcome instruments can be used by health care providers to document clinical outcomes in similar populations of patients with chronic sinusitis.
MOSHER AWARD HONORABLE MENTION
Authors: Rosenberg Seth I.
Published: November 2003

Objectives/Hypothesis 1) Develop a computerized technique to accurately compare acoustic neuroma size on routine computed tomography and magnetic resonance imaging (MRI) scans; 2) use this technique to determine the growth pattern in a large series of patients with acoustic neuroma who were conservatively managed; 3) describe the natural history of patients with acoustic neuromas who did not receive surgical intervention and those who underwent subtotal resection; 4) correlate the size and growth rate of acoustic neuromas to clinical presentation and auditory and vestibular testing; and 5) recommend guidelines for the management of patients with acoustic neuromas.

Study Design A retrospective study from 1974 to 1999 of patients with unilateral acoustic neuromas who had conservative treatment by serial imaging studies (80 patients) or subtotal resection (49 patients).

Methods All patient charts were evaluated for presenting symptoms, reasons for the type of management given, and clinical outcome. Charts were also reviewed with respect to serial audiological assessment, electronystagmography, and brainstem auditory evoked response. Imaging studies were analyzed using a computer technique so that serial studies could be compared to determine growth rates.

Results Rigorous computer analysis of tumor size and growth rate was statistically the same as the radiologist's description of the tumor size and growth rate. Of 70 patients who were older than 65 years of age old at the time their tumor was discovered, 4 (5.7%) required intervention and 18 (26%) were dead of unrelated causes. These patients had a mean follow‐up of 4.8 years (range, 0.01–17.2 y). Overall, growth rate for nonsurgical patients was 0.91 mm per year. Nonsurgical tumors did not grow or regressed in 42.3%. Overall postoperative growth rate for surgical subtotal resection patients was 0.35 mm per year. Surgical tumors did not grow or regressed after subtotal resection of acoustic neuroma in 68.5% of patients. Three patients (6.1%) required revision surgery because of tumor growth or the development of symptoms. Neither auditory nor vestibular testing was a reliable measure for determining tumor growth.

Conclusion Measurement of the maximal tumor diameter on MRI scans is a reliable method for following acoustic neuroma growth. There is no need to perform a rigorous analysis of tumor size to determine whether the tumor is growing significantly. The vast majority of patients older than 65 years with acoustic neuromas do not require intervention. The indications for intervention should be based on a combination of rapid tumor growth with the development of symptoms.
Hearing Results in Pediatric Patients With Chronic Otitis Media After Ossicular Reconstruction With Partial Ossicular Replacement Prostheses and Total Ossicular Replacement Prostheses
Authors: Murphy Terrence P.
Published: November 2003

ObjectiveTo examine hearing results in pediatric patients after ossicular reconstruction with partial ossicular replacement prostheses (PORPs) and total ossicular replacement prostheses (TORPs) in children with chronic otitis media.

MethodsA retrospective chart review was performed on 55 pediatric patients with chronic otitis media who underwent ossicular reconstruction from 1991 to 1998. Patients' audiograms were evaluated preoperatively and postoperatively for pure‐tone average (PTA), air‐bone gap (ABG), speech reception threshold (SRT), method of ossicular reconstruction, and management of the mastoid.

ResultsTwenty‐seven patients underwent ossicular reconstruction with TORPs. The average preoperative ABG was 40.1 dB, and the average postoperative ABG was 31.6 dB. Forty‐one percent of the children improved their PTA greater than 10 dB postoperatively, and 52% of children did not change their ABG by more than 10 dB postoperatively. Nineteen percent of children with TORPs had a postoperative ABG less than 20 dB, and 44% of children with TORPs had a postoperative ABG less than 30 dB. Twenty‐eight patients underwent ossicular reconstruction with PORPs. The average preoperative ABG was 29.7 dB, and the average postoperative ABG was 22.5 dB. Thirty‐two percent of patients improved their PTA by greater than 10 dB, while 57% of children with PORPs did not change their ABG by more than 10 dB postoperatively. Forty‐three percent of children with PORPs had an ABG of less than 20 dB postoperatively, and 71% of children with PORPs had a postoperative ABG less than or equal to 30 dB.

ConclusionsChildren who underwent ossicular reconstruction with PORPs had slightly better postoperative hearing than did children with TORPs. Postoperative hearing was essentially unchanged in approximately 55% of both groups. Preoperative hearing levels may be the most important factor determining postoperative hearing in nonstaged surgery for children with chronic otitis media. Long‐term hearing results in children with single‐stage surgery were not as good as those reported in the literature for staged surgery. Severe mucosal disease and eustachian tube dysfunction may contribute to poorer hearing results in children.
An Objective Method of Analyzing Cochlear Versus Noncochlear Patterns of Distortion‐Product Otoacoustic Emissions in Patients With Acoustic Neuromas
Authors: Telischi Fred
Published: November 2003

Objectives To objectify the effects of retrocochlear disease on distortion‐product otoacoustic emissions (DPOAEs) by developing a computer‐based software strategy for classifying DPOAE patterns as cochlear or noncochlear and to evaluate the sensitivities of these techniques in a large series of patients with unilateral acoustic neuromas.

Study Design Development of a novel, software‐based method of DPOAE analysis, which was evaluated with data obtained from a retrospective review of the results from audiometric tests performed in a series of patients.

Methods A computer‐based software strategy was developed, using frequency‐specific data from normal‐hearing adults, for the purpose of distinguishing cochlear from noncochlear patterns of hearing loss, by determining the discrepancies between DPOAEs and behavioral audiometry. Preoperative pure‐tone thresholds and DPOAEs from 97 patients with surgically confirmed acoustic neuroma were compared using an objective method and a standard, subjective technique that was considered to be the gold standard. The effects of bilateral hearing losses, such as noise‐induced hearing loss and presbycusis, were accounted for during the analysis to isolate the effects of the tumors on hearing thresholds and DPOAEs.

Results Overall, 55 (57%) of the tumor ears were assigned to the cochlear group (i.e., DPOAEs consistent with hearing thresholds), 40 (41%) to the noncochlear group (i.e., DPOAEs inconsistent with hearing thresholds), and 2 (2%) to an indeterminate group, using the subjective technique for classifying DPOAEs. There was no significant difference in the categorization of the patients with acoustic neuroma when employing the objective strategy. The objective algorithm, when modified to maximize the number of noncochlear identifications, led to assignments of 36 (37%) to the cochlear, 57 (59%) to the noncochlear, and 4 (4%) to the indeterminate categories.

Conclusions Subjective analysis of a large series patients with acoustic neuromas showed that the majority of ears with tumors demonstrated cochlear (57%), rather than non‐ cochlear (41%), patterns of DPOAEs. The computerized, software‐based algorithm developed for differentiating cochlear from noncochlear patterns of DPOAEs in patients with retrocochlear disease had a maximum sensitivity of 59%. This value was significantly higher than that reported in previous studies.
Down Syndrome: Analysis of Airway Size and a Guide for Appropriate Intubation
Authors: Shott Sally R.
Published: November 2003

Objectives/Hypothesis The purpose of this study is to prospectively evaluate the airway size of children with Down syndrome (DS). Previous studies have observed an increase in postintubation stridor in children with DS. Anesthetic literature suggests using a smaller endotracheal tube in children with DS, but more specific recommendations are not offered. With this study, recommendations are presented for the appropriate endotracheal tube size to use in children with DS undergoing intubation.

Study Design A prospective, nonrandomized study was performed on a cohort of 42 children with DS and 32 control subjects. Sizing of the airway was assessed through measurement of an air leak around the endotracheal tube at intubation. The size of the airway was also evaluated through measurements of the tracheal diameter at the “tracheotomy point” on magnetic resonance imagine (MRI) studies of the head and neck which were performed on a group of children with DS. These were compared with normative values of the tracheal diameter in children.

Methods The proper size of endotracheal tube in a population of children with DS and in a group of normal controls was determined. The “proper size” of an endotracheal tube was defined as that size of tube which allowed an audible air leak around the tube between 10 and 30 cm of H2O pressure. Anesthetic technique was controlled and identical for all study subjects. Participants had no previous history of airway compromise, stridor, or previous intubation. Weight and age were recorded and evaluated for their influence on the results. A retrospective evaluation was made of MRI studies of the neck that were performed on children with DS. Using measurement techniques described by Reed et al., the tracheal diameters at the “tracheostomy point” were compared with normative values for children. Measurements were both obtained by the author and confirmed by a pediatric radiologist.

Results Using this prescribed method to determine the proper size of endotracheal tube, the control group used endotracheal tubes that were predicted from established anesthesia charts and formulas. However, children with DS required endotracheal tubes at least two sizes smaller. Age was found to be a more reliable factor in predicting the endotracheal tube size. A table of endotracheal tube sizes for intubation in children with DS is presented. Evaluation of the tracheal diameter at the tracheotomy point revealed that children with DS have a smaller trachea when compared with control children. It is not only the subglottis that is smaller; the tracheal diameter as well must be assumed to be of a smaller diameter in children with DS.

Conclusions Children with DS have smaller airways than other children. This is because of an overall decrease in the diameter of the tracheal lumens. Initial intubation of a child with DS should be performed with an endotracheal tube at least two sizes smaller than would be used in a child of the same age without DS, to avert potential trauma to the airway.
Gene Therapy for Head and Neck Cancer
Authors: Gleich Lyon L.
Published: November 2003

Objectives/Hypothesis New treatment methods are needed for head and neck cancer to improve survival without increasing morbidity. Gene therapy is a potential method of improving patient outcome. Progress in gene therapy for cancer is reviewed with emphasis on the limitations of vector technology and treatment strategies. Given the current technological vector limitations in transmitting the therapeutic genes, treatments that require the fewest number of cells to be altered by the new gene are optimal. Therefore an immune‐based gene therapy strategy was selected in which the tumors were transfected with the gene for an alloantigen, human leukocyte antigen (HLA)–B7, a class I major histocompatibility complex (MHC). This would restore an antigen presentation mechanism in the tumor to induce an antitumor response. This gene therapy strategy was tested in patients with advanced, unresectable head and neck cancer.

Study Design Prospective trial.

Methods Twenty patients with advanced head and neck cancer who had failed conventional therapy and did not e‐press HLA‐B7 were treated with gene therapy using a lipid vector by direct intratumoral injection. The gene therapy product contained the HLA‐B7 gene and the β2‐microglobulin gene, which permits complete e‐pression of the class I MHC at the cell surface. Patients were assessed for any adverse effects, for changes in tumor size, for time to disease progression, and for survival. Biopsy specimens were assessed for pathological response, HLA‐B7 e‐pression, apoptosis, cellular proliferation, CD‐8 cells, granzyme, and p53 status.

Results There were no adverse effects from the gene therapy. At 16 weeks after beginning gene therapy, four patients had a partial response and two patients had stable disease. Two of the tumors completely responded clinically, but tumor was still seen on pathological examination. The time to disease progression in the responding patients was 20 to 80 weeks. The median survival in patients who completed gene therapy was 54 weeks, compared with 21 weeks in patients whose tumors progressed after the first cycle of treatment. One patient survived for 106 weeks without any additional therapy. HLA‐B7 was demonstrated in the treated tumors, and increased apoptosis was seen in the responding tumors.

Conclusion Significant advances have been made in the field of gene therapy for cancer. Alloantigen gene therapy has had efficacy in the treatment of cancer and can induce tumor responses in head and neck tumors. Alloantigen gene therapy has significant potential as an adjunctive treatment of head and neck cancer.
Laryngeal Reinnervation With the Hypoglossal Nerve: II. Clinical Evaluation and Early Patient Experience
Authors: Paniello Randal C.
Published: November 2003

Objectives/Hypothesis To determine whether the hypoglossal nerve (XII) can serve as a suitable donor for human laryngeal reinnervation.

Study Design Prospective, nonrandomized.

Methods Measurements were made on patients undergoing open neck procedures to determine the length of XII available and that required to perform XII–recurrent laryngeal nerve (RLN) anastomosis. The morbidity of combined XII and RLN injuries was studied using temporary lidocaine block of the ipsilateral XII in patients with unilateral vocal fold paralysis (UVFP). A pilot series of patients with UVFP who underwent XII‐RLN reinnervation was evaluated for morbidity of the procedure, and for improvement in voice and swallowing.

Results In 89 necks the average available length of XII was 2 cm less than that needed to reach the larynx, indicating the RLN stump must be at least 3 cm to allow tension‐free anastomosis. Twenty‐five patients with untreated UVFP underwent temporary lidocaine block of XII; 8 had slight changes in their speech, none had increased aspiration. Nine patients underwent XII‐RLN reinnervation. Postoperative speech analysis correlated well with the findings of the temporary lidocaine block of XII. One‐year follow‐up of five patients showed excellent voice quality, resolution of any preoperative aspiration, and minimal morbidity. Slight adductory movement of the reinnervated vocal fold was seen during tongue thrust. Electromyography confirmed substantial polyphasic action potentials in the thyroarytenoid muscle.

Conclusions The hypoglossal nerve is a very suitable donor for reinnervation of patients with UVFP. There should be enough length for primary XII‐RLN anastomosis in most patients. Donor site morbidity is acceptable. Preoperative lidocaine block of XII is a good predictor of actual donor site morbidity and could be used to assess patients undergoing facial‐hypoglossal anastomosis as well.
Benefit of Feeding Assessment Before Pediatric Airway Reconstruction
Authors: Willging Jay Paul
Published: November 2003

Objectives/HypothesisTo determine the utility of preoperative feeding assessments in children undergoing airway reconstruction, identifying parameters that correlate with functional deficits in swallowing and postoperative feeding difficulties.

Study DesignProspective, sequential enrollment.

MethodsTwo hundred fifty‐five patients with structural abnormalities of the upper aerodigestive tract underwent endoscopic swallow studies. Classification of preoperative feeding abilities, specific feeding disorders, and abnormal endoscopic feeding parameters were used to predict the postoperative course of patients undergoing airway reconstruction. The relationships between diagnoses and functional feeding categories and postoperative outcomes and functional feeding categories were appraised by χ2analysis.

ResultsThe median age of the study population was 2.5 years. Fifty‐three percent of the patients were tracheotomy dependent. Only 13% of the patients had diagnoses limited to the airway, with 45% of patients having three or more diagnoses. Worse preoperative feeding abilities were associated with the presence of a tracheotomy, age 2 years or less, and multiple underlying diagnoses. Neurological diagnoses were associated with worse feeding abilities. Preoperative feeding assessments directly altered the course of management of 15% of operative patients, by recommending a delay in the surgical correction, the placement of a gastrostomy tube preoperatively, or a modification in the surgical reconstruction planned for the patient. Postoperative airway protection predictions were 80% accurate. Twelve percent of the predictions involved patients who developed unforeseen complications that required additional treatments or prolonged the hospital stay secondary to difficulties with airway protection. There was no correlation between the preoperative feeding abilities of the patients and their postoperative course after airway reconstruction.

ConclusionTransient dysphagia is common after laryngotracheal reconstruction. Preoperative feeding abilities do not correlate with the postoperative airway protection abilities of a patient. Feeding assessments before pediatric airway reconstruction provide a means of identifying patients with poor airway protection mechanisms that may compromise the patient after reconstruction. Findings on swallowing evaluations that predict poor airway protective mechanisms are 1) pooling of secretions in the hypopharynx, 2) poor oral motor skills, allowing premature spillage of material into the hypopharynx where it penetrates the larynx, and 3) residue that persists in the hypopharynx after multiple swallows. The integration of information generated from the preoperative swallowing assessment promotes the selection of operative procedures that are optimal for that patient and highlights specific therapy issues that may need to be addressed in the postoperative management of the patient that may not have been obvious without the study.
Physician Experience With an Optical Image Guidance System for Sinus Surgery
Authors: Metson Ralph B. , Cosenza Mathew J. , Cunningham Michael J. , Randolph Gregory W.
Published: November 2003

Objectives/Hypothesis Intraoperative guidance systems have been developed which use infrared tracking technology to assist with anatomical localization during sinus surgery. Although the introduction of this technology is intended to increase the safety and efficacy of sinus surgery, little is known about its actual impact in the clinical setting. The objective of this report was to study the application and utilization of an image guidance system shared by multiple sinus surgeons in a specialty hospital.

Study Design Combined prospective case study and retrospective analysis of physician surveys.

Methods An optical‐based image guidance system (LandmarX, Xomed, Inc., Jacksonville, FL) was used by 34 physicians to perform 754 sinonasal surgeries over a 2.5‐year period at Massachusetts Eye and Ear Infirmary. In 19 cases, system registration was repeated during surgery to measure the effect of fiducial placement on system accuracy.

Results The measured accuracy of anatomical localization at the start of surgery (mean value, 1.69 ± 0.38 mm) was comparable to the perceived accuracy of 1 to 3 mm that was reported by 79% of surgeons surveyed. Operating room time (mean period, 130.6 ± 41.1 min) correlated with the surgical procedure performed (P < .05), but not with the disease stage or revision rate. According to a majority of surgeons, use of the image guidance equipment increased operating room time by 15 to 30 minutes during initial cases and by 5 to 15 minutes once experience with the equipment had been acquired. More than 90% of surgeons anticipated their continued use of the image guidance equipment for sinus surgery at a similar or greater level in the future.

Conclusion An optical‐based image guidance system can be successfully integrated into a multisurgeon operating room environment. Use of the system provides accurate anatomical localization during sinus surgery and results in a relatively high level of physician satisfaction.
Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and Long‐Term Results Using Magnetic Resonance Imaging in 82 Operations
Authors: Weber Rainer , Draf Wolfgang , Keerl Rainer , Kahle Gabriele , Schinzel Stefan , Thomann Silke , Lawson William
Published: November 2003

ObjectiveTo evaluate the intraoperative and late complications of osteoplastic sinus surgery with fat obliteration with long‐term magnetic resonance imaging (MRI) follow‐up.

MethodsThe operative records of all patients who underwent osteoplastic frontal sinus surgery with fat obliteration between January 1, 1986 and December 31, 1997 were reviewed and the postoperative clinical course and magnetic resonance imaging (MRI) scans were analyzed if available. MRI analyses revealed that changes in the distribution of fatty and fibrous tissue, the development of necrosis or oil cysts, recurrences, inflammatory complications, and mucoceles were time‐dependent occurrences.

ResultsEighty‐two operative records were evaluated and 59 patients were followed 1 to 12 years after surgery. Eighty‐six MRI scans in 51 patients were available for analysis. The most frequent intraoperative complications were exposure of orbital fat (19.5%), unintentional fracture of the anterior wall (19.5%), incorrect placement of the anterior wall (17%), and dural injury (9.8%). Persistent changes of the frontal contour (embossment, depression) occurred in 10.2% and the esthetic result was unfavorable in 5.1% of the cases. Mucoceles could be detected in 5 of 51 cases (9.8%). The amount of adipose tissue detectable in the last scan was less than 20% in the majority of cases (53%), and more than 60% in only 18% of the cases. The amount of adipose tissue decreased significantly with time (the median half‐life was 15.4 mo).

ConclusionsOsteoplastic frontal sinus surgery with fat obliteration is very useful and successful in patients in whom the frontal sinus is not accessible via an endonasal approach or the natural drainage cannot be reestablished. MRI is currently the most valuable diagnostic tool to evaluate the frontal sinus after obliteration with adipose tissue. The method has some limitations with regard to detection of small recurrent mucoceles and differentiating vital adipose tissue from fat necroses in the form of oil cysts. In these difficult cases, long‐term MRI follow‐up is necessary.
Airway Compromise in Thyroplasty Surgery
Authors: Weinman Eric C. , Maragos Nicolas E.
Published: November 2003

Objectives Airway compromise arising from thyroplasty procedures including Isshiki type I through IV thyroplasties, arytenoid adduction, and arytenoid fixation is uncommon yet potentially life threatening. Identification of incidence of obstruction and probable causes is important for preoperative planning, consultation, and postoperative care.

Study Design Retrospective review of all thyroplasty operations, including arytenoid adduction and arytenoid fi‐ation.

Methods Three hundred thirty‐two patients underwent a total of 630 thyroplasty procedures. Detailed information was gathered on patients manifesting symptoms of airway obstruction.

Results Seven patients required an unplanned tracheostomy for airway compromise. Five of 143 patients who underwent arytenoid adduction required a tracheostomy, for an incidence of 3.5%. The median interval to developing significant stridor requiring tracheostomy was 9 hours, with five of these seven patients requiring airway surgery within the first 18 postoperative hours. No patient receiving a type I thyroplasty alone developed significant airway compromise. Tracheostomy was required in two patients with underlying neuromuscular disease—one who underwent a bilateral type I thyroplasty and one who underwent an arytenoid fixation procedure.

Conclusion The percentage of airway complications after thyroplasty is low. However, arytenoid adduction and fixation operations have a significant risk of postoperative temporary tracheostomy and warrant preoperative discussion regarding tracheostomy and postoperative overnight hospital admission.
Noninvasive Fluorescent Identification of Bacteria Causing Acute Otitis Media in a Chinchilla Model
Authors: Spector Brian C. , Reinisch Lou , Smith Dana , Werkhaven Jay A.
Published: November 2003

Objectives To evaluate a noninvasive method of bacterial identification via fluorescence spectroscopy in the setting of acute otitis media in a chinchilla model.

Study Design Prospective.

Methods For each chinchilla, transbullar inoculation with Streptococcus pneumoniae, Haemophilus influenzae, or Staphylococcus aureus was performed bilaterally and clinical infection was determined by otoscopy. An optical fiber coupled to a spectrofluorometer allowed for the delivery of an excitation wavelength to the inflamed tympanic membrane and the acquisition of the resulting emission signal. Sequential emission spectra obtained over a range of excitation wavelengths were assembled by a computer algorithm, and a single, three‐dimensional plot was created for each test ear. Similarly, plots from the healthy external auditory canal (EAC) were also recorded. Twelve animals were used to establish a library of four reference plots representing the three bacteria and the EAC. Of the 24 ears available for study, 10 were excluded from analysis because of lack of clinical infection or presence of tympanic membrane perforation with purulent drainage. From four additional animals, four samples from ears infected with the above bacteria and three samples of the EAC served as unknowns. The unknown plots were analyzed by an investigator blinded to their identity.

Results Using a multiple correlation of the unknown to the reference plots, seven of seven samples were correctly identified.

Conclusions We were able to establish a prototype method for the noninvasive identification of a limited library of pathogens in a chinchilla model of acute otitis media.
Endoscopic Management of Skull Base Osteoradionecrosis
Authors: Chang Kai‐Ping , Tsang Ngan‐Ming , Chen Chao‐Yu , Su Jen‐Liang , Hao Sheng‐Po
Published: November 2003

Objective Osteoradionecrosis is one of the most serious complications in radiotherapy of nasopharyngeal carcinoma. We describe a new endoscopic approach to resolve resultant skull base osteoradionecrosis. The objective of this study is to evaluate the efficacy of endoscopic management of skull base osteoradionecrosis.

Study Design A prospective study of the outcome of endoscopic management for patients with skull base osteoradionecrosis.

Methods Between 1994 and 1998 si‐ patients who had irradiation previously for nasopharyngeal carcinoma had skull base osteoradionecrosis. A sinoscopic approach was applied for diagnosis and sequestrectomy. This diagnosis was based on the criterion of e‐posed necrotic bone after removing all crust in the nasopharyn‐ and further confirmed on pathological e‐amination after sequestrectomy. Effective cure was defined as intact mucosal coverage without any ulcer or exposed necrotic bone observed in the nasopharynx and the absence of antecedent accompanying symptoms after management.

Results Six patients (100%) were symptom free. Five (83.3%) patients had effective cure. There was no surgical morbidity or mortality.

Conclusion Endoscopic sequestrectomy is a justified approach to skull base osteoradionecrosis.
Temporal Approach for Resection of Juvenile Nasopharyngeal Angiofibromas
Authors: Dale Browne J. , Jacob Sera L.
Published: November 2003

Objective To describe a lateral preauricular temporal approach for resection of juvenile nasopharyngeal angiofibroma (JNA).

Study Design A retrospective review of five patients with JNA tumors that were resected by a lateral preauricular temporal approach.

Methods The medical records of five patients who underwent resection of JNA tumors via a lateral preauricular temporal approach were reviewed, and the following data collected: tumor extent, blood loss, hospital stay, and surgical complications.

Results Five patients with JNA tumors had resection by a lateral preauricular temporal approach. These tumors ranged from relatively limited disease to more e‐tensive intracranial, e‐tradural tumors. Using the staging system advocated by Andrews et al., 1 these tumors included stages II, IIIa, and IIIb. Four patients (stages II, IIIa, IIIa, and IIIb) who underwent primary surgical excision had minimal blood losses and were discharged on the first or third postoperative day with minimal transient complications (mild trismus, frontal branch paresis, serous effusion, and cheek hypesthesia). The remaining patient (stage IIIb) did well after surgery, despite having undergone preoperative radiation therapy and sustaining a significant intraoperative blood loss. There have been no permanent complications or tumor recurrences.

Conclusions A lateral preauricular temporal approach to the nasopharynx and infratemporal fossa provides effective exposure for resection of extradural JNA tumors. The advantages of this approach include a straightforward route to the site of origin, the absence of facial and palatal incisions, and avoidance of a permanent ipsilateral conductive hearing loss.
Intratympanic Gentamicin for the Treatment of Unilateral Meniere's Disease
Authors: Kaplan Daniel M. , Nedzelski Julian M. , Chen Joseph M. , Shipp David B.
Published: November 2003

Objective To determine the efficacy of intratympanic gentamicin instillation as treatment of incapacitating unilateral Meniere's disease, using a predetermined regimen with a fixed dose.

Study Design A prospective study from a single institution between 1988 and 1998.

Methods One hundred fourteen patients were enrolled in this study. Gentamicin (26.7 mg/mL) was administered three times daily for 4 consecutive days. The Committee on Hearing and Equilibrium Guidelines for Reporting Treatment Results in Meniere's Disease of the American Academy of Otolaryngology and Head and Neck Surgery (1985) were used.

Results Comprehensive data were available for 90 individuals. Complete control of vertigo was achieved in 76 (84.4%), substantial control in 8 (9.0%), limited control in 2 (2.2%), and insignificant control in 4 (4.4%) patients. Disability scores at the end of 2 years were as follows: 76 patients (84.4%) had no disability, 5 (5.6%) had mild disability, 2 (2.2%) had moderate disability, and 7(7.8%) had severe disability. Caloric testing responses, as determined using electronystagmography, were as follows: 71% of the patients had an absent ice‐water response, 16% had a positive ice‐water response, and in 13% there continued to be present a bithermal response. Hearing was worse in 22 patients (25.6%), unchanged in 41 (48.2%), and improved in 22 (25.6%).

Conclusions Intratympanic gentamicin administration using this particular protocol is an effective treatment option for patients with disabling unilateral Meniere's disease. Hearing loss is a distinct possibility, and patients should be advised accordingly.
Ultracytochemical Localization of the NADPH‐d Activity in the Human Nasal Respiratory Mucosa in Vasomotor Rhinitis
Authors: Ruffoli Riccardo , Fattori Bruno , Giambelluca Maria A. , Soldani Paola , Giannessi Francesco
Published: November 2003

Objectives Description of the ultrastructural localization of nitric oxide synthase in the blood vessels of the nasal respiratory mucosa in patients with vasomotor rhinitis.

Study Design This research was conducted on seven patients—men and women, ages 20 to 45 years—suffering from vasomotor rhinitis and who had undergone surgical therapy for reduction of the inferior turbinates.

Methods To study the ultrastructural localization of nitric oxide synthase, NADPH‐diaphorase cytochemistry was employed. Samples of the nasal mucosa were obtained from inferior turbinates.

Results The endothelial cells of the arterioles, capillaries , venules and cavernous sinuses revealed a distribution of the enzymatic activity similar to that found in unaffected subjects. A strong enzymatic activity was recognized in the smooth muscle cells of the cavernous sinuses. The smooth muscle cells of arterioles and venules were generally found to be negative to enzymatic reaction.

Conclusions This study suggests that the vascular disorders of the vasomotor rhinitis depend, at least in part, from nitric oxide synthase induction in the smooth muscle cells of the cavernous sinuses.
Functional Magnetic Resonance Imaging Using Iron Oxide Particles in Characterizing Head and Neck Adenopathy
Authors: Hoffman Henry T. , Quets Jerome , Toshiaki Taoka , Funk Gerry F. , McCulloch Timothy M. , Graham Scott M. , Robinson Robert A. , Schuster Michael E. , Yuh William T.
Published: November 2003

Objectives In lymph nodes harboring metastases the reticuloendothelial system is replaced by tumor cells and does not concentrate iron particles. This study assesses the value of contrast magnetic resonance imaging (MRI) using ultrasmall superparamagnetic iron oxide particles (Combidex, Advanced Magnetics, Inc., Cambridge, MA) to characterize and stage neck nodes.

Study Design Prospective analysis of neck imaging by Combidex MRI, with correlation from pathological assessment of resected lymph nodes.

Methods Nine patients underwent MRI and subsequent bilateral neck dissections (three), unilateral neck dissections (five) or fine‐needle aspiration (one). Each case was evaluated for the number, location, MRI characteristics, and pathological assessment of lymph nodes.

Results Forty‐nine separate nodal levels were evaluated with both Combidex MRI and pathological assessment. The presence of metastatic nodal involvement among 45 levels was correctly assessed by the Combidex MRI (three false‐negative results, one false‐positive result; sensitivity, 84%; specificity, 97%). Analysis was possible for 101 of the individual lymph nodes identified by MRI that could be correlated with individual nodes pathologically examined. Combidex MRI assessment was correct for 99 nodes (one‐false positive result, one false‐negative result; sensitivity, 95%, specificity, 99%). Standard MRI interpretation without Combidex identified that 12 of 18 nodes (67%) that were greater than or equal to 10 mm (greatest dimension) contained tumor, whereas 9 of 83 nodes (11%) that were less than 10 mm contained tumor.

Conclusions Combidex MRI provides functional information to characterize lymph nodes in the clinical staging of squamous cell carcinoma of the head and neck. The inability of MRI to identify small lymph nodes restricts the usefulness of this technique.
Follicular Variant of Papillary Carcinoma: The Diagnostic Limitations of Preoperative Fine‐Needle Aspiration and Intraoperative Frozen Section Evaluation
Authors: Lin Ho‐Sheng , Komisar Arnold , Opher Elana , Blaugrund Stanley M.
Published: November 2003

Objective Fine‐needle aspiration (FNA) and frozen section (FS) have been widely reported in the literature as having high sensitivity in the diagnosis of papillary carcinoma. With the increased recognition of the follicular variant of papillary thyroid carcinoma (FVPTC), several reports have pointed out the difficulty in diagnosing this variant of papillary carcinoma owing to its overlapping cytomorphological features with benign and malignant follicular lesions. We undertook this study to determine the sensitivity of FNA and FS in the diagnosis of FVPTC.

Methods Retrospective review of patients who underwent thyroidectomy from June 1994 to June 1999. Of the 63 patients found with a final pathological diagnosis of papillary thyroid carcinoma, only 47 had an adequate FNA and FS and were included in the study. These patients were divided into two groups, the usual type (n = 23) and the follicular variant (n = 24) of papillary carcinoma. Sensitivities of FNA and FS for these two groups of papillary carcinoma were then determined.

Results The sensitivity of the FNA was 25% and of the FS was 29% for the follicular variant of papillary thyroid carcinoma. This is in contrast to the sensitivity of FNA and FS for the usual papillary carcinoma, which were 74% and 87%, respectively.

Conclusion FNA and FS have low sensitivity in the diagnosis of the FVPTC. High degree of suspicion may increase the accuracy in the diagnosis of this variant of papillary carcinoma before or during surgery. However, the thyroid surgeon needs to realize that, like follicular carcinoma, FVPTC is often diagnosed only on final pathological examination.
Upper Airway Complications in Children After Bone Marrow Transplantation
Authors: Drew Brian , Peters Charles , Rimell Frank
Published: November 2003

Objective To describe the upper and lower airway complications in children during bone marrow transplantation (BMT).

Study Design Review of medical records of patients requiring airway intervention during BMT over a 4‐year period.

Results During the 4‐year period, 832 pediatric BMTs were performed. Of these, 87 patients (10.5%) required mechanical ventilation. Patients had intubation for a mean of 79 days (range, −7–638 d) after BMT. Patients received mechanical ventilation for a mean of 12 days (range, 1–85 d). Duration of ventilation was significantly longer in patients with difficult intubation; in these 54 patients there were 64 intubations. Of these intubations, 19 (30%) were difficult. These difficult intubations occurred in 16 (30%) patients. Patients with Hurler syndrome and congenital immunodeficiencies had significantly more difficult intubations than children with leukemia. The incidence of complications causing difficult intubation were difficulty visualizing cords, because of the presence of blood (63%); difficulty visualizing cords, because of edema (19%); anatomically narrowed airway (13%); limited neck extension (13%); and limited jaw opening (6%). The resulting mortality rate was 82% in children requiring intubation. Survivors were significantly younger than nonsurvivors.

Conclusions Pediatric BMT has become increasingly more common. Airway management is rarely required during the engraftment phase, but when intervention is required, it is often difficult, particularly in the nonleukemic child, and may require the skills of an otolaryngologist. Representative cases are presented, and management is discussed.
Esophageal Dysmotility As an Important Co‐factor in Extraesophageal Manifestations of Gastroesophageal Reflux
Authors: Knight Robert E. , Wells James R. , Parrish Rudolph S.
Published: November 2003

Objective Esophageal motility problems have been demonstrated in patients with noninflammatory typical gastroesophageal reflux (GER) and esophagitis, but the frequency of motility disorders in patients with extraesophageal manifestations of GER has not been studied. The primary aim of this study was to assess the frequency of esophageal motility disorders in patients with atypical GER.

Methods A prospective study of 112 consecutive patients with laryngopharyngeal reflux (LPR) symptoms and demonstrated physical findings consistent with LPR were studied. Patients were divided into one of the following diagnostic categories: hoarseness; chronic cough; dysphagia or globus pharyngeus; and paroxysmal laryngospasm. Of the 112 patients, 81 (72%) underwent esophageal manometry and ambulatory 24‐hour pH monitoring (pH‐metry), 19 (17%) had motility studies only, and 12 (11%) had pH‐metry studies only. Only patients who had motility studies were included in the analysis. Therefore the study population was 100 patients. Associations between diagnostic category, motility disorder, and abnormal reflux were evaluated with contingency‐table analyses.

Results Of the 100 patients, 29 (29%) presented normal motility function, 48 (48%) had ineffective esophageal motility, 10 (10%) had hypertensive lower esophageal sphincter (LES), and 9 (9%) and 4 (4%) had nutcracker esophagus and achalasia, respectively. There was a significant association between esophageal dysmotility and extraesophageal manifestations of GER. However, there was no statistically significant association between esophageal motility disorders and abnormal acid reflux in our patients with atypical GER.

Conclusions In the present study, the frequency of esophageal motility problems in patients with extraesophageal or atypical manifestations of GER was 73% and suggested that these problems exist as an accompanying condition or pathogenic co‐factor in some patients with atypical GER.
Elimination of Temporal Bone Cerebrospinal Fluid Otorrhea Using Hydroxyapatite Cement
Authors: Kveton John F. , Goravalingappa Ravi
Published: November 2003

Objective This report introduces a new method to control cerebrospinal fluid (CSF) otorrhea using hydroxyapatite cement (HAC) via a transmastoid approach. This technique eliminates the need for a transmastoid or middle cranial fossa approach with soft tissue repair and prolonged hospitalization caused by lumbar drainage.

Study Design Retrospective review.

Methods Thirteen cases of transmastoid repairs of CSF otorrhea using HAC from August 1996 to February 1999 were reviewed.

Results The CSF leak was controlled in every patient using HAC through a transmastoid approach. The reconstruction involved eight tegmen defects, three posterior fossa dural plate defects, and two congenital inner ear fistula secondary to Mondini malformation. Postoperative wound infection in one patient was the only complication that occurred. The average hospital stay was 48 hours. Follow‐up ranged from 12 to 44 months with no recurrence of CSF otorrhea.

Conclusion The successful use of HAC to control CSF otorrhea through a transmastoid approach reduces patient morbidity by obviating the need for middle cranial fossa approaches, donor soft tissue sites, and spinal drainage.