bluuebunny/crossref_metadata_2025 huggingface dataset:
Postural Stability of Preoperative Acoustic Neuroma Patients Assessed by Sway Magnetometry: Are They Unsteady?
Authors: Collins Melanie M. , Johnson Ian J. M. , Clifford Elaine , Birchall John P. , O'Donoghue Gerald M.
Published: November 2003

ObjectiveThe objective was to evaluate the preoperative postural stability of acoustic neuroma patients using sway magnetometry.

Study DesignProspective two‐center study.

MethodsFifty‐one patients (mean age, 53 years) diagnosed with unilateral acoustic neuroma on magnetic resonance imaging at two tertiary referral centers were studied. Preoperatively, each patient had sway patterns (with eyes open and with eyes closed, and standing on foam) recorded for 120 seconds by sway magnetometry. Path length for 30 seconds was calculated. The Romberg coefficient (path length with eyes open divided by path length with eyes closed) was calculated.

ResultsForty‐four percent of patients had abnormal path lengths with eyes open, and 49% with eyes closed. The Romberg coefficients were significantly lower than normal (P<.001; 95% CI, 0.19–0.87). Mean Romberg coefficient was 0.59 (normal value = 0.73), and all patients had a coefficient of less than 1.

ConclusionsHalf of preoperative acoustic neuroma patients are unsteady, exhibiting abnormal sway patterns based on path length measurements. The increase in sway path length demonstrable in normal subjects with eyes closed was significantly exaggerated in patients with acoustic neuroma.
Facial Nerve Stimulation at the Internal Auditory Canal: An Animal Model and Experimental Assessment
Authors: Kelley Timothy F. , Leonetti John P.
Published: November 2003

Objectives The main objective was to evaluate a canine model as a reliable animal model for the experimental study of the facial nerve at the internal auditory canal. The study also sought to begin testing the limits of facial nerve stimulation regarding electrically induced nerve damage.

Study Design Experimental and clinical analysis of facial nerve function after exposure and electrical stimulation in a canine model.

Methods Using a posterior fossa approach, the intracranial portion of the facial nerve was exposed from the brainstem to the internal acoustic meatus in 10 mongrel dogs. The nerve was then stimulated with variable frequency and amperage. The subjects were clinically examined for 2 weeks for evidence of facial nerve dysfunction. Both facial nerves were then harvested in each subject and histologically compared using light microscopy.

Results The canine model allowed for reliable exposure of the facial nerve at the internal auditory canal in all subjects (n = 10). The results also showed no functional or histopathological deficits in a canine facial nerve electrically stimulated at up to 50 stimulations of 1 mA per stimulation when stimulated at the internal auditory canal.

Conclusions The reported canine model is a reliable animal model for the study of the facial nerve at the internal auditory canal. The canine facial nerve can tolerate at least 50 stimulations at 1 mA and still remain functionally and histopathologically normal.
Reconstruction of the Entire Ossicular Conduction Mechanism
Authors: Battaglia Alex , McGrew Benjamin M. , Jackson C. Gary
Published: November 2003

Objectives/Hypothesis Stapes fixation combined with fixation, absence, or malformation of the malleus‐incus complex requires an uncommon surgical reconstruction and offers a unique combination of challenges and hazards. This situation may occur in the presence of severe tympanosclerosis, otosclerosis, congenital ossicular malformations, and revision surgery for either stapedectomy or chronic ear disease. In previous reports, this procedure has been grouped with total ossicular reconstruction without much distinction. However, the challenges unique to this problem deserve special consideration. The present report offers a treatment plan for a group of patients requiring reconstruction of the entire ossicular conduction mechanism including removal of the stapes footplate.

Study Design Retrospective review.

Methods Three thousand three hundred fifty (3350) charts of patients requiring total ossicular replacement prostheses (TORPs) were reviewed. Of this group of patients, only 21 of 3350 patients from 1977 to 1999 required TORP placement and removal of the stapes footplate. The patients were followed for an average period of 50 months.

Results Hearing results indicated an overall improvement in the air–bone gap of 10 dB, with 52% achieving an air–bone gap of less than 20 dB. Of the 21 cases, 5 revision surgeries were performed. Three were performed because of a displaced TORP (14.2%). and 2 were performed because of extruded TORPs (9.5%).

Conclusions Reconstruction of the entire ossicular conduction mechanism including removal of the stapes footplate can be successfully achieved with improvement of the air–bone gap of less than 20 dB. Hearing results and extrusion rates are comparable to reported results of TORP placement on a mobile footplate. Successful stapedectomy and simultaneous ossicular chain reconstruction can be performed as a single or staged procedure. Special attention is paid to avoid intrusion of the prosthesis into the vestibule.
Cellular Telephone Use and Risk of Intratemporal Facial Nerve Tumor
Authors: Warren Hillary G. , Prevatt Angela A. , Daly Kathleen A. , Antonelli Patrick J.
Published: November 2003

Objectives/Hypothesis Microwave radiation exposure from cellular telephone use has been implicated in the development of intracranial tumors. The intratemporal facial nerve (IFN) is exposed to higher levels of cellular telephone radiation than intracranial tissues. The purpose of the study was to determine whether cellular telephone use is associated with an increased risk of IFN tumors.

Study Design Case‐control using a structured telephone survey at an academic, tertiary‐care referral center.

Methods Patients with IFN tumors (n = 18) were case‐matched with patients treated for acoustic neuroma (n = 51), rhinosinusitis (n = 72), and dysphonia or gastroesophageal reflux disease (n = 69). Risk of facial nerve tumorigenesis was compared by extent of cellular telephone use and other risk factors.

Results The odds ratio of developing an IFN tumor was 0.6 (95% CI, 0.2–1.9) with any handheld cellular telephone use and 0.4 (95% CI, 0.1–2.1) with regular cellular telephone use. No factors were associated with an increased risk for IFN tumor development.

Conclusions Regular cellular telephone use does not appear to be associated with a higher risk of IFN tumor development. The short duration of widespread cellular telephone use precludes definite exclusion as a risk for IFN tumor development.
Transnasal Endoscopic Medial Maxillectomy for Inverting Papilloma
Authors: Sadeghi Nader , Al‐Dhahri Saleh , Manoukian John J.
Published: November 2003

Objective To describe the new technique of transnasal endoscopic medial maxillectomy.

Study Design Study design included application of the new technique in the management of five patients with inverting papilloma; retrospective review of five patients who had lateral rhinotomy with medial maxillectomy for inverting papilloma; comparison of transnasal endoscopic medial maxillectomy to open medial maxillectomy for scope of resection, margin control, operative time, and surgical access; and detailed description of transnasal endoscopic medial maxillectomy.

Methods Charts were reviewed and tabulated for operative time, duration of follow‐up, and recurrence. Pathology reports were reviewed for number and orientation of the specimens and for margin control.

Results Operative time was shorter for patients managed with transnasal endoscopic medial maxillectomy. All patients with transnasal endoscopic medial maxillectomy had one large, well‐oriented specimen with margin control. There was no recurrence in either group.

Conclusions Transnasal endoscopic medial maxillectomy providing full access to the maxillary and ethmoid sinuses is described in detail. Transnasal endoscopic medial maxillectomy is an effective, reproducible technique with less operative time and morbidity and, possibly, better pathological tumor mapping than open medial maxillectomy for selected patients. Maxillary sinus involvement with inverting papilloma is not a contraindication for this technique. Strong illumination, superior resolution, and angled visualization, coupled with exact osteotomies, make transnasal endoscopic medial maxillectomy an efficacious technique for inverting papilloma with extension limited to the maxillary and ethmoid sinuses.
Long‐Term Hearing Outcome in Patients Receiving Intratympanic Gentamicin for Ménière's Disease
Authors: Wu Iee Ching , Minor Lloyd B.
Published: November 2003

Objective To determine the long‐term hearing outcome in patients with intractable vertigo caused by unilateral Ménière's disease who were treated with intratympanic injection of gentamicin.

Study Design The study was a longitudinal analysis of hearing and control of vertigo in patients with unilateral Ménière's disease who received intratympanic gentamicin.

Methods Pure‐tone thresholds and speech discrimination scores on audiometry were analyzed, along with the control of vertigo. Criteria described in 1995 by the American Academy of Otolaryngology—Head and Neck Surgery (AAO‐HNS) were used. Patients treated with intratympanic gentamicin had “definite” Ménière's disease and had intractable vertigo despite optimal medical therapy, no symptoms suggestive of Ménière's disease in the contralateral ear, and serviceable hearing in the contralateral ear. The study analyzed the outcomes of 34 patients for whom follow‐up data were available for periods greater than 24 months after intratympanic gentamicin.

Results Complete control of vertigo (AAOHNS Class A) was obtained in 90% of the patients. Profound sensorineural hearing loss occurred as a result of gentamicin injection in 1 of the 34 patients (3%). When data from all patients were grouped together, hearing was improved in 5 (15%), unchanged in 23 (68%), and worse in 6 (17%) patients. This distribution of hearing outcome is similar to that in patients whose symptoms of Ménière's disease were managed with medical measures. Recurrent vertigo developed in 10 patients (29%) at an interval of 4 to 15 months after initially complete control. Treatment with additional intratympanic injection(s) of gentamicin did not result in a change in hearing.

Conclusion The risk of hearing loss in patients treated with infrequent intratympanic injection(s) of gentamicin is low.
Technical Refinements and Precautions During Ionomeric Cement Reconstruction of Incus Erosion During Revision Stapedectomy
Authors: Chen Douglas A. , Arriaga Moisés A.
Published: November 2003

Objective The study describes the technical precautions and short‐term hearing results of fast‐setting ionomeric cement (SerenoCem) for managing incus erosion in revision stapedectomy.

Study Design Observational and retrospective chart review.

Methods Consecutive patients undergoing ionomeric cement incus reconstruction during revision stapedectomy had surgery on an ambulatory basis in a tertiary care referral center. Main outcome measures included technical details, precautions, and recommendations for handling this new material and 6‐week hearing outcomes comparing preoperative and postoperative air‐conduction and bone‐conduction thresholds.

Results A small amount of ionomeric cement on the tip of otological picks applied to the incus remnant successfully reconstitutes the original length of the long process of the incus. In revision stapedectomy, a crimp‐on prosthesis may be placed on the cement‐lengthened incus. Six‐week postoperative audiograms demonstrated significant closure of the air–bone gap in operated cases. Our experience in a failed case leads us to recommend that the setting time for the cement be increased to no less than 20 minutes as opposed to the manufacturer's recommendation of 10 minutes. Also, revision stapedectomy was more likely to be successful when the prosthesis was placed to the incus remnant and stabilized with cement, rather than placing the prosthesis on the cement itself.

Conclusions Ionomeric cement permits direct reconstruction of a pathologically shortened incus in revision stapedectomy. Surgeons must be aware of precaution and limitations of this new material. Preliminary results indicate significant hearing improvement with this technique when appropriate precautions are taken.
Stapes Prosthesis Attachment: The Effect of Crimping on Sound Transfer in Otosclerosis Surgery
Authors: Huber Alexander M. , Ma Furong , Felix Heidi , Linder Thomas
Published: November 2003

Objectives/Hypothesis Although in stapes surgery successful hearing improvement may be achieved in the majority of patients, unsatisfactory closure of the air–bone gap can be recorded. One of many reasons for unexpected failures of stapes surgery may be the insufficient crimping of a stapes prosthesis onto the incus. The objectives of the study were to assess the amount of sound transmission loss in response to the quality of prosthesis crimping and to identify a required loop attachment pattern to obtain good sound transmission results.

Study Design Experimental.

Methods A temporal bone model was developed to measure the sound transmission properties between incus and prosthesis on 17 fresh human temporal bones. The attachment of a titanium stapes piston was assessed without crimping, followed by loose crimping and tight fixation to the incus, using scanning laser Doppler interferometry, endoscopic photography, micro grinding technique, and scanning electron microscopy. An algorithm had to be developed to simulate acoustical stimulation using electromechanical stimulation.

Results Optimal tight crimping of the stapes piston revealed consistent good sound transfer function ranging from 0 to 7 dB loss, and loss remained, on average, at 2 dB. The mean transmission losses for conditions of loose crimping and no crimping were surprisingly small (within 10 dB). However, these unusual crimping conditions allowed a wide range of losses up to 28 dB. A close coupling at least at two opposite points was obligatory to obtain consistently good results.

Conclusions Perfect hearing reconstruction necessitates ideal crimping of a prosthesis to obtain consistently good results. However, the final functional gain depends on many different intraoperative and postoperative factors.
Radiation Following Surgery for Oral Cancer: Impact on Local Control
Authors: Magge Keshav T. , Myers Eugene N. , Johnson Jonas T.
Published: November 2003

Objectives The use of postoperative radiation therapy (RT) is commonly used in the treatment of patients with high‐risk squamous cell carcinoma of the head and neck. However, few data exist that quantitate the incremental benefit of RT when administered following surgery. The retrospective study was designed to measure the incremental benefit of adjuvant RT after surgery on control of the primary lesion when compared with patients undergoing surgical therapy alone for squamous cell carcinoma of the oral cavity.

Study Design Retrospective chart.

Methods Previously untreated patients with squamous cell carcinoma of the floor of mouth or oral tongue who were treated between 1974 and 1998 were eligible for study. A minimum follow‐up of 2 years was required. Tumor site, stage, and RT data were correlated with local control.

Results Patients with missing or incomplete data and those lost to follow‐up or dead as a result of intercurrent disease with follow‐up of less than 2 years were censored. A group of 211 patients who could be evaluated was available for the study. Radiation therapy was administered postoperatively to 58 patients, and 153 patients were treated with surgery alone. In the group treated with combined therapy, the average irradiation dose was 5850 cGy; this group included 35 patients who received more than and 16 who received less than 5700 cGy.

Conclusions The incremental benefit in terms of control of tumor at the primary site for patients receiving postoperative RT was between 0% and 7%. Surgery alone controlled 80% to 85% of primary tumors. The dose of postoperative RT did not correlate with local control.
Inhibition of Epidermal Growth Factor Receptor Signaling Decreases p63 Expression in Head and Neck Squamous Carcinoma Cells
Authors: Matheny Keith E. , Barbieri Christopher E. , Sniezek Joseph C. , Arteaga Carlos L. , Pietenpol Jennifer A.
Published: November 2003

Objectives/Hypothesis Both the epidermal growth factor receptor (EGFR) and the p53 homologue p63 are overexpressed in a significant number of cases of head and neck squamous cell carcinoma (HNSCC). Epidermal growth factor receptor and p63 both possess oncogenic properties, including the potential to increase cell proliferation and antagonize apoptosis. ZD1839 (“Iressa”) is an adenosine triphosphate–competitive inhibitor specific to the EGFR tyrosine kinase currently under evaluation as a chemotherapeutic agent in HNSCC. The objective was to investigate whether p63 expression is decreased after treatment of HNSCC cells with ZD1839. Downregulation of p63 by ZD1839 would identify a potential molecular relationship between EGFR signaling and p63 and could provide insight into the mechanism of action of ZD1839.

Study Design In vitro examination of p63 expression after ZD1839 treatment.

Methods A human HNSCC cell line, SCC‐012, was treated with varying doses of ZD1839. p63 protein and messenger RNA levels were analyzed by Western and Northern blot analyses. The effect of ZD1839 on SCC‐012 cell cycle was analyzed by flow cytometric analysis.

Results In SCC‐012 cells there was a dose‐dependent decrease in p63 protein and messenger RNA levels over the course of ZD1839 treatment. Levels of phosphorylated MAPK decreased and p27KIP‐1 levels increased after ZD1839 treatment. ZD1839 treatment induced a twofold increase in G1‐phase cells and a 3.5‐fold decrease in S‐phase cells consistent with growth arrest.

Conclusion ZD1839 downregulates p63 expression at the messenger RNA level, suggesting that p63 is a downstream target of EGFR signaling.
Otoplasty: An Analysis of Technique Over a 33‐Year Period
Authors: Stucker Fred J. , Vora Neil M. , Lian Timothy S.
Published: November 2003

Objective To compare the merits of otoplasty technique with a diverse patient population as experienced spanning a period greater 30 years.

Study Design A review of a series of otoplasty cases that occurred in two distinctly different clinical settings during a 33‐year period.

Methods A retrospective analysis of 211 patients undergoing otoplasty from 1969 to 1982 in a military hospital setting was compared with 118 patients receiving otoplasty from 1982 to 2002 in a university/private practice setting. The patient population consisted of 180 adults and 149 children.

Results Otoplasty patients in the military setting were primarily adults, whereas those in the university/private practice setting were primarily children. In the adult population, 98.9% of patients required use of lateral conchal cartilage resection combined with a mattress suture technique. In the pediatric population, all patients required use of a mattress suture technique and in 83.2% of selected cases limited lateral conchal cartilage resection was required.

Conclusion Otoplasty technique involving lateral conchal cartilage resection, mattress suture fixation, or a combination of both is applicable to diverse patient populations.
Videofluoroscopic Swallow Studies in Unilateral Cricopharyngeal Dysfunction
Authors: Halum Stacey L. , Merati Albert L. , Kulpa Judith I. , Danielson Susan K. , Jaradeh Safwan S. , Toohill Robert J.
Published: November 2003

Objectives/Hypothesis Although the cricopharyngeus muscle is a ring‐like structure, unilateral cricopharyngeal dysfunction can produce significant dysphagia. This entity has not been well described in the literature. The aims of the study were to identify the characteristic findings on videofluoroscopic swallow studies in patients with dysphagia secondary to unilateral cricopharyngeal dysfunction, to note the associated vagal nerve injury, and to evaluate patient outcomes following ipsilateral cricopharyngeal myotomy.

Study Design Retrospective clinical investigation.

Methods The clinic charts, electromyographic tests, videostroboscopic examinations, and videofluoroscopic swallow studies were reviewed from a series of patients who presented to our institution from 1993 to 2001 with dysphagia and findings on videofluoroscopic swallow studies suggestive of unilateral cricopharyngeal dysfunction on posterior–anterior view. In patients treated with ipsilateral cricopharyngeal myotomy, postoperative findings on swallow studies and patient outcomes were also reviewed.

Results Eighteen patients demonstrated findings characteristic of unilateral cricopharyngeal muscle dysfunction on videofluoroscopic swallow study. The common feature was a unilateral shelf‐like barrier at the cricopharyngeus on the posterior–anterior view with pooling of liquid bolus in the ipsilateral pyriform sinus and episodic shunting to the contralateral side. Eight patients did not have evidence of cricopharyngeal dysfunction (ie, cricopharyngeal bar) on lateral films. Of the 18 patients, 14 had histories consistent with vagal injury secondary to trauma (n = 2), neoplastic involvement (n = 7), iatrogenic injury (n = 2), or central nervous system disease (n = 3). Results of videostroboscopic examinations demonstrated vocal fold motion impairment in 14 patients, and electromyographic test results confirmed unilateral vagal injuries in those who underwent electromyographic testing (n = 6). In the remaining 4 of 18 patients, videostroboscopic examinations demonstrated normal vocal fold abduction but impaired lengthening with a posterior glottic gap, and electromyographic test results (n = 4) indicated unilateral superior laryngeal nerve involvement. Of the 15 patients treated with ipsilateral cricopharyngeal myotomy, 1 patient required postoperative esophageal dilations for an esophageal stricture distal to the cricopharyngeus, whereas the remaining 14 patients had functional resolution of their dysphagia.

Conclusion In patients presenting with dysphagia and evidence of unilateral vagal injury, careful assessment of posterior–anterior view on videofluoroscopic swallow study should be included to evaluate for unilateral cricopharyngeal dysfunction.
A Murine Model of Cholesteatoma‐Induced Bone Resorption Using Autologous Dermal Implantation
Authors: Sudhoff Holger , Liebehenz Yvonne , Aschenbrenner Jessica , Jung Jae , Hildmann Henning , Dazert Stefan
Published: November 2003

Objective To investigate a novel murine model for dermal implant–induced osteolysis analogous to bone resorption observed in middle ear cholesteatoma.

Study Design Animal experiment.

Methods We placed autologous dermal implants on the surface of mouse calvaria. The calvaria were examined at days 1, 3, 5, 7, and 14 after implantation by histological study and tartrate‐resistant acid phosphatase immunohistochemical processing to detect osteoclasts.

Results Dermal implants showed a significantly increased osteoclast density compared with control samples. The dermal implant tissue remained viable and produced a robust, localized inflammatory osteolytic response on the adjacent calvarial surface. Osteoclasts were predominantly found on the surface of the calvarium with the greatest osteoclast density seen at 5 to 7 days after implantation.

Conclusion The mouse model is expected to be a useful tool for investigating the pathogenesis of localized inflammatory bone resorption related to cholesteatoma.
Endonasal Laser Dacryocystorhinostomy: Its Role in Anticoagulated Patients
Authors: Smithard A. , Wynne D. , Bingham B. J. G. , Jones N. S.
Published: November 2003

Objective To report the results of endoscopic laser‐assisted dacryocystorhinostomy in anticoagulated patients.

Study Design A retrospective study of 16 consecutive anticoagulated patients with distal nasolacrimal duct obstruction treated by endoscopic laser‐assisted dacryocystorhinostomy.

Methods A case note review was made of all patients treated with endoscopic laser‐assisted dacryocystorhinostomy who were taking coumadin in two centers between 1993 and 2000. The parameters of age, gender, indications for surgery, surgical findings, complications, and outcome were analyzed. The mean follow‐up time was 14 months (range, 9–26 mo).

Results Fifteen of the 16 patients who were treated had an eventual successful outcome, but 6 patients required revision surgery. The patient whose symptoms were not improved was shown to have functional epiphora. No patient had a problem with primary or secondary epistaxis, and no patient required admission. A major benefit was the lack of disruption of anticoagulant therapy.

Conclusions Endoscopic laser‐assisted dacryocystorhinostomy is a safe, efficient technique for the relief of distal nasolacrimal duct obstruction in anticoagulated patients. Not only does it avoid any disruption to their anticoagulant therapy, but it also can be performed as an outpatient procedure.
Ipsilateral Full‐Thickness Forearm Skin Graft for Covering the Radial Forearm Flap Donor Site
Authors: Shiba Keisuke , Iida Yumiko , Numata Tsutomu
Published: November 2003

Objectives/Hypothesis The technique of the ipsilateral full‐thickness forearm skin graft for covering the defect of radial forearm free flap (RFFF) improves aesthetic impairment at the recipient and donor sites by split‐thickness skin graft repair and omits the need to make an extraoperative site for harvesting the skin graft. However, in this technique, the RFFF is limited in size. In the present study, we considered a model of the forearm and calculated the possible size of the RFFF for using this technique.

Methods The calculation was conducted under assumptions that the isosceles‐triangle skin graft is elevated as its height is twice the RFFF length in the direction of the forearm axis and that the forearm skin defect can be primarily closed with a width shorter than one‐fourth of the wrist circumference. The calculation revealed that this technique is feasible when the RFFF width, that is, the length vertical to the forearm axis, is shorter than half of the wrist circumference. We repaired the RFFF defect using this technique in 15 patients with head and neck cancer in whom the RFFF size conformed to the above‐mentioned condition.

Results When the RFFF width was shorter than half of the wrist circumference and the isosceles‐triangle skin graft was elevated as its height was twice the RFFF length, the RFFF defect could be repaired using this technique in all 15 patients.

Conclusion The above‐mentioned condition (that the RFFF width is shorter than half of the wrist circumference) is useful for determining whether or not the technique of ipsilateral full‐thickness forearm skin graft can be used for covering the RFFF defect.
A Case of Paranasal Sinus Angiolipoma
Authors: Pfannenstiel Travis J. , Boseley Mark , Roach Latonia
Published: November 2003

Objective To present the first documented case of an angiolipoma of the maxillary sinus, our treatment of the patient, and the 1‐year follow‐up results. At the conclusion of the report, the reader should be able to discuss the incidence, treatment options, and long‐term prognosis of angiolipomas of the paranasal sinuses.

Study Design A case study reporting on a single patient with the diagnosis of maxillary sinus angiolipoma.

Methods Review of diagnostic studies, the operative technique, and the patient's chart for the 1‐year period after treatment.

Results The patient remains free of disease 1 year after definitive surgical treatment.

Conclusions Angiolipomas are exceedingly rare in this location. The accepted treatment for this disease in other regions of the body consists of wide local excision with close follow‐up. The extent of the disease found in this patient required a medial maxillectomy for en bloc resection. We would advocate such an approach for other physicians who are faced with a patient with this rare diagnosis.
Quality of Life Assessment in Nasal Airway Obstruction
Authors: Rhee John S. , Book David T. , Burzynski Mary , Smith Timothy L.
Published: November 2003

Objectives/Hypothesis Quality of life (QOL) assessment of patients with nasal obstruction has not been well studied. The objectives of the study were to determine the QOL of patients with nasal obstruction, to identify baseline variables predictive of patients' QOL, and to examine the relationship of QOL scores with patient assessment of nasal obstruction.

Study Design Preliminary, cross‐sectional study of a larger, prospective investigation.

Methods Forty individuals met the criteria for inclusion. Participants were required to have a surgically treatable diagnosis of septal deviation, nasal valve collapse, and/or turbinate hypertrophy. Quality of life assessment was performed using the Rhinoconjunctivitis Quality of Life Questionnaire and the Rhinosinusitis Disability Index. Demographic data, along with patient assessment of nasal obstruction with a visual analogue scale, were recorded.

Results Both instruments demonstrated good inter‐item correlation as measured by Cronbach's alpha. Demographic variables, previous nasal surgeries, and comorbid conditions were not significantly correlated with QOL scores with either instrument. Correlations between visual analogue scale scores and the Rhinoconjunctivitis Quality of Life Questionnaire “sleep” (correlation coefficient [r] = 0.35, P = .02) and “nasal symptom” (r = 0.36, P = .02) domains demonstrated a trend toward significance. Patients with nasal valve collapse reported higher visual analogue scale scores for nasal obstruction compared with those with septal deviation alone (P <.01).

Conclusions Patients with nasal valve collapse demonstrated greater perception of nasal obstruction than those with septal deviation alone. The Rhinoconjunctivitis Quality of Life Questionnaire appears to be a more sensitive instrument than the Rhinosinusitis Disability Index for patients with nasal obstruction. However, existing measures may lack sensitivity in estimating the QOL of patients with nasal obstruction. A disease‐specific instrument for nasal obstruction may be necessary to further evaluate this disease process.
Age‐Related Mechanisms of Cricoid Cartilage Response to Injury in the Developing Rabbit
Authors: Cherukupally Shilpa Reddy , Adams Allison B. , Mankarious Leila A.
Published: November 2003

Objective To evaluate age‐related mechanisms of cricoid cartilage response to injury in an animal model.

Study Design A pilot study using monoclonal antibodies to chondrocyte proliferation markers collagen II, aggrecan, and proliferating cell nuclear antigen (PCNA) to evaluate age‐related response of injured cricoid cartilage.

Methods Twenty‐seven New Zealand white rabbits aged 4 weeks, 8 weeks, and 1.5 years were studied. Six animals in each age group underwent intracartilaginous injury through cricofissure and tracheofissure. Three animals of each group were used as control subjects. The animals were killed 4 weeks after injury, their cricoid cartilages harvested, and 7‐μm sections of tissue obtained. The cricoid tissue sections were stained with immunofluorescent monoclonal antibody markers to collagen II, aggrecan, and PCNA.

Results In all age groups, no control animals had symptoms of airway compromise or immunohistochemical abnormality. For all three markers of chondrocyte proliferation, the 4‐week‐old animals showed markedly increased staining at the injured edges of cartilage. The 8‐week‐old animals showed mild increased extracellular staining, and the 1.5‐year‐old animals showed no increased staining compared with uninjured areas of the cricoid ring and with control animals.

Conclusion There was a progressive, age‐related attenuation of staining for markers of chondrocyte proliferation in the 8‐week and 1.5‐year‐old rabbits compared with the 4‐week‐old rabbit cricoids.
Dermatofibrosarcoma Protuberans of the Head and Neck: Treatment With Mohs Surgery Using Inverted Horizontal Paraffin Sections
Authors: Tom William David , Hybarger Charles Patrick , Rasgon Barry Mitchell
Published: November 2003

Objective To describe results of treating dermatofibrosarcoma protuberans of the head and neck with a Mohs surgical technique in which tumor margins were evaluated with inverted horizontal paraffin sections to identify the margin of resection necessary to achieve tumor‐free borders.

Study Design Retrospective case study of nine patients.

Methods In each case, Mohs surgery using inverted horizontal frozen‐section analysis was continued until tumor‐free margins were achieved. The tumor‐free specimens collected during this procedure were immediately reprocessed by using inverted horizontal paraffin sectioning, and the histological results of the two techniques were compared. To identify the margins of resection needed to achieve tumor‐free margins, preoperative lesion size was compared with postoperative defect size.

Results Paraffin section analysis showed persistent tumor in seven of the nine patients in whom the frozen‐section technique was used to clear the tumor. Tumor‐free margins were achieved in all patients by using one additional excision. The tumor had spread extensively beyond clinical margins and required a mean minimum margin of 3.7 cm around the gross area of tumor (margin range, 2.5–6.0 cm). Patients treated by this technique showed no local, regional, or distant recurrence at follow‐up performed at a mean time of 43 months postoperatively (range, 19–74 mo).

Conclusions Dermatofibrosarcoma protuberans of the head and neck is a tumor that shows extensive infiltration beyond gross margins. Wide local excision with 2‐ to 3‐cm margins results in an unacceptably high recurrence rate; larger excisional margins are necessary to remove all disease. Accurate margin identification achieved by using Mohs surgery with rush paraffin section analysis results in complete tumor removal and excellent control rates. This method should be preferred for treatment of dermatofibrosarcoma protuberans of the head and neck.
Alpha 1‐Antitrypsin and Ilomastat Inhibit Inflammatory Proteases Present in Human Middle Ear Effusions
Authors: Antonelli Patrick J. , Schultz Gregory S. , Kim Karen M. , Cantwell John S. , Sundin David J. , Pemberton Philip A. , Barr Philip J.
Published: November 2003

ObjectivesProteases of both the serine and metalloproteinase families have been shown to play a role in the pathogenesis of otitis media (OM). Inhibitors of proteases from each of these families have been shown to beneficially impact disease progression in a number of related chronic inflammatory conditions, but their use has not been studied in OM. The purpose of this study was to assess the activity of the protease inhibitors recombinant alpha 1‐antitrypsin (rAAT) and ilomastat on inflammatory proteases present in human middle ear effusions (MEEs), with a view to their potential utility in the treatment of OM.

Study DesignProspective and ex vivo.

MethodsMEEs were collected from 100 patients presenting for middle ear surgery, most commonly tympanostomy tube placement or treatment of acute posttympanostomy otorrhea (APTO). MEEs were analyzed for the presence of matrix metalloproteinases (MMPs) and human neutrophil elastase (HNE) and the inhibitory activity of rAAT and ilomastat on these proteases, respectively.

ResultsMMP levels were highest in APTO, and HNE was highest in chronic suppurative OM and APTO. High levels of MMP and HNE (>3 mAU/min) were found in 52% and 37% of MEEs, respectively. Ilomastat and rAAT demonstrated significant inhibition of MMP and HNE activity (>30% reduction), respectively, in 80% and 82% of MEEs with high levels of activity.

ConclusionsProteases are commonly found in OM. Ilomastat and rAAT are potent inhibitors of proteases in MEEs across a wide range of OM in humans. Investigation into the potential therapeutic benefits of these protease inhibitors is warranted.
Botulinum Neurotoxin for Pharyngeal Constrictor Muscle Spasm in Tracheoesophageal Voice Restoration
Authors: Hamaker Ronald C. , Blom Eric D.
Published: November 2003

Objectives/Hypothesis The purpose of the study was to evaluate the effectiveness of Botulinum neurotoxin (Botox) for elimination of pharyngeal constrictor muscle spasm in tracheoesophageal voice restoration.

Study Design A retrospective review was made of 62 patients between 1991 and 2002 who had Botox as the initial treatment for pharyngeal constrictor muscle spasm.

Methods One hundred units of Botox properly diluted in 3 mL saline was instilled unilaterally under electromyographic guidance after fluoroscopic identification and marking of the contracted pharyngeal constrictor muscles. The patients were divided into three groups based on their response to the first Botox injection: group I, complete relaxation of the pharyngeal constrictors resulting in fluent voice, intratracheal phonation pressure of 20 to 40 cm H2O, and the ability to say 15 to 20 uninterrupted syllables; group II, hypertonic or incomplete relaxation of the pharyngeal constrictors resulting in intratracheal phonation pressure of 45 to 70 cm H2O and the ability to say 7 or 8 syllables; and group III, failure to produce relaxation of the pharyngeal constrictors.

Results After the first injection of Botox, 49 (79%) patients were in group I or II (41 in group I and 8 in group II) and group III consisted of 13 patients. Thirty‐four patients (55%) had group I (28) or II (6) responses for greater than 6 months. A second Botox injection enabled 6 of the 13 failures to move into group I. In all, 8 pharyngeal constrictor muscle myotomies (13%) were ultimately required in the 62 patients. The group I speaker for the longest period has enjoyed 11 years of fluency and successful daily use of a tracheostoma valve after two Botox injections.

Conclusion Botox relaxation of the pharyngeal constrictor muscles has proven to be effective, has replaced secondary pharyngeal myotomy for the initial treatment of pharyngeal muscle spasm, and is the only treatment in patients who are not candidates for elective surgery. Radiographic assessment, electromyographically monitored injection, and the number of Botox units appear to be important to successful outcomes.
Invasive Fungal and Bacterial Infections of the Temporal Bone
Authors: Marzo Sam J. , Leonetti John P.
Published: November 2003

Objectives/Hypothesis Objectives were to highlight the importance of surgical therapy in treating invasive polymicrobial infections of the temporal bone, to discuss the importance of antifungal therapy, and to review the differential diagnosis of ear canal granulomatous disorders.

Study Design Retrospective case review at a tertiary care medical center.

Methods A retrospective chart review of all patients diagnosed with invasive polymicrobial temporal bone infections was performed. Four patients were identified. All patients required surgical therapy for definitive management. All patients were followed for at least 1 year or until death.

Results Three of four patients had invasive fungi as pathogens. One patient had an occult squamous cell carcinoma. At the time of writing, one patient was free of disease, two were dead of disease, and one was alive with disease.

Conclusion Invasive polymicrobial temporal bone infections can occur in immunocompromised patients and can possibly harbor an occult malignancy. Surgical debridement may be necessary to arrive at a correct diagnosis. Modified radical mastoidectomy with parenteral antibiotic therapy and other adjunctive measures may be necessary for disease resolution.
Tutorials in Clinical Research: Part VII. Understanding Comparative Statistics (Contrast)–Part A: General Concepts of Statistical Significance
Authors: Neely J. Gail , Hartman James M. , Forsen James W. , Wallace Mark S.
Published: November 2003

Objectives/Hypothesis The present tutorial is the seventh in a series of Tutorials in Clinical Research. The specific purpose of the tutorial (Part A) and its sequel (Part B) is to introduce and explain three commonly used statistical tools for assessing contrast in the comparison between two groups.

Study Design Tutorial.

Methods The authors met weekly for 10 months discussing clinical research studies and the applied statistics. The difficulty was not in the material but in the effort to make the report easy to read and as short as possible.

Results The tutorial is organized into two parts. Part A, which is the present report, focuses on the fundamental concepts of the null hypothesis and comparative statistical significance. The sequel, Part B, discusses the application of three common statistical indexes of contrast, the χ2, Mann‐Whitney U, and Student t tests.

Conclusions Assessing the validity of medical studies requires a working knowledge of research design and statistics; obtaining this knowledge need not be beyond the ability of the busy surgeon. The authors have tried to construct an accurate, easy‐to‐read, easy‐to‐apply, basic introduction to comparing two groups. The long‐term goal of the present tutorial and others in the series is to facilitate basic understanding of clinical research, thereby stimulating reading of some of the numerous well‐written research design and statistical texts. This knowledge may then be applied to the continuing educational review of the literature and the systematic prospective analysis of individual practices.
Lesion Formation in Radiofrequency Surgery of the Tongue Base
Authors: Stuck Boris A. , Köpke Julian , Maurer Joachim T. , Verse Thomas , Eckert Andreas , Bran Gregor , Düber Christoph , Hörmann Karl
Published: November 2003

Objectives Temperature controlled radiofrequency volumetric tissue reduction (RFVTR) of the tongue base is a minimally invasive technique for the treatment of obstructive sleep apnea. But despite its widespread use, little is yet known about in vivo effects in humans. Such knowledge would be essential for evidence‐based criteria in the selection of energy application.

Methods In a preparatory in vitro study, porcine tongues were preserved in growing medium. Lesions with different amounts of energy were applied, and maximum diameters were assessed. In the in vivo study, 11 patients were treated with RFVTR at the tongue base by employing different energy levels (800, 600, 400, or 200 J) on two application sites. Magnetic resonance imagery scans were performed 4 to 6, 8 to 10, and 24 hours after surgery. An inversion recovery technique was used to visualize the lesions.

Results RFVTR created lesions at the porcine tongue from 50 J and higher. Maximum lesion sizes were achieved with 400 J. In vivo, all the lesions were clearly visible in the postoperative scans. Lesion size increased with the amount of energy applied. Maximum diameters were created from 600 J and higher. Higher amounts of energy only resulted in a slight increase in lesion length.

Conclusions The application of 600 J at 85°C leads to optimal lesion sizes. Higher amounts of energy will not lead to a relevant increase in tissue necrosis. With regard to the time needed for application, 600 J appears to be the ideal adjustment for energy delivery in the treatment of the human tongue.
Modified Maxillomandibular Advancement for the Treatment of Obstructive Sleep Apnea: A Preliminary Report
Authors: Goh Yau Hong , Lim Kheng Ann
Published: November 2003

Objective A prospective study to evaluate the modified maxillomandibular advancement (MMA) technique for the treatment of obstructive sleep apnea (OSA).

Methods Eleven patients underwent modified MMA for the treatment of OSA. All the patients underwent presurgical and postsurgical polysomnography, nasolaryngoscopy, and clinical facial photographic assessment. The results were analyzed after a minimum of 6 months postsurgery (mean, 7.7 months).

Results The preoperative polysomnography results were as follows: apnea index, 55.7 ± 19.8; apnea‐hypopnea index, 70.7 ± 15.9; lowest oxygen saturation, 58.6 ± 12.3%; longest apnea/hypopnea, 67.9 ± 23.7 seconds; and arousal index, 47.1 ± 18.2. The postoperative polysomnography results were as follows: apnea index, 3.4 ± 3.4; apnea/hypopnea index, 11.4 ± 7.4; lowest oxygen saturation, 83.9 ± 8.8%; longest apnea/hypopnea, 38.2 ± 24.6 seconds; and arousal index, 15.1 ± 7.3. The mean postoperative body mass index (BMI) was 27.2 ± 3.3. The mean BMI change after surgery was 6.5%.

Conclusion The preliminary review has demonstrated that the modified MMA technique for the treatment of OSA is highly effective in the treatment of severe OSA without the significant facial profile change commonly associated with the traditional MMA technique.
Paratracheal Lymph Node Involvement in Advanced Cancer of the Larynx, Hypopharynx, and Cervical Esophagus
Authors: Timon Conrad V. , Toner Mary , Conlon Brendan J.
Published: November 2003

Objectives/Hypothesis The presence of nodal metastatic disease in head and neck cancer is the foremost prognostic factor. Although neck dissection is the surgical gold standard for the treatment of cervical lymphatic spread, the paratracheal nodal group is not routinely included in the dissection. The study determined the nodal yield, presence of metastases, and prognostic importance of paratracheal nodes in patients with advanced carcinoma of the upper aerodigestive tract.

Study Design Prospective histological and survival analysis.

Methods Over a 4‐year period (October 1994–June 1998), consecutive patients undergoing laryngectomy with or without pharyngectomy or cervical esophagectomy underwent paratracheal node dissection on a prospective basis. Nodal tissue was examined for the presence of metastases. Statistical comparison of survival probability was determined by use of log‐rank/χ2 test.

Results Fifty patients have been included in the study to date, with a minimal follow‐up of 3 years. The average number of paratracheal nodes dissected was three per side (range, 1–5). Thirteen (26%) patients demonstrated histological evidence of paratracheal nodal metastases (larynx, 20%; postcricoid/cervical esophageal region, 43%). Five patients (10%) had positive paratracheal nodes alone in a histologically negative cervical neck dissection. The majority of positive paratracheal nodes were less than 1 cm in diameter and appeared negative preoperatively. The absence of positive paratracheal nodes may have a survival benefit.

Conclusion The study highlighted the propensity of advanced carcinoma of the upper aerodigestive tract to involve the paratracheal nodes. This area should be routinely dissected in the surgical management of these tumors.