Inferior turbinectomy versus submucosal diathermy for inferior turbinate hypertrophy.

In order to compare and evaluate bilateral inferior turbinectomy (BIT) and submucosal diathermy (SMD), we retrospectively examined these two well-known techniques for treatment of nasal obstruction due to bilateral congestion of the inferior turbinates. One hundred patients with bilateral nasal obstruction were divided into 4 groups according to their nasal airflow patency. Forty-nine patients underwent BIT, and 51 patients underwent SMD. All 100 patients were followed for 2 months after surgery. Patients with difficult postoperative courses were followed up to 1 year after surgery, in order to decide on the necessity of operative revision. Postoperative improvement in nasal breathing after BIT was reported for 96% of patients 2 weeks after surgery, and for 88% 2 months after surgery. Only 1 BIT patient had to undergo revision operation. Diathermy showed good results in 78% of cases 2 weeks after surgery. The efficacy of the procedure was reduced to 76% 2 months after surgery. Twenty percent of SMD patients were advised to undergo operative revision. Postoperative bleeding occurred in 20% of BIT patients and in only 4% of SMD patients. We found that the extent of postoperative improvement does not depend on preoperative conditions; therefore, it is impossible to predict the extent of postoperative improvement on the basis of the results of preoperative assessment. Both procedures can be performed under local anesthesia, are relatively safe and effective, and do not need expensive instrumentation that may not be available in many medical centers.

Effects of peritonsillar infiltration on post-tonsillectomy pain. A double-blind study.

The concept that local infiltration of the operative area with a local anesthetic when using general anesthesia could alleviate postoperative pain is well known. We tested this concept on 129 patients scheduled for elective tonsillectomy. The patients were investigated in a double-blind, randomized study, and the operation was carried out via the standard technique of infiltrating the peritonsillar area preoperatively. The results indicated that preincisional infiltration of the tonsils with bupivacaine hydrochloride markedly decreased the intensity of pain following tonsillectomy, well beyond the immediate postoperative period.

Drug-induced tinnitus and other hearing disorders.

Tinnitus and hearing loss, both reversible and irreversible, are associated both with acute intoxication and long term administration of a large range of drugs. The mechanism causing drug-induced ototoxicity is unclear, but may involve biochemical and consequent electrophysiological changes in the inner ear and eighth cranial nerve impulse transmission. Over 130 drugs and chemicals have been reported to be potentially ototoxic. The major classes are the aminoglycosides and other antimicrobials, anti-inflammatory agents, diuretics, antimalarial drugs, antineoplastic agents and some topically administered agents. Prevention of drug-induced ototoxicity is generally based upon consideration and avoidance of appropriate risk factors, as well as on monitoring of renal function, serum drug concentrations, and cochlear and auditory functions before and during drug therapy. Ototoxicity, although not life-threatening, may cause considerable discomfort to patients taking ototoxic drugs, and in some cases drug discontinuation may be necessary to prevent permanent damage. Much research has been performed to investigate the causes and mechanisms of ototoxicity, to try to prevent this complication. Despite these efforts, ototoxicity still occurs, and there is much work to be done in order to understand the mechanism of ototoxicity of different drugs and to prevent hearing loss and tinnitus in the future.

Nd:YAG laser turbinate surgery animal experimental study: preliminary report.

The chronically hypertrophic nasal turbinate is a challenging problem for otolaryngologists. Although some success has been achieved with a number of medical and surgical methods, other forms of treatment are still needed. In this study, encouraging results were achieved using the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser on canine turbinates. Clinical and histological results showed that with Nd:YAG laser surgery, coagulation occurs in the deep cavernous vessels and submucosal glands of the turbinate, while the overlying mucosa remains intact.

Complication of jet ventilation during microlaryngeal surgery.

Complications during jet ventilation for microlaryngoscopy, which is usually a relatively safe procedure, are rare. Those described have included hypoventilation, pneumothorax, pneumomediastinum, subcutaneous emphysema, pneumoperitoneum, and gastric distention. We describe herein a case of a life-threatening complication during jet ventilation with a Carden's tube that ended in laparotomy.

Periosteum-wrapped alloplasts for reconstructive head and neck surgery.

Methylmethacrylate is widely used by orthopaedic and neurosurgeons for bone reconstruction. However, there is not much information about the interaction between methylmethacrylate and soft tissues. A prospective canine study was designed to examine the morphologic and histologic aspects of the use of methylmethacrylate with soft tissues. A previous study has shown that by wrapping the prosthesis with dense connective tissue, such as periosteum, better results can be achieved in tracheal reconstruction. Ten wrapped and 10 unwrapped pieces of methylmethacrylate were implanted in dogs, and were removed at intervals of 2, 4, 8, 11 and 16 weeks. Gross morphologic and histologic examination showed better incorporation of the wrapped implants into the surrounding soft tissues with less inflammation when compared to the unwrapped pieces. We suggest that connective tissue wrapped methylmethacrylate alloplasts are better tolerated by surrounding soft tissues and may lead to improved reconstructive results.

Controlled laryngoplasty for vocal cord medialization: a technique using tissue expansion.

Laryngeal framework surgery has become an increasingly popular alternative to Teflon injection for vocal rehabilitation. Vocal cord medialization requires custom tailoring of the implant's size and shape to optimize individual vocal quality, whether it be via the interposition of Silastic implants between the thyroid ala and the inner thyroid perichondrium or through a cartilage window. A new technique is described for vocal cord medialization using an implanted miniature tissue expander. Intraoperative and postoperative vocal cord medialization was achieved in a canine model by controlled percutaneous filling of a remote injection valve. The implants were well tolerated and allowed continued control of vocal cord position for several weeks. Using this technique, vocal quality can be fine-tuned with a degree of precision not previously possible. The advantages, limitations, and technical aspects of expansion laryngoplasty are discussed.

[A new operative technique for deformations of the nose and septum].

Deviations of the external nasal pyramid, together with the nasal septum, are quite common but unfortunately, difficult to manage. We present our experience in 310 operations using the transfixion approach and repositioning of the nasal septum in the midline. This is done by scoring the septal cartilage in its basal attachment to the maxillary crest, providing a "swinging door" which can be sutured finally as desired. Our studies in dogs demonstrated that this technique does not cause long-term perforation of the nasal septum.

The combined use of muscle flaps and alloplasts for tracheal reconstruction.

This report documents our experience with a different concept in reconstructive head and neck surgery. This concept, we hoped, would enable us to reconstruct anatomic regions with a special contour that is otherwise difficult to achieve with conventional flaps and grafts. The first stage of this method includes implantation of a preshaped alloplastic material in a donor site of a commonly used myocutaneous flap and waiting 4 to 6 weeks for the implant to "take." The second stage includes raising the pedicled flap with the implant and transferring it to reconstruct the defect. As a model for this approach, tracheal defects in dogs were created and reconstructed. The technique used in this study can be specifically applied to reconstruction of tracheal defects, ie, subglottic stenosis, and also can be used for other defects in the head and neck region.

Auditory brainstem evoked potentials in evaluating the efficacy of surgical ventilation of the middle ear.

Conductive hearing loss in children is most commonly associated with Secretory otitis media (S.O.M.). Since auditory brainstem evoked potentials (ABEP) reflect conductive damage in prolonged peak latencies, the present study evaluated the efficacy of surgery for ventilating the middle ear, by comparing changes in peak latencies. These changes were compared in 4 groups of children (4-12 years old): children with S.O.M. in the past, who recovered as a result of conservative treatment; children with S.O.M. in the past, who had been operated on with insertion of ventilation tubes (V.T.); children with S.O.M. in the past, who had been operated on and who still had V.T. at the time of study, and a control group with healthy ears. In all, 183 ears were tested. The results indicate that there is no significant audiometric and electrophysiological difference between the groups who recovered with or without V.T.

Auditory brainstem evoked potentials in asymptomatic lead-exposed subjects.

Auditory Brainstem Evoked Potentials (ABEP) were recorded from 29 adults and children, accidentally exposed to lead through food until approximately a year prior to this study. ABEP were recorded in response to 75 dBHL clicks presented at rates of 10/sec. and 55/sec. Average values were calculated for peak latency and for interpeak latency differences. Average values of the effect of increasing stimulus rate were calculated as well. Similar values were calculated for normative child and adult control groups. IPLD(I-III) showed the most significant and recurring results, with longer intervals in lead-exposed children compared with their control group. Increasing stimulus rate, on the other hand, affected the adult lead-exposed subjects more than the children. These results may imply an impairment of the peripheral portion of the auditory system with axonal and myelin involvement. ABEP is suggested as a sensitive detector of subclinical lead exposure effects on the nervous system.

Auditory brainstem evoked potentials in insulin-dependent diabetics with and without peripheral neuropathy.

Auditory Brainstem Evoked Potentials (ABEP) were recorded from 33 insulin-dependent diabetes mellitus (IDDM) patients (17 with diabetic peripheral neuropathy and 16 without) as well as from 20 normals. Pure-tone audiometry, speech reception threshold and discrimination were also evaluated. Sub-clinical pure-tone threshold elevation was observed for IDDM patients with neuropathy. Pure-tone thresholds of IDDM patients without neuropathy were not significantly different from those of normals. ABEP abnormality (at 10/sec click rate) was observed in 31% of IDDM patients with neuropathy, rising to 44% when 55/sec click rate measures were included. Abnormalities included bilateral and symmetrical peak-latency prolongations for all waves, greater for the later waves, and prolongation of V-I and V-III interpeak latency differences, all at 10/sec, and only prolonged peak latency for I at increased rate. Abnormalities coincided with microangiopathy and peripheral neuropathy. The incidence of ABEP abnormality for IDDM patients without neuropathy was only 12%, unilateral and sporadic in nature. As a group, IDDM patients with neuropathy had significantly prolonged IV and V peak-latencies, compared with the normals, or with the IDDM patients without peripheral neuropathy. In contrast, IDDM patients without neuropathy resembled the normals in all respects. ABEP have proven useful in understanding the variety of pathologies underlying the clinical manifestation of diabetes.

Auditory brain-stem evoked potentials in patients undergoing dialysis.

Auditory brain-stem evoked potentials (ABEPs) and pure-tone audiograms were obtained for 38 patients with renal failure, undergoing dialysis, before and after a dialysis session, and for 40 healthy normal subjects. Blood chemistry was also evaluated for each patient before and after dialysis. ABEP abnormality (using 10/sec click rate) was observed for 24% of the patients, rising to 44% when 55/sec measures were included. Abnormalities included prolongations of peak latencies for both click rates, and prolongation of interpeak latency differences. Pre-dialysis calcium was significantly different between patients with or without ABEP abnormality. In addition to this chronic effect on ABEPs, an acute effect of the dialysis session was found. Blood chemistry data, ABEP latencies and I-III interpeak latency differences were significantly different before, as compared to after dialysis. The acute effect of dialysis on blood calcium levels correlated with its effect on latencies of peaks III and V at 10/sec click rate, and on peaks I and V latency at 55/sec. These results may indicate the types of dysfunction revealed by increased stimulus rate measures.

Auditory brainstem evoked potentials in blast injury.

Blast injury typically consists of a mixed conductive and sensorineural hearing loss. The sensorineural component includes temporary as well as permanent threshold elevations. Auditory brainstem evoked potentials (ABEP) are sensitive to functional changes in various levels along the auditory pathway. ABEP were recorded from 37 survivors of blasts and latency measures were correlated with clinical findings. Prolongation of peak latencies was correlated with the conductive component of blast-induced hearing loss, as well as with the TTS component of the sensorineural impairment. No central effects of blast on the auditory system were detected. In addition to their objectivity, ABEP hold the promise of differentiating between the permanent and temporary effects of blast on hearing.

Applications of auditory evoked potentials to evaluate hearing disorders: assets and limitations.

A variety of auditory evoked potentials for audiometric use are briefly reviewed and their assets and shortcomings discussed. Auditory brainstem evoked potentials provide the most audiometric parameters per patient evaluation time. Illustrative case reports are summarized to demonstrate the assets and pitfalls in evoked potential audiometric evaluations. Frequency contents of the stimulus used to evoke the potentials, the normative values for parameters evaluated, and the notion that the potentials reflect only the functioning of their generators must be constantly borne in mind. The primary concern must be the patient's welfare, and unnecessary procedures should be avoided.

Permanent tracheostomy.

A technique designed to create a permanent, wide open, and stable tracheal stoma is based on two corresponding U-shaped flaps: one from the anterior tracheal wall, the other from the skin in the suprasternal notch. The method described in this article has proved to be efficient, practical, well tolerated, and readily reversible. Its applications when indicated may reduce the side effects and complications associated with tracheostomy. Our clinical experience with this technique covers eight patients who tolerated the procedure well. The follow-up period exceeds 2 years.