MR imaging of patients with carotidynia.

BACKGROUND AND PURPOSE: Carotidynia is an idiopathic neck pain syndrome associated with tenderness to palpation over the carotid bifurcation. Although well known in the otolaryngology and neurology literature, the validity of the entity has recently been questioned, in part because of the almost uniform absence of radiologic or pathologic findings. We report the MR findings in five patients with carotidynia. METHODS: During a period of 44 months, five patients with clinical signs and symptoms consistent with carotidynia were referred for imaging from the otolaryngology service. Each patient underwent MR imaging of the neck on a 1.5-T system. The studies included, as a minimum, pre- and postcontrast axial and postcontrast coronal T1-weighted images. Two patients also had axial T2-weighted imaging and another two patients underwent duplex sonography of the carotids. RESULTS: All five patients had abnormal enhancing tissue surrounding the symptomatic carotid artery centered at the level of the distal common carotid and carotid bifurcation. This tissue had intermediate signal intensity on T1-weighted images and showed marked enhancement. In all patients, the remaining visualized portions of the carotid artery were normal. Normal flow voids were present throughout the vessel, and the caliber of the vessels was always within normal limits. There was no evidence of intramural hematoma, cervical lymphadenopathy, or atherosclerotic disease of the vessel. In one patient, repeat imaging after resolution of symptoms showed an absence of the previous abnormality. CONCLUSION: The MR findings in these patients, along with the lack of any findings to suggest alternative diagnoses, support the existence of carotidynia as a distinct clinical entity.

Corticosteroid treatment for idiopathic facial nerve paralysis: a meta-analysis.

OBJECTIVE: A meta-analysis was designed to evaluate facial recovery in patients with complete idiopathic facial nerve paralysis (IFNP) by comparing outcomes of those treated with corticosteroid therapy with outcomes of those treated with placebo or no treatment. STUDY DESIGN: Meta-analysis of prospective trials evaluating corticosteroid therapy for idiopathic facial nerve paralysis. METHODS: A protocol was followed outlining methods for trial selection, data extraction, and statistical analysis. A MEDLINE search of the English language literature was performed to identify clinical trials evaluating steroid treatment of IFNP. Three independent observers used an eight-point analysis to determine inclusion criteria. Data analysis was limited to individuals with clinically complete IFNP. The endpoints measured were clinically complete or incomplete facial motor recovery. Effect magnitude and significance were evaluated by calculating the rate difference and Fisher's Exact Test P value. Pooled analysis was performed with a random effects model. RESULTS: Forty-seven trials were identified. Of those, 27 were prospective and 20 retrospective. Three prospective trials met the inclusion criteria Tests of heterogeneity indicate the trial with the smallest sample size (RD = -0.19; 95% CI, -0.58-0.20), to be an outlier. It was excluded from the final analysis. Analyses of data from the remaining two studies indicate corticosteroid treatment improves complete facial motor recovery for individuals with complete IFNP. Rate difference demonstrates a 17% (990% CI, 0.01-0.32) improvement in clinically complete recovery for the treatment group based on the random effects model. CONCLUSIONS: Corticosteroid treatment provides a clinically and statistically significant improvement in recovery of function in complete IFNP.

Saline irrigation in the prevention of otorrhea after tympanostomy tube placement.

OBJECTIVES: Comparison of intraoperative saline irrigation to otic drops in the prevention of postoperative otorrhea in children with middle ear effusion undergoing bilateral myringotomy with ventilation tubes. STUDY DESIGN: This study was designed as a blinded, controlled, prospectively randomized trial. METHODS: Study children were randomly assigned to receive either otic drops for 3 days postoperatively or saline irrigation of the middle ear space at the time of myringotomy. Only children with effusion present at the time of surgery were included. All children were evaluated for drainage 7 to 14 days postoperatively, and the degree of drainage was graded from 0 to 4. RESULTS: Of the 84 patients entered into the study, 62 patients were eligible for data analysis (16 failed follow-up, 6 records were lost). Of the patients who completed the study, not all had bilateral effusions, resulting in 111 ears for inclusion in the study. Fifty-two ears underwent irrigation, and 10 were noted to have otorrhea (19.2%). Fifty-nine ears received otic drops, resulting in 21 ears with otorrhea (35.6%). Evaluating the degree of otorrhea with a five-point Leichert scale, the average score per ear was 0.42 for the saline irrigation group and 1.07 for the control group. The rate and degree of drainage were both statistically reduced in the saline irrigation group (P < .05). CONCLUSIONS: Using middle ear irrigation at the time of tympanostomy may be more effective than antibiotic drops in preventing postoperative otorrhea.

Overview of telemedicine applications for otolaryngology.

OBJECTIVE/HYPOTHESIS: As we evolve into the managed care era, telemedicine technologies can help to provide efficiencies for the entire health care system. Our practice is centered around a residency training program in a federal facility. Our goal was to lay the groundwork for an entire service being on-line. STUDY DESIGN: Prospective. METHODS: The stepwise process is as follows: needs assessment to examine what part of the practice would lend itself to telemedicine deployment; usability studies to select the best equipment; study in-house to normalize the technology to the current standard of care comparing control subjects with experimental subjects; and deploying remote units to study remote referral. RESULTS: Video-otoscopy captures the image of an eardrum that can be sent from a remote site in a store-forward mode. After normalizing the standard of care, the potential for diagnosing and treating certain ear conditions such as hearing loss is readily apparent. An audiogram, pertinent laboratory data, and history and physical performed by the referring primary care provider would allow the patient to be seen and triaged virtually. Time savings for the patient and the otolaryngologist would be gained. Initial data indicate a greater than 90% correlation with handheld otoscopy and binocular microscopy. In speech sciences, a need existed to evaluate and treat patients from remote sites where speech therapists are unavailable. The use of live video teleconferencing to evaluate and treat patients in-house has preliminary results that show no difference in outcomes. Studying the proctoring of remote surgeons is also a need, as one of our military missions. Initial data show no difference in outcomes when residents are proctored by attending physicians from a physically separated control room in the hospital. We also participate with the Internet Tumor Board, which links four remote sites with our medical center. Different sites scroll through the slides that are listed on a Web site while linking each site with audio teleconferencing. We are initiating Internet Grand Rounds using the same technology. CONCLUSION: These efforts performed in a stepwise approach will lead to an otolaryngology--head and neck surgery service that is on-line for the next millennium, with telemedicine advances normalized to the standard of care.

Evaluation of lower cranial nerve deficits.

Patients with cranial base tumors often present with cranial neuropathies or develop cranial deficits as a consequence of skull base surgery. Deficits involving cranial nerves IX, X, XI, and XII can lead to significant morbidity for patients. A standard evaluation of a patient with a suspected skull base lesion or a postsurgical patient would consist of a complete history and physical examination, including a bedside examination and videofluoroscopy. Other modalities, including fiberoptic endoscopic examination of swallowing safety, ultrasound, and manofluorography, are used less frequently.

Sodium ipodate (oragrafin) in the preoperative preparation of Graves' hyperthyroidism.

Fourteen Graves' hyperthyroid patients who had been prepared for surgery with sodium ipodate (SI) 500 mg orally twice daily for 3 days were retrospectively studied. SI was administered in combination with propylthiouracil (10 cases) and beta blockers (all cases), which had been previously initiated. Free serum thyroxine (T4) and total triiodothyronine (T3) concentrations were measured before and after SI therapy on the morning of surgery. SI treatment significantly reduced total T3 concentration from 445.9 to 193.4 ng/dL (P < 0.0001) and free T4 concentration from 3.874 to 2.800 ng/dL (P = 0.0003). Preoperatively, only one patient had persistent tachycardia, and intraoperatively this same patient required beta blockers. Blood loss was unremarkable or reduced (average blood loss, 121 mL). On clinical examination glands were firm with normal or somewhat decreased vascularity. On histologic study all glands demonstrated changes consistent with treated Graves' disease. Preoperative treatment with SI appears to be a safe and efficacious method of preparing hyperthyroid patients for surgery.

Endoscopic sinus surgery complications in residency.

Otolaryngology has seen a rapid proliferation of functional endoscopic sinus surgery, and there is variability in the teaching of the procedure, in part because of the seriousness of the complications. A retrospective review of 106 consecutive cases was conducted at a teaching program to evaluate complications. Complication rates were combined and compared with the reported complication rates of other teaching programs and practicing otolaryngologists. The complication rate in our program was 13.9%; all were minor complications. This compared favorably with the rates of other programs (6% to 29%). The combined complication rate for residency training programs (16.6%) was significantly greater than the nonresident complication rate (10.5%). When divided into major and minor complications, the resident minor complication rate (15.9%) was significantly greater than the nonresident rate (8%), yet the major complication rates were significantly less for the resident group (0.7%) than for the nonresident group (2.5%). In addition, complications were significantly greater when procedures were performed under general anesthesia as compared with local anesthesia, and estimated blood loss was significantly greater under general anesthesia.

Ketorolac tromethamine and hemorrhage in tonsillectomy: a prospective, randomized, double-blind study.

Ketorolac tromethamine (KT) is a nonsteroidal, antiinflammatory analgesic. Its nonsedating property makes it an attractive analgesic for sleep apnea patients undergoing uvulopharyngopalatoplasty, but its antiplatelet activity makes the potential for postoperative hemorrhage a concern. A prospective, randomized, double-blind study was designed to evaluate the bleeding risk of KT using adult tonsillectomy patients as the model. Patients were randomized into two groups receiving Meperidine (MP) (controls) or KT for the first postoperative day. Posttonsillectomy bleeding rates of 7% (3/43) in the MP group and 18.9% (7/37) in the KT group were demonstrated, but this difference was not statistically significant. The number of KT doses administered had no effect on the incidence of bleeding or the number of cases requiring return to the operative suite for hemostasis. Although this study did not attain statistical significance, the trend towards increased hemorrhage with KT is worrisome. This study and other reports in the literature support the manufacturer's warning that the use of KT is contraindicated in major surgery.

Wound healing. Tensile strength vs healing time for wounds closed under tension.

OBJECTIVES: To measure tensile strength of wounds closed with and without tension in rats, delineating the postoperative time interval when tensile strength is equal. To study patterns of growth in tensile strength. DESIGN: Transverse incisions on the backs of control rats were closed with minimal tension. In experimental animals, after excision of skin from the back, wounds were closed with closing tensions in excess of 70 g. Animals were killed at designated healing intervals for tensile-strength testing of wounds. SUBJECTS: One hundred Sprague-Dawley rats were divided into 5 groups days 5, 7, 10, 14, and 21, with equal numbers of control and experimental animals in each group. Wounds from 94 animals were available for breakload testing. INTERVENTION: Closing tensions were measured for transverse incisions on the backs of control animals before closure and after removal of 50 to 60 mm of skin from the backs of experimental animals. RESULTS: Tensile strength was not significantly different on day 5. However, wounds closed under tension showed significantly higher tensile strength on 7, 10, 14, 21. Polynomial regression suggests a cubic relationship between healing time and tensile strength. CONCLUSIONS: Results suggest that tensile strength of wounds closed under tension exceeds that of tensionless wounds as early as day 7 following surgery. This study also illustrates the 2 periods of rapid increase in wound tensile strength that probably coincide with specific stages of wound healing.

Wound healing: effects of closing tension, zyplast, and platelet-derived growth factor.

Previous studies have shown that beginning 5 to 7 days from wounding, the tensile strength of wounds closed under tension in rats is significantly higher than the tensile strength of wounds closed without tension. This study evaluated the effects of increased closing tension, zyplast implant (ZI), and human recombinant platelet-derived growth factor (PDGF) on the tensile strength of wounds. Six groups of 12 rats each were divided into two main subsets: wounds were closed without tension in three groups and with high tension of approximately 100 g in the three other groups. In both no-tension and high-tension groups, one subgroup received no intervention (controls), one subgroup received ZI (zyplast controls), and one subgroup received ZI-PDGF (ZI used as a carrier for PDGF). Healing was evaluated by tensile strength determinations at 5 days. For the controls, wounds closed under tension showed a trend toward higher tensile strength, but statistical significance was not reached. Compared with controls, tensile strength was 45% lower in the wounds with ZI and closure with tension (P = .0063) and 38% lower in the wounds with ZI and closure without tension (P = .007). Treatment with ZI-PDGF resulted in 69% higher tensile strengths (P = .049) as compared with ZI controls for wounds closed with tension. This study demonstrated the beneficial effect of PDGF in accelerating healing in wounds closed under tension. Although ZI was able to deliver PDGF to the wound, the use of this substance as a carrier is questioned since it was detrimental to healing.

Laryngocele associated with squamous carcinoma in a 20-year-old nonsmoker.

A laryngocele associated with squamous cell carcinoma of the larynx is reported in a 20-year-old man without a history of smoking. This is the youngest reported case of carcinoma associated with laryngocele in the literature. This association is supported by the patient's young age and his nonsmoking status. However, this case does not appear to support the conclusion that laryngoceles predispose to the development of squamous cell carcinoma. The clinical history supports the tumor obstruction theory, whereby a laryngocele developed from an obstructing carcinoma of the ventricle.

Laryngeal reconstruction following vertical partial laryngectomy.

Laryngeal reconstruction following vertical partial laryngectomy (VPL) with arytenoidectomy was studied in 30 dogs. Variations of a superiorly based thyroid cartilage flap (TCF) were used for reconstruction. In addition, sternohyoid muscle reconstruction and endolaryngeal muscle coverage were studied. Larynges were recovered after a 6-month period in 28 surviving dogs and were analyzed by endoscopic photographs and axial whole-organ sections. Endoscopic assessment (n = 18) demonstrated good results for arytenoid replacement (100%), pseudocord position (94%), pseudocord development (94%), and airway patency (100%). Arytenoid replacement was judged as completely (78%) or partially (22%) replaced. This was accomplished by a pseudocord extending to the cricoid in the horizontal plane. Pseudocord position was judged as normal (83%) or paramedian (11%), with the remainder lateralized (6%). Pseudocord development was judged as complete (72%) or partial (22%), with the remainder poor (6%). Reviewing both endoscopic photographs and gross sections (n = 28), airways were all normal without laryngeal or tracheal stenosis. Histologic assessment (n = 24) also demonstrated good results for arytenoid replacement (79%), pseudocord position (87%), and TCF survival in the glottic plane (79%). Arytenoid replacement was judged as complete (62%) or partial (17%), with the remainder poor (21%). Pseudocord position was judged as normal (50%) or paramedian (37%), with the remainder lateralized (13%). TCF survival was judged as total (63%) or partial (16%). Although not present in the glottic plane in the remaining cases (21%), a portion of the TCF was always present in the supraglottic region. The TCF was largely replaced by bone in the region of the pseudocord, and was covered by nonkeratinizing stratified squamous epithelium and a thick fibrous layer. Breakdown over the TCF was infrequent, with a small focus of granulation tissue over cartilage present in 1 (4%) of 24 cases. Clinically insignificant granulation tissue was present in a total of 6 (25%) cases. In the other 5 cases, this was over muscle or over permanent sutures. Focal cartilage necrosis was present in 2 (8%) of 24 cases, and was localized, self limiting, and deep to the endolaryngeal surface. When the TCF failed to survive histologically, poorer results for arytenoid replacement and pseudocord position generally resulted. However, this apparent difference was not statistically significant due to small sample sizes and variability in results. Other factors that may have kept this difference from becoming larger were thought to be contraction of th e normal cord towards the operated side with fore-shortening of the glottis, and medial rotation and ossification of the posterior thyroid ala remnant.(ABSTRACT TRUNCATED AT 400 WORDS)

Wound tension in rhytidectomy. Effects of skin-flap undermining and superficial musculoaponeurotic system suspension.

This study was conducted to determine the effects of skin-flap undermining and superficial musculoaponeurotic system (SMAS) suspension on wound-closing tension. Nine sides from five fresh-frozen cadavers were used, with closing tension measured at the two main anchor points, anteriorly (A) and posteriorly (P), with and without SMAS plication for minimal (MIN), intermediate (INT), and maximal (MAX) skin-flap undermining. Results indicated that closing tension was significantly decreased with SMAS plication, both A and P, for all three levels of skin undermining. The average decrease in closing tension with SMAS plication was: A-MIN 191 g, A-INT 95 g, A-MAX 83 g, P-MIN 235 g, P-INT 68 g, and P-MAX 70 g (P < .001 for all). Considering the effect of skin-flap undermining alone, closing tension decreased with wider skin-flap undermining, both with and without SMAS plication. The tension-reducing effect of SMAS plication was decreased with wider skin-flap undermining. Regression analysis determined a second-order exponential curve relating closing tension to skin excision.

Effects of aerosolized dexamethasone on acute subglottic injury.

Aerosolized dexamethasone was used in a two-phase study to determine the possible effects on acute subglottic injury in the ferret animal model. In phase 1, equivalent subglottic injuries were made in 10 animals by using the brush technique, and the animals were divided into two groups. The treatment group received aerosolized dexamethasone at 2, 4, and 6 hours postinjury. All animals were examined 2, 4, 6, and 24 hours after the injury. The clinical condition of each animal was evaluated and their airways were measured. The animals were then painlessly killed and the larynges were frozen, sectioned, and photographed at 1-mm intervals. A computer-linked digitizer pad was used to measure the subglottic dimensions. The results show a trend for the treated animals to have a larger subglottic airway as compared to the untreated (control) group. The phase 1 study suggests that there may be an improvement in the subglottic airway when treated acutely with aerosolized dexamethasone. In phase 2, 20 additional animals were studied by using the same methods of injury and treatment as in phase 1. The subglottic airways of these animals were evaluated with histomorphometric analysis on fixed histologic sections. A statistically significant difference was found between the subglottic airways of the treated and untreated animals favoring treatment with aerosolized dexamethasone. Aerosolized dexamethasone appears to be beneficial in preserving the subglottic airway after injury, possibly secondary to decreasing the edema associated with injury.

Postoperative risk following uvulopalatopharyngoplasty for obstructive sleep apnea.

A study was conducted to assess oxygenation and respiratory changes on the first and second postoperative nights after uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea (OSA). Twelve patients were postoperatively evaluated with 8-hour nocturnal polysomnography on four occasions: (1) PREOP--night before UPPP, (2) POPN1--first postoperative night, (3) POPN2--second postoperative night, and (4) 3MOS--3-month follow-up study. Results demonstrate that apnea index (AI) and respiratory disturbance index (RDI) were significantly improved at 3MOS from PREOP levels: AI (p less than 0.01) and RDI (p less than 0.05). There were no statistical differences from PREOP to POPN1 or POPN2 for AI, RDI, lowest oxyhemoglobin saturation (LSAT), or number of desaturations (#DESAT). One of twelve patients dropped LSAT greater than 10% from PREOP to POPN1 or POPN2 (82% PREOP to 71% POPN2). Patients were grouped by PREOP LSAT greater than or equal to 80% or less than 80%, and the postoperative change in LSAT was evaluated by comparing PREOP to a value averaging POPN1 and POPN2. Patients with LSAT greater than or equal to 80% decreased by 2.6%; patients with LSAT less than 80% improved by 6.2%. This change in LSAT between groups was statistically different (p = 0.02). These data suggest that in the majority of patients, preoperative indices remain unchanged for at least 2 days after surgery, even for patients who demonstrated improvement at 3 months. However, worsening does occur in some patients. On the basis of the results of this study and clinical experience with the postoperative course, a selective management protocol is outlined.