State-of-the-art for osteoplastic frontal sinus operation.

Endoscopic ethmoid and frontal sinus surgery have reduced but not eliminated the indication for the osteoplastic adipose obliteration operation. An updated technique for this operation is presented for treating chronic frontal sinus disease, cerebrospinal fluid leakage by way of frontal sinus, and sinucutaneous fistulae.

Use of the radial forearm fasciocutaneous free flap and montgomery salivary bypass tube for pharyngoesophageal reconstruction.

BACKGROUND: Head and neck reconstructive surgeons involved in pharyngoesophageal reconstruction have several options available to repair the defect after partial or total laryngopharyngectomy. There is no uniform agreement among head and neck surgeons as to which of the most frequently used techniques offers the best results. METHODS: A retrospective study was performed on 20 consecutive patients who had undergone reconstruction of the hypopharynx and cervical esophagus using a radial forearm free flap with Montgomery salivary bypass tube at the Massachusetts Eye and Ear Infirmary in Boston, Massachusetts, and St. Louis University, Department of Otolaryngology-Head and Neck Surgery between 1992 and 1996. This reconstruction was used for primary reconstruction after total or partial laryngopharyngectomy with cervical esophagectomy, partial pharyngectomy sparing the larynx, and for reconstruction of the stenotic neopharynx after laryngectomy. RESULTS: The overall rate of pharyngocutaneous fistula was 20%, and the rate of postoperative stricture was 10%. Of patients reconstructed with this technique, 85% were able to resume oral alimentation, whereas 15% remained G-tube dependent. Of the 18 patients who did not have their larynges remain intact, 6 were able to develop useful tracheoesophageal speech. CONCLUSIONS: The results of this study show that the radial forearm fasciocutaneous free flap in combination with the Montgomery salivary bypass tube is extremely useful for reconstruction of partial and circumferential defects of the hypopharynx and cervical esophagus.

Montgomery Thyroplasty Implant for vocal fold immobility: phonatory outcomes.

Forty-three patients with a diagnosis of unilateral vocal fold immobility underwent thyroplasty type I with the Montgomery Thyroplasty Implant System. Preoperative and postoperative evaluations were completed by means of videostroboscopic, acoustic, and aerodynamic measures. Clinicians' perceptions of vocal quality and patients' satisfaction with the surgery and vocal quality were determined. Improvements after surgery were observed for glottal closure, vocal fold amplitude, mucosal wave activity, average intensity, maximum intensity range, maximum phonation time, glottal airflow, average sound pressure, and subglottal pressure. Average postsurgical fundamental frequency values fell within normal limits and did not display significant changes relative to presurgical values. The clinicians' perceptual evaluations indicated an improvement in voice quality for most patients. A majority of patients expressed satisfaction with the surgery and resulting voice quality. The results of the present study, in combination with the surgical advantages that have been described for the Montgomery Thyroplasty Implant System, support the view that this approach offers an attractive alternative for treating unilateral vocal fold immobility.

Mucociliary transport pathway on laryngotracheal tract and stented glottis in guinea pigs.

We investigated the laryngotracheal mucociliary transport pathway of guinea pigs in vivo and immediately postmortem. Only intraperitoneal anesthesia was used during the procedure to avoid the disturbance of mucociliary function. Resin particles were used as the marking substance. A microcolpohysteroscope was placed at different levels in the laryngotracheal region for observing the marking particles and recording the transport pattern. The tracheal mucociliary transport flow primarily moved along the posterior wall and both lateral walls in a zigzag trace. Upon reaching the subglottis, the resin particles stayed underneath the vocal cords, and a whirlpool phenomenon developed. The majority of the particles were shifted and directed onto the posterior glottic area. With a short delay, some resin particles crossed over the free edge of the vocal cords and turned posteriorly along the medial upper cordal margin. No mucociliary transport could be observed on the entire upper surface of the true vocal cords, which is covered by squamous epithelium. Occasionally, a few resin particles in the vicinity of the epiglottic root traveled along the aryepiglottic folds toward the posterior commissure. All streams of mucociliary transport finally joined together in the interarytenoid area. After leaving the glottis, the resin particles traveled to the hypopharynx and entered the esophagus through the motion of deglutition. The pattern of mucociliary clearance in the laryngotracheal region was not delayed by stenting.

The role of image-guidance systems for head and neck surgery.

BACKGROUND: Although image-guidance systems have gained widespread acceptance for neurosurgical procedures, their role for extracranial surgery of the head and neck is yet to be defined. OBJECTIVES: To describe the authors' experience with image-guidance systems and to measure the effects of image-guided technology on the performance of minimally invasive otolaryngological procedures. DESIGN: Prospective cohort study. METHODS: Optical- and electromagnetic-based image-guidance systems were used during the performance of endoscopic surgery on patients with disease of the paranasal sinuses, orbit, skull base, and temporal bone (n = 79). Results were compared with those in control patients who underwent similar surgery without image guidance during the same period (n = 42). RESULTS: Intraoperative anatomical localization was accurate to within 2 mm at the start of surgery in all cases. Accuracy degraded by 0.89 +/- 0.20 mm (mean +/- SE) during the operative procedure. The use of an image-guidance system increased operating room time by a mean of 17.4 minutes per case (image-guidance group, 137.3 +/- 6.0 minutes [mean +/- SE]; control group, 119.9 +/- 5.7 minutes; P=.006) and increased hospital charges by approximately $496 per case. Intraoperative blood loss (image-guidance group, 178.4 +/- 18.0 mL [mean +/- SE]; control group, 149.4 +/- 20.1 mL) and complication rates (image-guidance group, 2.7%; control group, 4.7%) did not differ significantly between groups. CONCLUSIONS: Image-guidance systems can provide the head and neck surgeon with accurate information regarding anatomical localization in cases with poor surgical landmarks caused by extensive disease or prior surgery; however, the use of such systems is associated with increased operative time and expense.

Validation of a voice outcome survey for unilateral vocal cord paralysis.

Current methods to assess voice outcomes in patients with unilateral vocal cord paralysis (UVCP) are limited by expense, reliability, or lack of a true patient-relevant focus. The purpose of this study was to develop and validate a patient-based, disease-specific instrument, the Voice Outcome Survey (VOS), that is brief, reliable, and sensitive to real clinical change in patients with UVCP. Fifty-six consecutive patients with uncompensated UVCP and without complicating comorbid illness received the VOS, the Medical Outcome Study Short Form 36-Item Health Survey (SF-36), and a voice laboratory analysis before and 6 months after type I thyroplasty. Overall, reliability of the VOS was excellent (r = 0.87, P < 0.0001). The VOS index was significantly (P < 0.05) correlated to subscales of the SF-36 including social functioning (SF) (r = 0.56) and physical role functioning (r = 0.35), as well as changes in objective voice measures such as phonation time (r = 0.51) and average intensity (r = 0.44). The VOS index was the most sensitive measure to clinical change after surgery (standardized response means: VOS, 1.92; phonation time, 0.68; SF, 0.58; physical role functioning, 0.53; intensity, 0.51). The VOS is a brief, valid, reliable, and highly sensitive measure of disease-specific health status in patients with UVCP.

Manometric study of paranasal sinus mucoceles.

A paranasal sinus mucocele is a chronic cystlike lesion characterized by slowly progressive remodeling and expansion of the surrounding osseous walls. If left untreated, it may cause significant facial deformity, ophthalmic disturbances, and, in the worst instance, intracranial complications. According to a review of the literature, there is a long-held view that positive pressure exists within paranasal sinus mucoceles; however, to our knowledge, pressure measurements have not been recorded in humans. In this study, pressure measurements were taken of 4 paranasal sinus mucoceles by means of an 18-gauge needle probe and an amplified pressure transducer. The average value was +15 cm H2O with a range of +4 to +39 cm H2O. This study confirms the long-standing assumption that positive pressure exists within paranasal sinus mucoceles. The magnitude of the pressure was comparable to that which was found to be associated with bone resorption in several previously published studies. Further studies are needed to determine whether positive pressure and osseous remodeling are causally related in this condition.

Evidence for laryngeal paralysis in cricoarytenoid joint arthritis.

OBJECTIVE/HYPOTHESIS: To demonstrate denervation atrophy of laryngeal muscles in a case of gout involving the cricoarytenoid joint. METHODS: The posterior cricoarytenoid (PCA) and arytenoideus (A) muscles from a 72-year-old man with extensive gout were compared with those from a normal adult larynx (age and sex unknown) using stereologic techniques for changes in muscle composition and fiber diameter. RESULTS: The PCA and A muscles in the gout specimen contained changes Indicative of muscle degeneration. In the PCA the volume fraction (VF) of intact muscle was 0.30, of degenerating muscle 0.13, and of fat 0.16. A normal PCA had a VF for intact muscle of 0.64 and 0 for degenerating muscle and fat. Similar changes were seen in the gout A muscle but were not measured. Muscle fiber diameters in the gout PCA (1,024 fibers) showed a significantly higher atrophy and hypertrophy factor than the normal PCA (1,255 fibers). The variability coefficient in the gout PCA (487) was almost double that in the normal PCA (290). Although muscle fiber diameters were not measured in the A muscle in gout, variability in fiber size was seen. CONCLUSIONS: The pattern and magnitude of muscle fiber degeneration in the PCA and A muscles from a larynx with gout fixation of the cricoarytenoid joint indicate neural degeneration. Since similar changes were not found in the thyroarytenoid (TA) and lateral cricoarytenoid (LCA), the neuropathy is selective for the posterior branch of the recurrent laryngeal nerve. This neuropathy is likely responsible for vocal cord adduction (stridor) and incomplete closure of the posterior commissure (aspiration) associated with acute cricoarytenoid arthritis. In chronic cricoarytenoid joint arthritis, ankylosis of the joint space maintains the adducted cord position.

Cervical Thorotrast granuloma: a review of the literature and a new treatment modality.

Extravasation of thorium dioxide after transcervical carotid angiography has resulted in persistent open draining neck wounds. These difficult problems have remained a challenge for the treating head and neck surgeon. Neck dissection has been the mainstay of treatment in the past; however, this has been fraught with complications. The application of doxycycline sclerosis is described in the successful resolution of a large thorotrast granulomatous neck wound. A review of the literature and the management options of Thorotrast granulomas are discussed.

Montgomery thyroplasty implant system.

A standardized system has been developed to treat unilateral vocal cord paralysis by medialization of the paralyzed cord. The Montgomery Thyroplasty Implant System consists of a medialization implant, measuring devices, and surgical instruments. The surgical instruments are used to locate, measure, and create a window in the thyroid lamina in which the implant is placed. The measuring devices are used to predetermine the correct implant size. There are five sizes for males (8 to 12 mm) and five for females (6 to 10 mm), with the size representing the distance of medialization. The implant consists of a firm, three-tiered base that locks the implant in the cartilage, and a soft, triangular top that serves to medialize the cord. The standardization of the base allows for revision or reversal at a later date without disturbing the window. The thyroplasty system and surgical procedures are described. Preliminary results of 176 patients who have undergone the Montgomery Thyroplasty Implant System procedure are presented.

Chronic maxillary atelectasis.

Chronic maxillary atelectasis is a descriptive term that refers to a persistent decrease in the sinus volume of the maxilla from inward bowing of the antral walls. Case reports with comparable clinical presentations have appeared sporadically in the literature; however, this disorder has remained poorly defined. The purpose of this study is to provide a formal definition of this condition by the establishment of diagnostic and staging criteria. A 10-year case analysis identified 22 adults, and a review of the literature revealed another 25. The average age at presentation in our study was 38.3 years. Most patients were symptomatic, and some presented with diplopia and hypoglobus. Inward bowing of the antral wall(s) and persistent opacification on computed tomography made the diagnosis. Chronic maxillary atelectasis was separated into three stages according to the degree of wall deformation. While most patients were symptomatic, a past history of absent or mild symptoms referable to the nose and sinuses was encountered more often in those patients with osseous wall deformation (p = .041). Mild or absent symptoms at the time of diagnosis should not be considered a negative risk factor for the development of facial deformity, especially if the sinus has features consistent with complete pneumatization. A middle meatal antrostomy appears to relatively safely correct the sinus problem, while orbital floor reconstruction for hypoglobus, found in stage III of the disease, can be accomplished effectively via a transconjunctival approach using a combination of bone allograft and porous polyethylene sheets.

Manometric study of complete ostial occlusion in chronic maxillary atelectasis.

The effect of complete ostial occlusion on static pressure within the human maxillary sinus has not been previously studied. In this study, a novel way to directly determine maxillary sinus pressure is described. Maxillary sinus pressures were measured in five patients with chronic maxillary atelectasis (CMA); these values were compared to values obtained from the contralateral side and from patients with chronic sinusitis. Measurements were made by introducing an 18-gauge needle probe through the membranous fontanel of the maxillary sinus and recording the pressure value with an amplified, pressure-sensitive transducer. The average value recorded in five patients with atelectasis of the maxillary sinus and complete ostial occlusion was -8.4 +/- 2.6 cm H20 (mean +/- standard deviation). Static pressure measurements of the contralateral antrum were isobaric, as were measurements found in patients with chronic sinusitis. This study reports for the first time the sinus pressure of completely occluded maxillary ostia in patients with CMA. These results may improve our understanding of the development of ostial occlusion and its role in the pathogenesis of CMA and sinusitis.

Treatment of chronic paranasal sinus pain with minimal sinus disease.

A common problem for otolaryngologists are patients who present with recurrent, persistent sinus pain that appears out of proportion to the findings on physical examination. Often these patients have a history of recurrent sinusitis that required antibiotics or surgical intervention. Many have had repeated surgical procedures because of this pain. Other common past medical histories may include allergic rhinitis, facial trauma, or dental disease. Patients who have experienced documented acute sinusitis in the past will often present de novo with similar symptoms, but lack any objective evidence of a new active sinus infection. However, the diagnosis of sinusitis is not clearly removed from the patient's or clinician's mind, and the patient is further frustrated by the lack of adequate diagnosis, treatment, and resolution of symptoms. These patients may or may not be experiencing an upper respiratory tract infection or allergy with nasal drainage. Often, they are emotionally distraught from recurrent and persistent pain, the lack of resolution of their symptoms, dependency on narcotics and other analgesics, multiple consultations with a variety of clinicians, and the impingement of their symptoms on employment, interpersonal relationships, and societal and family obligations. If sinusitis is not found to be present, the otolaryngologist must help the patient understand this point, reassure him or her that the otolaryngologist will still be vigilant for the development of sinusitis, and refocus the history and workup for some other cause of the recurrent and persistent paranasal pain. We review various treatment approaches to paranasal pains that are not the result of sinusitis.

Microbiology of tracheal granulation tissue associated with silicone airway prostheses.

Granulation tissue formation and contraction is inevitable during the healing of open wounds. The presence of infection and a foreign body, such as a silicone airway prosthesis or other tracheotomy tube, magnifies this response. In airway reconstruction, wound contraction secondary to chronic inflammation is a liability. Cultures of granulation tissue were taken from 12 patients with silicone cannulas of T-Tubes. Polymicrobial colonization predominated, with variable combinations of gram-positive, gram-negative, and anaerobic organisms being present. On the basis of sensitivity data, amoxicillin-clavulanate potassium and ciprofloxacin hydrochloride were chosen as empirical antimicrobials. Anecdotally, impressive decreases in the quantity of granulation tissue were seen. We recommend a prospective trial to more accurately define the role of antibiotics in this setting.

Management of airway obstruction in cicatricial pemphigoid.

Cicatricial pemphigoid is a chronic vesiculobullous disease of the mucosal epithelium that primarily involves the oral cavity and the eyes. The clinical and histologic features are identical to those of bullous pemphigoid, and these features often can be nonspecific for other disease processes. It is not unusual for a period of 1 year or more to elapse before a diagnosis is made. The diagnosis of cicatricial pemphigoid requires characteristic lesions and histopathologic evidence of immunoglobulin deposition along the basement membrane, as well as a high index of suspicion. The authors detail a case of cicatricial pemphigoid resulting in airway obstruction and present the treatment required for both stabilization of the airway and resolution of the disease process.

Teflon granuloma of the larynx: etiology, pathophysiology, and management.

Intralaryngeal Teflon injection for correction of unilateral vocal cord paralysis is known to produce a foreign body giant cell reaction. In our practice, we have seen increasing numbers of patients who had developed dysphonia related to Teflon injection. This patient series was reviewed, as were the surgical technique to correct this condition, voice results, and acoustic analysis of a subset of the patient series. We conclude that dysphonia, secondary to Teflon injection, can be either from overinjection of Teflon or inappropriate injection, or from the proliferative granulomatous response of the larynx to the Teflon. Our technique of laser incision into the superior aspect of the Teflon implant, followed by vaporization and preservation of a margin of mucosa of the cord medially, resulted in improved voice in 8 of 11 patients treated in this manner. Acoustic and aerodynamic analyses reveal significant deficits in vocal function that may persist after procedures used to correct this condition.

Combined thyroplasty type I and inferior constrictor myotomy.

The preoperative evaluation and technique of combined thyroplasty and inferior constrictor myotomy are described and illustrated. The results in cases in which thyroplasty type I and inferior constrictor myotomy were done as separate procedures are compared to those in cases in which thyroplasty and inferior constrictor myotomy were combined in the same operation. The end results obtained with these two approaches did not differ significantly; however, with the exception of brain stem disease, patients undergoing the combined procedure at an early date are more likely to be spared gastrostomy and aspiration pneumonia. Diseases of the brain stem (ie, stroke and metastatic disease such as breast cancer) respond poorly to an inferior constrictor myotomy. In such cases the patient can best be rehabilitated with a thyroplasty type I along with a gastrostomy or laryngeal closure procedure.

Dural defects of the temporal bone.

Cerebrospinal fluid leakage (otorrhea or otorhinorrhea) from the temporal bone is the end result of rupture of the arachnoid membrane or herniation of the brain through a defect in the protective dura mater and calvarium. The rupture may be small, admitting only a herniation of arachnoid (meningocele), or be large enough to accommodate brain tissue (encephalocele). Flow of cerebrospinal fluid through either type of fistula may be a trickle or profuse, chronic or intermittent, and usually ceases temporarily for a few weeks following an attack of meningitis. The etiology, anatomy, signs and symptoms, and various methods of treatment for cerebrospinal fluid otorrhea and otorhinorrhea are discussed.