Application of cine nuclear magnetic resonance imaging for sequential evaluation of response to angiotensin-converting enzyme inhibitor therapy in dilated cardiomyopathy.

Cine nuclear magnetic resonance (NMR) imaging was used to serially measure cardiovascular function in 17 patients with New York Heart Association class II or III heart failure and left ventricular ejection fraction less than or equal to 45% who were treated for 3 months with benazepril hydrochloride, a new angiotensin-converting enzyme inhibitor, while continuing treatment with diuretic agents and digoxin. Interobserver reproducibilities for ejection fraction (r = 0.94, SEE 3.3%), end-systolic volume (r = 0.98, SEE 10.6 ml), end-diastolic volume (r = 0.99, SEE 8.29 ml), end-systolic mass (r = 0.96, SEE 15.4 g), end-systolic wall stress (r = 0.91, SEE 10 dynes.s.cm-5) and end-systolic stress/volume ratio (r = 0.85, SEE 0.13) demonstrated applicability of cine NMR imaging for the serial assessment of cardiovascular function in response to pharmacologic interventions in patients with heart failure. During 12 weeks of treatment with benazepril, ejection fraction increased progressively from 29.7 +/- 2.2% (mean +/- SEM) to 36 +/- 2.2% (p less than 0.05), end-diastolic volume decreased from 166 +/- 14 to 158 +/- 12 ml (p = NS), end-systolic volume decreased from 118 +/- 12 to 106 +/- 11 ml (p less than 0.05), left ventricular mass decreased from 235 +/- 13 to 220 +/- 12 g (p less than 0.05), end-systolic wall stress decreased 29% from 90 +/- 5 to 64 +/- 5 dynes.s.cm-5 (p less than 0.05), end-systolic pressure decreased from 92.6 +/- 3.7 to 78.8 +/- 5.3 (p less than 0.05) and end-systolic stress/volume ratio, a load-independent index of contractility, decreased from 0.83 +/- 0.05 to 0.67 +/- 0.06 (p less than 0.05), demonstrating that improved ejection fraction is due to afterload reduction.

Hypoglossal-facial nerve interpositional-jump graft for facial reanimation without tongue atrophy.

The hemitongue paralysis that occurs as a result of a classic hypoglossal-facial nerve crossover procedure can result in profound functional deficits in speech, mastication, and swallowing. The procedure is not an option in patients with bilateral facial paralysis or those at risk for combined cranial nerve deficits. To address some of the drawbacks and limitations of this classic procedure, we developed the hypoglossal-facial nerve interpositional jump graft (12-7 jump graft) procedure. This procedure involves interposing a nerve graft between a partially severed but functionally intact twelfth cranial nerve and the degenerated seventh cranial nerve, and is often combined with other reanimation procedures. To date, we have performed 33 12-7 jump graft procedures in 30 patients (three were treated for bilateral facial paralysis); this report describes the procedure and its indications, and details the results of 23 procedures performed in 20 patients for whom 24-month follow-up data are available. Twelfth nerve deficits occurred in only three patients in this report. Recovery of facial function began between 3 and 24 months postoperatively. Facial tone and symmetry were achieved in every patient, no patient had significant mass movement, and 13 patients (two of whom were treated for bilateral facial paralysis) had excellent and three had superb restoration of facial movement. These results show the 12-7 jump graft to be a valuable adjunct for facial reanimation in selected patients.

Gadolinium-enhanced magnetic resonance imaging of the facial nerve in herpes zoster oticus and Bell's palsy: clinical implications.

Gadolinium-enhanced magnetic resonance imaging was used in the evaluation of the facial nerve in four patients with idiopathic facial paralysis and six with herpes zoster oticus (HZO). Enhancement of the facial nerve was seen in all patients with Bell's palsy, and 50 percent of patients with HZO. The most consistent area of enhancement in both disorders involved the premeatal and labyrinthine segments. Although the images showed changes consistent with the type of viral process that is known to occur in these disorders, we found no significant correlation between the intensity or pattern of facial nerve enhancement on the images, the severity or duration of the disease, or the patient's prognosis for recovery. Nevertheless, gadolinium-enhanced MRI does have a place in the evaluation and decisions for management of select cases of facial paralysis.

Anterior neopharyngeal diverticulum following laryngectomy.

While less common than stricture, recurrent neoplasm, and neuromuscular dysfunction, neopharyngeal diverticulum must be considered in the differential diagnosis of postlaryngectomy dysphagia. Symptoms of difficulty clearing the neopharynx during and after a swallow, with regurgitation of undigested material, should alert the clinician to this possibility. Experience with 3 postlaryngectomy patients with anterior neopharyngeal divericulae serve as the springboard for discussion of the clinical spectrum, radiologic features, contributory pathophysiologic factors, and therapeutic options concerning this condition. Surgical indications, approaches, and potential hazards are reviewed.

The location of the maxillary os and its importance to the endoscopic sinus surgeon.

As functional endoscopic sinus surgery continues to gain popularity and support, the necessity for a clear and accurate understanding of the anatomy of the ostiomeatal complex becomes essential. To clarify this anatomy, serial cadaver dissections were performed and the anatomy of the ostiomeatal complex was detailed in three dimensions, with an emphasis on precise localization of the internal os of the maxillary sinus as it relates to the orbit, natural antronasal canal, and ethmoid infundibulum. Measurements of the position of the internal os relative to the position of the anterior and posterior walls of the maxillary sinus and the position of the orbit were taken. The dimensions and configuration of the antronasal canal and its relationship to the infundibulum were also detailed. These measurements and relationships must be understood for an endoscopic sinus surgeon to locate the natural ostia without injuring the orbit.

Managing segmental facial nerve injuries by surgical repair.

This report describes our experiences and evolving philosophy with regard to managing segmental facial nerve injuries. We present the results of 13 facial nerve repairs of traumatic injury to a segment of the facial nerve. All peripheral facial nerve branches contribute essential elements to normal mimetic facial movement; therefore, we recommend early, appropriate repair of the nerve segment. This recommendation is based on principles established for managing disruptions of the main trunk of the facial nerve. It offers the patient the chance for complete recovery of facial function.

Early facial reanimation following radical parotid and temporal bone tumor resections.

A retrospective study of 35 patients who underwent early facial reanimation following extirpative parotid and temporal bone surgery requiring facial nerve sacrifice was performed. Regional facial reanimation performed immediately or within several days included 16 patients who underwent temporalis muscle transposition and 27 who underwent gold weight or eyespring lid reanimation with lower lid tightening. Simultaneous nerve grafts or nerve crossover procedures were performed in 22 patients. The authors' favored approaches to facial reanimation are discussed, with an emphasis on the value of early reanimation using properly selected techniques.

Streptococcal endocarditis temporally related to transesophageal echocardiography.

A case of streptococcal sanguis endocarditis temporally related to a transesophageal echocardiogram is reported; and the literature on the incidence of bacteremia occurring during transesophageal echocardiography is reviewed. On the basis of this case and review of the literature, a reevaluation of the current guidelines for endocarditis prophylaxis during this procedure is recommended.

Split calvarial grafts in maxillofacial reconstruction.

Experience with thirty-seven patients demonstrating the versatility of the split calvarial graft in facial reconstruction is presented. A total of sixty grafts have been used with no evidence of significant clinical reabsorption, infection, or extrusion; advantages and limitations are discussed. We conclude that the split calvarium represents a readily available and reliable source of membraneous bone for grafting maxillofacial defects with minimal limitations and low morbidity.

Familial multiple cervical paragangliomas: report of a kindred and review of the literature.

Heredofamilial paragangliomas account for less than 10% of those arising in the head and neck. Multiplicity, multicentricity, and bilaterality is roughly three times more common than in the spontaneous variety. Not unlike other hereditary neuroendocrine tumor syndromes, familial paragangliomas appear to follow an autosomal dominant transmission, with variable penetrance and expressivity. This article describes a surgical experience with nine bilateral, multicentric cervical paragangliomas (7 carotid body, 1 vagal, and 1 sympathetic) occurring in four siblings less than 35 years of age. The literature on familial paragangliomas of the head and neck is reviewed. The postulated genetic mechanisms accounting for these and other hereditary tumors are discussed. The clinical and surgical aspects of spontaneous and familial paragangliomas are compared.

Early gold weight lid implant for rehabilitation of faulty eyelid closure with facial paralysis: an alternative to tarsorrhaphy.

Although tarsorrhaphy has been the mainstay of treatment for lagophthalmus associated with facial paralysis, it has many drawbacks which make it a less than ideal procedure. Gold weight implantation is a functionally and cosmetically superior alternative in many patients. Eighteen patients with both reversible and irreversible facial (eyelid) paralysis underwent early gold weight implantation for rehabilitation of faulty eyelid closure with satisfactory results. The advantages and disadvantages of this technique, when compared with other methods of correcting paralytic lagophthalmus, are discussed.

Squamous cell carcinoma of the thyroid: a diagnostic dilemma.

Four cases of primary squamous cell carcinoma of the thyroid gland are reported. Thorough evaluation confirmed these lesions to be of primary thyroid origin rather than from metastasis or direct invasion from contiguous structures. These cases illustrate the aggressive nature of the disease and the propensity for local and distant metastases. The clinicopathologic data presented here underscore the challenge in diagnosis and treatment of this rare entity.

Otolaryngologic manifestations of pregnancy.

A unique group of ear, nose, and throat disorders are associated with pregnancy. While most are benign and reverse after parturition, some do not. These disorders may be classified categorically by site into cutaneous, otologic, rhinologic, oral, pharyngeal, and laryngeal manifestations. The etiology and pathogenesis of these disorders are discussed, making every attempt to separate fact from conjecture. Therapeutic recommendations are made based on available information.

Vocal cord paralysis and recovery with thyroid lymphoma.

Vocal cord paralysis has been reported in 33 patients with thyroid lymphoma for an estimated overall incidence of 17%. There is little expectation of vocal cord function recovery, both because neoplastic invasion is believed irreversible and since surgery often necessitates sacrifice of the recurrent laryngeal nerve. Unlike in most well differentiated thyroid malignancies, external radiation therapy plays a vital role in the treatment of thyroid lymphoma. The patient presented here had complete recovery of vocal cord function following radiation therapy for a large thyroid lymphoma associated with vocal cord paralysis. This is the first reported case of such recovery following treatment for a thyroid neoplasm. The rather rapid and complete recovery of neural function suggests that, at least in some, paralysis is caused by reversible compression rather than by neural invasion or tumor-induced neurolysis.

Anterolateral extrapharyngeal approach for cervical osteophyte-induced dysphagia. Literature review.

While it is estimated that hypertrophic cervical osteophytes occur in up to 20% to 30% of the population, they are only rarely associated with dysphagia. Pathophysiologically, dysphagia may occur secondary to 1) mechanical compression with partial obstruction, or 2) periesophageal inflammation caused by pharyngoesophageal motion over the osteophytes. A careful history, indirect laryngoscopy, cineesophagography, and lateral cervical spine films establish the diagnosis in most patients. While routine rigid endoscopy is potentially hazardous in view of the recognized risk of inadvertent pharyngoesophageal perforation, it may be necessary in selected patients to rule out the presence of other more common causes of dysphagia. Conservative management consisting of sedation, antiinflammatory medication, and reassurance is often sufficient in patients with only mild to moderate and often transient symptoms. The value of surgical therapy for this disorder has been debated, but most agree that surgical excision is appropriate in selected patients whose symptoms are severe and progressive. In this report, two patients illustrate the dichotomy between and value of both conservative and surgical approaches. While both transoropharyngeal and transcervical extrapharyngeal surgical approaches have been used, a comprehensive review of the results of such procedures has not been reported. In this report a detailed description of the anterolateral extrapharyngeal approach for the excision of these osteophytes is given, and its value compared to other surgical techniques discussed.