The role of ostiomeatal complex obstruction in maxillary fungus ball.

OBJECTIVE: The aim of this study was to clarify the role of ostiomeatal complex obstruction in maxillary fungus ball. STUDY DESIGN AND SETTING: Comparative study in a hospital setting of the mean Lund-Mackay scores for the anterior ethmoid and frontal sinuses of 54 versus 48 patients with maxillary fungus ball versus chronic unilateral rhinosinusitis, respectively. RESULTS: In cases with partial opacification in the maxillary sinus, the anterior ethmoid and frontal sinuses were diseased in the chronic unilateral rhinosinusitis group but not in the maxillary fungus ball group. In cases with total opacification in the maxillary sinuses, all anterior ethmoid and frontal sinuses in both groups were diseased, but the disease condition of the frontal sinuses was significantly less severe in the maxillary fungus ball group (P < 0.001). CONCLUSION AND SIGNIFICANCE: In this era of evidence-based medicine, we provide statistical data supporting the principle that maxillary fungus ball is not associated with osteomeatal complex obstruction and that another as-yet-unexplained mechanism must be responsible. EBM RATING: B-3b.

A comparison assessment of videotelescopy for diagnosis of pediatric otitis media with effusion.

OBJECTIVES: A correct diagnosis of pediatric otitis media with effusion (OME) is imperative for instituting an appropriate treatment. The aim of this study was to compare the diagnostic efficacies of videotelescopy, pneumatic otoscopy, and tympanometry for detecting the presence or absence of pediatric OME, and thereby, to recommend a standardized procedure for assessing possible OME in the outpatient setting of a referral center. STUDY DESIGN: Prospective study. METHODS: Between November 1999 and May 2002, 104 children were enrolled in this comparison study of diagnostic methods for OME. Based on a presumptive diagnosis of OME or atelectasis of the eardrum, patients under 12 years of age were admitted to the ward for ventilation-tube insertion. In the 2 days prior to surgery, videotelescopy, pneumatic otoscopy, and tympanometry were performed. Myringotomies were subsequently conducted under general anesthesia to confirm the presence or absence of OME. Type B tympanograms were accepted as positive results for ears with effusion. RESULTS: : Of the 201 ears assessed in the study, middle-ear effusion was detected in 179, while the remaining 22 ears were found to be dry on myringotomy. It was demonstrated that videotelescopy had the highest sensitivity (97.8%), specificity (100%), and accuracy (98.0%), reflecting significantly better results than those for pneumatic otoscopy and tympanometry. CONCLUSIONS: In our study, videotelescopy seemed to be better than pneumatic otoscopy and tympanometry for diagnosis of pediatric OME. It may be has the potential to become the standard diagnostic and teaching procedure for pediatric OME in the outpatient setting of a referral center, and for validation of pneumatic otoscopy.

Bacteriology of medically refractory acute otitis media in children: a 9-year retrospective study.

OBJECTIVE: To identify the causative organisms for medically refractory acute otitis media (AOM) in children, and to recommend the appropriate antibiotics for these patients. STUDY DESIGN: Retrospective chart review. METHODS: The medical records for 671 children (1258 ears) undergoing myringotomies between January 1993 and December 2001 were retrospectively reviewed. "Medically refractory" AOM is defined as AOM requiring emergency myringotomy because of toxicity persisting despite second-phase antibiotics. Of these, 18 children were enrolled in our study, with 25 of the ears affected by medically refractory AOM. Myringotomy was performed for pus drainage, bacterial culture and susceptibility studies in all cases. Clinical factors were analyzed to demonstrate possible relationships with microbiological findings. RESULTS: Bacteria were recovered in specimens taken from 12 ears. The positive culture rate was 48%. Bacteriological studies showed mostly growing gram-positive bacteria, such as coagulase negative staphylococcus, Staphylococcus aureus and Streptococcus pneumoniae (in decreasing order of incidence). The sensitivity rate to pre-myringotomy antibiotics was 85.7%. With the exception of Pseudomonas aeruginosa and two ears with intracranial complications or pneumonia, all other isolated microorganisms were susceptible to first-generation cephalosporins. No statistically significant differences were noted between culture rates and clinical factors. CONCLUSION: The distribution of organisms in our medically refractory AOM cases differed from that for simple AOM, with gram-positive bacteria having significantly higher rates of incidence. Combining intravenous aminoglycoside with first-generation cephalosporin is considered an inexpensive and effective treatment covering all potential microorganisms. Vancomycin or third-generation cephalosporins are only needed for major complications or other coincident infections extant during the initial presentation.

Managements of complicated otitic abscess.

The advent of antibiotics has significantly reduced the incidence and associated morbidity of otogenic complications. Its presentation, however, has dramatically changed and appears as a masked condition despite the presence of a potentially fatal complication. Between 1998 and 2001, 3 cases of otitic abscesses, including mastoid subperiosteal abscess, zygomatic abscess, and retropharyngeal abscess, were collected retrospectively. Their clinical presentation, results of investigations, and response to treatment were reviewed. After admission, intravenous antibiotics were prescribed and early surgeries were performed for eradication of infection source. The patients exhibited excellent postoperative recovery, without facial palsy, vertigo or other complications. To be a contemporary otologist, we should not overlook such severe complications of otologic diseases. Appropriate intravenous antibiotics and adequate surgeries, as soon as possible, are recommended. Advanced magnetic resonance imaging or computed tomographic scans of the temporal bone with wider windows are necessary.

The contralateral ear in patients with middle ear cholesteatoma after long-term follow-up.

BACKGROUND: We aimed to develop a strategy for long-term follow-up of the contralateral ear in patients with cholesteatoma and to determine if the patients' age at surgery for cholesteatoma affects the condition of the contralateral ear during this follow-up. METHODS: From May to November 1999, patients followed for previous cholesteatoma surgery were enrolled. The contralateral ears were examined by the senior author (Dr. Lien). The past otologic records were checked, especially for the condition of the contralateral ear. McNemar test was used to check the pre- and post-follow-up difference. Kaplan-Meier analysis was used to determine the long-term normal rate of initially normal contralateral ears. A log-rank test was used to detect the difference in such normal rate among different age groups. RESULTS: A total of 75 patients were enrolled (47 females and 28 males). The average age at surgery was 38.1 years, and the mean follow-up period was 67.6 months. The normal rate of the contralateral ears was 60.0% at the beginning; and decreased to 50.7% (p = 0.065) at the end of the observation period. The average time for an initially normal contralateral ear to develop an abnormality was 108.9 months. The 5- and 10-year normal rates, calculated by the Kaplan-Meier analysis, were 86.8% and 80.1%. The group who underwent surgery for a cholesteatomatous ear when younger than 35 years had a better prognosis than patients who were older than 35 years at surgery in terms of the normal rate of the initially normal contralateral ears. CONCLUSIONS: We emphasize the need for concern about the contralateral ear in patients with a cholesteatomatous ear. Long-term follow-up of more than 10 years is needed to detect any abnormalities early. Although younger patients had a better prognosis in the initially normal contralateral ear than older patients, this finding could be attributed to the fact that younger patients were alert to seek medical care earlier.

Fibrous dysplasia of the ethmoid sinus.

Although craniofacial bone is the second common site of fibrous dysplasia involvement, it is rarely found in the paranasal sinus. Among fibrous dysplasia of the head and neck, the maxilla and mandible are the most frequent sites to be involved. Fibrous dysplasia becomes dormant in adolescence and early adult life and is more common in female. It is one of the fibrous osseous lesions and should be differentiated from osteoma and ossifying fibroma. Radiographically, fibrous dysplasia showed "groundglass" bone appearance on CT scans with bone window. Histopathologically, it presents woven-type bone embedded in a cellular fibrous stroma without osteoblastic rimming. We presented a case of 25-year-old female with fibrous dysplasia in her right side ethmoid sinus. She visited to us with the chief complaint of right side headache since adolescence. The lesion was removed by endoscopic sinus surgery and pathology proved fibrous dysplasia. The patient was free of headache after operation. The advance of endoscopic sinus surgical technique, makes it an optimal method for the pathological diagnosis and treatment to avoid the cosmetic problems caused by external approach in limited paranasal sinus fibrous osseous lesions.

Angiofibroma of the hypopharynx.

Primary extranasopharyngeal angiofibroma is very rare. To date, approximately 60 cases have been reported in the English literature. Only 1 case was confined to the posterior wall of hypopharynx. In August 2000, a 68-year-old man presented with a 6-month history of progressive foreign-body sensation in the throat and intermittent inspiratory stridor. Endoscopic examination of the larynx and pharynx revealed a nonpulsatile, pink-grayish, polypoid mass arising from the posterior pharyngeal wall of the left hypopharynx. Under general anesthesia, this tumor mass was subsequently removed by the endoscopic CO2 laser. The histologic diagnosis was an angiofibroma. Three-year follow-up found no evidence of tumor recurrence or post-operative complications.

Parosteal osteosarcoma of the mastoid bone following radiotherapy for nasopharyngeal carcinoma.

Radiation-induced tumors subsequent to nasopharyngeal carcinoma are very rare. To date, no post-irradiation parosteal osteosarcoma of the craniofacial bone has been reported in the English literature. In October 2000, a 57-year-old Chinese woman presented 5 years after radiotherapy for nasopharyngeal carcinoma with a 6-month history of a gradually enlarging left postauricular mass. CT scans revealed a densely calcified mass with radiating bony spicules, applied to left mastoid tip. The lesion was excised en-bloc through a postauricular incision. The histologic diagnosis was a parosteal osteosarcoma. Because of inadequate safe margins and the patient refusal of another surgery, 6600 cGy of radiation was subsequently administered to the temporal bone. Post-operative follow-up in 3 years was negative for any evidence of tumor recurrence and post-irradiation complications.

Malignant fibrous histiocytoma of the maxillary sinus presenting as toothache.

Malignant fibrous histiocytoma (MFH) is a high-grade and aggressive sarcoma. It is relatively rare in the head and neck region. Its diagnosis is based on immunohistochemical stains. Wide excision followed by postoperative radiotherapy is believed to be the treatment of choice for MFH. In October 2001, a case of MFH in the maxillary sinus, which presented as a toothache at the beginning, was successfully diagnosed and treated. Using the external approach, the tumor mass was completely removed, and postoperative radiotherapy was subsequently performed. Seventeen months after the surgery, the patient was clinically well without any evidence of local recurrence or distant metastasis.

Voice rehabilitation in laryngectomees: comparison of daily-life performance of 4 types of alaryngeal speech.

BACKGROUND: We compared 4 kinds of alaryngeal speech available in Taiwan in the performance of daily-life tasks. The speech methods included pneumatic device (Taiwan tube), electrolaryngeal speech, esophageal speech, and tracheoesophageal prosthesis. METHODS: Questionnaires covering various communication situations in daily-life tasks as well as subjective feelings about using alaryngeal speech were distributed to members of The Taiwan Laryngectomees' Association and were collected mostly in April 2000 in their annual meeting. RESULTS: A total of 108 members responded to the questionnaire (totally 160 were questionnaires distributed). The mean age of respondents was 68.6 years, and the average time after surgery was 14.5 years. A pneumatic device was used by 58.8% of the responders, esophageal speech was used by 24.7%, an electrolarynx by 10.3%, and a tracheoesophageal prosthesis by 6.2%. No statistical difference was noted among patients using any of the 4 devices in terms of 13 communication tasks in daily life, except 4 questions such as the convenience of alaryngeal speech, embarrassment in face of strangers, the effort required to speak, and the discomfort in throat/neck/mouth when speaking. No statistical differences were noted among the 4 devices in terms of intelligibility. CONCLUSIONS: All 4 alaryngeal speech methods can serve most of the communication functions in daily life tasks with no differences in intelligibility. Limitations in loudness and tone were common problems. It is crucial for surgeons to understand the performance of various alaryngeal speeches in daily life during rehabilitation consultations with patients.

Diagnostic methods for otitis media with effusion in children.

BACKGROUND: Correct diagnosis of otitis media with effusion (OME) in children is imperative for instituting appropriate treatment. This study aims to establish the diagnostic value of pneumatic otoscopy, tympanometry, acoustic reflectometry and videotelescopy by comparing them with myringotomy findings. METHODS: Between November 1999 and July 2001, we conducted a prospective study on diagnosis of OME in children. The children studied were candidates for ventilation tube insertions or other ENT surgeries. All tests, including acoustic reflectometry, tympanometry, pneumatic otoscopy and videotelescopy, were performed two days before surgery. Myringotomy or tympanocentesis was then performed to confirm the presence or absence of OME. A type B tympanogram was accepted as a predictor of effusion. The curve angle of acoustic reflectometry with cut-point of 69 degrees (< or = 69 degrees) was also used to predict the presence of OME. RESULTS: Eighty-nine children (58 males and 31 females), ranging in age from 1 to 13 years, participated in the study. Of 172 ears assessed in the study, middle ear effusion was detected in 124; the remaining 47 ears were found to be dry at myringotomy or tympanocentesis. Videotelescopy gave the highest sensitivity, specificity and accuracy, followed by pneumatic otoscopy, tympanometry and acoustic reflectometry. CONCLUSIONS: Videotelescopy seems to have the potential to become the standard for diagnosis of OME in children and for validation of pneumatic otoscopy. When videotelescopy is not available, tympanometry could be an instrumental adjunct to pneumatic otoscopy. Although acoustic reflectometry gave the worst results, it is still useful for assessing and screening OME in children because of the ease and speed of its operation irrespective of crying, cerumen, an air seal in the ear, or lack of cooperation from the young children.

Mastoid-obliteration surgery with cartilage for suppurative cholesteatomatous ears.

BACKGROUND: Autologous cartilage has been widely used as a material for tympanoplasty and mastoid-obliteration surgery. Since it remains vulnerable to an infectious condition, this study aims to evaluate if it can be used for a chronic suppurative cholesteatomatous ear to achieve single-stage tympanoplasty with mastoidectomy and obliteration of the cavity. METHODS: From January 1988 to August 1998, the records of patients with cholesteatoma who received cartilage-obliteration surgery performed by Dr. Lien were examined for any infection-associated problems within three months after the operation. The Fisher's exact test was used to compare the difference in the incidence of post-operative infection-associated problems between suppurative ears and non-suppurative ears. RESULTS: One hundred and seven surgical procedures performed upon 96 patients were included in this study, with 97 being primary surgical procedures and ten being revision surgery for previous open cavity with cholesteatoma recurrences. The average follow-up was 47.7 months. At time of surgery, there were 59 non-suppurative ears; 48 ears were suppurative and cultured. Granulations were found in the middle ear or mastoid for 42 ears (39.3%). Five ears (4.7%) exhibited infection-associated post-operative problems within three post-operative months. Three cases (5.1%) were non-suppurative ears and two cases (4.2%) were suppurative ears. There was no significant statistical difference when examined with the Fisher's Exact test. CONCLUSIONS: In an immunocompetent patient with a cholesteatomatous chronic suppurative ear, autologous cartilage could potentially tolerate an infection condition to serve as a material for mastoid-obliteration in a single-stage surgical procedure.

Videofiberoptic examination of the pharyngoesophageal segment and esophagus in patients after total laryngectomy.

BACKGROUND: Posttreatment follow-up in patients with squamous cell carcinoma of the head and neck is critical because of the high risk of recurrence or a new primary tumor. However, in patients who have undergone total laryngectomy, evaluation of the pharyngoesophageal segment (PES) and esophagus is difficult. METHODS: Sixty patients who had undergone total laryngectomy received a videofiberoptic examination of the PES and esophagus at the OPD office during follow-up. RESULTS: Satisfactory examination was achieved in 56 (93%) of the patients. Each procedure was completed within 15 minutes. Although only 11 (18%) of the patients were symptomatic at follow-up, 19 patients (34%) had significant findings, including one local recurrence and two secondary esophageal cancers. Patients were asymptomatic in all three cases. CONCLUSIONS: Videofiberoptic examination is a simple, effective, and relatively noninvasive method that can be performed in the OPD office to evaluate the PES and esophagus in patients after total laryngectomy.