Waldenstrom's macroglobulinemia and sensorineural hearing loss.

Waldenstrom's macroglobulinemia, (WM) first described in 1944, is an uncommon disease caused by the abnormal production of immunoglobulin M monoclonal macroglobulin. Presenting signs and symptoms most frequently include fatigue or generalized weakness; tendency to bleed from mucosal surfaces; characteristic retinal lesions, including dilated and tortuous retinal veins, retinal hemorrhages, and exudates; lymphadenopathy; hepatosplenomegaly; sensory motor peripheral neuropathy; worsening normochromic anemia; increased sedimentation rate; and extremely high serum viscosity. Hearing loss is an unusual presenting symptom of WM; only 6 cases are reported in literature. The etiology of hearing loss is unclear; however, hyperviscosity and thrombus formations are the most likely causes. We present a patient diagnosed with WM whose initial presenting symptoms were hearing loss and progressive sensory peripheral neuropathy with subsequent development of lymphadenopathy and hyperviscosity syndrome. Treatment with Fludarabine lead to improvement of her hearing and neurological deficits, as well as resolution of her other hyperviscosity-related symptoms.

Incidence of carcinoma in incidental tonsil asymmetry.

OBJECTIVE: To determine the incidence of malignancy in patients with incidentally discovered unilateral tonsillar enlargement with an otherwise normal physical examination. STUDY DESIGN: A retrospective review of our institution's experience with unilateral tonsillar enlargement. RESULTS: During a five-year period, 570 patients underwent tonsillectomy at our institution. Of patients undergoing tonsillectomy, 49 patients (8.6%) underwent tonsillectomy with normal mucosa, no lymphadenopathy, and asymmetry of the tonsils. Two (4.8%) of the 49 patients with unilateral enlargement had the presence of malignancy. The two adult patients had B-cell lymphoma. Of all of the patients undergoing tonsillectomy, 0.35% had occult malignancy. In additional, the ability of the clinically assessed size (1+, 2+, 3+, and 4+) to predict volume was evaluated. The clinically assessed size and pathologically measured volume were significantly correlated (R = 0.333, P < .013). In 60.5% of the patients, the clinically assessed size and the pathologically measured volume agreed with the asymmetry reported on physical examination. CONCLUSION: A relatively high number of tonsillectomies will be performed to yield an approximately 5% positive rate of malignancy within removed tonsils that are asymmetrical with normal mucosa and no cervical adenopathy.

Acanthamoeba sinusitis with subsequent dissemination in an AIDS patient.

Otolaryngologists can play an important role in the care of patients with acquired immunodeficiency syndrome (AIDS) and/or human immunodeficiency virus infection. We present the case of an AIDS patient who was hospitalized for dehydration and who was soon found to have sinusitis and subsequent disseminated infection caused by Acanthamoeba. To treat the Acanthamoeba infection, the patient was started on oral itraconazole and intravenous metronidazole; i.v. pentamidine was added 2 days later. Despite aggressive therapy, on the eleventh day of hospitalization, the patient was obtundent and provided minimal response to noxious stimuli. He died on the sixteenth day of hospitalization. This case is one of only six reported cases of Acanthamoeba associated with sinusitis. Current therapeutic regimens have not been successful for most of these patients, and the prognosis is poor.

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.

Effect of pentoxifylline on the healing of guinea pig tympanic membrane.

Although most tympanic membrane perforations heal spontaneously, persistent perforations frequently require treatment by otolaryngologists. Initial management strategies include keeping the ear dry, ensuring aural hygiene, and using topical antibiotics. For persistent perforations, paper patching or myringoplasty may be required. Recently, agents such as hyaluronic acid and epidermal growth factor have been used to promote tympanic membrane healing. Similarly, pentoxifylline, a pharmaceutical agent with hemorrheological and antithrombotic properties, has been shown to increase perfusion and accelerate wound healing. This double-blinded prospective study attempts to examine the effect of pentoxifylline on tympanic membrane healing of 50 guinea pigs subjected to myringotomy. Serial examinations and histopathologic sectioning of the tympanic membranes revealed no significant difference in rate of healing or quality of repair between the pentoxifylline and control groups.

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.

Management of lateral sinus thrombosis.

OBJECTIVES: Review the clinical signs and symptoms, management, bacteriology and outcomes of patients treated for lateral sinus thrombosis. STUDY DESIGN: A retrospective review of six patients, treated from 1993 through 1998, with an intraoperatively confirmed diagnosis of lateral sinus thrombosis. METHODS: All charts from 1993 through 1998 coded for sinus thrombosis, meningitis, brain abscess, otitic hydrocephalus, subdural abscess, and mastoidectomy were reviewed. Operative reports, radiological examinations, laboratory data, culture data and other pertinent data were reviewed. RESULTS: The presenting symptoms ranged from headache to mental status changes. All patients had a history of chronic ear disease and all had at least one additional intracranial complication. The range of additional intracranial complications included otitic hydrocephalus, epidural abscess, and brain abscess. All of the infections were polymicrobial, with a predominance of anaerobes. There were no mortalities; morbidities included anacusis, acute respiratory distress syndrome, reoperation, seizures, septic cardiomyopathy, transfusion, ventriculoperitoneal shunt and nutritional supplementation. CONCLUSION: In patients with otologic disease, complaints of headache, earache or photophobia should warrant an evaluation. The presence of lateral sinus thrombosis mandates further investigation for additional intracranial complications. Conservative surgical intervention, consisting of removal of all perisinus infection and needle aspiration of the sinus, has been found to be effective. Lateral sinus thrombosis is an uncommon complication of otitis media, with potentially significant morbidities, necessitating a high index of suspicion.

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.

Absorption of topical cocaine in rhinologic procedures.

Although topical intranasal cocaine remains a common anesthetic in nasal surgery, controversy surrounds its dosage and mucosal absorption. A prospective study of 12 patients undergoing nasal surgery was performed to evaluate the absorption of cocaine solution from standard cotton pledgets. Of a 160-mg cocaine solution applied, a mean amount of 102 mg or 63.8% was recovered by gas chromatography/mass spectrometry analysis. Similar analysis of nasopharyngeal packs revealed less than 1.5% cocaine loss in the nasopharynx. Serum levels of cocaine were rarely detectable and did not correlate with either the amount of nasal absorption or time of mucosal contact. These results indicate that less than 37% of cocaine is absorbed from cotton pledgets during nasal surgery. The cocaine dose of 160 mg, used by many otolaryngologists, did not result in significant plasma levels.