Concurrent management of suppurative intracranial complications of sinusitis and acute otitis media in children.

OBJECTIVE: Intracranial complications of sinusitis and acute otitis media (AOM) are rare but life-threatening events. In children with suppurative intracranial complications, concurrent neurosurgical and otolaryngological (ORL) intervention has been recommended to optimize outcomes. The aim of this study was to investigate outcomes following concurrent neurosurgical and ORL intervention. METHODS: A retrospective cohort study of children undergoing neurosurgical intervention for intracranial complications of sinusitis or AOM in two neurosurgical centres in Ireland was conducted. RESULTS: 65 children were identified. Mean age was 11.9 years. The most prevalent symptoms were headache, pyrexia, altered level of consciousness, facial swelling, and vomiting. Subdural empyema (n = 24, 36.9%) and extradural abscess (n = 17, 26.2%) were the most common complications. 54 underwent same admission ORL intervention; 47 (87%) were performed concurrently or earlier. For rhinogenic infections, 35 (64.8%) underwent endoscopic sinus surgery (ESS), 13 (24.1%) underwent frontal sinus trephine, and 5 (9.3%) underwent maxillary sinus washout alone. For otogenic infections, 10 (90.9%) underwent mastoidectomy and 7 (63.6%) underwent tympanostomy tube placement. 19 (29.2%) had post-operative neurological deficits, of which 2 (3.1%) were permanent. Streptococcus intermedius was the most common pathogen (n = 30, 46.2%). Concurrent intervention reduced the prevalence of residual collection (p = 0.018) and the need for revision neurosurgical intervention (p = 0.039) for sinogenic complications. The same trends did not achieve statistical significance for the otogenic group. Mortality was 0%. CONCLUSION: Intracranial complications of sinusitis and AOM are best managed in a specialist centre with multidisciplinary input. Concurrent ORL and neurosurgical intervention reduces abscess recurrence and requirement for revision neurosurgery in sinogenic complications and should represent the standard of care. ESS is the ORL modality of choice in experienced hands.

Massive subcutaneous emphysema following routine endotracheal intubation.

Upper aerodigestive tract injury after endotracheal intubation is a rare but serious complication. The case of a 57-year-old female, who developed extensive neck and pneumomediastinum following a knee arthroscopy under general anaesthesia, is presented. Possible mechanisms of injury and management options are discussed.

High resolution computed tomography and magnetic resonance imaging in the pre-operative assessment of cochlear implant patients.

Optimal imaging protocols for cochlear implantation have yet to be determined. Pre-operative computed tomography (CT) and magnetic resonance image (MRI) scans are used to assess cochlear anatomy and patency, to delineate surgical access, and to aid in choice of side for implantation. However, opinion still differs as to which modality provides more information in pre-operative assessment, or if, indeed, a combination of the two is superior. The first 88 patients on the Irish National Cochlear Implant Programme (NCIP) were retrospectively studied to determine the accuracy of pre-operative CT and MRI in predicting abnormalities at the time of surgery. Correlation with surgical findings was determined in three separate groups of patients (those who had CT only, those who had MRI only, and those who had both CT and MRI performed). Of the 24 patients that had both CT and MRI performed, both modalities had a 79 per cent correlation with surgical findings. CT and MRI reports concurred in 75 per cent of cases. Specificity and negative predictive value were high (86 per cent and 90 per cent, respectively). CT alone (47 cases) correlated with surgery in 39 cases (83 per cent); MRI alone (17 cases) correlated in 15 cases (88 per cent). The findings of this study suggest that CT and MRI are effective at predicting normal inner ear anatomy, and thus at predicting the patient and the cochlea most suitable for implantation. Both modalities are useful in determining the side of implantation, thus avoiding potential surgical difficulties in cases of unilateral abnormalities. There was no significant difference between the ability of MRI and CT to detect abnormalities at the time of surgery. In this series the combination of CT and MRI has not been shown to be superior to either modality used alone, although anecdotal evidence to the contrary was noted.

Topical mitomycin application after laryngotracheal reconstruction: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To explore the effect of mitomycin treatment on the pediatric airway following laryngotracheal reconstruction. DESIGN: Randomized, double-blind, placebo-controlled trial. PATIENTS: Children aged 2 to 17 years with subglottic or upper tracheal stenosis undergoing laryngotracheal reconstruction at a single, tertiary care, children's hospital. INTERVENTION: At the time of extubation or stent removal, the children underwent bronchoscopy and 0.4 mg/mL (2 mL of a 0.2-mg/mL solution of either mitomycin or an equal volume of isotonic sodium chloride was directly applied to the subglottic region for a single application of 2 minutes. These children then underwent interval endoscopy at 2 weeks, 6 weeks, and 3 months postoperatively for assessment of their airways. RESULTS: Granulation tissue was graded on a scale of 0 (none) to 4 (near-total or total occlusion). Videotapes of endoscopies were independently observed and graded by 3 pediatric otolaryngology fellows with a subsequent interobserver agreement of 91.6%. The results were then dichotomized to represent a single cohort in which further surgical intervention would be required and another separate cohort in which further surgery would not be required. At the 1-year mark, interim analysis was performed by a Data Safety and Monitoring Committee. At this time, 13 children had been randomized to the mitomycin-treated arm of the study and 11 children to the placebo-treated arm. A 2-tailed Fisher exact test revealed a value of 1.00. The Data Monitoring and Safety Committee advised that the trial should be stopped because the distributions between the 2 populations were almost identical. CONCLUSION: We cannot reject the null hypothesis that a single topical dose of mitomycin exerts an equal benefit as does isotonic sodium chloride when applied to the pediatric airway after laryngotracheal reconstruction.

Pulmonary embolism following tonsillectomy.

Acute post-operative pulmonary embolism is a serious potentially life-threatening complication which is not anticipated in young patients undergoing non-major surgery. We report a case in which a 32-year-old previously healthy woman developed a major pulmonary embolism following tonsillectomy. Subsequent investigations revealed the presence of an occult malignancy. This case highlights the role of paraneoplastic hypercoagulable states in the aetiology of venous thromboembolism and the importance of thromboprophylaxis in the presence of confirmed or suspected malignancy. To our knowledge no case of major pulmonary embolism occurring after tonsillectomy has been previously reported.

Post-nasal space oncocytoma: a different approach to a rare tumour.

Oncocytomas are rare tumours that occur predominantly in the major salivary glands, particularly the parotid of older individuals. We present the exceptionally rare occurrence of an oncocytoma in the post-nasal space and its treatment for the first time via a Le Fort I osteotomy. The potential for local spread to the surrounding skull base makes it vital to achieve good oncological clearance. We found that this was possible using the Le Fort I technique and would recommend that this approach should be considered in future, when approaching such lesions.

Nitinol stent insertion for post-pneumonectomy syndrome.

Post-pneumonectomy syndrome is an unusual condition, that can occur a variable period of time after a patient has had a pneumonectomy. Management of this syndrome has been described using a number of different techniques, often with considerable mortality. We present a case report where this condition was treated successfully by insertion of an expandable Nitinol stent. This is the first time this technique has been described to treat this condition, and we feel it may be the procedure of choice in managing these patients.

Surgery for pediatric subglottic stenosis: disease-specific outcomes.

To set the foundation to develop a disease-based, operation-specific model to predict the outcome of pediatric airway reconstruction surgery, we performed a retrospective database review of children operated on at a single, tertiary-care children's hospital. Over the 12-year period 1988 to 2000, a total of 1,296 airway reconstruction procedures were performed. Out of these, charts were identified for 199 children who underwent laryngotracheal reconstruction for a sole diagnosis of subglottic stenosis. Children were excluded from the study if their disorder included supraglottic, glottic, or upper tracheal disease. The main outcome measures were Myer-Cotton grade-specific decannulation and extubation rates, including both operation-specific and overall results. There were 101 children who underwent double-stage laryngotracheal reconstruction. The operation-specific decannulation rates for Myer-Cotton grades 2, 3, and 4 were 85% (18/21), 37% (23/61), and 50% (7/14) (chi2 analysis, p = .0007). The overall decannulation rates were 95% (20/21), 74% (45/61), and 86% (12/14) (chi2 analysis, p = .04). There were 98 children who underwent single-stage laryngotracheal reconstruction. The operation-specific extubation rates for Myer-Cotton grades 2, 3, and 4 were 82% (37/45), 79% (34/43), and 67% (2/3) (chi2 analysis, p = .63). The overall extubation rates were 100% (45/45), 86% (37/43), and 100% (3/3) (chi2 analysis, p = .03). Logistic regression analysis showed no effect of age (less than or greater than 2 years of age) on operation-specific or overall outcome parameters. We conclude that laryngotracheal reconstruction for pediatric subglottic stenosis remains a challenging set of procedures in which multiple operations may be required to achieve eventual extubation or decannulation. Children with Myer-Cotton grade 3 or 4 disease continue to represent a significant challenge, and refinements of techniques are being examined to address this subset of children. Disease-based, operation-specific outcome statistics are the first step in the development of a meaningful predictive model.

Nitinol stents: their value in tracheobronchial obstruction.

Recurrent tracheobronchial obstruction whether due to a benign or malignant cause is not always amenable to surgery and one is left with the dilemma of what to do for a patient who is slowly asphyxiating. Various modalities have been employed in the past with varying degrees of success. However due to the recent innovations in 'superelastic' biocompatible alloys we present our clinical experience with a new generation of metallic stents made from Nitinol. Over a 12-month period we inserted eight stents in six patients with malignant and benign tracheobronchial obstruction. Almost all patients had dramatic improvement in their symptoms and there was little airway reaction observed up to 18 months after insertion. However, one should exercise caution in inserting them for benign conditions as we regard them as permanent implants. Also evident is the inherent morbidity in this group of patients and this needs to be carefully considered prior to treatment.

Head and neck schwannomas--a 10 year review.

Schwannomas of the head and neck are uncommon tumours that arise from any peripheral, cranial or autonomic nerve. Twenty-five to 45 per cent of extracranial schwannomas occur in the head and neck region and thus are usually in the domain of the otolaryngologist. They usually present insidiously and thus are often diagnosed incorrectly or after lengthy delays, however, better imaging and cytological techniques have lessened this to some degree more recently. For benign lesions conservative surgical excision is the treatment of choice bearing in mind possible vagal or sympathetic chain injury. Malignant schwannomas are best treated with wide excision where possible. The role of adjuvant therapy remains uncertain and irrespective of treatment modality prognosis is poor with an overall survival of 15 per cent. However, recent advances in ras oncogene inhibitors may hold hope for the future.

Head and neck squamous cell carcinoma: better to be young.

Most head and neck squamous cell carcinoma patients are elderly, with few younger than 40 years. Controversy exists in the literature regarding outcomes for younger patients. The goal of this research project was to compare baseline features and outcomes for young patients (/=65 years). To investigate the relationship between age and important presenting features and outcomes, 1160 recently diagnosed patients first treated at Washington University between 1980 and 1991 were identified from an existing database. Full 5-year survival information was available for 1030 patients (89%). Overall, the 5-year survival rate was 46% (478/1030); young patients (65%, 26/40) had a significantly better survival rate than middle-aged (52%, 292/566) or old patients (38%, 160/424) (chi(2) = 24.5; P = 0. 001). Survival was also related to smoking, comorbidity, primary site, TNM stage, and nodal disease. Age remained a significant factor even after we controlled for these other factors. Young patients developed fewer recurrent and new primary tumors. We conclude that young patients have a much better overall prognosis than older patients. The reasons for this difference are unclear, but it appears that the impact of age goes beyond an actuarial effect.

The Westaby T-Y tracheobronchial stent in otolaryngology.

The Westaby T-Y tracheobronchial silicone stent can be used for the relief of upper airway obstruction beyond the limit of a standard tracheostomy tube. We report on our experience in the use of the Westaby tube in 10 patients over a five-year period. The general features of the tube, indications for its use, and its method of insertion are described. The versatility and advantages over other stents are discussed. Two cases reports are described and the clinical course and outcomes of the individual patients are outlined.

Development of a new staging system for recurrent oral cavity and oropharyngeal squamous cell carcinoma.

BACKGROUND: Approximately 33% of patients with squamous cell carcinoma of the oral cavity and oropharynx develop a recurrence. The management of recurrent tumors can be challenging to both physician and patient, at least in part due to the lack of an accurate and clinically applicable staging system for these patients. The purposes of this study were to examine the survival patterns of patients presenting with recurrent oral cavity and oropharyngeal tumors, to identify key factors affecting prognosis, and to combine these factors to create a new staging system to predict survival and aid in planning therapy. METHODS: The methods included a retrospective chart review of 641 patients with oral cavity and oropharyngeal squamous cell carcinoma who underwent their initial treatment at Washington University between 1980 and 1992. From this population, 249 patients (39%) developed a recurrence. RESULTS: The overall 2-year survival rate was 20% (50 of 249 patients). Six variables affected survival significantly: histologic differentiation, initial (prior to first therapy) TNM stage, initial treatment, time to recurrence, extent of recurrence, and treatment of recurrence. These six variables were entered into a logistic model to determine the individual prognostic significance of each variable. Two variables were found to be statistically significant: initial TNM stage (chi-square test = 7.67; P = 0.0056) and extent of recurrence (chi-square test = 11.75; P = 0.0006). Using the process of conjunctive consolidation, these two variables were combined to create a new staging system for recurrent tumors of the oral cavity and oropharynx. CONCLUSIONS: This staging system provides accurate estimates of prognosis, involves no new technology to implement, demonstrates statistically significant differences in survival by stage, and may aid both the physician and the patient in planning therapy.

Development of a new staging system for patients with recurrent laryngeal squamous cell carcinoma.

BACKGROUND: The management of recurrent head and neck squamous cell carcinoma can be challenging to both physician and patient. This is due at least in part to the lack of an accurate and clinically applicable staging system for these patients. The purposes of this study were to examine the survival patterns of patients presenting with recurrent laryngeal tumors, identify key factors affecting prognosis, and combine these factors to create a new staging system to predict survival. METHODS: The methods included a retrospective chart review of 473 patients with laryngeal squamous cell carcinoma who received their initial treatment at Washington University between 1980 and 1992. From this population, 126 patients (27%) who developed recurrence were identified. RESULTS: The overall 2-year survival rate was 40% (50 of 124 patients). Four variables affected survival: initial TNM stage, initial treatment, morphologic extent of recurrence, and treatment of recurrence. These variables were entered into a multivariate analysis to determine independent prognostic significance. Three variables were found to be statistically significant: TNM stage (chi-square = 4.6; P = 0.03), initial treatment (chi-square 14.3; P = 0.0002), and extent of recurrence (chi-square = 19.4; P = 0.0001). The process of conjunctive consolidation was used to combine significant variables to create a new staging system for laryngeal recurrence. CONCLUSIONS: This staging system provides accurate estimates of prognosis, involves no new technology to implement, can aid both the patient and physician in planning treatment, and can be used in observational studies to assess the relative effectiveness of competing therapies.