Closure of cerebrospinal fluid leakage after transsphenoidal surgery: technical note.

It is necessary to pack the sella turcica to prevent the leakage of cerebrospinal fluid after transsphenoidal surgery if the arachnoid has been torn. The packing is usually supported by nasal cartilage. If this is not available, we recommend the Synthes minifragment plate to support the intradural pack.

Primary intrasellar germinoma in a woman presenting with secondary amenorrhea and hyperprolactinemia.

A 32-year-old woman with secondary amenorrhea was found to have an elevated level of serum prolactin, partial diabetes insipidus, and a subtle visual field defect. A primary intrasellar tumor was noted on the computed tomographic scan. Although the tumor had some characteristics of a prolactinoma, transsphenoidal exploration revealed a primary germinoma. The tissue diagnosis led to appropriate treatment with radiotherapy. The tumor regressed, and the patient had a spontaneous pregnancy. Had dopamine agonists been used initially, amelioration of the hyperprolactinemia and delay in the proper diagnosis and treatment would have occurred.

Vascularized fibular graft to replace resected cervical vertebral bodies. Case report.

Use of a vascularized free fibular graft is described as a method of replacing excised cervical vertebrae when severe instability is present. The vascularized bone graft heals more rapidly and with greater strength than a nonvascularized autogenous graft.

Combined otolarygologic and neurosurgical approaches to tumors of the temporal bone and skull base.

Craniofacial resections are extensive procedures with serious potential complications and may not lead to cure but appear to offer an appreciable palliative benefit. This is acceptable for situations normally considered inevitably fatal. Most neoplasms of the head and neck are relatively slow growing and metastasize to distant sites late in their course. This can lead to months or years of suffering. Eliminating a bulky, unsightly, painful neoplasm can make remaining life more tolerable. Further, if cure is to be at all possible, an attempt must be made at total excision. In the recent experience of the Lahey Clinic with five patients utilizing a combined approach, results have been gratifying for both patients and surgeons.

Venous air embolism in head and neck surgery.

Venous air embolism can occur under many circumstances, including head and neck surgery when the head is elevated. Embolized air obstructs the pulmonary outflow tract of the right ventricle or the pulmonary arterioles. Small volumes are tolerated or dispersed, but larger volumes can lead to severe physiologic changes. The Doppler precordial monitor is the most effective means of detection and should be used in major operations on the head and neck. Treatment methods are discussed and should be understood by all otolaryngologic surgeons.

Neuro-otologic manifestations of sarcoidosis.

Sarcoidosis is an idiopathic disease which presents in anatomic areas of concern to otorhinolaryngologists. It can cause dysfunction of both auditory and vestibular systems. In patients known previously to have sarcoidosis, this disease should be seriously considered. In patients presenting with otologic disorders and associated facial nerve paralysis or other neuropathies, uveitis, granulomatous meningitis or diabetes insipidus, sarcoidosis should be suspected. An examination of the eyes as well as a chest X-ray is imperative. Sudden and fluctuating neurosensory hearing loss has been reported. There is a great need for the study of temporal bones from sarcoidosis patients.

Posterior table fractures of the frontal sinus: I. An experimental study.

Experiments using cats were performed to examine the natural history of posterior table fractures of the frontal sinus and the methods available for treatment. Elevation of depressed fractures and obliteration by either fat or osteoneogenesis and fibrosis were the modalities of treatment used. Comparisons were made with untreated controls. Fascia reinforcement of the dura and plugging of the nasofrontal duct were variables. The nasofrontal duct is critical in the natural history of these injuries. All fractures of the posterior table heal if drainage into the nose is maintained. Fractures which are elevated heal by bony union with associated mucosal and dural healing. Loose fragments of the posterior table heal if left in place. Mucoceles form if the nasofrontal duct is obstructed, if mucosa is inadequately removed during obliteration and, in some instances, where islands of mucosa are isolated by mucosal laceration. Viable adipose tissue in the sinus prevents significant ingrowth of mucosa from the nasofrontal duct. Growth of mucosa into fracture lines was not a problem. Both adipose transplants and intrasinus fascia reinforcement appeared to contribute to well defined posterior table healing.

Tuberculosis of the larynx.

Tuberculosis of the larynx, once a common disease, has become quite rare with the advent of anti-tuberculous chemotherapy. In the pre-antibiotic era two modes of laryngeal infection were recognized; bronchogenic and hematogenous. The literature is briefly reviewed. Thirteen patients in the past 15 years in whom tuberculous laryngitis was diagnosed upon indirect laryngoscopy by members of the University of Michigan Department of Otorhinolaryngology are presented. Bronchogenic infection was present in 11, and in two patients the disease was consistent with hematogenous spread. Tissue biopsy from a case of bronchogenic contamination demonstrated epithelioid tubercles, while numerous subepithelial acid-fast bacilli without typical tuberculous histological change were present in a case of hematogenous laryngeal infection. A case of cicatricial laryngeal stenosis was successfully treated surgically by laryngofissure, excision of fibrosis with arytenoidectomy, and free mucous membrane grafting. Finally, the initial subtle presentation of many of our patients emphasizes the importance of a consideration of tuberculosis in the differential diagnosis of chronic laryngitis.

Neodymium-YAG laser intranasal photocoagulation in hereditary hemorrhagic telangiectasia: an update report.

Hereditary hemorrhagic telangiectasia is a challenging problem for the otolaryngologist since frequent, often severe epistaxis is the major symptom. Options for therapy in the past have included nasal packing, electrocautery, systemic estrogens, septal dermatoplasty, arterial embolization, and arterial ligation. Although successful treatment has been achieved with some of these methods, particularly septal dermatoplasty, other forms of therapy are needed prompting the use of laser photocoagulation. The neodymium yttrium-aluminum-garnet (Nd-YAG) laser was used to treat a group of 19 patients with hereditary hemorrhagic telangiectasia over a 4-year period without complications. Endonasal laser photocoagulation was effective in decreasing epistaxis in patients not requiring frequent transfusions prior to laser therapy. Three patients with the most severe epistaxis received minimal or no benefit from Nd-YAG laser photocoagulation. In most patients Nd-YAG photocoagulation is successful in treating epistaxis associated with hereditary hemorrhagic telangiectasia and should be a therapeutic option for this chronic disease having no available cure.

Benign lesions of the larynx: should the laser be used?

The use of the carbon dioxide (CO2) laser in the treatment of patients with benign laryngeal lesions, excluding respiratory papillomatosis, has been questioned because of potential adverse thermal effects on surrounding tissue. We question whether wound healing and subsequent quality of voice would be better if the surgeon used the "cold technique" with microlaryngeal instruments. Since the advent, in 1987, of a small-spot (0.3 mm) CO2 laser micromanipulator and more precise microlaryngeal instruments, we have redefined our use of the CO2 laser for benign laryngeal lesions. Over the past 4 years, in a series of 68 consecutive patients with vocal cord nodules, polyps, polypoid changes, or granulomas, the CO2 laser was useful for mucosal micro-flap dissection techniques and for vascular lesions. Smaller pedunculated lesions, such as vocal cord nodules, were more efficiently removed with the new microlaryngeal instrumentation. The combined selective use of a microspot CO2 laser at low-power settings (1 to 3 W), with 0.1-second pulses, and with precise microlaryngeal instruments will give the best results.

Otolaryngologic manifestations of sarcoidosis: presentation and diagnosis.

Neuro-otologic manifestations of sarcoidosis are rare. Dizziness in particular is a rare presenting complaint of the patient afflicted with this systemic granulomatous disorder. Head and neck and sinonasal presentations of this disease are more common. We reviewed our experience with six such patients who presented for management of their otolaryngologic (ORL) manifestations in order to delineate the involvement of the otolaryngologist in the treatment and diagnosis of these patients, with a focus upon the relevant tests and procedures in the otolaryngologist's de novo diagnosis of sarcoidosis. Studies ordered in the course of otolaryngologic evaluation and their utility in the diagnosis of sarcoidosis by the otolaryngologist are reviewed and classified into useful, supportive, and ancillary. The otolaryngologist played an important role in diagnosis, with four of six patients diagnosed to have sarcoidosis on the basis of their otolaryngologic presentations. Biopsy was performed by the otolaryngologist for diagnosis of sarcoidosis in all four of these cases. Steroids were central to treatment. Oral steroid therapy was the principal treatment: both patients with neuro-otologic sarcoid were successfully managed with oral steroids. Intralesional steroids were necessary to treat the skin lesion. One of six patients patients experienced complications related to steroid use.

Holmium: yttrium aluminum garnet laser-assisted endoscopic sinus surgery: laboratory experience.

Endoscopic sinus surgery has gained wide acceptance since its introduction into the United States. Complex sinus anatomy and troublesome bleeding have been associated with complications, which vary in severity from synechia to blindness and leakage of cerebrospinal fluid. Endoscopic sinus surgery using a holmium: yttrium aluminum garnet pulsed solid-state laser oscillating at 2.1 microns with fiberoptic delivery was performed in the laboratory, and the results were compared with those of conventional endoscopic sinus surgery. Three beagle dogs, six human cadaver heads, and one calf head were used in the in vivo and in vitro studies to evaluate the bone ablation, tissue coagulation, and hemostatic properties of the holmium: yttrium aluminum garnet laser. Modified endoscopic telescopes for sinus surgery, a newly developed handpiece for fiberoptic delivery, and other surgical instruments were used. The results indicate that the holmium: yttrium aluminum garnet laser and new delivery instrumentation provide good hemostasis and controlled soft-tissue ablation and bone removal. The access to all sinuses in the human cadaver model was very good. The canine in vivo study showed delayed but complete healing on the laser-treated side. Clinical evaluation of the holmium: yttrium aluminum garnet laser is warranted to increase the precision and safety of endoscopic sinus surgery.

Carbon dioxide laser in removal of polytef paste.

Teflon injection is the most popular surgical technique for improvement of voice in patients with a unilaterally paralyzed larynx. The results with this method usually are good, but cases of overinjection with resultant poor voice, airway compromise, or both, do occur. The carbon dioxide laser has become a standard instrument for laryngeal surgery, and it might reasonably be used in attempts to correct the overinjected vocal cord. Realizing that Teflon could share flammable characteristics with other polymers, such as rubber and polyvinylchloride, we investigated the effect of the carbon dioxide laser on fresh polytef paste (Mentor O & O Inc, Hingham, Mass) before using it in a patient with an overinjected hemilarynx. Fresh paste was found to ignite after exposure to standard laser power at normal time settings, both in room air and in an oxygen-enriched atmosphere. To determine the effect of the laser on Teflon in situ, the paste was injected subcutaneously and intramuscularly into a rat. After a suitable interval of time, the Teflon was found to glow but not ignite when exposed to the laser under standard operating conditions. Only under high power in an oxygen-enriched environment did ignition occur. In our patient, the laser was used to incise the mucosa over the polytef granuloma, and standard microsurgical (nonlaser) techniques were used to complete the removal with good results. Laryngologists should be aware of the dangers of using the carbon dioxide laser on or near Teflon, especially in freshly injected vocal cords.

New microspot micromanipulator for carbon dioxide laser surgery in otolaryngology. Early clinical results.

A new micromanipulator with microspot capability has been developed for carbon dioxide laser surgery in otolaryngology. The instrument features new infrared optics, which provide smaller laser spot sizes than those achievable with conventional micromanipulators (300 micron using a 400-mm operating microscope lens). The conventional red helium-neon aiming laser is replaced with a nonlaser fiberoptic image, and a power defocus control on the joystick manipulator eliminates external defocus controls. Less surrounding tissue trauma occurs with this new instrument by using a higher power density with average power settings of 1 to 2 W for cutting and ablation of tissue. Eight patients with benign laryngeal disease and one patient with dysplastic changes of the vocal cord were treated successfully without complications.

Intranasal approach to the sella turcica.

A transseptal approach to the sella turcica is described which is entirely intranasal and avoids the sublabial incision. The first incision is unilateral along the caudal edge of the septum, and the second incision is made across the base of the nasal columella. This allows the speculum to open the width of both nasal chambers, giving adequate exposure. The septal cartilage is either preserved or resected except for a caudal strut. The difficult dissection of mucosa from the nasal floor and maxillary crest is avoided. This technique is rapid and straightforward and results in a cosmetically acceptable scar.

Laser excision of early vocal cord carcinoma: indications, limitations, and precautions.

Forty-six patients referred for laser surgery of early vocal cord carcinoma were treated by laser excisional techniques with or without radiotherapy. Mean follow-up was 3.5 years. There was a 90% rate of carcinoma control (18 of 20 patients) in patients with untreated mid-vocal cord T1 carcinomas without involvement of the anterior commissure or vocal process or deep muscle invasion. Larger, more invasive T1 vocal cord tumors (13 patients) had laser excision followed by radiotherapy without recurrence. Careful patient selection and accurate histopathologic evaluation are key elements for successful treatment.

Endoscopic treatment of subglottic and tracheal stenosis by radial laser incision and dilation.

Five patients with severe fibrous subglottic and tracheal stenosis were treated by endoscopic radial laser incision and dilation using both carbon dioxide and neodymium:yttrium aluminum garnet lasers. Good results were noted without complications in all patients in a follow-up period of at least 1 year. Careful selection of patients, excluding those with tracheal collapse or tracheomalacia, and preservation of tracheal epithelium with minimal heat and mechanical trauma are considered essential for good results.

Treatment of cancer of the larynx. Analysis of success and failure.

The treatment of patients with cancer of the larynx must consider the potential for multiple sites of origin and the possibility of regional metastasis. Treatment options must also address effects on the voice, deglutition, and the sphincteric function of the larynx which protects the lungs. Fortunately, our advanced techniques in surgery--reconstruction, radiotherapy, and endoscopic laser application--enable us to choose from and use these modalities in combination. Induction chemotherapy appears to be a promising, albeit unproved, adjuvant therapy. The oncologist dealing with cancer of the head and neck must select appropriate individualized therapy in a multidisciplinary environment.

History taking in dizziness. The most important diagnostic step.

When faced with a complaint of dizziness, the primary care physician may be tempted to assume that the cause is inner ear dysfunction and that the patient needs to be referred to an otologist. According to Dr Hybels, however, most dizzy patients do not have an ear problem and a carefully executed history is likely to pinpoint the correct diagnosis. The following article delineates the fine points of history taking and discusses some of the most common causes of dizziness.

The neck mass. 1. General concepts and congenital causes.

A carefully taken history and thorough physical examination are the first steps in establishing the cause of a neck mass. Location, size, consistency, and mobility of the mass provide clues and are useful for comparison during follow-up. Further studies are ordered on the basis of the impressions gathered from this evaluation. Congenital neck masses can be found in patients of any age. Thyroglossal duct and branchial cleft cysts and fistulas are formed by incomplete obliteration of the thyroglossal duct and branchial clefts during embryonic development. Other congenital causes include lymphangiomas, cystic hygromas, dermoid cysts, and hemangiomas. Laryngoceles are acquired cysts that arise from an anatomic remnant, the laryngeal ventricle. Treatment for these neck masses is nearly always surgical removal.