Hearing loss and cerebrospinal fluid pressure: case report and review of the literature.

A decrease in cerebrospinal fluid pressure may result in an endolymphatic hydrops through a patent cochlear aqueduct or through the fundus of the internal auditory canal. This hydrops typically leads to low-frequency sensorineural hearing loss. We describe the case of a man who presented with a subjective and objective hearing loss in addition to a headache 4 days after he had undergone a dural puncture. We treated him with a standard epidural blood patch. Immediately after treatment, his hearing improved and his headache resolved.

Retrospective study and review of polymorphous low-grade adenocarcinoma.

OBJECTIVES/HYPOTHESIS: We review a single institution's experience with polymorphous low-grade adenocarcinoma. To our knowledge, this is the largest patient series of polymorphous low-grade adenocarcinoma with clinical follow-up in the otolaryngology literature. STUDY DESIGN: We retrospectively identified 19 patients with polymorphous low-grade adenocarcinoma who had adequate clinical follow-up and pathologic specimens available for examination. METHODS: All pathologic materials were reviewed by one head and neck pathologist. RESULTS: The median follow-up was 9.6 years. The most frequently affected sites were the hard palate (12 patients) and soft palate (9 patients). Fifteen patients had their initial treatment at our institution, and four patients presented with a recurrent tumor. Five patients had a local recurrence after surgery; of those patients, two had initially presented with recurrent tumors. Local tumors recurred as late as 15 years after the initial surgery. One patient had regional nodal disease 20 years after the initial procedure, and another had lung metastasis. No patients received chemotherapy. The most common initial diagnoses were polymorphous low-grade adenocarcinoma, adenoid cystic carcinoma, and pleomorphic adenoma. CONCLUSIONS: Polymorphous low-grade adenocarcinoma is an increasingly recognized malignancy that originates predominantly in the minor salivary gland. Our experience confirms good local control after a wide local excision is performed, but local recurrences can occur despite having negative margins after surgery. The delayed local recurrences and regional nodal metastases noted in our series show that prolonged follow-up is needed. This series also reports one of the first pathologically confirmed cases of distant metastasis.

Tracheostomy in critically ill patients.

Tracheostomy is a common critical care procedure in patients with acute respiratory failure who require prolonged mechanical ventilatory support. Tracheostomy usually is considered if weaning from mechanical ventilation has been unsuccessful for 14 to 21 days. A recent clinical trial suggested that early tracheostomy may benefit patients who are not improving and who are expected to require prolonged respiratory support. In this study, early tracheostomy improved survival and shortened duration of mechanical ventilation. Minimally invasive bedside percutaneous tracheostomy was introduced recently as an alternative to the traditional surgical technique. In expert hands, the 2 techniques are equivalent in complications and safety; however, the bedside percutaneous approach may be more cost-effective. Tracheostomy should be considered early (within the first week of mechanical ventilation) in patients with a high likelihood of prolonged mechanical ventilation. Depending on local medical expertise and costs, either the percutaneous or the surgical technique may be used.

Patient choice in treatment of vestibular schwannoma.

OBJECTIVES: There are options available to patients newly diagnosed with vestibular schwannoma. Our institution employs stereotactic radiosurgery, microsurgical removal, and watchful waiting. There are no studies in the literature examining which of these treatment options patients are choosing. STUDY DESIGN AND SETTING: Using retrospective chart review from January 2000 through December 2001, we noted several variables and patients' initial treatment choices. RESULTS: During the 24-month study period, 139 patients were seen at our institution with a new diagnosis of vestibular schwannoma and made a clear initial treatment choice. Of these, 32 (23%) patients elected watchful waiting; 51 (36%) underwent stereotactic radiosurgery, and 56 (40%) underwent surgical removal. Surgical excision correlated with younger age and larger tumor size. CONCLUSIONS: Our initial hypothesis, that patients choosing treatment would choose stereotactic radiosurgery more than 50% of the time, was untrue for the time course studied. SIGNIFICANCE: This is the first study to examine patient choice in treatment of vestibular schwannoma.

Management of synchronous subglottic stenosis and bronchial stenosis with a modified endotracheal tube.

We present the case of a tracheostomy tube-dependent 6-month-old infant with synchronous airway lesions, including grade III subglottic stenosis and left main bronchomalacia with recurrence of granulation tissue and stenosis. Because the infant was at high risk for complications from the tracheostomy tube, decannulation was the desired outcome. The airway lesions were managed by single-stage laryngotracheal reconstruction and short-term stenting of the subglottis and left main bronchus. The greatest challenge was management of progressive stenosis caused by recurrence of granulation tissue in the left main bronchus. A novel modification of a soft silicone elastic endotracheal tube was devised to provide continued ventilation of both lungs while the corrected lesions healed. The role for this type of stent and the benefits and difficulties associated with its use are discussed.