Benign osteoblastoma of the maxillary sinus.

Benign osteoblastoma is an uncommon fibro-osseous neoplasm with a predilection for the vertebrae and long bones, and a 2-to-1 male-to-female ratio of occurrence. Peak incidence occurs in the second decade, with 80% of all patients being under 30 years of age. The clinical, radiographic, and histologic presentation of a large maxillary sinus osteoblastoma is reviewed. Preoperative embolization of this vascular neoplasm is advocated.

Trichoepithelioma: report of an unusual case and review of the literature.

Trichoepitheliomas are benign and uncommon skin tumors presenting in the head and neck region. Although they can be solitary, they occur more frequently as multiple lesions with an autosomal dominant inheritance. To the surgeon, they often present the problem of clinical differentiation from basal-cell carcinoma. An unusual case is described, and experience in the treatment of 19 patients is reviewed.

MR of nasolabial cysts.

We report the MR imaging findings in two cases of nasolabial cysts. Demonstration of their extraosseous location with cross-sectional imaging should prevent confusion with maxillary cysts and obviate unwarranted dental or maxillary surgery.

Rhinosinusitis. Current concepts in evaluation and management.

Sinusitis is one of the most common health complaints leading to a physician office visit in the United States. Recently standardized terminology with diagnostic parameters are outlined. Following this is a detailed discussion of the basics of relevant history and physical examinations, laboratory and radiology testing, the appropriate selection of pharmacotherapy, and the indications for surgical intervention.

Effects of tympanic membrane scars on tympanometry: a study in cats.

The efficacy of tympanometry in the diagnosis of ossicular abnormalities and the differentiation of such from eardrum scarring is controversial. This paper presents a study of the tympanometric effects of specific eardrum scars and ossicular abnormalities in cats. For both normal eardrums and healed myringotomies, a normal middle ear could be differentiated from stapes fixation or incudostapedial discontinuity using static immittance parameters and tympanogram morphology. Twenty percent myringectomy scars caused abnormal 660 Hz tympanograms but this effect could be distinguished from changes caused by a concomitant ossicular abnormality. The very low impedance of a 50% myringectomy scar resulted in tympanograms which could not be differentiated from an ossicular discontinuity alone. With this neomembrane, stapes fixation could not even be differentiated from an ossicular discontinuity. This study supports the view that tympanometry should be interpreted as part of a battery of tests which includes otoscopy, audiometry, and acoustic reflex measurements.

Pseudotumor of the head and neck masquerading as neoplasia.

Four unusual cases of pseudotumor, which had clinical and radiographic findings suggesting neoplasia, are presented. One involved the maxillary sinus, destroying the lateral wall, and extending to the infratemporal fossa and the orbit. The second presented as an enlarging lacrimal gland tumor with ipsilateral parotid adenopathy, and the third as a large parapharyngeal mass that was diagnosed as a lymphoma on aspiration cytology. The fourth case documented the rare occurrence of a congenital pseudotumor, manifesting as proptosis in a neonate and thought to be a fibrosarcoma on frozen section study. Aggressive pseudotumors must be distinguished from malignancy to avoid unnecessary surgery or irradiation. Some cases can be distinguished from neoplasms by their dramatic response to oral steroid therapy, and others by characteristic features on CT or MRI. Due to the diverse cellular proliferation, aspiration cytology is infrequently helpful and diagnosis can be difficult on frozen section study. An approach to the diagnosis and management of pseudotumors is detailed.

Surgical management of choanal atresia.

Our experience with the diagnosis and surgical management of 37 patients with congenital atresia or severe stenosis of both posterior nasal choanae is presented. Twenty-five were repaired transnasally and 12 were repaired transpalatally. Soft stents were fashioned from Silastic tubing and used for 6 to 12 weeks postoperatively. In 64% of the transnasal operations and 83% of the transpalatal operations, full patency of both choanae was achieved without the necessity of dilatations. In most of the remaining operations, one lumen remained patent.

Facial plastic surgery in an otolaryngology training program.

The medical complications and unsatisfactory results of facial plastic surgery performed by residents under close supervision are compared with those of the staff who train them and the literature. In 502 rhinoplasty, rhytidectomy, browlift, blepharoplasty, otoplasty, dermabrasion, and chemical peel procedures, there were no significant differences between the resident and staff operations except that residents required more time to perform the procedure. Operations which might be combined at one sitting should be staged during a resident's early experience with cosmetic surgery.

Management of canal stenosis with a transposition flap.

Stenosis of the external auditory canal is difficult to manage. Numerous surgical procedures have been advocated for its correction and all function to varying degrees, but repeat stenosis remains a problem. Our experience, with the use of a superiorly based preauricular transposition flap in combination with an endaural and postauricular approach in 5 patients, 8 ears, is presented. In 3 patients, 5 ears, the stenosis was congenital; in 1 patient, 1 ear, traumatic; and in 1 patient, 2 ears, secondary to chronic external otitis. With a follow-up of 1 to 9 years, the functional and cosmetic results have been satisfactory in all cases.

Neonatal respiratory distress from rhinitis medicamentosa.

Rhinitis medicamentosa from topical vasoconstrictor abuse results in nasal obstruction which can be life-threatening in neonates. Neonates are obligate nasal breathers, most learning oral respiration by 2 months of age. A neonate was started on topical phenylephrine at birth, and by 3 weeks of age was having multiple daily episodes of apnea and cyanosis. An evaluation documented edematous, obstructing nasal turbinates, as well as polycythemia, cardiomegaly, and prominence of the pulmonary vasculature. A nasopharyngeal airway alleviated the obstruction until the turbinates recovered, and the other abnormalities quickly resolved.

Mini-craniotomy for management of CSF otorrhea from tegmen defects.

CSF otorrhea arising from defects in the tegmen and middle fossa dura may be congenital or acquired. It may be spontaneous or secondary to trauma, chronic ear disease, tumor or surgical treatment. In the six cases presented, the tegmen defect and associated CSF leak were secondary to chronic ear disease in two cases, to mastoid surgery in two cases, to temporal bone fracture and congenital origin in one case each. The successful management of these patients utilizing a mini-craniotomy in conjunction with mastoid surgery is described. Mini-craniotomy facilitates precise extradural, intracranial placement of an autogenous graft over the tegmen defect which can be technically difficult in the transmastoid approaches, yet avoids the morbidity and potential complications of a full middle fossa craniotomy. It does not significantly add to the length of the mastoid procedure or its complications.

Carotid arteriospasm.

Arteriospasm can result from manipulation or fresh blood around an artery. This myogenic reflex can spread to obliterate collateral flow and can last from minutes to days. Ischemic strokes from carotid spasm ensue neurosurgical procedures, endarterectomies, and even chiropractic manipulation. The diagnosis and prevention of arteriospasm are presented, and a patient who has carotid arteriospasm following excision of a branchial cleft cyst is detailed. If the vessel constriction is noted at surgery, topical application of a local anesthetic is effective. Transfusion, hydration, oxygenation, and maintenance of blood pressure are the cornerstones of nonoperative therapy.

Evaluation of and access to posterior orbital tumors.

Head and neck surgeons enter the peripheral orbit for the therapy and/or biopsy of the most common expanding lesions, i.e., thyroid ophthalmopathy, direct extension of paranasal disease, pseudotumor and metastases. It is in this space between the bony orbital walls and the extraocular muscle cone that a majority of primary orbital neoplasms occur. The four basic approaches to posterior orbital tumors are: lateral orbitotomy through the temporal fossa with a modified Kronlein procedure, medial orbitotomy utilizing a Lynch incision and lacriminal sac mobilization, superior orbitotomy via a Naffziger frontotemporal crainotomy, and inferior exposure/decompression through the maxillary sinus. Case examples of the former two approaches are presented. None of these standard procedures allows full exposure of the posterior orbit. A combined cranio-facial-orbital access to this region utilizing a modified maxillectomy and frontotemporal craniotomy is detailed.

The efficacy and safety of transantral ethmoidectomy.

With the advent of new endoscopic instruments, rhinologists are reassessing and modifying ethmoidectomy techniques. Despite this renewed interest, the transantral ethmoidectomy has received little attention, even though this procedure has the advantages of avoiding an external incision, safely delineating the medial orbital wall, and simultaneously treating ethmoid and maxillary sinus disease. The present study compared 74 transantral ethmoidectomy procedures and 47 external ethmoidectomy procedures. The two groups of patients were comparable with respect to age and gender. There was no statistical difference between the two groups with regard to blood loss. Complications were less frequent in the transantral group. Of the 97 patients treated for ethmoid sinusitis, outcome was more successful in the transantral group than in the external ethmoidectomy group when assessed by the need for additional medical or surgical treatment.

Sinus neoplasia.

After an overview of the epidemiology, histology, and evaluation of nasal and sinus neoplasms, this article discusses surgical advances in facial translocation, skull base dissection, and defect reconstruction. With the aforementioned, the question of what is technically resectable vs what is curable has become an important but as yet unanswered question. Radiation therapy, combined with surgery or as palliation, presents special challenges in the head and neck, and ports must be carefully defined to minimize damage to vision and adjacent cranial structures. Chemotherapy is usually reserved for palliation, though some report favorable results with induction treatment of squamous cell carcinomas with platin-based regimens.

Head and neck burns. Evaluation and current management.

More than half of the 150,000 burn patients hospitalized in the United States each year have head and neck involvement, with 3% to 7% sustaining concomitant inhalation injury. With advances in fluid replacement therapy and specialized burn care units, mortality has fallen from near 100% to 24% for burns of 75% to 90% of body surface area. The most common causes of death are respiratory complications and sepsis. Inhalation injuries can be diagnosed by laryngoscopy, and compromised airways can then be intubated (with tracheotomy for long-term management) and sloughing mucosa and inspissated mucus removed by serial bronchoscopy. Sepsis is minimized by early excision of burn eschar and autografting or, in the widely burned, temporary coverage with cadaver allograft, porcine xerograft, or skin substitutes until successive crops of autografts are available. The head and neck presents substantial reconstructive and rehabilitative challenges, which must be addressed in aesthetic units.

Management of xeroderma pigmentosum.

Xeroderma pigmentosum is an autosomal recessive disease associated with a defect in DNA repair from damage by ultraviolet light. It is characterized by the development of cutaneous malignancies in childhood and by death from the local or systemic complications thereof by the third decade of life. The head and the neck are the most frequently affected areas. Management involves sunlight avoidance and prompt biopsy of any new skin lesion. Due to the chronic nature of the disease, it is necessary to excise the least amount of tissue consistent with tumor removal in order to preserve skin for future procedures. In some patients, radiation therapy and/or certain chemotherapeutic agents are abnormally cytotoxic and must be utilized with caution.

'Medial maxillectomy' for lateral nasal wall neoplasms.

Lateral rhinotomy and "medial maxillectomy," an en bloc resection of the medial maxillary sinus, ethmoid sinus with the lamina papyracea, medial orbital floor, and lacrimal fossa-duct, have been advocated for lateral nasal wall neoplasma. Experience with 35 (of 41) patients followed up at least 30 months (median, 57 months) postoperatively is reported. There was a 9% recurrence for benign tumors and 15% for malignant neoplasms, the latter only in the patients with nonmelanoma malignant neoplasms not receiving postoperative radiotherapy. The most frequent complications were cavity crusting, epicanthal scarring, and epiphora.

Orbital decompression in Graves' disease.

OBJECTIVE: The authors' experience with surgical decompression of the orbits in patients with Graves' orbitopathy is reviewed. DESIGN: One hundred twenty-six consecutive primary orbital decompressions were retrospectively studied. SETTING: Tertiary care university hospitals. PATIENTS: All patients were referred by ophthalmologists for surgical decompression after failure of a trial of oral steroid therapy, and many had had orbital irradiation. INTERVENTION: Antral-ethmoidal or transconjunctival surgical decompression was accomplished in all. MAIN OUTCOMES: Measurements of visual acuity, ocular motility, and proptosis were accomplished preoperatively and a minimum of 3 months postoperatively. Surgical complications were tallied. RESULTS: Mean reduction of proptosis by antral-ethmoidal decompression was 5.3 mm, and 3.6 mm by the transconjunctival approach. Visual acuity improved in 34 orbits, was unchanged in 91 orbits, and decreased in one orbit. In a subgroup of 30 patients in whom ocular motility was quantified by prism cover test preoperatively, motility was unchanged or improved in 21 and was decreased in nine. Complications were infrequent. CONCLUSION: The antral-ethmoidal and transconjunctival approaches to orbital decompression are safe and effective.

Neurotropic cutaneous tumors of the head and neck.

OBJECTIVE: To determine the outcomes of patients with neurotropic cutaneous tumors of the head and neck. DESIGN: A retrospective review was conducted of 7852 charts of patients who underwent micrographically controlled excisions of skin cancers of the head and neck between 1984 and 1995, identifying neurotropic tumors and the outcomes of their treatments. SETTING: Tertiary care center (university hospital). PATIENTS: Thirty-seven patients with neurotropic tumors were identified (and confirmed by secondary histological review), constituting 0.47% of all patients. The median age at presentation was 68 years and all except an albino were white. Nine patients had basal cell carcinomas and 28 had squamous cell carcinomas. Twenty-five patients (69%) were referred after at least 1 prior excision was performed a median of 16 months previously. INTERVENTION: All patients underwent micrographic mapping and excision of the cutaneous portion of the tumor. As necessitated by tumor spread, additional soft tissue, skull base, and/or intracranial surgery and postoperative irradiation were also conducted. MAIN OUTCOME MEASURES: Thirty-four patients (3 patients were unavailable for follow-up) were assessed by physician examination a minimum of 19 months after treatment (median, 33 months). RESULTS: Of 25 patients with extracranial disease only, 19 had no evidence of disease during follow-up and 1 died of intercurrent disease at 20 months without evidence of tumor persistence. Of the 9 patients with intracranial neurotropic tumors at the time of presentation, 1 remained with no evidence of disease, 1 died of intercurrent disease at 21 months without evidence of tumor persistence, and the other 7 either died of or are living with an intracranial tumor. CONCLUSIONS: Micrographic tissue mapping to detect and then encompass neurotropic cutaneous malignancies, along with conventional surgery for deeper tumor invasions and irradiation in selected cases, was successful in 19 patients (76%) with an extracranial tumor. For those with neurotropic tumors approaching or penetrating the skull base, the prognosis was poor regardless of therapy method.