Influence of different approaches to the cerebellopontine angle on the function of the intermediate nerve.

OBJECT: Surgery in the cerebellopontine angle (CPA) is a standard procedure at many centers. Outcome is focused mainly on preservation of hearing and facial function postoperatively. The nonmotor part of the facial nerve, the intermediate nerve, is nearly neglected nowadays. METHODS: A retrospective study was designed, including a questionnaire that was sent to 178 patients who had undergone surgery between 2000 and 2004. Data were obtained in 156 cases. The questionnaire was divided into five parts assessing the presence of increased tearing, reduced tearing, salivation disturbances, increased nasal secretions, and abnormalities in taste. Finally, a self-assessment of patient symptoms was analyzed. RESULTS: Postoperatively, 70 patients (45%) experienced crocodile tears, whereas 62 (40%) had dry eyes. Disturbances in taste were noted in six patients (4%) preoperatively and in 52 patients (33%) after surgery. Increased nasal secretion was noted in 68 patients (44%) postoperatively. An analysis of the correlation between the surgical approach used and disturbances in the intermediate nerve revealed a strong tendency to a higher rate of symptoms following the middle fossa approach (p = 0.071, chi-square test). CONCLUSIONS: Data in this study demonstrate the clinical importance of nonmotor defects associated with CPA tumor removal. More than 50% of the patients in this study reported postoperative crocodile tears, dry eyes, nasal secretions, and/or taste disturbances. These sequelae may affect both short- and long-term postoperative quality of life to the same extent as deafness or transient facial paresis. The risk of injury seems to be higher after the middle fossa approach.

Gold laser versus curettage adenoidectomy: incidence of complications and otorrhea after concurrent pressure-equalization tube placement.

OBJECTIVES: To measure the incidence of postoperative complications and otorrhea in patients undergoing Gold laser or curettage adenoidectomy with pressure-equalization (PE) tube placement. STUDY DESIGN: A prospective study of 100 patients, ages 8 to 48 months, undergoing Gold laser (n = 50) or curettage adenoidectomy (n = 50) and PE tube placement in a pediatric outpatient setting. METHODS: Pediatric patients with chronic otitis media with effusion and adenoid hypertrophy after failure of medical management were included in the study. Adenoid size and middle ear status were recorded at surgery. The total adenoidectomy procedure time was recorded. All patients were evaluated at 1 week, 1 month, and 4 months postoperatively. The incidence of nasal complications and otorrhea was recorded. RESULTS: There was no statistical difference in age, race, sex, adenoid size, or middle ear status between groups. The laser group had a shorter procedure time (P = .001) and a lower incidence of otorrhea (P = .024). There was no difference in nasal complications between groups. CONCLUSIONS: The Gold laser adenoidectomy technique can be safely performed with PE tube placement and may offer advantages over the traditional curettage adenoidectomy technique.

Laryngeal trauma: review of literature.

Laryngeal trauma is a rare injury that can lead to rapid airway deterioration if not treated in a timely, proper manner. Due to its infrequent occurrence, many different management strategies have evolved. All approaches stress an immediate stabilization of the airway, followed by a diagnostic protocol that demarcates different groupings based on the extent of laryngeal trauma. Treatment regimens, ranging from medical to surgical, are then based on such groupings. The uniformity of the management strategy mentioned above is misleading given the variation of management in the literature. This paper reviews the management strategy for laryngeal trauma, while detailing the different approaches described in the literature.

Institutional Oversight of the Graduate Medical Education Enterprise: Development of an Annual Institutional Review.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) fully implemented all aspects of the Next Accreditation System (NAS) on July 1, 2014. In lieu of periodic accreditation site visits of programs and institutions, the NAS requires active, ongoing oversight by the sponsoring institutions (SIs) to maintain accreditation readiness and program quality. METHODS: The Ochsner Health System Graduate Medical Education Committee (GMEC) has instituted a process that provides a structured, process-driven improvement approach at the program level, using a Program Evaluation Committee to review key performance data and construct an annual program evaluation for each accredited residency. The Ochsner GMEC evaluates the aggregate program data and creates an Annual Institutional Review (AIR) document that provides direction and focus for ongoing program improvement. This descriptive article reviews the 2014 process and various metrics collected and analyzed to demonstrate the program review and institutional oversight provided by the Ochsner graduate medical education (GME) enterprise. RESULTS: The 2014 AIR provided an overview of performance and quality of the Ochsner GME program for the 2013-2014 academic year with particular attention to program outcomes; resident supervision, responsibilities, evaluation, and compliance with duty-hour standards; results of the ACGME survey of residents and core faculty; and resident participation in patient safety and quality activities and curriculum. The GMEC identified other relevant institutional performance indicators that are incorporated into the AIR and reflect SI engagement in and contribution to program performance at the individual program and institutional levels. CONCLUSION: The Ochsner GME office and its program directors are faced with the ever-increasing challenges of today's healthcare environment as well as escalating institutional and program accreditation requirements. The overall commitment of this SI to advancing our GME enterprise is clearly evident, and the opportunity for continued improvement resulting from institutional oversight is being realized.

Nasal provocation testing as an international standard for evaluation of allergic and nonallergic rhinitis.

Standardized nasal provocation testing (NPT) has been shown to be a safe and very useful tool in the diagnosis of allergic and nonallergic rhinitis. However, in the United States, its use has been mostly limited to scientific investigations, and it has not yet been widely accepted as a standard diagnostic procedure in clinical practice. NPT aims to identify and quantify the clinical relevance of inhalant allergens or occupational irritants. During NPT, nasal respiratory mucosa is exposed to an airborne substance suspected to cause symptoms in the respective individual. Clinical reactions are monitored in a controlled and standardized fashion. Nasal secretions, symptoms such as itching, sneezing and, most importantly, nasal obstruction are assessed as well as ocular, bronchial, cutaneous, and systemic reactions. To achieve objective data on changes in nasal airflow and patency after the challenge, anterior rhinomanometry and acoustic rhinometry have been included in the standard protocol of NPT. By monitoring changes of nasal airflow on one hand and of nasal geometry on the other hand, these methods display nasal function in a graphic way just as speech and pure tone audiometry do for auditory function. Also, by their objective nature, these methods offer a clear and internationally comparable standard. This review outlines a protocol for NPT and discusses practical applications and clinical indications. The use of rhinomanometry and acoustic rhinometry as objective diagnostic tools is emphasized. For the diagnosis of allergic and occupational rhinitis, standardized NPT should be regarded as an international diagnostic standard.

Intratympanic dexamethasone and hyaluronic acid in patients with low-frequency and Ménière's-associated sudden sensorineural hearing loss.

BACKGROUND: Steroids are widely used for the treatment of cochleovestibular disorders. Direct steroid application in the middle ear cavity, when combined with a round window membrane permeability-modulating substance, increases the level of the steroid reaching the target cells. We measured hearing in patients with idiopathic isolated low-frequency sensorineural hearing loss and in patients with sudden sensorineural hearing loss and a history of Ménière's disease. Contradictory reports about effectiveness of intratympanic steroid therapy on vertigo control and hearing improvement in patients with Ménière's disease exist in the literature. METHODS: Eighteen patients with isolated low-frequency idiopathic sudden sensorineural hearing loss and 21 patients with sudden sensorineural hearing loss and a history of Ménière's disease were prospectively evaluated. The acute effect of the intratympanic application of dexamethasone with hyaluronic acid on hearing outcome after failure of an initial standard treatment with intravenous steroid and vasoactive substances was assessed. Evaluation was based on standard pure-tone audiometry findings. RESULTS: After intratympanic injection of dexamethasone and hyaluronic acid, 14 of the 18 patients with isolated low-frequency sensorineural hearing loss showed a significant improvement in hearing. After intratympanic therapy, 15 patients with a previous history of Ménière's disease and idiopathic isolated low-frequency sensorineural hearing loss showed an improvement in hearing on pure-tone audiometry, four remained unchanged, and two showed a tendency toward a slight deterioration. CONCLUSION: Intratympanic combined dexamethasone/hyaluronic acid application provides a reliable and safe therapeutic option for improvement of hearing in patients with isolated low-frequency idiopathic sudden sensorineural hearing loss or sensorineural hearing loss resulting from Ménière's disease who have failed intravenous steroid and vasoactive treatments.