Management of late extrusions of cochlear implants.

OBJECTIVES: The study aimed to identify the important principles in repairing and preventing delayed cochlear implant extrusions. STUDY DESIGN: The study design was a retrospective, international database review and three case presentations from the authors' local database. SETTING: The study was conducted at a tertiary referral center. PATIENTS: Cochlear Corporation's database of 8,665 implantees in North and South America and Israel was studied. A subset of this database, consisting of 74 patients implanted through the Louisiana State University/Eye, Ear, Nose and Throat (LSU/EENT) project, is analyzed separately and provides the case reports. INTERVENTION: Surgical repair of skin breakdown over the edge of three cochlear implants using a two-layer, pericranial and scalp rotation flap technique was performed. MAIN OUTCOME MEASURES: A functioning cochlear implant with a healthy skin covering was measured. RESULTS: The three LSU/EENT cases reported here used a pericranial flap to repair the capsule of the implant and a large scalp rotation flap to repair the skin defect. A novel pericranial tuck-under technique is especially useful for the Nucleus Mini-22 implant. With this technique, the authors have had a 100% success rate (3 of 3). The basic principles used in the repair and in the initial implant surgery are discussed. CONCLUSIONS: The following conclusions were reached: 1) avoid skin closure lines parallel to the cochlear implant edge that are closer than 1.5 cm from the implant edge; 2) excise enough skin and scar around the dehiscence to achieve principle 1; 3) design a large, well-vascularized anterior- or posterior-based scalp rotation flap to cover this defect; and 4) close the implant capsule defect with a well-vascularized pericranial flap.

Persistent dysphagia and dysphonia following cervical spine surgery.

Persistent dysphagia and dysphonia following anterior cervical spine surgery have been underdiagnosed. Understanding the physiologic mechanism resulting in post-surgical dysphagia and dysphonia is essential to providing appropriate treatment. Two cases of protracted dysphagia and dysphonia following left anterior cervical corpectomy were reviewed. Videofluoroscopic evaluation, videostroboscopic assessment and laryngeal nerve-conduction testing were used to determine swallowing, vocal fold and cranial nerve integrity; to assess the ability to achieve oral nutrition; and to direct therapy and surgical procedures to improve swallowing and voice. With a multidisciplinary approach, the physiologic problems of post-surgical dysphagia and dysphonia can be addressed and therapeutic and/or surgical treatments initiated promptly.

Utility of helical computed tomography in the study of arytenoid dislocation and arytenoid subluxation.

Conventional computed tomography (CT) has been considered a mainstay in the evaluation of the larynx. A major difficulty with utilizing this modality, especially in the study of the arytenoid, is the time necessary to perform a thin-slice examination through a structure that has a propensity to move with respiration and swallowing. Helical CT not only significantly reduces the time necessary to study the larynx, but enables one to perform multiple high-resolution multiplanar reconstructions. Eleven patients with arytenoid abnormalities documented by strobovideolaryngoscopy or direct laryngoscopy were imaged with helical CT. A comprehensive radiographic examination illustrating the cricoarytenoid relationship in all of the subjects was completed in less than 20 seconds by using axial reconstructions in 2-mm-thick slices at 1-mm intervals, with subsequently derived sagittal and coronal reconstructions. Helical CT may be a useful adjunct in the diagnosis of arytenoid subluxation or dislocation.

Dysphonia in the elderly: diagnosis and management of age-related voice changes.

In our laryngology practice, we have noted an increasing number of elderly patients referred to us for problematic dysphonia. We present our findings of the most common disorder affecting this age group. A sample of 47 consecutive patients over age 60 with dysphonia revealed presbylaryngis, ie, age-related anatomic and physiologic changes, as the most common etiology found in this tertiary referral practice, accounting for 30% (14 patients) of new diagnoses. None of the patients with presbylaryngis received this diagnosis from the referral source. Understanding the anatomic and physiologic changes of the aging vocal tract, along with the clinical correlation of each change, is crucial in evaluating this group of patients. Managing this disorder includes specific goal-oriented speech therapy, with surgery as an adjunct should conservative therapy prove unsuccessful. Earlier recognition of this disorder and prompt intervention are key factors in reversing vocal decompensation, with a primary effect of improving the quality of life for the patient with age-related dysphonia.

Health care crisis: the head and neck cancer patient and affordable health insurance.

In an evaluation of 30 patients with head and neck cancer, we found that 14 (46%) were uninsured at the time of diagnosis and 15 (50%) had yearly incomes below the poverty level. Tobacco and alcohol were identified as risk factors in 25 (83%) of the patients. These patients spent an average of $2,781 on carcinogenic agents yearly, increasing the risk of cancer 55 times that of the unexposed population, whereas the cost of a health insurance policy was $2,321 per year. To remedy the disparities and incongruities of this situation, we advocate patient education to influence behavioral change in these high-risk groups, a lowering of insurance rates, legal reform, and continued physician activism toward managing the current health care crisis.

Verrucous carcinoma of the larynx: role of human papillomavirus, radiation, and surgery.

There is confusion regarding verrucous carcinoma of the larynx, an enigmatic, well-differentiated variant of squamous cell carcinoma known for local recurrence and anaplastic transformation following irradiation. This report adds 12 new cases and reviews the literature concerning radiation results versus surgical results. Treatment of 37 patients with primary radiotherapy resulted in a 49% cure rate and a 51% failure rate; the death rate from anaplastic transformation was 11%. Primary surgery on 144 patients resulted in a 92.4% cure rate, a 7.6% initial failure rate, and a 3.5% rate of deaths attributed to neoplasm. Isolation of human papillomavirus type 16 (HPV-16) DNA sequences indicates that the lesion is genetically abnormal. Radiation-induced DNA breaks may activate these sequences. These findings support a surgical approach. Treatment recommendation for T1 lesions is carbon dioxide laser excision to minimize tissue trauma and local recurrence. For T2 to T4 lesions, the recommendation is sound oncologic extirpation. Neck dissection is not indicated.

Local anesthesia in rhinoplasty: a new twist?

Twenty volunteers were asked to compare pain upon injection during septorhinoplasty using buffered versus unbuffered local anesthetics. The concentration of the buffer was one part sodium bicarbonate to five parts local. The surgeons performing the operation were asked to identify any difference in hemostasis or duration of anesthesia. Eighteen of twenty patients found the buffered anesthetic to be less painful and better tolerated. No difference in hemostasis or duration of action was noted between the buffered or unbuffered solution, however, faster onset of action was noted with the buffered solution. The addition of sodium bicarbonate as a buffering agent to the local anesthetics lidocaine and bupivacaine can significantly reduce pain upon injection. A solution of 5cc 2% lidocaine with 1:100,000 epinephrine, 5cc 0.25% bupivacaine with 1:200,000 epinephrine, and 2cc of 7.5% sodium bicarbonate mixed just prior to injection is a safe, effective, less painful local anesthetic with rapid onset of action and full efficacy.

Tracheomalacia repair using ceramic rings.

Tracheomalacia resulting from tracheostomy or compressive thyroid disease often represents a difficult problem in airway management. In an attempt to improve this condition, biocompatible ceramic rings were surgically implanted in 16 patients to restore normal patency of the airway by first expanding the tracheal lumen lateral, and then in an anterior dimension. Preoperatively, patients displayed moderate to severe obstruction with marked restrictions in lifestyle, as confirmed by history, physical examination, and airway resistance studies. Additionally, three of these patients were trach-dependent at the time of implantation. Postoperatively all 16 patients have normal airway resistance parameters with a dramatic improvement in lifestyle, whereas the three with tracheostomy were successfully decannulated. The routine use of these rings has alleviated the need for rib/cartilage grafts, primary resections with anastomosis, prolonged periods of cannulation, and multiple surgeries. Our experience in the use of ceramic rings for tracheomalacia repair will be presented, highlighting selection criteria for their use, intraoperative placement, perioperative complications, and post-operative followup for a minimum of 6 months.

Meibomian gland adenocarcinoma of the eyelid metastasizing to parotid lymph nodes.

Meibomian Gland Adenocarcinoma (MGA) is a rare tumor of the eyelid. We present two patients with this tumor that metastasized to the ipsilateral parotid nodes, along with a description of the disease and its response to various modes of treatment.

Chronic cough due to angiotensin-converting enzyme inhibitors.

The ACE-inhibiting drugs enalapril and captopril may result in a chronic and sometimes severe cough for which no pathologic cause can be found. Drug-induced cough should therefore be considered in any symptomatic patient taking these medications. In such cases, prompt withdrawal of the drug and substitution of a non-ACE inhibitor is curative and conserves the time and resources of the patient and the physician by avoiding unnecessary diagnostic and therapeutic measures.

Adhesives in larynx repair.

Guinea pig laryngeal fractures were used as a model to compare the ease of application and effectiveness of the fibrinogen-adhesive system with the ease of application and effectiveness of cyanoacrylate glue and control fractures stinted with contralateral gelatin film. Seven fibrin adhesive-treated and two cyanoacrylate glue-treated guinea pigs were perfused after 60 and 35 days, respectively. The larynges were serial sectioned, and the wound sites were compared. The fibrinogen adhesive system was easier to dispense than cyanoacrylate glue, did not require a completely dry surface, and stabilized within 3 minutes. Cartilage segment alignment with focal, complete fracture healing and symmetrical chondrocyte proliferation were seen in fibrogen adhesive-stinted larynges. In the cyanoacrylate glue-treated larynges, there was no alignment and minimal, asymmetrical chondrocyte proliferation. Gelatin film-stinted controls exhibited similar features. Thus, fibrogen adhesive was easier to apply and more effectively bound laryngeal fractures than cyanoacrylate glue or gelatin film.

Cholesterol granuloma of the petrous apex.

Cholesterol granuloma of the petrous apex is caused by a foreign body response to cholesterol crystals. This condition has infrequently been described, but it can prove to be highly destructive. Obstruction of drainage, with failure of ventilation of a normally aerated space and subsequent hemorrhage, yields blood breakdown products which liberate cholesterol. Osteitis, bone erosion, and bone resorption have all been reported, but major bone destruction is rare. It should always be considered by otologists and skull base surgeons when evaluating lesions of the petrous apex. This article reviews the more common causes of primary lesions of the petrous apex, with special emphasis on the clinical findings, pathophysiology, and surgical considerations in cholesterol granuloma. Two pertinent case histories are included.

Fixation of laryngeal stents.

With the advent of the CO2 laser, the transendoscopic placement of stents and keels has become an important adjunct in the surgical treatment of laryngeal webs and stenosis. Fixation of stents, however, is often difficult and cumbersome. Here, we describe two relatively simple techniques of laryngeal stent construction, placement, and fixation.

Sicca syndrome--diagnostic perplexities.

Patients presenting with xerostomia and other signs of Sjogren's syndrome pose diagnostic problems. Many other underlying diseases cause these symptoms and a systematic evaluation is necessary to make an accurate diagnostic assessment. There are immunological tests and histological studies which help make them distinctive and are herein outlined. Patients with this information presenting with sicca syndrome, therefore, can be more accurately assessed and have better treatment regimens instituted. The "sicca syndrome," which is a disorder discussed primarily in the rheumatology literature, is rarely a topic in the otolaryngology literature, although there are often presenting symptoms of this problem in the head and neck. This paper reviews this problem, discusses the confusion regarding terminology, and outlines a practical method of diagnosis for the clinician.

Argon laser destruction of cutaneous telangiectatic lesions.

An ophthalmological slit lamp argon laser was used on 8 patients with multiple cutaneous and mucosal telangiectasis; 6 patients had telangiectatic lesions of various etiologies and 2 had hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease). Bleeding from trauma was the primary symptom with cosmesis as a secondary consideration. The telangiectatic lesions were photocoagulated using the argon laser with precise microscopic control. The optimum dose was determined by varying the spot diameter, beam power, shutter speed and number of applications until the lesions were visually ablated. All treatments were accomplished on an outpatient basis with no anesthesia or sedation and minimal reported patient discomfort. No lesions have recurred over a 12 month follow-up.

Carbon dioxide laser treatment of laryngeal stenosis.

Six patients ranging from 3 to 67 years of age were treated for acquired laryngeal stenosis. Five of these patients were considered failures from conventional surgical techniques including multiple open endolaryngeal procedures and repeated dilations. Using the carbon dioxide laser, the various obstructing lesions were excised microendoscopically and injected with interstitial steroids. After one to six procedures, all of these patients now have adequate airways and serviceable voices.

Anatomical consequences of CO2 laser surgery of the guinea pig ear.

A modified American Optical (Model 100) CO2 laser was used to produce lesions in the tympanic membranes, ossicles, and cochlear capsules of guinea pigs. Even with the lowest available intensities and durations (0.4 watts, 50 msec), there was damage to the inner ear. Although laser surgery of the ear can avoid mechanical trauma and bleeding as well as increase accuracy, the use of commercial lasers in ear surgery should be avoided until a proven unit is available.

Laser surgery and immunotherapy in the management of laryngeal papilloma.

Twenty-three cases of laryngeal papilloma have been treated and followed for four years utilizing laser excision and laser excision/immunotherapy. Fourteen cases responded well to laser excision alone, nine did not and immunotherapy was instituted as adjunctive treatment. To date, immunotherapy has contributed little to the relief in this group of refractory cases.

Bone-conduction electrocochleography: clinical applications.

Cases are presented which show the clinical utility of recording an electrocochleographic response to bone-conducted stimuli. The procedure is fraught with problems of acoustic control and artifact generation, but has distinct although limited values in clarifying masking dilemmas in patients with bilateral hearing loss.