Multidimensional scaling of nasal voice quality.

Listeners judged the dissimilarity of pairs of synthesized nasal voices that varied on 3 dimensions. Separate nonmetric multidimensional scaling (MDS) solutions were calculated for each listener and the group. Similar 3-dimensional solutions were derived for the group and each of the listeners, with the group MDS solution accounting for 83% of the total variance in listeners' judgments. Dimension 1 ("Nasality") accounted for 54% of the variance, Dimension 2 ("Loudness") for 18% of the variance, and Dimension 3 ("Pitch") for 11% of the variance. The 3 dimensions were significantly and positively correlated with objective measures of nasalization, intensity, and fundamental frequency. The results of this experiment are discussed in relation to other MDS studies of voice perception, and there is a discussion of methodological issues for future research.

Cranial growth unrestricted during treatment of deformational plagiocephaly.

OBJECTIVES: The Dynamic Orthotic Cranioplasty (DOC) Band(TM) is a cranial orthosis used to treat deformational plagiocephaly. The ability of this device to redirect growth and thus, improve craniofacial asymmetry has raised concerns regarding the potential restriction of cranial growth. The purpose of this study was to evaluate the growth of the head during correction of plagiocephaly. METHODS: The study sample consisted of 190 children: 81 females (42. 6%) and 109 males (57.4%) All patients had been diagnosed with nonsynostotic plagiocephaly, did not have other significant medical conditions, were compliant with DOC protocol, and had complete anthropometric measurements at entrance and exit from treatment. Growth of the head was evaluated using head circumference, maximum cranial width and maximum cranial length. Correction of plagiocephaly was evaluated by documenting the reduction of craniofacial asymmetry of the cranial vault, skull base and face. Paired t tests were used to assess the significance of changes in these anthropometric measurements. Differences were considered significant if p < 0.05. RESULTS: Average entrance age was 6.5 months with a mean treatment time of 4.1 months. Statistical analysis demonstrated highly significant reductions in asymmetry in all three regions (p < 0.001). More importantly, these corrections were achieved with synchronous growth of the skull as demonstrated by highly significant increases (p < 0.001) in head circumference, maximum cranial width and maximum cranial length. CONCLUSIONS: These findings document statistically significant increases in cranial growth in association with concomitant reductions of the cranial asymmetries associated with deformational plagiocephaly.

Sternocleidomastoid imbalance versus congenital muscular torticollis: their relationship to positional plagiocephaly.

OBJECTIVE: The purpose of this study was to investigate the existence of sternocleidomastoid (SCM) imbalance in a plagiocephalic population and further clinically describe its difference, if any, from congenital muscular torticollis (CMT). If SCM imbalance is different from CMT, then the development of terminology and a differential diagnosis may allow early recognition and intervention and possible prevention of positional plagiocephaly in the first place. DESIGN: This was a retrospective, random review of 100 patients referred for orthotic correction of their positional plagiocephaly. SETTING: The data was collected in a private orthotic clinic and was directed by a physical therapist. The patients were seen on a weekly or biweekly basis. PATIENTS: Eighty-three patients diagnosed with positional plagiocephaly that were referred for Dynamic Orthotic Cranioplasty during 1996 were studied. RESULTS: Sixty-four percent of the sample was identified as having SCM imbalance and 12% was diagnosed with CMT. There were no statistically significant differences between the characteristics of these two groups in relation to the etiological factors of positional plagiocephaly. The only observed difference was related to symptoms of the neck itself. CONCLUSIONS: Seventy-six percent of the sample was found to have some degree of SCM dysfunction, whether it be SCM imbalance or CMT. The finding that over three quarters of our population suffers from some form of SCM dysfunction, either SCM imbalance or CMT, suggests that any degree of SCM dysfunction may act as a precursor to positional plagiocephaly and therefore should be recognized and treated at the earliest opportunity.

Importance of early recognition and treatment of deformational plagiocephaly with orthotic cranioplasty.

OBJECTIVES: Infants with positional plagiocephaly often exhibit complex multistructural asymmetries that affect the face and skull base as well as the cranial vault. Dynamic Orthotic Cranioplasty (DOC) was developed as a nonsurgical alternative for the treatment of positional plagiocephaly. The effectiveness of DOC has been discussed elsewhere. The purpose of this study was to assess the influence of factors such as entrance age, treatment time, and initial severity on the effectiveness of correction. METHODS: The study sample consisted of 258 children with cranial vault asymmetry (CVA) treated prior to 1 year of age. In addition, 246 patients (92%) exhibited concurrent skull base (SBA) and orbitotragial depth (OTDA) asymmetries. All patients had been diagnosed with nonsynostotic plagiocephaly, did not have other contributing medical conditions, were compliant with DOC protocol, and had complete anthropometric measurements at entrance and exit from treatment. RESULTS: Mean age at start of treatment was 6.5 (+/-1.9) months (range, 2.8 to 11.0 months), with an average treatment time of 4.1 (+/-2.2) months. The effects of the treatment variables were analyzed using three-way analysis of variance. As expected, initial severity was significantly associated with the amount of correction (p = .0001). However, treatment time was not significant (p > .05). Most importantly, the analysis revealed that, having accounted for initial severity, entrance age had a statistically significant effect [F(1,254) = 8.36, p = .0042] on the correction of CVA. Similar results were identified for both the SBA [F(1,254) = 5.53, p = .0195] and the OTDA [F(1,254) = 5.22, p = .0231] asymmetries. CONCLUSIONS: These findings support clinical observations that earlier intervention results in significantly improved treatment of plagiocephaly, independent of the severity of the presenting asymmetries.

Bilateral sagittal split mandibular osteotomies as an adjunct to the transoral approach to the anterior craniovertebral junction. Technical note.

Transoral approaches are used to expose the craniovertebral junction anteriorly. In patients in whom there is limited mandibular excursion, the placement of retractors and/or surgical instruments is difficult, and midline "stairstep split mandibulotomy" has been advocated as an adjunctive procedure. Although effective, this approach requires external splitting of the lip as well as median glossotomy or a lateral mucosal incision. The purpose of this study was to show that bilateral sagittal split mandibular osteotomies (BSSMOs), which are used in orthognathic surgery, represent a safer and more effective alternative to the stairstep split mandibulotomy when performed as an adjunct to the transoral approach because all incisions are intraoral and the plane of retraction is rostrocaudal instead of lateral. Hospital records and radiographic files of four patients who underwent BSSMO/transoral approach for odontoidectomy between 1994 and 1997 were reviewed retrospectively. There were three women and one boy (mean age 37.8 years, range 11-68 years). Predisposing conditions included rheumatoid arthritis (two patients), Klippel-Feil syndrome (one patient), and congenital occipitocervical instability (one patient). Jaw mobility was limited in all patients. In addition, one patient had macroglossia, another micrognathia, and another retrognathia. The BSSMO provided excellent exposure for resection of the odontoid process, as verified on follow-up magnetic resonance imaging or computerized tomography studies obtained in all patients. All mandibles were rigidly fixed by placing anterior mandibular border titanium plates and unicortical screws, and there was no incidence of nonunion or of lingual or inferior alveolar nerve injuries. The mean follow-up period was 26 months. The BSSMO is an excellent, less invasive adjunct to the transoral approach in patients with limited jaw mobility.

Multiple-birth infants at higher risk for development of deformational plagiocephaly.

OBJECTIVE: Deformational plagiocephaly refers to the development of an abnormal head shape in infants resulting from externally applied molding forces, which may occur either prenatally or postnatally. We have observed that an unexpectedly high number of multiple-birth infants have presented to our center with this condition. The purposes of this investigation were to: 1) determine the significance of this observation; and 2) examine the risk factors that may make this population more susceptible to the development of plagiocephaly. MATERIALS AND METHODS: A retrospective review of our database was performed to identify those infants who were of multiple-birth origin. The parents of these infants were contacted by phone to complete a survey regarding the prenatal and postnatal history of their child. Similar information was obtained for the state of Arizona from the Office of Vital Statistics. A chi2 analysis was used to compare the incidence of multiple births in Arizona with the incidence of multiple births in our treatment population. RESULTS: Between 1993 and 1996, 69 (8.6%) of the 801 infants treated for deformational plagiocephaly at our Phoenix center were of multiple-birth origin. Four infants who had been treated postoperatively after surgery for craniosynostosis, as well as 5 patients who had been referred from out of state, were excluded from further study. The chi2 analysis of the remaining 60 patients confirmed that a statistically significant number of plural-birth infants had presented with deformational plagiocephaly. Four risk factors were identified as having occurred at high frequency in this population: in utero constraint, supine sleeping position, torticollis, and prematurity. CONCLUSIONS: The current findings of this investigation confirm that a significant number of multiple-birth infants have presented to our clinic with deformational plagiocephaly. Compared with their singleton counterparts, plural infants seem to be at higher risk for the development of deformational plagiocephaly, because they are more likely to be exposed to multiple risk factors.deformational plagiocephaly, multiple birth, plurality.

Treatment of craniofacial asymmetry with dynamic orthotic cranioplasty.

Dynamic Orthotic Cranioplasty (DOC) was developed to treat craniofacial deformities associated with positional plagiocephaly. This investigation describes the treatment of more than 750 patients with the DOC Band since 1988. All patients undergoing DOC treatment were fit with a custom fabricated orthosis made from a plaster impression taken from the infant's head. When the orthosis was applied, the corrective pressure was directed to hold growth at the calvarial prominences and redirect symmetrical growth. A detailed medical history was obtained and anthropometric measurements were taken at start, exit, 12, 18, and 24 months follow-up. This information was recorded in a database created in Microsoft Excel. Mean length of treatment was 4.3 months with an average entrance age of 6.9 months. Analysis of anthropometric data showed significant reduction in mean cranial vault, skull base, and facial asymmetries. Correction of the more difficult skull base was documented with computed tomography. Our anthropometric and clinical observations document complete or near complete correction of asymmetry for a wide variety of head shapes. Based on the results of this investigation, we are able to support the earlier claims of our pilot study, which concluded that DOC is effective in the treatment of positional plagiocephaly.

Potential pitfalls in the work-up and diagnosis of choanal atresia.

To increase an awareness of the developmental anatomy of the nasal cavity as it applies to the radiologic work-up of choanal atresia and frontoethmoidal cephaloceles, we report two cases that demonstrate potentially serious imaging pitfalls. Two neonates with nasopharyngeal obstruction were imaged with CT and MR. Both patients had surgically proved bilateral bony choanal atresia. In addition to choanal atresia, CT showed a radiolucent, or nonossified cribriform plate and mucoid secretions within the nasal fossa, adjacent to the cribriform plate, which approximated the attenuation of brain parenchyma. In one of the patients, a preoperative diagnosis of nasopharyngeal encephalocele resulted in surgical exploration. At surgery, however, the cartilaginous cribriform plate was found to be intact.

Secondary craniofacial problems following skull base surgery.

Skull base wounds remain the most challenging that a skull base surgeon faces because of the unique and unforgiving requirements of the intracranial compartment. To successfully reconstruct these defects after complex exposure and radical resection around vital structures, a most conservative approach must be taken (i.e., one must choose the option that has the greatest chance to be successful, even if it means taking the extra time and effort of doing a free tissue transfer). Indeed, one can take no short cuts if the skull base would be left with a tenuous repair. Close postoperative surveillance of the patient for complications and maximal medical management is essential. Because of the difficulty of examining the hidden skull base wound postoperatively, surgeons must have a low threshold for re-exploration if a complication is suspected. As the first decade of the multidisciplinary skull base team approach passes, and long-term results are being assessed, the question of "is it worth it?" is fair. The reported series are showing increased survival rates and decreased complication rates. Therefore, the answer would appear to be "yes". The question is best answered, however, by the individual patient who previously had no hope for treatment of his or her deep-seated skull base tumor.

Etiology of positional plagiocephaly in triplets and treatment using a dynamic orthotic cranioplasty device. Report of three cases.

In 1994 a set of triplets presented to the authors for treatment of their positional plagiocephaly with Dynamic Orthotic Cranioplasty (DOC). The three 8-month-old infants were diagnosed with severe, moderate, and mild plagiocephaly. Only the severe and moderate cases were treated with the DOC band. The mild case was not treated with the DOC band because it was thought that the condition could be addressed through alteration in the child's sleeping position. The child with severe deformation required 8.5 months of treatment with two DOC bands and had significant residual asymmetries at the end of the treatment course. The child with moderate deformity required 2.5 months of treatment with only one DOC band and had excellent correction of the initial asymmetries. The results of their treatment provide a unique forum for discussing the etiology of positional plagiocephaly, as well as those factors that can influence the efficacy of DOC treatment.

Posterior skull base transfacial approaches.

Transfacial approaches to the midline skull base provide direct access for resection of complex lesions. The transfrontal nasal-orbital and transmaxillary (Levels III and V) approaches have become the "work horses" of our skull base team, in that either alone or in combination, they provide access to most parts of the anterior skull base and clivus. The flexibility offered by the ability to select a Level I or Level II approach in place of a Level III approach, or a Level VI approach in place of a Level V approach, however, greatly enhances the individualization of treatment strategy. The overlapping exposure shared by these techniques provides flexibility in the choice of surgical exposure and allows multiple factors to be considered, including tumor location and size.

Transplanted demineralized bone graft in cranial reconstructive surgery.

Surgical reconstruction of cranial deformities and synostosis is occasionally accompanied by incomplete bone growth to cover all areas of cranial vault that have been exposed in the correction. The restrictive nature of some forms of synostosis require more bone in the repair than is available using the child's natural skull for autogenous bone cranioplasty. Rib and iliac crest autografts have been used with success. These grafts must be harvested form a remote site with increased morbidity. A split-thickness skull autograft is the cranioplasty material of choice but children under the age of 6 years may lack the skull thickness needed to use this technique. Perforated demineralized bone matrix has been transplanted in 46 operations in 42 patients from 1990 to 1995 for repair of residual skull defects in children having previously undergone craniofacial repairs, for primary reconstruction of the cranial vault for patients with synostosis and for repair of skull defects resulting from trauma and skull tumor excisions. The vast majority of grafts have resulted in complete closure of the defect, providing a matrix for new bone formation. These patients are presented. Surgical techniques of cranial defect repair with perforated demineralized bone matrix are discussed.

Radical resection of anterior skull base tumors.

The transfacial approaches give the surgeon wide exposure for resecting skull base lesions. The classification system, using six levels, helps plan the best surgical strategy. Our experience with the transfacial approaches has been associated with acceptably low rates of morbidity and mortality. Our small experience with carotid sacrifice reflects our practice of preserving the ICA whenever possible. We recommend preserving the ICA with benign tumors because they do not invade the artery, or they invade it to a limited extent. In contrast, we recommend radical tumor resection and sacrifice of the ICA with malignant tumors, because they directly threaten the integrity of the ICA and a patient's survival. The ICA should not be considered a limitation to radical tumor resection, because the ICA can be safely reconstructed with an appropriate bypass procedure.

Treatment of positional plagiocephaly with dynamic orthotic cranioplasty.

Dynamic orthotic cranioplasty (DOC) was developed to treat asymmetrical head shape of a nonsynostotic origin, which is defined by the term positional plagiocephaly. These positional deformations have been found to correlate with a number of environmental factors. Infants with positional plagiocephaly may exhibit complex multistructural asymmetry affecting the cranial vault, face, and skull base, or expression may be local in nature. Between 1988 and 1993, we performed DOC on 124 infants with positional plagiocephaly. Through clinical, anthropometric, radiographic, and statistical evaluation, we found that DOC corrects positional deformation of the cranial vault, skull base, and upper face, with no evident relapse following treatment. The design and the global approach to deformation address a wide spectrum of abnormal head shapes. The procedure is dynamic and customized, and it does not rely on passive growth alone for improvement.

Comparison of skin necrosis in rats by using a new microneedle electrocautery, standard-size needle electrocautery, and the Shaw hemostatic scalpel.

"Microneedle" electrocautery was compared against the standard-size needle electrocautery and the Shaw hemostatic scalpel to determine the differences in tissue necrosis when used as a cutting instrument. Incisions were made on the dorsal skin of anesthetized white rats using each of the three devices with the no. 15 scalpel as control. The specimens were submitted for histological evaluation. The microneedle caused less necrosis than the standard-size needle electrocautery (0.18 vs 0.27 mm, p < 0.01) and less necrosis than the Shaw hemostatic scalpel set at 220 degrees F (0.18 vs 0.25 mm, p < 0.05). The microneedle electrocautery was also found to be an instrument that causes very little tissue distortion during fine dissection and helps to minimize blood loss in craniofacial and neurosurgical operations.

The self-retained Le Fort I osteotomy.

Because inferior repositioning of the maxilla after Le Fort I osteotomy has a high relapse rate, a modified bone cut oriented obliquely upward has been tried in 29 patients. The modification allows extrusion of the fragment while maintaining good bony contact, thus eliminating the need for bone grafts. It also permits self-retention of the fragment and can be adapted to movements in any plane.

The use of miniplates in craniomaxillofacial surgery.

Miniplates were used in craniomaxillofacial surgery for fixation in the skull, maxilla, and/or mandible in 74 patients with minimal or no intermaxillary wiring. Procedures included forehead and orbital repositioning, frontofacial advancement, Le Fort III and particularly Le Fort I osteotomies, as well as mandibular osteotomies and fracture repair. The miniplates provided stable fixation and, compared with other techniques, improved airway safety. The complication rate was low: there were no infections, but two plates (1 percent) became exposed in the buccal sulcus. Although application of miniplates lengthened surgery and increased the cost of the procedure, the savings in intensive care monitoring more than offset these costs. The stability of fixation minimizes the opportunity to reposition the fragments postoperatively with training elastics. Therefore, meticulous technique is mandatory, with particular emphasis on passive fitting of the plates and precise drilling of screw holes.

Management of high bile duct carcinoma.

Based on experience with six patients with high bile duct carcinoma, a rational therapeutic approach is proposed. When extent of tumor precludes resection, the authors recommend palliation with a biliary-enteric anastomsis to avoid the complications and inconveniences of long-term transhepatic stenting. This is best accomplished with construction of a left cholangiojejunostomy using the round ligament approach. Temporary bilobar decompression may be necessary in select cases.