Management of acute blunt and penetrating external laryngeal trauma.

OBJECTIVES/HYPOTHESIS: Improve the care of acute external laryngeal trauma by reviewing controversies and the evolution of treatment. DATA SOURCE: Internet-based search engines, civilian and military databases, and manual search of references from these sources over the past 90 years. REVIEW METHODS: Utilizing the above-mentioned sources, electronic and manual searches of primary topics such as laryngeal trauma or injury, emergency tracheotomy, airway trauma, intubation versus tracheotomy, cricothyrotomy, esophageal trauma, and emergent management of airway injuries in civilian and combat zones. Citations were reviewed, selected reports analyzed, and the most relevant articles referenced. RESULTS: Optimal treatment of acute laryngeal trauma includes early identification of injuries utilizing a directed history and physical examination. Timely management of the wounded airway is essential. The choice of intubation, tracheotomy, or cricothyrotomy must be individualized. Computed tomography (CT) may assist in differentiating patients who can be observed versus those who require surgical exploration. In selected patients, laryngeal electromyography and stroboscopy may also be useful. Surgery should begin with direct laryngoscopy and rigid esophagoscopy to evaluate the hard and soft tissues of the larynx, and to visualize the pharynx and esophagus. Minor endolaryngeal lacerations and abrasions may be observed, whereas more significant injuries require primary closure via a thyrotomy. Laryngeal skeletal fractures should be reduced and fixated. Endolaryngeal stenting is reversed for massive mucosal trauma, comminuted fractures, and traumatic anterior commissure disruption. CONCLUSIONS: Acute external injury to the larynx is both life threatening and a potential long-term management challenge. Although a rare injury, sufficient experience now exists to recommend specific treatments, and to preserve voice and airway function.

Electromyographic and histologic evolution of the recurrent laryngeal nerve from transection and anastomosis to mature reinnervation.

OBJECTIVES: To describe the natural evolution of recurrent laryngeal nerve (RLN) reinnervation in an animal model. STUDY DESIGN: Twenty Sprague Dawley rats underwent unilateral RLN transection and anastomosis. Animals were sacrificed at 4, 8, 12, 16, and 20 weeks. Prior to sacrifice, each rat underwent electromyography (EMG) and visual grading of vocal fold motion. Bilateral RLNs were harvested and evaluated histologically. RESULTS: EMG revealed synkinetic reinnervation at all time periods except at 4 weeks. EMG evolution plateaued at 16 weeks. Vocal fold motion was slight in three rats at 4 weeks but was otherwise absent except for one rat at 12 weeks. Histologic changes of the axons and their myelin sheaths were consistent at each time period. At 16 weeks, histologic changes plateaued. CONCLUSIONS: Consistent EMG, histologic, and vocal fold motion changes occur at specific time periods during RLN reinnervation after transection and anastomosis in a rat model. Reinnervation is mature at 16 weeks. Findings corroborate theories of preferential and synkinetic reinnervation after RLN transection. Use of a rat model to investigate the effect of interventions on RLN reinnervation requires a minimum of 16 weeks between transection and investigation to allow for maturation of reinnervation.

Quantity and three-dimensional position of the recurrent and superior laryngeal nerve lower motor neurons in a rat model.

OBJECTIVES: We sought to elucidate the 3-dimensional position and quantify the lower motor neurons (LMNs) of the recurrent laryngeal nerve (RLN) and the superior laryngeal nerve (SLN) in a rat model. Quantification and mapping of these neurons will enhance the usefulness of the rat model in the study of reinnervation following trauma to these nerves. METHODS: Female Sprague-Dawley rats underwent microsurgical transection of the RLN, the SLN, or both the RLN and SLN or sham surgery. After transection, either Fluoro-Ruby (FR) or Fluoro-Gold (FG) was applied to the proximal nerve stumps. The brain stems were harvested, sectioned, and examined for fluorolabeling. The LMNs were quantified, and their 3-dimensional position within the nucleus ambiguus was mapped. RESULTS: Labeling of the RLN was consistent regardless of the labeling agent used. A mean of 243 LMNs was documented for the RLN. The SLN labeling with FR was consistent and showed a mean of 117 LMNs; however, FG proved to be highly variable in labeling the SLN. The SLN LMNs lie rostral and ventral to those of the RLN. In the sham surgical condition, FG was noted to contaminate adjacent tissues--in particular, in the region of the SLN. CONCLUSIONS: Fluorolabeling is an effective tool to locate and quantify the LMNs of the RLN and SLN. The LMN positions and counts were consistent when FR was used in labeling of either the RLN or the SLN. Fluoro-Gold, however, because of its tendency to contaminate surrounding structures, can only be used to label the RLN. Also, as previously reported, the SLN LMNs lie rostral and ventral to those of the RLN. This information results in further clarification of a rat model of RLN injury that may be used to investigate the effects of neurotrophic factors on RLN reinnervation.

Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources.

OBJECTIVE: To determine if comorbid dysphagia in all hospitalized patients has the potential to prolong hospital stay and increase morbidity. Dysphagia is increasingly prevalent with age and comorbid medical conditions. Our research group has previously shown that dysphagia is a bad prognostic indicator in patients with stroke. DESIGN: Analysis of national database. MAIN OUTCOME MEASURES: The National Hospital Discharge Survey (NHDS), 2005-2006, was evaluated for presence of dysphagia and the most common comorbid medical conditions. Patient demographics, associated disease, length of hospital stay, morbidity and mortality were also evaluated. RESULTS: There were over 77 million estimated hospital admissions in the period evaluated, of which 271,983 were associated with dysphagia. Dysphagia was most commonly associated with fluid or electrolyte disorder, esophageal disease, stroke, aspiration pneumonia, urinary tract infection, and congestive heart failure. The median number of hospitalization days for all patients with dysphagia was 4.04 compared with 2.40 days for those patients without dysphagia. Mortality increased substantially in patients with dysphagia associated with rehabilitation, intervertebral disk disorders, and heart diseases. CONCLUSIONS: Dysphagia has a significant impact on hospital length of stay and is a bad prognostic indicator. Early recognition of dysphagia and intervention in the hospitalized patient is advised to reduce morbidity and length of hospital stay.

From virtual reality to the operating room: the endoscopic sinus surgery simulator experiment.

OBJECTIVE: Establish the feasibility of a predictive validity study in sinus surgery simulation training and demonstrate the effectiveness of the Endoscopic Sinus Surgery Simulator (ES3) as a training device. STUDY DESIGN: Prospective, multi-institutional controlled trial. SETTING: Four tertiary academic centers with accredited otolaryngology-head and neck surgery residency programs. SUBJECTS: Twelve ES3-trained novice residents were compared with 13 control novice residents. METHODS: Subjects were assessed on the performance of basic sinus surgery tasks. Their first in vivo procedure was video recorded and submitted to a blinded panel of independent experts after the panel established a minimum inter-rater reliability of 80 percent. The recordings were reviewed by using a standardized computer-assisted method and customized metrics. Results were analyzed with the Mann-Whitney U test. Internal rater consistency was verified with Pearson moment correlation. RESULTS: Completion time was significantly shorter in the experimental group (injection P = 0.003, dissection P < 0.001), which, according to the rater panel, also demonstrated higher confidence (P = 0.009), demonstrated skill during instrument manipulation (P = 0.011), and made fewer technical mistakes during the injection task (P = 0.048) compared with the control group. The raters' post hoc internal consistency was deemed adequate (r > 0.5 between serial measurements). CONCLUSION: The validity of the ES3 as an effective surgical trainer was verified in multiple instances, including those not depending on subjective rater evaluations. The ES3 is one of the few virtual reality simulators with a comprehensive validation record. Advanced simulation technologies need more rapid implementation in otolaryngology training, as they present noteworthy potential for high-quality surgical education while meeting the necessity of patient safety.

Observations of recurrent laryngeal nerve injury and recovery using a rat model.

OBJECTIVES/HYPOTHESIS: To evaluate standardized recurrent laryngeal nerve (RLN) injuries using a rat model via minimally invasive transoral electromyography (ToL EMG) and histologic studies. METHODS: Forty-two female Sprague Dawley rats weighing 200 g to 250 g underwent crush injury to the right RLN using a calibrated pressure clip (0.61 N or 1.19 N) for 60 seconds. Following injury, serial ToL EMGs were performed on abductor and adductor laryngeal muscles during respiratory cycles and spontaneous vocal fold abduction on day 4 and then weekly for 6 weeks. Vocal fold motion associated with spontaneous respiration was graded from 0 to 4. Rats were sacrificed at different time points for histologic evaluation of injured nerves. RESULTS: EMG signals showed fibrillation potentials on day 4 in all experimental conditions. Crushed RLN, regardless of force, exhibited polyphasic potentials at 2 weeks postinjury. Normal motor unit potentials and recruitment patterns were observed in EMG signals at 4 weeks for all 0.61 N clip animals. Six weeks following crush injury, motor unit potentials having normal appearance were observed in most animals. Synkinetic EMG signals were observed at 5 weeks and 6 weeks in the 1.19 N clip animals. Endoscopic evaluation of vocal fold mobility was consistently normal at 6 weeks only following 0.61 N crush injury. CONCLUSIONS: This model is useful to simulate intraoperative RLN injuries and to better understand the electrophysiologic events during nerve recovery. The severity of injury to the RLN dictates histologic, neurologic and functional recovery of the laryngeal motor system. This model is useful to evaluate the efficacy of systemic and local neurotropic agents in the treatment of RLN injury.

Triological thesis: concurrent endoscopic sinus surgery and cosmetic rhinoplasty: rationale, risks, rewards, and reality.

OBJECTIVES/HYPOTHESIS: To examine the effect of concurrent endoscopic sinus surgery (ESS) on the postoperative course of cosmetic rhinoplasty (CR), identify any specific contraindications, and to develop more useful treatment regimen in patients undergoing concurrent ESS and CR. STUDY DESIGN: Retrospective case-control study. METHODS: Consecutive patients undergoing CR (performed by the principal investigator (PI) in a tertiary care academic practice) at the same operative setting as ESS from June 2004-June 2007 were identified. Additionally, patients undergoing CR (also by the PI) without ESS over the same time period (matched for gender, age, and rhinoplasty approach and techniques) were identified and used as control subjects. The office and hospital charts of these patients were reviewed for details of pre-, intra-, peri-, and postoperative care, preoperative CT scans as well as for patient and physician observations. Specifically noted were details regarding the type of cosmetic changes sought, course of symptoms of chronic sinusitis, prior treatment, surgical techniques used for both ESS and CR, and postoperative treatment with antibiotics and corticosteroids. Additionally, a literature review of articles describing concurrent CR and ESS was performed. RESULTS: Thirteen patients were identified who underwent ESS at the same time as CR. There were no cases of cerebrospinal fluid leak, epistaxis, orbital complications, septal perforation, cellulitis or saddle nose deformity. No correlation was found between sinus surgery performed and need for revision surgery (CR or ESS) or postoperative infections. However, the time to patient reported resolution of postoperative nasal swelling was significantly higher in patients undergoing concurrent ESS/CR compared to CR only (dorsal swelling: 9.62 +/- 6.18 (ESS/CR) vs. 5.85 +/- 1.95 (CR) weeks, P = .0469; nasal tip swelling: 19.31 +/- 13.02 (ESS/CR) vs. 10.38 +/- 2.96 (CR) weeks, P = .0240, unpaired t test). The same relation held true for doctor noted postoperative edema (nasal dorsal edema: 10.62 +/- 7.32 (ESS/CR) vs. 6.31 +/- 2.72 (CR) weeks, P = .0582; nasal tip edema: 21.46 +/- 15.66 (ESS/CR) vs. 12.23 +/- 4.10 (CR) weeks, P = .0508, unpaired t test). Among patients who underwent concurrent ESS and CR, this time was highly correlated with the severity of sinus disease on preoperative CT scanning (r(2) = 0.8573, P < .0001). A greater need for postoperative corticosteroid injections in the ESS/CR group was suggestive but not statistically significant (30.8% vs. 0%, P = .0957). CONCLUSIONS: While our data supports concurrent ESS and CR as safe, our findings suggest that the presence and treatment of concurrent sinonasal disease prolongs the patients' recovery from CR. This may be due to the effects of sinus pathology and manipulation of sinonasal venous and lymphatic drainage patterns or could be due to subclinical infectious soiling of rhinoplasty tissue planes. We recommend a two-team approach to promote excellent surgical technique, avoid surgeon fatigue, and enhance patient care. We recommend adequate medical management of chronic sinusitis prior to surgery, pre, intra and postoperative antibiotic coverage, appropriate postoperative sinus toilet beginning 1 week after surgery and careful and close patient follow-up to optimize results. Most importantly, we advocate close coordination of sinonasal and rhinoplastic care in a two-team approach to maximize care.

Development of the ethmoid sinus and extramural migration: the anatomical basis of this paranasal sinus.

Frontal and/or maxillary sinusitis frequently originates with pathologic processes of the ethmoid sinuses. This clinical association is explained by the close anatomical relationship between the frontal and maxillary sinuses and the ethmoid sinus, since developmental trajectories place the ethmoid in a strategic central position within the nasal complex. The advent of optical endoscopes has permitted improved visualization of these spaces, leading to a renaissance in intranasal sinus surgery. Advancing patient care has consequently driven the need for the proper and accurate anatomical description of the paranasal sinuses, regrettably the continuing subject of persistent confusion and ambiguity in nomenclature and terminology. Developmental tracking of the pneumatization of the ethmoid and adjacent bones, and particularly of the extramural cells of the ethmoid, helps to explain the highly variable adult morphology of the ethmoid air sinus system. To fully understand the nature and underlying biology of this sinus system, multiple approaches were employed here. These include CT imaging of living humans (n = 100), examination of dry cranial material (n = 220), fresh tissue and cadaveric anatomical dissections (n = 168), and three-dimensional volume rendering methods that allow digitizing of the spaces of the ethmoid sinus for graphical examination. Results show the ethmoid sinus to be highly variable in form and structure as well as in the quantity of air cells. The endochondral bony origin of the ethmoid sinuses leads to remarkably thin bony contours of their irregular and morphologically unique borders, making them substantially different from the other paranasal sinuses. These investigations allow development of a detailed anatomical template of this region based on observed patterns of morphological diversity, which can initially mask the underlying anatomy. For example, the frontal recess, ethmoid infundibulum, and hiatus semilunaris are key anatomical components of the ethmoid structural complex that are fully documented and explained here on the basis of the template we have developed, as well as being comprehensively illustrated. In addition, an exhaustive 2000-year literature search identified original sources of nomenclature, in order to help clarify the persistent confusions found in the literature. Modified anatomical terms are suggested to permit proper description of the ethmoid region. This clarification of nomenclature will permit better communication in addition to eliminating redundant terminology. The combination of anatomical, evolutionary, and clinical perspectives provides an important strategy for gaining insight into the complexity of these sinuses.

Evaluation of functional recovery of recurrent laryngeal nerve using transoral laryngeal bipolar electromyography: a rat model.

OBJECTIVES: We developed a standardized method of minimally invasive transoral laryngeal (ToL) bipolar electromyography (EMG) for evaluation of recurrent laryngeal nerve (RLN) recovery after a controlled crush injury in a rat model. METHODS: Ten 200- to 250-g Sprague-Dawley rats underwent a controlled crush injury to the left RLN performed with 60 seconds of use of a calibrated aneurysm clamp with a closing force of 0.61 N. Serial ToL bipolar EMG was performed on adductor muscles and the posterior criocoarytenoid muscle during spontaneous vocal fold motion under anesthesia. Each animal underwent ToL EMG immediately after surgery and 1, 3, and 6 weeks after surgery. RESULTS: The EMG signals showed normal motor unit potentials and recruitment patterns 3 weeks after crush injury. Endoscopic evaluation of vocal fold mobility yielded consistently normal findings 6 weeks after crush injury. CONCLUSIONS: We have developed a standardized method of crush injury to the rat RLN model and a minimally invasive transoral bipolar spontaneous EMG technique to serially evaluate and follow nerve injury and recovery in rats. This model is intended to simulate intraoperative RLN injury, to elucidate the electrophysiological events that occur during nerve recovery, and to form the basis for studying agents to enhance such recovery.

The path of nasal reconstruction: from ancient India to the present.

Nasal reconstruction, first described over 2600 years ago in India, has undergone several modifications in its development. However, there is a misconception that this surgery began with the forehead flap repair, and the history of the subsequent two and a half millennia is poorly represented in most surgical texts. This article presents a review of the historical significance of nasal injuries in antiquity and the various technical developments along the path to modern nasal reconstruction, from ancient India through medieval Europe to modern England and America. Although written texts from 6th-century BC India through 16th-century AD Europe described pedicle flap repair of nasal defects, it was not until the late 18th century that the first written description of the forehead flap appeared. Forehead flap repair developed on an alternate pathway, being transmitted via an oral tradition, typically within families of craftsmen, at least as early as the 14th century. These ancient authors recognized the need for accurate flap design and sizing, donor site repair, precise tissue apposition, protection of the flap pedicle, hemostasis, deepithelialization of the wound, and replacement of intranasal lining. By appreciating ancient surgical techniques and examining the particular issues these procedures attempted to address, the surgeon will gain an additional and more detailed perspective of nasal reconstruction that will aid in providing excellent care to his patients.

The voice and laryngeal dysfunction in stroke: a report from the Neurolaryngology Subcommittee of the American Academy of Otolaryngology-Head and Neck Surgery.

OBJECTIVE: Stroke is the third leading cause of death in the United States, behind heart disease and cancer. It affects as many as 5% of the population over 65 years old, and this number is growing annually due to the aging population. A significant portion of stroke patients that initially survive are faced with the risk of aspiration, as well as quality-of-life issues relating to impaired communication. The goal of this paper is to define the scope of practice in otolaryngology for these patients, and to review pertinent background literature. STUDY DESIGN: Consensus report and retrospective literature review. RESULTS: Otolaryngology involvement in these patients is critical to their rehabilitation, which often requires an interdisciplinary team of specialists. This committee presentation explores epidemiological data regarding the impact of stroke and its complications on hospitalizations. A pertinent review of neuroanatomy as it relates to laryngeal function is also discussed. State-of-the-art diagnostic and therapeutic procedures are presented. CONCLUSION: There is a well-defined set of diagnostic and therapeutic options for laryngeal dysfunction in the stroke patient. SIGNIFICANCE: Otolaryngologists play a critical role in the interdisciplinary rehabilitation team.

Assessing and documenting general competencies in otolaryngology resident training programs.

OBJECTIVES: The objectives of this study were to: 1) implement web-based instruments for assessing and documenting the general competencies of otolaryngology resident education, as outlined by the Accreditation Council of Graduate Medical Education (ACGME); and 2) examine the benefit and validity of this online system for measuring educational outcomes and for identifying insufficiencies in the training program as they occur. METHODS: We developed an online assessment system for a surgical postgraduate education program and examined its feasibility, usability, and validity. Evaluations of behaviors, skills, and attitudes of 26 residents were completed online by faculty, peers, and nonphysician professionals during a 3-year period. Analyses included calculation and evaluation of total average performance scores of each resident by different evaluators. Evaluations were also compared with American Board of Otolaryngology-administered in-service examination (ISE) scores for each resident. Convergent validity was examined statistically by comparing ratings among the different evaluator types. RESULTS: Questionnaires and software were found to be simple to use and efficient in collecting essential information. From July 2002 to June 2005, 1,336 evaluation forms were available for analysis. The average score assigned by faculty was 4.31, significantly lower than that by nonphysician professionals (4.66) and residents evaluating peers (4.63) (P < .001), whereas scores were similar between nonphysician professionals and resident peers. Average scores between faculty and nonphysician groups showed correlation in constructs of communication and relationship with patients, but not in those of professionalism and documentation. Correlation was observed in respect for patients but not in medical knowledge between faculty and resident peer groups. Resident ISE scores improved in the third year of the study and demonstrated high correlation with faculty perceptions of medical knowledge (r = 0.65, P = .007). CONCLUSIONS: Compliance for completion of forms was 97%. The system facilitated the educational management of our training program along multiple dimensions. The small perceptual differences among a highly selected group of residents have made the unambiguous validation of the system challenging. The instruments and approach warrant further study. Improvements are likely best achieved in broad consultation among other otolaryngology programs.

Combined anterior-to-posterior and posterior-to-anterior approach to paranasal sinus surgery: an update.

OBJECTIVES: To develop an anatomically and functionally based approach to endoscopic intranasal ethmoidectomy; to develop such an approach using the salient features of the anterior-to-posterior (AP) and posterior-to-anterior (PA) intranasal sinus operations; to assess the safety of this form of ethmoidectomy in a patient population. STUDY DESIGN: Retrospective chart review of patients undergoing ethmoidectomy by the authors or by residents under their direct supervision. SETTING: University teaching hospital. RESULTS: Two thousand three hundred and forty-four patients underwent either unilateral or bilateral ethmoidectomies between April 1992 and August 2005. A complication rate of 0.34% was observed. CONCLUSIONS: Combining an AP approach to conserve sinus anatomy with a PA approach to avoid surgery directed toward the skull base provides a functional and safe procedure, as demonstrated by the reported results.

The Edwin Smith Papyrus: the birth of analytical thinking in medicine and otolaryngology.

The Edwin Smith Papyrus, discovered in 1862 outside of Luxor, Egypt, is the oldest known surgical text in the history of civilization. The surviving scroll, a copy of an earlier text from around 3,000 B.C., gives us remarkable insight into the medical practice of ancient Egyptians in the Nile River bed during the dawn of civilization. The Papyrus is divided into 48 cases, most of which describe traumatic injuries. The text instructs the physician to examine the patient and look for revealing physical signs that may indicate the outcome of the injury. Although in modern medicine we take for granted that the use of physical examination and rational thinking lead to an accurate conclusion, 5,000 years ago, this was extraordinary. The Edwin Smith Papyrus cast aside the prevailing magic and mysticism of that time in favor of logic and deductive reasoning. As Egyptian civilization declined during the next millennium, the teachings of the Papyrus would be lost. It would not be until 300 B.C. when Hippocrates and his disciples in ancient Greece would once again revive logic in medical thinking and teaching. It is believed that the ancient Greeks had knowledge of the contents of the Edwin Smith Papyrus and its teachings and used them as the basis for their writings. As Europe entered the Dark Ages, so did medicine yet again, reverting to spells and prayers instead of judgment and reason. Although Hippocrates teachings were recognized by some scholars during the Middle Ages, they did not make up the basis for mainstream medical knowledge. With the dawn of the Renaissance, medicine would finally purge itself of its past supernatural foundation. Hippocratic teachings were used to form the basis of modern medicine, and medical pioneers in the 17 century studied the ancient Greek texts as the origin for their ideas. Many of the concepts physicians and patients today take as common knowledge originated in the Edwin Smith Papyrus. The authors attempt to uncover some of these fundamental ideas and trace them through time until their incorporation in our modern medical knowledge base. It is the rational, logical, and advanced thinking exhibited in the Edwin Smith Papyrus that mandates its respect from modern otolaryngologists and all physicians alike.

3,3'-Diindolylmethane, a cruciferous vegetable derived synthetic anti-proliferative compound in thyroid disease.

Considerable epidemiological evidence exists to link thyroid disease with differing patterns of dietary consumption, in particular, cruciferous vegetables. We have been studying the anti-thyroid cancer (TCa) activity of indole-3-carbinol (I3C) found in cruciferous vegetables and its acid catalyzed dimer, 3,3'-diindolylmethane (DIM). There are no studies as yet to elucidate the effect of these compounds on the altered proliferative patterns in goiter or thyroid neoplasia. In this study, we tested the anti-proliferative effects of I3C and DIM on four different thyroid cancer cell lines representative of papillary (B-CPAP and 8505-C) and follicular carcinoma of the thyroid (CGTH-W-1 and ML-1), and primary human goiter cells. Cell survival and IC50 values for I3C and DIM were calculated by the XTT assay and cell cycle distribution analysis was done by flow cytometry. DIM was found to be a better anti-proliferative agent than I3C in both papillary and follicular TCa resulting in a greater cytotoxic effect at a concentration over three fold lower than predicted by the molar ratio of DIM and I3C. The anti-proliferative activity of DIM in follicular TCa was mediated by a G1 arrest followed by induction of apoptosis. DIM also inhibited the growth of primary goiter cells by 70% compared to untreated controls. Contrary to traditional belief that cruciferous vegetables are "goitrogenic", DIM has anti-proliferative effects in glandular thyroid proliferative disease. Our preclinical studies provide a strong rationale for the clinical exploration of DIM as an adjuvant to surgery in thyroid proliferative disease.

Neurosurgical implications of allergic fungal sinusitis.

OBJECT: Allergic fungal sinusitis (AFS) is a form of paranasal mycosis that often involves bone destruction and extension into the orbit and anterior skull base. Treatment consists of surgical extirpation and a course of corticosteroids. Despite frequent intracranial involvement, AFS is rarely reported in the neurosurgical literature. METHODS: The records of 21 patients with the histological diagnosis of AFS were reviewed. The histological diagnosis was based on findings of branching septated fungi interspersed with eosinophilic mucin and Charcot-Leyden crystals without fungal invasion of soft tissue. The average age of the 21 patients in this study was 25 years (range 9-46) and the male/female ratio was 3.75:1. All patients were immunocompetent. All had a history of chronic sinusitis and imaging findings of expansile disease involving multiple sinuses. Fifteen patients had nasal polyposis, eight had erosion of bone, which was observed on computerized tomography (CT) scans, eight had disease extending intracranially, and six had disease that involved the lamina papyracea. All patients underwent transnasal and/or transmaxillary endoscopic approaches for debridement and irrigation, six underwent orbital decompression, and three underwent a bifrontal craniotomy for removal of intracranial extradural disease. No patient had a cerebrospinal fluid leak. Postoperatively, one patient was treated with amphotericin B and the other 20 were treated with a short course of corticosteroids. The follow-up period ranged from 2 to 19 years. CONCLUSIONS: Allergic fungal sinusitis is a unique form of fungal disease that may mimic anterior skull base and paranasal sinus tumors. A cranial base team approach of neurosurgeons and otolaryngologists is recommended. Most cases can be successfully managed with transnasal and/or transmaxillary endoscopic techniques. A craniotomy is rarely indicated unless there is the suspicion of dural invasion or extensive intracranial and/or intraorbital involvement that is inaccessible from below.

Use of sodium fluorescein solution for detection of cerebrospinal fluid fistulas: an analysis of 420 administrations and reported complications in Europe and the United States.

BACKGROUND: Localization of dural fistulas in the region of the anterior or lateral skull base may be difficult. For many years, a sodium fluorescein solution of 0.5 to 5% (2.5-50 mg) has been administered intrathecally by way of the lumbar space. However, fluorescein is not commercially available for this stated purpose in either Germany or the United States. METHODS: Retrospectively, 420 fluorescein applications by the authors were retrospectively analyzed. Under the Freedom of Information Act, the United States Federal Drug Administration and the manufactures of fluorescein were queried for adverse reaction reports. RESULTS: Four hundred twenty fluorescein applications in 305 patients could be evaluated. Mean age of recipients was 46.9 years, ranging from 1 to 82 years. At a concentration of 5% fluorescein, 26 patients on the day of surgery and 69, 37, 34, and 14 patients on days 2 through 4 suffered from minor side effects that may or may not have been related to this drug. Two of these patients had grand mal seizures, which were attributable to simultaneous intrathecal application of contrast medium. All other side effects were thought to be the result of a postspinal headache and related lumbar puncture. At a concentration of 0.5%, the intraoperative intrathecal administration of 0.5 to 2 mL of fluorescein followed by 4 to 5 days of lumbar drainage resulted in some degree of spinal headache without other complications. In both groups, no patient had sequelae longer than 4 weeks. An additional seven complications were reported to the Federal Drug Administration and the fluorescein manufacturers at doses of 100 to 700 mg. CONCLUSIONS: Complications from intrathecal application of fluorescein appears to be dose dependent. At concentrations of 5%, or preferably lower, side effects are transient. A grand mal seizure can be minimized when following the general cautions of lumbar puncture and dose. The patient should be supervised for 24 hours. A written informed consent from patients for use of fluorescein is recommended.

Zones of approach for craniofacial resection: minimizing facial incisions for resection of anterior cranial base and paranasal sinus tumors.

OBJECTIVE: Anterior cranial base tumors are surgically resected with combined craniofacial approaches that frequently involve disfiguring facial incisions and facial osteotomies. The authors outline three operative zones of the anterior cranial base and paranasal sinuses in which tumors can be resected with three standard surgical approaches that minimize transfacial incisions and extensive facial osteotomies. METHODS: The zones were defined by performing dissections on 10 cadaveric heads and by evaluating radiographic images of patients with anterior cranial base tumors. The three approaches performed on each cadaver were transbasal, transmaxillary, and extended transsphenoidal. RESULTS: Three zones of approach were defined for accessing tumors of the anterior cranial base, nasal cavity, and paranasal sinuses. Zone 1 is exposed by the transbasal approach, which is limited anteriorly by the supraorbital rim, posteriorly by the optic chiasm and clivus, inferiorly by the palate, and laterally by the medial orbital walls. This approach allows access to the entire anterior cranial base, nasal cavity, and the majority of maxillary sinuses. The limitation imposed by the orbits results in a blind spot in the superolateral extent of the maxillary sinus. Zone 2 is exposed by a sublabial maxillotomy approach and accesses the entire maxillary sinus, including the superolateral blind spot and the ipsilateral anterior cavernous sinus. However, access to the anterior cranial base is limited. Zone 3 is exposed by the transsphenoidal approach. This approach accesses the midline structures but is limited by the lateral nasal walls and intracavernous carotid arteries. An extended transsphenoidal approach allows further exposure to the anterior cranial base, clivus, or cavernous sinuses. The use of the endoscope facilitates tumor resection in the nasal cavity and paranasal sinuses. CONCLUSION: The operative zones outlined offer minimally invasive craniofacial approaches to accessing lesions of the anterior cranial base and paranasal sinuses, obviating facial incisions and facial osteotomies. Case illustrations demonstrating the approach selection paradigm are presented.

Endoscopic and transconjunctival orbital decompression for thyroid-related orbital apex compression.

OBJECTIVE: To evaluate the efficacy and safety of a combined endoscopic and transconjunctival orbital decompression in patients with thyroid-related orbitopathy with orbital apex compression. STUDY DESIGN: Retrospective review. METHODS: A sequential series of patients with thyroid-related orbitopathy presenting with orbital apex compressive myopathy with and without optic neuropathy who were undergoing combined endoscopic and transconjunctival decompression by the same surgeons from 1992 to 2001 was reviewed. Patients were regularly evaluated preoperatively and postoperatively over a 3- to 55-month period to record the effects of this approach on visual acuity, Hertel exophthalmometry, and diplopia. Complications and secondary ophthalmological procedures were reviewed. RESULTS: Between 1992 and 2001, 72 combined endoscopic and transconjunctival decompressions were performed on 41 patients with orbital apex compression. Visual acuity improved in 89.3% of the patients with compressive optic neuropathy (P <.0005) and in 34.1% of those without neuropathy. Proptosis was reduced by 3.65 mm, on average. There was one case of transient intraoperative cerebrospinal fluid extravasation at the site of the optic nerve decompression, and one patient developed epistaxis. CONCLUSIONS: The study supports the treatment of thyroid-related orbital apex compression with and without compressive optic neuropathy by a combined transconjunctival and endoscopic approach. This approach offers short hospital stays, excellent visual recovery, and minimal complications in patients with thyroid-related orbital apex compressive myopathy and related compressive optic neuropathy. The beneficial effects observed in the patients with visual loss continued to improve over time and were significant (P <.001).

Multiple motor unit recordings of laryngeal muscles: the technique of vector laryngeal electromyography.

OBJECTIVES: To display time-series firing rate and recruitment data for multiple, simultaneously active motoneurons activating human laryngeal muscles. These data provide specific information about how laryngeal muscle force is being controlled by the central nervous system at the level of the lower motoneuron. METHODS: A quadrifilar needle electrode was used to record multi-channel myoelectric signals from thyroarytenoid muscle of normal subjects during tasks ranging from quiet breathing to a short sentence. Motor unit action potentials of the signal space were identified and tracked throughout task productions using pattern recognition and Precision Decomposition software. RESULTS: We present the first recordings and analyses of multiple motor unit activations in the larynx. The firing times and mean firing rates are plotted for each identified motor unit, which reveal recruitment and decruitment information and the database from which common firing statistics across motor units may be derived. CONCLUSIONS: This study provides new information about neuromuscular physiology of the larynx. Specifically, the results reveal the ordered recruitment and firing patterns of multiple motor units and the existence of common drive from the central nervous system. The technique may prove fundamental to understanding various neuromuscular pathologies such as laryngeal spasm and to assist clinical prognosis of laryngeal paresis and the diagnosis of certain neurogenic disorders.