Admission planning and complications of direct laryngoscopy.

Increasingly, third party payers are challenging the necessity of a hospital admission for endoscopic procedures. Direct laryngoscopy (DL), with or without open, rigid esophagoscopy or flexible, fiberoptic bronchoscopy, was evaluated for the incidence of perioperative complications and associated risk factors. A retrospective review of 200 in-patient admissions between 1987 and 1990 for direct laryngoscopy or panendoscopy is presented. Complications were classified as major for untoward events that required hospitalization for proper management. Complications were otherwise considered minor. The incidence of major complications was at least 19.5%, with minor complications occurring in 21% of patients. The total population was partitioned into subsets according to the occurrence of major complications, minor complications, and no complications. For the total population and each subset, distributions were developed by age, sex, habitus, physical status level, diagnosis of malignancy, presence of a malignant lesion in the aerodigestive tract, or medical history of head and neck surgery or radiation therapy. Statistical analysis indicates that these parameters do not offer reliable predictors of which patients are at risk for minor or major complications. It is concluded that all patients who undergo direct laryngoscopy are most safely managed in an in-hospital setting for a period on the order of 24 hours.

The velopharyngeally inadequate child: phonologic change with intervention.

Diagnostic therapy is often recommended for children before physical management of the velopharyngeal structures. There is, however, limited information about the effectiveness of such intervention programs. This study describes the changes that occurred in a 3-year-old child's production of speech during a period of diagnostic therapy, and the changes that occurred following the fitting of a prosthesis. The mother served as the primary intervener, guided by a speech-language pathologist. The mother was able to change the child's speech so that more of her productions were at a correct place of articulation. After structural management, nasal and glottalized productions disappeared from the child's speech, but glottal stops did not.

Middle ear development. III: Morphometric changes in the conducting apparatus of the Mongolian gerbil.

Middle-ear structural ontogeny was examined in 12 age groups of Mongolian gerbils between 2 and 42 days after birth. Measurements of tympanic membrane surface area; depth of the tympanic membrane cone; the lengths of the malleus and incus long processes; and stapes footplate, annular space, and oval window areas were obtained using video micrographs and computer digitization techniques. The incus long process matured first at 3.5 days after birth, while the pars flaccida surface area was the last middle-ear variable studied to reach adult size (26 days after birth). The incus long process increased its length by 30% from 0.5 mm to 0.65 mm. The malleus long process, however, demonstrated much more relative growth (47%). Pars tensa area expanded from 6.35 mm2 at two days after birth to its adult size of 16.9 mm2 and the stapes footplate expanded by 50%. The developmental changes observed in middle-ear anatomy are then discussed with regard to their contribution to the functional maturation of both the middle ear and more central auditory function.

Chiari-I malformation associated with asymmetric sensorineural hearing loss.

Chiari-I malformation is a deformity of the structures of the posterior fossa in which there is inferior herniation of the cerebellar tonsils through the foramen magnum without significant caudal dislocation of the brainstem. Patients are usually asymptomatic until adulthood, when they commonly present with recurrent headaches, weakness, vertigo and/or imbalance, nystagmus and hearing loss. A review of 226 consecutive patients evaluated for asymmetric sensorineural hearing loss revealed 32 patients with retrocochlear pathology. Three of these patients were discovered to have a Chiari-I malformation by magnetic resonance imaging as their only pathology. We suggest a possible association between a Chiari-I malformation and isolated asymmetric sensorineural hearing loss secondary to long-standing traction on the eighth cranial nerve.

Open tube versus flexible esophagoscopy in adult head and neck endoscopy.

Open tube esophagoscopy is the mainstay of otolaryngic esophageal examination. Over the last 30 years flexible endoscopes have become popular and are challenging the open tube esophagoscope for use in otolaryngic practice. This study examines all open tube esophagoscopies performed on adult patients at the University of Pennsylvania over an 8-year period for the diagnosis and treatment of foreign bodies, strictures, functional disorders, and carcinoma. Open tube esophagoscopy is most useful for foreign body extraction, examination of the cervical esophagus, and dilation of pliable strictures. For most other indications flexible esophagoscopy provides improved visualization with lower morbidity. For patients with squamous cell carcinoma of the head and neck we found a 1.4% incidence of secondary esophageal malignancies and a 28% incidence of false-negative barium swallow studies. We recommend esophagoscopy for all patients with carcinoma of the upper aerodigestive tract. The otolaryngologist should be adept at both flexible and open tube esophagoscopy in order to allow optimal examination of and therapeutic intervention in the upper aerodigestive tract.

Localization of the carotid artery within the tonsillar fossa by Doppler flow mapping.

Injury to the internal carotid artery during procedures performed in the tonsillar fossa can be catastrophic. Tonsillectomy or uvulopalatopharyngoplasty was performed on 32 patients at the Hospital of the University of Pennsylvania or the Children's Hospital of Philadelphia. Using Doppler ultrasonography, the course of the internal carotid artery in the postsurgical tonsillar fossa was mapped. The results indicate that, in the majority of patients, the internal carotid artery is located between 20% and 60% of the total width across the tonsillar fossa, as measured from the posterior pillar. Appreciation of the surgical anatomy of the tonsillar fossa with respect to the internal carotid artery should contribute to improved intraoperative judgment and further limit the risk of vascular injury during oropharyngeal procedures.

Inverted papillomas of the nasal septum.

The inverted papilloma is a true neoplasm of the nose and paranasal sinuses with unusual biological and clinical characteristics. It is a benign process which exhibits certain malignant features such as recurrence, localized destruction of tissues and the possibility of malignant degeneration. Inverted papillomas occur most commonly on the lateral nasal wall, but a small percentage are discovered elsewhere including the ethmoid and sphenoid sinuses, the nasopharynx and the nasal septum. Controversy exists about whether septal papillomas are true inverted papillomas or whether they represent the more commonplace squamous papillomas found in the upper respiratory tract. Two case reports of inverted papillomas of the nasal septum are presented as well as a review of the literature on these neoplasms.