Practice of otolaryngology via telemedicine.

Teleotolaryngology is becoming a reality as a result of improvements in technology and telecommunications. This prospective, clinical trial was designed to demonstrate the utility of three telemedicine systems in an otolaryngology practice. Optel is a desktop system used in the office. Picasso is a mobile system used from various locations throughout the hospital. The Georgia Statewide Telemedicine Program (GSTP) is a large, sophisticated system used from a fixed site within a rural hospital. Patients with a wide variety of ear, nose, and throat problems were presented to consultants at two medical teaching centers in Georgia. Fifty-four consults were completed over a 24-month period. In addition, three teleconsultations demonstrated enhanced capabilities for continuing medical education (CME) and health care networks. Nine different specialty fields were accessed by the otolaryngologist. Five consults were completed via the Optel system; 13 via the Picasso system; and 36 via GSTP. Overall, teleotolaryngology provided quality audio and visual communication between the physicians that significantly improved diagnostic capabilities and treatment options for the patient.

An optimal choice: home intravenous hydration after tonsillectomy.

Most tonsillectomies are performed as outpatient procedures in an ambulatory care facility. The postoperative period can be protracted, which can cause dehydration and readmission to the hospital. Timely intervention with home intravenous (IV) hydration can help prevent this complication. A prospective clinical trial was designed to evaluate the benefit of home IV therapy after tonsillectomy. One hundred consecutive patients underwent tonsillectomy. Fifty returned home without home IV hydration and another 50 returned home with home IV hydration. Clinical data were collected by the homecare nurse during the postoperative period. Comparison between these two groups showed that the patients with home IV hydration had less morbidity. Daily assessment of the patient by telephone is the best screening method to determine the need for IV hydration for the posttonsillectomy patient.

Analysis of vocal fold function in the miniswine model.

Correlation of the vocal fold vibratory pattern with the postoperative surgical wound should demonstrate to the laryngologist the critical depth of injury at which the functional voice would be adversely affected. An animal model was selected to study these changes. Twelve adult miniswine were operated on in this prospective study. The right true vocal fold was surgically altered; the left true vocal fold was the control. An interval of 6 weeks was allowed for healing, and then changes in vocal fold function were studied by stroboscopy, photography, voice recording, and electroglottography. Laryngectomy provided tissue for histopathological correlation. The results showed that injury at the junction of the lamina propria and vocalis muscle consistently caused significant vibratory dysfunction resulting in poor phonation.

Hypothyroidism following radiotherapy for head and neck cancer.

Hypothyroidism is not commonly considered a complication of radiotherapy for head and neck cancer. A series of 96 patients treated with radiotherapy alone or combined with surgery for head and neck cancer was retrospectively studied. All patients had radiation ports that included the thyroid gland. Hypothyroidism after radiotherapy was documented in 26% of all patients. The majority of patients had subclinical hypothyroidism manifested by elevated thyroid-stimulating hormone (TSH) levels. The incidence of hypothyroidism dramatically increased to 65% when radiotherapy was combined with surgery that included a partial thyroidectomy. In addition, we report the unusual occurrence of massive head, neck, and hypopharyngeal edema caused by severe hypothyroidism in two patients. We advocate routine monitoring of head and neck cancer patients for hypothyroidism after radiotherapy involving the thyroid gland and recommend levothyroxine replacement therapy for subclinical hypothyroidism.

Treatment of radiation- and chemotherapy-induced stomatitis.

Severe stomatitis is a common problem encountered during either radiation therapy or chemotherapy. Most therapeutic regimens are empirical, with no scientific basis. The purpose of this study is to determine the efficacy of various topical solutions in the treatment of radiation- or chemotherapy-induced stomatitis. Eighteen patients were entered into a prospective double-blinded study to test several topical solutions: (1) viscous lidocaine with 1% cocaine; (2) dyclonine hydrochloride 1.0% (Dyclone); (3) kaolin-pectin solution, diphenhydramine plus saline (KBS); and (4) a placebo solution. Degree of pain relief, duration of relief, side effects, and palatability were evaluated. The results showed that Dyclone provided the most pain relief. Dyclone and viscous lidocaine with 1% cocaine provided the longest pain relief, which averaged 50 minutes This study provides objective data and defines useful guidelines for treatment of stomatitis.

Nasal polyps: a manifestation of allergy?

The cause of nasal polyps is speculative. In the 1930s nasal polyps were considered to be a manifestation of allergy. This theory was challenged in the 1970s. Many patients with nasal polyps have no identifiable allergic disease. The purpose of this study is to better define the relationship between allergy and nasal polyps. Twelve patients with nasal polyps were evaluated by history, physical examination, skin testing, nasal smear for eosinophils, specific IgE determination from serum, nasal secretions, and nasal polyp fluid. Similar data were collected from three control groups: (1) 10 patients with allergic rhinitis, (2) 10 patients with nonallergic rhinitis, and (3) 10 patients with no known nasal disease. By comparing the incidence of markers for allergic disease in patients with nasal polyposis to each of the three control groups, the role of allergic disease in nasal polyposis was delineated.

The changing picture of facial fractures. 5-Year review.

A decline in the overall number and severity of facial fractures has been observed at Madigan Army Medical Center, Tacoma, Wash. Hospital records of patients (N = 262) who were treated for fractures of the zygoma, maxilla, and mandible between 1983 and 1987 were reviewed. The three leading causes of facial fractures were assault (35%), vehicular accidents (26%), and sports (12%). The preferred treatment modality consisted of open reduction and internal fixation with plates. Societal influences have been responsible for this declining trend in the number and severity of facial fractures. This pattern will impact on training programs that necessitate physician rotations at large trauma centers to provide necessary exposure to maxillofacial injuries.

Hereditary carcinoma syndromes associated with benign head and neck tumors.

Hereditary forms of carcinoma may be associated with benign head and neck tumors. Many of these hereditary carcinoma syndromes present first to the otolaryngologist. Two unusual cases of Gardner's and Muir--Torre's syndromes illustrate the hereditary carcinoma syndromes associated with head and neck lesions. We describe the use of new genetic markers and propose a diagnostic algorithm.

Aggressive paranasal sinus ossifying fibroma.

Sixty-one cases of an aggressive OF involving the paranasal sinus area are reviewed from the literature. We describe another case of this unusual lesion in an 11-year-old girl. These tumors share a similar radiographic appearance, aggressive clinical behavior, and tendency for recurrence after incomplete treatment. Our experiences show that active OF accurately describes this entity and avoids the confusing histologic nomenclature usually encountered. The head and neck surgeon should be aware of this diagnosis so aggressive en bloc resection can be employed whenever possible.

A device for the intraoperative identification of the recurrent laryngeal nerve in piglets.

The recurrent laryngeal nerve (RLN) is one of the most frequently injured nerves in head and neck surgery. Routine identification of the RLN during thyroid surgery has reduced the injury rate from 10% to less than 4%. Difficulty in identification of the RLN contributes to this surgical morbidity. Devices previously used for intraoperative identification of the RLN have failed to achieve the simplicity and reliability necessary for clinical use. This animal study uses a simple double-ballooned endotracheal tube and pressure transducer system, which assists intraoperative RLN identification through nerve stimulation and graphic documentation of vocal fold (VF) motion. Iatrogenic injury is demonstrated by a dampened stimulation-pressure tracing. The RLNs of three piglets were injured and examined, and the degree of injury was correlated with perioperative nerve stimulation patterns. The piglet proved to be an adequate model for laryngeal research. An FDA-approved multi-institutional prospective human study using this system of identification of the RLN is in progress.

Evaluation of head and neck cancer patients. A national survey.

A review of the recent literature of otolaryngology-head and neck surgery reveals minimal guidance as to the use of laboratory and radiographic studies in the initial evaluation and subsequent follow-up of patients with head and neck cancer. A national survey was prepared and was sent to 105 otolaryngology-head and neck surgery teaching departments with 53 institutions responding. This survey shows that a baseline of laboratory and radiographic studies are routinely ordered. Follow-up is monthly the first year and every other month the second year. Specialized laboratory tests and radiographic studies are ordered on a case-by-case basis and based on cost effectiveness, research orientation, available resources, and, most importantly, the patient's needs.

Lymphoscintigraphy of the neck.

Lymph node imaging has been helpful in managing patients with lymphoma, melanoma, and breast cancer. To evaluate 38 patients with head and neck cancers, 99mTc minicolloid was injected adjacent to the tumor and into a similar area on the uninvolved side. Lymphoscintigraphy of the neck was performed at 3- and 5-hour intervals after injection and bilateral cervical lymphatic drainage was observed. Each patient then underwent a neck dissection. The pathologic node findings were then correlated with the neck scans. Results confirmed that cervical lymphatic drainage is unpredictable in 50% of the patients once the channels are involved with metastatic disease. Lymphoscintigraphy is not a reliable method of detecting early metastatic cervical carcinoma.