Case report: Liposarcoma of the sinonasal tract.

Nasal and paranasal malignant tumours account for less than 5% of all head and neck malignancies. Epithelial malignancies overwhelmingly predominate, with squamous cell carcinomas representing the most frequent histological subtype in this location. Soft-tissue sarcomas of the nasal cavity and paranasal sinuses are exceedingly rare. Here, we report two cases of myxoid liposarcomas that occurred in the nasal and paranasal regions, both of which presented diagnostic challenges and could not be diagnosed definitively from intraoperative frozen sections. These cases reinforce the notion that, while they are uncommon, sarcomas in general and liposarcomas in particular should still be considered as part of the differential diagnosis in patients presenting with obstructive symptoms in the nasal and paranasal sinuses.

Comparison of antral tap with endoscopically directed nasal culture.

OBJECTIVES/HYPOTHESIS: The diagnosis of acute bacterial rhinosinusitis continues to generate controversy in critically ill patients. The efficacy of endoscopically directed cultures in these patients is unknown. We compared antral tap (AT) with endoscopic tissue culture (ETC) of the osteomeatal complex in an intensive care unit (ICU) setting. METHODS: Twenty patients admitted to a surgical/trauma ICU were evaluated by AT and ENB for the presence of rhinosinusitis. All patients had 1) a fever of unknown origin without resolution on empiric antibiotic therapy for > or =48 hrs; 2) other sources of fever ruled out; 3) computed tomography scan evidence of mucoperiosteal thickening +/- sinus air/fluid levels; and 4) attempt at conservative treatment with topical decongestants and removal of all nasal intubation. Microbiologic data were collected and analyzed for any statistical difference between groups. RESULTS: A total of 29 sides underwent simultaneous tap and endoscopically directed tissue culture. The mean age was 40 years (range, 23-77 y) with 85% being males. Fifteen of 20 (75%) patients in the AT group were culture-positive. Of the 49 isolates from the AT, 55% yielded Gram-negative bacilli (Acinetobacter sp. 37%) and 45% yielded Gram-positive cocci. The ETC group was culture-positive in 18 of 20 (90%) patients. Of the 52 isolates from the ETC, Gram-negative bacilli were found in 58% (Acinetobacter sp. 33%) and 42% yielded Gram-positive cocci. The ETCs were culture-positive in all but 1 patient with positive taps. There appeared to be a concordance between AT and ETC in 60% of the patients. In five instances (25%), results of the AT or ETC changed ICU management. Two patients ultimately required sinus surgery. CONCLUSIONS: Sinus taps and/or endoscopically directed tissue cultures led to a change in ICU care in 25% of ICU patients studied. In patients with fever of unknown origin and computed tomography evidence of sinusitis, an antral tap continues to provide important information concerning maxillary sinusitis. However, ETC may give as good a representation of the microbiology and secondary inflammatory changes responsible for bacterial ICU rhinosinusitis causing fever of unknown origin. Further study on a larger group of patients is needed.

Endoscopic resection of esthesioneuroblastoma.

Esthesioneuroblastoma (olfactory neuroblastoma) is a rare malignant neoplasm originating from neuroepithelial cells. Treatment for this tumor has traditionally required a craniofacial resection through an external approach. The safety and efficacy of transnasal endoscopic resection is uknown. A series of five patients with Kadish stage A or B lesions of the anterior skull base were resected and immediately reconstructed endoscopically over a nine-year period. There were 2 males and 3 females with a mean age of 64 years. Three patients were treated primarily and two were treated secondarily for recurrences after failing a traditional external craniofacial resection and postoperative radiotherapy. All primary lesions received adjuvant radiotherapy. The mean follow-up time was 31 months. All patients were discharged within 4 days or less. Operative complications included temporary postoperative infraorbital anesthesia (1 patient), unplanned cerebrospinal fluid leak (1 patient), and can orbital hematoma (1 patient). None of these complications resulted in any permanent sequelae. Two patients had prolonged nasal crusting for up to one year due to a variety of factors; large cavities, radiation therapy, and exposed lyophilized dural graft. However, all skull base defects healed without any short- or long-term sequelae. There have been no local recurrences. Two patients (1 primary and 1 secondary) developed regional metastasis to the orbit or cervical lymph nodes managed with primary transorbital excision or modified neck dissection, respectively. All but one patient remain free of disease by clinical, endoscopic, and radiographic (CT or MRI) surveillance. The remaining patient recurred distally as an undifferentiated carcinoma in his temporal bone and lungs 12 months after the initial resection. In experienced hands select cases of esthesioneuroblastoma can be safely excised and reconstructed endoscopically with comparable degrees of tissue removal as with external approaches. Short-term oncologic results in this mall series of patients appear to be comparable to traditional methods. Longer follow-up on a larger series of patients is warranted.

A stepwise surgical technique using the medial orbital floor as the key landmark in performing endoscopic sinus surgery.

HYPOTHESIS: The medial orbital floor (MOF) and adjacent bony ridge of the antrostomy, when combined with columellar measurements, are easily identifiable and consistent anatomic reference points from which critical orbital and skull base structures can be found during endoscopic sinus surgery. METHODS: Two examiners, with varying endoscopic sinus surgery experience, performed endoscopic and direct measurements from the columnella and medial orbital floor to critical orbital and skull base structures on 11 human cadaver heads (18 sides). The distances to four critical skull base or orbital structures and to the anterior and posterior wall of the sphenoid sinus were measured. The mean, ranges, and standard deviations for all measurements (endoscopic and direct) were calculated and simple regression analysis was performed. RESULTS: The mean and range of values for each of the variables correlated well between examiners, and between endoscopic and direct measurements. There was slightly more variability in measurements when the MOF was used. However, the differences were no more than a few millimeters and did not appear to affect the overall clinical use of these values. CONCLUSIONS: The MOF and adjacent bony ridge of the antrostomy, when combined with columellar measurements, are easily identifiable and consistent anatomic landmarks that are not affected by the presence of significant inflammatory disease or previous surgery. These reference points provide even the most inexperienced surgeon with precise anatomic localization within the paranasal sinuses. They also determine the correct anteroposterior trajectory into the sphenoid sinus, whereby inadvertent intracranial or intraorbital complications may be avoided.

Endoscopic sinus surgery in previously irradiated patients.

PURPOSE: Our purpose was to evaluate the safety and efficacy of endoscopic sinus surgery in irradiated patients with absolute indications for sinus surgery. PATIENTS AND METHODS: During 5 years at a tertiary referral center, more than 200 patients received irradiation to a field that included the paranasal sinuses. Complaints related to the sinuses are common in such patients and often include crusting and increased mucus drainage. Six patients presented with significant sinus infections in the absence of tumor recurrence and failed medical management. Additional problems included epiphora and nasal obstruction caused by cicatricial choanal stricture. Surgical interventions included ethmoidectomy, multiple osteotomies, debridement of scarred or devitalized tissue, and dacryocystorhinostomy. Outcome measures included intraoperative findings and complications, length of hospital stays, endoscopic assessments of the healing over 6 months post-operatively, and improvement or persistence of symptoms over 2 to 3 years of follow-up. RESULTS: Surgery can be technically difficult because of derangements of normal anatomy and dehiscence of important structures. Although bleeding problems, prolonged admission, and delayed healing were noted in certain cases, they did not result in long-term morbidity. CONCLUSIONS: Endoscopic sinus surgery has become an invaluable tool in the treatment of refractory sinusitis. Our literature review has revealed no information, however, regarding endoscopic sinus surgery in previously irradiated patients. Theoretically, such patients are at risk for healing problems and anatomic derangements, which could lead to complications. There is, nevertheless, a theoretical benefit to avoiding external approaches in patients who might heal poorly.

A fine-cut technique for permanent laryngeal sectioning.

BACKGROUND: A new technique for permanent sectioning of the human spinal cord has provided superior images over those produced with traditional methods. Application of this technique for sections of the human larynx may yield cost-effective, efficient, and accurate laryngeal anatomic dissections. STUDY DESIGN AND METHODS: This study was designed to evaluate this technique for dissections of the human larynx. Laryngeal sections from cadavers were submerged in a celloidin solution, a derivative of wallpaper plaster, and frozen to -15 degrees C. After preparation, axial and coronal cuts of 100 microm were made with a Macrocut Tome sectioning system. RESULTS: Sections were completed in approximately 30 hours. Digitized photographs of the laryngeal sections provide detailed images of precise anatomic relationships. CONCLUSION: Celloidin-based sectioning of the human larynx yields precise anatomic information beyond standard radiographic imagining and previous permanent laryngeal sectioning techniques in a cost-efficient and timely manner. Black and white fine-section photographs are provided.

Acoustic analysis of the singing and speaking voice in singing students.

The singing power ratio (SPR) is an objective means of quantifying the singer's formant. SPR has been shown to differentiate trained singers from nonsingers and sung from spoken tones. This study was designed to evaluate SPR and acoustic parameters in singing students to determine if the singer-in-training has an identifiable difference between sung and spoken voices. Digital audio recordings were made of both sung and spoken vowel sounds in 55 singing students for acoustic analysis. SPR values were not significantly different between the sung and spoken samples. Shimmer and noise-to-harmonic ratio were significantly higher in spoken samples. SPR analysis may provide an objective tool for monitoring the student's progress.

Efficacy of transoral intraluminal Wallstents for tracheal stenosis or tracheomalacia.

OBJECTIVES: The efficacy and safety of intraluminal Wallstent Endoprosthesis (Boston Scientific/ Medi-Tech, Quincy, MA) placement to restore airway patency in patients with tracheal stenosis or tracheomalacia are unknown. STUDY DESIGN: Retrospective review in setting of tertiary, referral, and academic center. METHODS: A retrospective review of 13 consecutive patients over a 2-year period who underwent transoral resection of tracheal stenosis and immediate transoral Wallstent placement. One patient had tracheomalacia. All of the patients were considered at high risk for transcervical surgery or had failed prior traditional open procedures. RESULTS: The average patient age was 54.2 years, with nine male and four female patients. All had Cotton/Myer stenoses (grades II to IV) with moderate to severe degrees of inspiratory stridor. Four patients were tracheotomy dependent. The length of stenosis varied from 1 to 4 cm. One patient had a 10-cm segment of tracheomalacia. At the time of writing, none of the patients has had a problem with significant migration or extrusion and most of the patients have incorporated the stent well without any short-term obstructive granulation tissue. After a mean follow-up of 15 months (range, 4-24 mo). 10 of the 12 patients with stenosis (83%) have remained free of any inspiratory noise during breathing. The one patient with tracheomalacia also has remained free of symptoms. CONCLUSIONS: Transoral Wallstents appear to be safe and may be a reasonable alternative in the restoration of airway patency in select patients with tracheal stenosis or tracheomalacia.

Treatment of acute and chronic rhinosinusitis.

Rhinosinusitis is a common health complaint that is often seen by primary care physicians and otolaryngologists in the United States. The complicated anatomy of the paranasal sinuses, as well as the multiple etiologies, contributes to the complexity that one often faces in trying to ameliorate or eradicate this disease in affected individuals. A full understanding of the fundamentals of rhinosinusitis, as well as the treatment options available for the different types, is important. It is very important for the physician to take an organized, step-by-step approach to the management of each patient with this complicated disease. As most cases of rhinosinusitis presenting to the generalist's office will be of viral origin, antibiotics should not be given unless the patient has purulent rhinorrhea or worsening symptoms lasting more than 5 days, or total symptoms lasting longer than 10 days. When medical treatment fails or is incomplete, adjunctive surgical treatment becomes an option. Generally, the symptoms that are most helped by surgery include persistent headaches, nasal obstruction, and recurrent or persistent purulent rhinorrhea unresponsive to medical management. Appropriate and timely referral for specialty care will result in the definitive management of recalcitrant rhinosinusitis when medical management alone fails or in cases where a complication or malignancy is suspected. This article reviews the current understanding of the anatomy, pathophysiology, classification, diagnosis, and potential complications of rhinosinusitis. It also describes the current approach to the treatment of both acute and chronic rhinosinusitis.

Efficacy of computed tomographic image--guided endoscopic sinus surgery in residency training programs.

OBJECTIVE: To determine the efficacy of computed tomographic image-guided endoscopic surgery in the hands of inexperienced surgeons. STUDY DESIGN: Four second-year otolaryngology residents, with no prior experience performing ethmoidectomies, performed endoscopic sinus surgery (ESS) on formalin-fixed human cadaveric specimens with and without the aid of computer-assisted surgery (CAS). METHODS: Each resident was asked to identify critical sinus, orbital, and skull base structures while performing a total ethmoidectomy and multiple sinusotomies. Their surgical accuracy (percentage of correctly identified structures), total operative time, and incidence of major complications were recorded for each side. A total of 16 sides were evaluated (8 with and 8 without CAS). Statistical significance between groups was determined by means of Pearson's chi2 analysis. RESULTS: Statistical analysis showed a significant difference (P = .001) in the mean accuracy of identifying critical anatomical landmarks between the CAS (97%) and non-CAS (76.8%) groups. Although not statistically significant, operative time appeared to be longer in the group using CAS (average of 67 vs. 80 min). Three major intracranial complications were documented only in the group not using CAS. CONCLUSIONS: Although, unquestionably, a thorough knowledge of the anatomy remains essential for performing ESS, CAS improves surgical accuracy and reduces the risk of major intracranial or intraorbital complications for residents. In additional, our data suggest that this technology may enhance surgical efficiency and improve the learning curve by reducing operative time (below one's normal baseline) while maintaining a greater than 90% accuracy in identifying critical anatomical landmarks.

Relationship between aerodynamic measures of glottal efficiency and stroboscopic findings in asymptomatic singing students.

Singing requires exquisite coordination between the respiratory and phonatory systems to efficiently control glottal airflow. Asymptomatic singing students underwent pulmonary function testing (PFT), videostrobolaryngoscopic examination, and measures of glottal efficiency (maximum phonation time [MPT], glottal flow rate [GFR], and phonation quotient [PQ]) performed in both a sung and spoken tone. Pulmonary function and glottal efficiency values were within reported normative data for professional singers. However, sung tones were made with significantly higher GFR and PQ and lower PQ than spoken tones. The mean GFR was not related to the degree of glottal closure (by videostrobolaryngoscopy) or underlying pulmonary support.

Thyroplasty type I: short- versus long-term results.

OBJECTIVE: After thyroplasty type I, significant improvement has been reported in objective measures of vocal function. The purpose of this investigation was to compare the short- and long-term results in patients undergoing thyroplasty type I. METHODS: Data on 26 patients who had undergone thyroplasty type I for management of unilateral vocal fold paralysis were compared from before surgery to the short-term (1-month) and long-term (>1-year) postoperative assessment points. Statistical analysis included paired tests to assess the significance of between-group differences. RESULTS: Significant differences were found between the preoperative and both postoperative evaluations for the measures of mean glottal flow rate, maximum phonation time, jitter, shimmer, and harmonic-to-noise ratio. However, no significant differences were found between the 1-month and >1-year assessment points. CONCLUSIONS: The results for the parameters studied appeared to reach maximum improvement within 1 month after surgery. It is possible that the effects of time, including the normal aging process, hormonal changes, or other alterations in general health, may require longer follow-up to better address these issues.

Diagnosis and management of allergic fungal sinusitis with orbital involvement.

PURPOSE: Allergic fungal sinusitis (AFS) is a noninvasive disease characterized by recurrent sinusitis. This condition is commonly treated with surgical debridement and several months of systemic corticosteroids. The treatment of AFS is examined in this study. METHODS: A retrospective case series of three patients with AFS. RESULTS: All three patients were treated with surgical debridement and less than one month of systemic corticosteroids. The patients then were treated with intranasal corticosteroids and monitored closely. Antifungal therapy was not used. All three patients remained disease-free during follow-up ranging from 12 months to 36 months. CONCLUSIONS: Surgical debridement and systemic corticosteroids for less than four weeks followed by intranasal corticosteroids may provide long-term control of AFS. Additional study is recommended to examine further the optimal treatment for AFS.

Endoscopic cerebrospinal fluid rhinorrhea repair: is a lumbar drain necessary?

OBJECTIVES: To determine the necessity for lumbar drains during endoscopic cerebrospinal fluid (CSF) rhinorrhea repair. METHODS: Thirty-three patients underwent endoscopic repair of CSF rhinorrhea without a lumbar drain during a 7-year period. The size of the dural defect ranged from a microleak (less than 1 mm dural defect) to a 3-cm dural defect of the anterior skull base. RESULTS: All of the procedures in patients with smaller defects (<5 mm) were performed on an outpatient basis. Thirty-two patients (97%) had complete resolution of their CSF leak after 1 procedure without any recurrence (average follow-up 29 months). CONCLUSION: A lumbar drain is not routinely necessary for successful closure of CSF rhinorrhea of any size. Smaller dural defects may be safely performed on an outpatient basis without complications.

Failure of cricopharyngeal myotomy to improve dysphagia following head and neck cancer surgery.

OBJECTIVE: To determine whether cricopharyngeal myotomy can improve dysphagia associated with head and neck cancer surgery. DESIGN: Prospective, randomized, multicenter trial. SETTING: Twelve clinical sites across the United States. PATIENTS: Between 1989 and 1994, 125 patients undergoing combined modality therapy for head and neck cancer, including resection of the tongue base or supraglottic larynx, were prospectively entered into the trial. INTERVENTION: Cricopharyngeal myotomy on a randomized basis. MAIN OUTCOME MEASURES: Videofluoroscopic examination to determine oropharyngeal swallowing efficiency, which is defined as the ratio of percentage of the bolus swallowed to total swallowing time using 3 different bolus consistencies. RESULTS: No significant difference in oropharyngeal swallowing efficiency between myotomy vs no myotomy was seen at 6 months of follow-up regardless of bolus consistency. CONCLUSIONS: In this prospective test of cricopharyngeal myotomy, the procedure fails to significantly improve dysphagia associated with head and neck cancer surgery. The efficacy of this surgical procedure in other disease entities should also be rigorously explored.

Incidence of abnormal laryngeal findings in asymptomatic singing students.

OBJECTIVE: Abnormalities in the mucosal lining of the vocal folds may interfere with the normal vibratory patterns and result in vocal limitations, especially for singers whose demands are great. A prospective, longitudinal study was undertaken to investigate the incidence of laryngeal abnormalities in asymptomatic singing students. METHODS: Sixty-five singing students at the school of music underwent videostroboscopic evaluation and completed a comprehensive questionnaire. Videos were rated by 3 experienced clinicians, and interrater reliability was calculated. Results were correlated with demographic factors, background medical history, and singing history. RESULTS: Five students (8.3%) exhibited early signs of benign vocal fold lesions (2 with nodules and 3 with cysts). A high incidence of posterior erythema (n = 44; 73.4%), suggesting possible reflux, was found. CONCLUSIONS: A surprisingly high number of otherwise asymptomatic singing students demonstrated abnormal laryngeal findings. Their relationship with vocal performance will be addressed as well as implications for preventative measures.

Sino-orbital aspergillosis in acquired immunodeficiency syndrome.

OBJECTIVE: To describe the clinical features, causes, imaging characteristics, treatment, and outcome of patients with the acquired immunodeficiency syndrome (AIDS) and sino-orbital aspergillosis. DESIGN: Records of 5 patients were reviewed. Results of imaging and histopathologic examinations and clinical courses of the patients were studied. RESULTS: There were 3 women and 2 men (mean age, 34.0 years). All had received a diagnosis of AIDS, and mean CD4+ cell count was 0.014 x 10(9)/L (14 cells/mm3). Computed tomographic scanning exhibited heterogeneous, enhancing sino-orbital soft tissue lesions with bony erosion, and magnetic resonance imaging disclosed soft tissue masses hypointense on T1- and T2-weighted images. The infection involved 1 or more paranasal sinuses, with extension into the right orbit in 3 patients and into the left orbit in 2. Patients were treated with aggressive surgical debridement and intravenous antifungal agents. In addition, local irrigation of amphotericin B was performed in 3 patients. Aspergillus fumigatus was found to be the cause in all 5 patients. Intracranial extension developed in 4 patients, and all subsequently died. The 2 longest surviving patients were the only ones being treated with protease inhibitors. Three patients had a history of frequent marijuana smoking. CONCLUSIONS: Sino-orbital aspergillosis is a progressive, relentless, and usually fatal opportunistic infection of advanced AIDS. Patients are first seen with long-standing headache and proptosis with minimal external inflammatory signs. Marijuana smoking may increase the risk for development of sino-orbital aspergillosis in these patients. Aggressive surgical and medical treatment, combined with newer combination therapies using protease inhibitors, may improve the longevity of these patients.

Endoscopic Lothrop procedure: the University of Miami experience.

Over a 2-year period, 21 patients with clinical and radiologic evidence of persistent or recurrent frontal sinusitis who had a prior ethmoidectomy and/or frontal sinusotomy underwent an endoscopic Lothrop procedure. The patients' chief complaints were headaches (13), nasal obstruction and/or purulent rhinorrhea (4), orbital abscess/cellulitis (2), anosmia (1), and cough (1). Preoperative frontal headaches were present in 19 patients. The common frontal ostium remained patent (> 50% of intraoperative size) by flexible fiberoptic examination and transillumination 2-24 months postoperatively in 12 of 21 patients (57%). Eighteen of 21 patients (86%) had improved or resolved chief complaints. All but 4 of 19 patients (21%) with preoperative frontal headaches had improved or resolved symptoms. Two patients required additional surgery during the follow-up period. The endoscopic Lothrop procedure is a viable option before frontal sinus obliteration in patients with recurring frontal sinusitis who have failed conventional endoscopic techniques. The surgical technique and results will be presented.

Laryngeal injuries after short- versus long-term intubation.

Forty-five patients were seen over a 5-year period with laryngeal injuries following endotracheal intubation (ETI). The mean duration of ETI was 5.6 days (2 hours to 37 days). Patients intubated for less than 24 hours were most likely to present with a vocal fold immobility or an anterior glottic web. Long-term intubation was associated with the development of subglottic stenoses and granulomas. Patients with vocal fold immobility were seen more often after ETI for surgical reasons and had a significantly higher incidence of previous intubation and tobacco usage. Subglottic stenoses were seen in younger patients intubated for medical reasons and associated with nasogastric tubes and longer periods of intubation.