Cerebrospinal Fluid Otorrhea After a Routine Tympanostomy Tube Placement: A Review of the Literature on Hyrtl Fissure.

OBJECTIVE: To review the literature on Hyrtl fissure (HF) and contribute our experience with a 2-year old who developed cerebrospinal fluid (CSF) otorrhea during routine tympanostomy tube placement. METHODS: Data Sources: Pubmed and Google Scholar searches were conducted of articles in the English language literature from all time periods using the words Hyrtl, Hyrtl's fissure, HF, and tympanomeningeal fissure. Study Selection: All relevant articles were reviewed to identify cases of HF. RESULTS: Data Extraction: Nineteen cases, including ours, are described. Patient characteristics, method(s) of diagnosis and repair, and outcomes are reported. Computed tomography and intraoperative endoscopic images from our case are included. Presentation is more common in children (66.7% of cases where age was stated, n = 10) than in adults (33.3%, n = 5), and is most commonly unilateral (89.5%, n = 17). Cerebrospinal fluid otorrhea was the most common presentation. Six were discovered after tympanostomy tube placements while 3 were identified during cochlear implant work-up or after device failure. Surgical approaches described include endaural, transcanal, retrosigmoid, postauricular, and posterior fossa endoscopic. Multiple materials including bone wax, bone pate, fascia, muscle, and tissue sealant have been used. Our case describes an endoscopic repair in a child, which was successful at a 2-year follow-up. Data Synthesis: The small number of cases limits the utility of statistical analysis (n = 19). CONCLUSIONS: Hyrtl fissure is a rare but important entity that may be discovered when routine procedures have unexpected results. Hyrtl fissure should be included in the differential diagnosis when there is persistent clear otorrhea after a tympanostomy tube, cochlear implant misinsertion, meningitis, or unexplained middle ear effusion in an adult.

Cadaveric Study of an Endoscopic Keyhole Middle Fossa Craniotomy Approach to the Superior Semicircular Canal.

OBJECTIVE: Demonstrate that an endoscopic keyhole approach to the middle cranial fossa is technically feasible for repair of semicircular canal dehiscence. STUDY DESIGN: Cadaveric technical feasibility/methods development study. SETTING: Tertiary care military medical center. PATIENTS: Three fresh cadaveric heads (six sides). INTERVENTION(S): Endoscopic minimally invasive approach to the middle cranial fossa using the Medtronic Fusion Guidance system. MAIN OUTCOME MEASURE(S): Ability to identify the surgical landmarks of the middle cranial fossa and successfully identify and instrument the superior semicircular canal. RESULTS: In every attempt, the arcuate eminence was successfully identified under endoscopic visualization and with the assistance of surgical navigation. The superior semicircular canal was unroofed, and its location confirmed visually and with the navigation system. The opened canal was then plugged with bone wax, bone pate, and covered with fascia. The 15-mm burr hole craniotomy provided ample room for one working instrument and a 4-mm 0-degree endoscope. CONCLUSION: The endoscopic keyhole approach to superior semicircular canal dehiscence is technically feasible in a human cadaveric model. Further studies will determine 1) if this approach is possible and safe in vivo, 2) is associated with improved surgical outcomes, and 3) if surgical navigation aids in this approach.

Comparison of nitinol stapes pistons with conventional stapes pistons: a cadaver study.

Objective. To visually compare the Nitinol "smart" stapes prosthesis to conventional manual crimping stapes pistons in temporal bone cadaver specimens. Main Outcome Measures. 10 otolaryngologists were given a photograph of the randomly ordered stapes pistons and asked to use the pictures to answer questions about each stapes piston. The answers to the survey were then recorded for analysis. Results. 8 of 9 Nitinol pistons were described as circular, and 3 of 9 manual crimped pistons were described as circular (P < .05). 6 of 9 Nitinol pistons were considered to be in contact with >66% of the incus and 3 of 9 to be in contact with 34-66% of the incus. 3 of 9 manually crimped pistons were considered to be in contact with >66% of the incus, 3 with 34-66% contact and 3 with less than 34% contact. Conclusions. The Nitinol "smart" stapes pistons were considered to provide a more circular and circumferential crimping and to have greater contact with the long process of the incus than conventional stapes pistons.

The effects of smoking on the rate of postoperative hemorrhage after tonsillectomy and uvulopalatopharyngoplasty.

OBJECTIVE: To evaluate the rate of posttonsillectomy hemorrhage and any change that smoking causes in patients who undergo tonsillectomy. DESIGN: Retrospective chart review. SETTING: Military tertiary referral center. PATIENTS: The study included 1036 adult patients who underwent tonsillectomy either alone or in conjunction with another procedure. MAIN OUTCOME MEASURES: The rate of postoperative hemorrhage was reviewed in all patients who underwent tonsillectomy at our medical center, and an investigation was conducted to determine whether smoking caused any alteration in this rate. RESULTS: A total of 1010 patients were included in the study, with a total bleeding rate of 6.7%. There was a significant increase in the rate of bleeding in all patients when they were divided into smokers and nonsmokers (10.2% and 5.4%, respectively; P = .01). The large difference was found by subset analysis to be attributable to a marked increase in postoperative hemorrhage in the patients who underwent uvulopalatopharyngoplasty (10.9% in smokers vs 3.3% in nonsmokers; P = .006) and remained significant when they were further subdivided by sex. Men who underwent tonsillectomy alone also bled significantly more than women (11.2% and 5.4%, respectively; P = .02). All other subsets analyzed did not reach statistical significance. CONCLUSIONS: Smoking does appear to increase the rate of posttonsillectomy hemorrhage in patients who undergo uvulopalatopharyngoplasty with tonsillectomy, but not in those who undergo tonsillectomy alone. This modifiable risk factor may help clinicians further counsel their patients before surgery, but further study is needed to ascertain that these findings apply to a broader patient base.

An unusual case of adult airway obstruction from a lymphovenous malformation.

Lymphatic, venous, and mixed lymphovenous malformations are low-flow lesions that are present at birth and grow proportionately with the patient. We describe an unusual presentation of a lymphovenous malformation in an adult. A 19-year-old man presented to the emergency department with complaints of recent upper respiratory tract symptoms, increasing left-sided sore throat, voice change, odynophagia, dysphagia, and occasional subjective fevers and blood-tinged sputum. Examination revealed the presence of a left peritonsillar bulge consistent with a peritonsillar abscess; however, findings on needle aspiration were negative. The patient was admitted for intravenous steroid and antibiotic therapy. Within 24 hours, his airway became compromised, and he underwent an awake tracheotomy and biopsy, which showed a lymphovenous malformation. Magnetic resonance imaging the following day revealed a large, poorly circumscribed, heterogeneous left parapharyngeal mass consistent with a vascular malformation. With continuation of the steroids and antibiotics, the lesion regressed, and the patient was subsequently decannulated. At the 1-year follow-up, he exhibited no clinical symptoms, and he was in good health off steroids.

Pacific Northwest survey: posttympanostomy tube water precautions.

OBJECTIVES: To determine what recommendations are given to patients or parents of patients with tympanostomy tubes regarding water exposure and to elucidate any recommendation differences between primary care and specialty care physicians. DESIGN: Clinical survey. SETTING: General community in the Pacific Northwest, including Washington, Oregon, and Idaho. PARTICIPANTS: Physician surveys (N = 1116) were mailed to otolaryngologists, pediatricians, and family practitioners in the Pacific Northwest. Questions included what, if any, water precautions are given to patients or parents of patients who underwent tympanostomy tube insertion. Data were tabulated and compared among the 3 physician groups. MAIN OUTCOME MEASURES: Recommendations regarding water exposure. RESULTS: A response rate of 23.5% (n = 263) was obtained. Most respondents were self-described otolaryngologists (n = 150) followed by family practitioners (n = 77) and pediatricians (n = 36). chi(2) Analysis of the responses from each specialty group showed an overall significant difference about swimming precautions (P < .001). Further analysis of these data shows that many otolaryngologists (47% [n = 71]) and most primary care physicians (73% [n = 83]) recommend the use of barrier devices for swimming. Another 47% of otolaryngologist respondents allow swimming without any water precautions. With regard to depth of dive, there was no statistical significance found between the physician groups. CONCLUSIONS: Recommendations for swimming precautions are not universal among the physician groups that routinely see patients with tympanostomy tubes. Most primary care physicians and many otolaryngologists continue to prescribe water precautions to patients or parents of patients with tympanostomy tubes, despite published articles that have shown no reduction in the incidence of otorrhea from the use of barrier devices or from the avoidance of swimming.

Focused high-risk population screening for carotid arterial stenosis after radiation therapy for head and neck cancer.

BACKGROUND: Cervical radiation for head and neck cancer has been associated with an increased incidence of carotid arterial stenosis. Modern radiation therapy delivers higher doses with increasing long-term survival. Accordingly, the prevalence of radiation-associated carotid stenosis may be higher than previously reported. Phase I of this prospective study was to establish the prevalence of carotid artery stenosis after high-dose cervical radiation. METHODS: From a prospectively maintained database, we identified patients who had received cervical high-dose radiotherapy (minimum 5,500 cGy). All patients were screened with bilateral carotid arterial duplex ultrasonography. We defined disease as "normal or mild" if the carotid stenosis was <50%, and "significant" if >50%. The relationship between standard demographic risk factors and screening outcomes was then analyzed. RESULTS: Screening was performed in 40 patients (mean age 68.2 years, range 26 to 87). Patients received a mean cumulative radiation dose of 6,420 cGy (range 5,500 to 7,680), with a mean duration of 10.2 years since their last radiation treatment. Sixteen patients (40%) had significant carotid artery stenosis. Patients with and without significant stenosis were comparable in terms of age, radiation dose, tobacco use, comorbidities, and postradiation interval (P = not significant). Six patients (15%) had unilateral complete carotid occlusion and 6 patients (15%) had significant bilateral carotid stenosis. Three patients (7.5%) had sustained a previous stroke after radiation therapy. CONCLUSIONS: The prevalence of carotid arterial disease in patients with prior cervical radiation therapy is clinically significant and warrants aggressive screening as part of routine preradiation and postradiation care. Focused screening of this high-risk population may be cost effective and medically beneficial in terms of risk factor modification and stroke prevention, and will be examined in phase II of this study.

Remission of chronic inflammatory demyelinating polyneuropathy following adenotonsillectomy.

Patients with chronic inflammatory demyelinating polyneuropathy (CIDP) experience proximal- and distalextremity weakness, sensory loss, and often hyporeflexia or areflexia. CIDP is associated with a variety of concomitant medical illnesses, which often manifest weeks before the onset of muscle weakness and paresis. We describe what we believe is the first reported case of an association between CIDP and recurrent acute adenotonsillitis, which we observed in an 11-year-old girl. Following adenotonsillectomy, the patient's CIDP went into remission and her overall physical condition improved with physiotherapy.