The workforce in otolaryngology-head and neck surgery: moving into the next millennium.

OBJECTIVE: The goal was to examine the current scope of otolaryngologists' practices, their geographic distribution, and the roles otolaryngologists and other specialists play in caring for patients with otolaryngic and related conditions of the head and neck. STUDY DESIGN: A large national survey and administrative claims databases were examined to develop practice profiles and compile a physician supply for otolaryngology. A focus group of otolaryngologists provided information to model future scenarios. RESULTS: The current and predicted workforce supply and demographics are at a satisfactory level and are decreasing as a proportion of the increasing population. Empiric data analysis supports the diverse nature of an otolaryngologist's practice and the unique role for otolaryngologists that is not shared by many other providers. Together with the focus group results, the study points to areas for which more background and training are warranted. CONCLUSIONS: This study represents a first step in a process to form coherent workforce recommendations for the field of otolaryngology.

Use of ototopical antibiotics in treating 3 common ear diseases.

Prompted by rising rates of antibiotic resistance, lack of standardized treatment regimens, and new treatment alternatives, the American Academy of Otolaryngology-Head and Neck Surgery convened an expert consensus panel to consider recommendations for the responsible use of antibiotics in chronic suppurative otitis media, tympanostomy tube otorrhea, and otitis externa. The Panel concluded that in the absence of systemic infection or serious underlying disease, topical antibiotics alone constitute first-line treatment for most patients with these conditions, finding no evidence that systemic antibiotics alone or in combination with topical preparations improve treatment outcomes compared with topical antibiotics alone. Topical preparations should be selected on the basis of expected bacteriology and informed knowledge of the risk-benefit of each available preparation. The use of nonototoxic preparations in treating acute otitis externa (when the tympanic membrane is perforated or its status is unknown), chronic suppurative otitis media, and tympanostomy tube otorrhea should be considered.

Audiologic and otolaryngologic findings in progeria: case report.

Progeria is a rare syndrome, with an estimated incidence of 1 per 250,000 births. Although children with progeria have the appearance of premature aging or senility, the term is misleading because reported cases of progeria have not manifested most physical or biochemical aspects of old age. Many children with progeria appear normal at birth and then progressively, and rather rapidly, develop the characteristic features during early childhood. Although first described in the 1880s, only approximately 100 cases of progeria are reported in the international literature. The single case study of hearing in progeria, which appeared in 1965, is limited to pure-tone and speech audiometry findings. We report the results of otolaryngologic examination and pure-tone, speech, immittance, and auditory brainstem response (ABR) audiometry for a 5-year-old female with progeria. The patient had a mild-to-moderate, bilateral, conductive hearing loss. Immittance measurements were consistent with fixation of the ossicular chain and this was confirmed surgically. Mildly prolonged ABR wave I-V latencies suggest possible auditory central nervous system involvement.

Nasal avulsion injuries.

The nose is the most frequently traumatized portion of the human face. High-speed motor vehicle accidents and interpersonal violence commonly produce bony pyramid and septal damage and occasional minor soft-tissue damage. Major soft-tissue injuries are much less commonly encountered. Avulsion injuries of this type may involve skin only or the bony and cartilaginous framework as well. The severity of these injuries can range from total avulsion to minor skin loss and anywhere within the spectrum between. My experience is reviewed, management guidelines and options are detailed, and selected cases are presented.

Combined otolaryngological and neurosurgical approach in treating sinus fractures.

Frontal sinus injury in patients with closed head trauma is significant. Fractures of the anterior and posterior table as well as injury to the nasofrontal duct system requiring exploration, and often times obliteration of the frontal sinus, are not uncommon. Some patients present with frontal sinus damage along with intracranial pathology that requires craniotomy for treatment of the intracranial problem. In these patients, the neurosurgeon typically performs a bifrontal scalp flap to expose the cranium. A bone flap that transects the superior margin of the frontal sinus is then elevated and removed. This allows direct visualization of the anterior and posterior sinus walls and both nasofrontal ducts, subsequently facilitating reduction of fractures, debridement, and obliteration or ablation, if necessary, without creating another bone flap. The surgeon gets an overall picture of the sinus without the added trauma associated with the creation of an osteoplastic flap.

Fluorescein elimination as a measure of island flap perfusion.

The fluorescein test has been used as a means of assessing flap viability for almost 40 years. This study was performed in an attempt to determine if recording of the elimination of dye--combined with dye uptake measurement--could provide reliable and consistent monitoring of island flap perfusion.

Frontal sinus obliteration using liposuction.

Frontal sinus obliteration is performed for a variety of reasons, including chronic sinus disease, traumatic injuries, mucoceles, and osteomas of the sinus. Once the decision is made to obliterate the sinus, it is paramount that all mucosal remnants be removed and that the material used to fill the irregular expanses of the frontal sinus help prevent recurrence of the disease process. The materials most commonly used for this purpose are fat, muscle, and pericranium. Fat obtained from the abdomen, gluteal area, or lateral thigh is probably the most frequently used substance. The procurement of fat in the traditional way adds significant time to the operation and is associated with significant morbidity at the donor site. Fat obtained in this manner is often bulky and does not truly conform to the sinus contour. In an attempt to minimize operating time and donor-site morbidity--as well as obtain a more malleable graft--we used liposuction to obtain our fat grafts for sinus obliteration. Using this method, we were able to obtain an adequate amount of tissue from either the abdomen or lateral thigh in all patients. We have used this technique in eleven patients, with follow-ups ranging from 3 to 18 months. We have had no donor-site morbidity and (to date) there has been no recurrence of sinus disease in these patients. While the follow-up period is not adequate for final evaluation in these patients, we believe this is a valuable adjunct to frontal sinus surgery.

Fourier analysis of infantile stridor: preliminary data.

Preliminary data from 3 patients suggest that computerized (Fourier) analysis of infantile stridor can be instructive. Several recordings are quickly collected with a microphone and digital oscilloscope at the patient's bedside. The data are later sent to a computer for spectral analysis. Averaging of several spectra from each patient depicts only those sounds that are consistent from sample to sample. Subtraction of background noise from the averaged stridor removes all but those sounds that are produced by the patient. The results show that the spectra are relatively consistent from sample to sample within the same patient, and that different patients with different pathologies have distinct patterns in their spectra. It thus appears that further acoustical studies of infantile stridor will be productive. We are optimistic that data from a larger series of patients will indicate those spectral patterns which are characteristic of a specific laryngotracheal pathology, and perhaps facilitate rapid diagnosis without invasive procedures. An additional potential of this analysis is that pre- and post-operative spectra can be subtracted to show those sounds that improved or worsened. Such serial comparisons during the management of airway problems could be useful in evaluating treatment.

Bronchomalacia in the neonate.

Congenital bronchomalacia is a disease typically associated with infants between 1 and 12 months of age; cases in children less than 1 month of age are rare. Bronchomalacia is commonly associated with tracheomalacia and rarely warrants operative intervention. Three cases of bronchomalacia are presented, including two unusual cases of bronchomalacia associated with neuromuscular disorder, one complicated by hypotonia. These patients required ventilatory support in the form of continuous positive airway pressure to prevent lobar collapse. Following tracheobronchial and neuromuscular maturation, these infants were able to weaned from respiratory assistance without further sequelae. Bronchomalacia is discussed, the literature reviewed, and the standard therapies presented. The results indicate a possible relationship between neuromuscular disorders and respiratory collapse.

Airway-obstructing epiglottic cyst.

Laryngeal cysts, particularly epiglottic cysts, are generally benign lesions which cause mild dysphagia or hoarseness. We report a case of an epiglottic cyst that caused almost complete airway obstruction. A 43-year-old man presented with progressive dysphagia, hoarseness, and airway obstruction secondary to a large cystic mass involving the entire epiglottis and filling the hypopharynx. He required emergency tracheotomy to secure the airway, and the cyst was incised and drained. Following a subsequent recurrence, laser excision of the cyst was performed and the problem resolved. The cystic mass was found to fill the valleculae, and involved the lingual and laryngeal surfaces of the epiglottis and the left false vocal cord. A review of laryngeal cysts is presented with emphasis on anatomic and embryologic considerations. The potential lethal nature of these lesions is emphasized.

Postoperative macroglossia causing airway obstruction.

Macroglossia can cause a wide spectrum of problems in the pediatric population. Airway obstruction is the most severe of the sequelae and must be handled promptly. Typically, congenital macroglossia does not present with sudden airway obstruction, however, traumatic or postoperative macroglossia can. Iatrogenic postoperative macroglossia is presented and mechanisms of injury discussed. Preventative and therapeutic measures are outlined.

Clinical assessment of flap perfusion by fiberoptic fluorometry.

Perfusion fluorometry, a method which quantifies tissue fluorescence after intravenous fluorescein injection, has been highly predictive of skin flap survival in animals. It is advantageous because it is objective, simple, noninvasive, repeatable, and can be used to monitor flap perfusion constantly by following both uptake and elimination of dye. We applied this method clinically to a variety of flaps used in head and neck surgery. All flaps with good fluorometric values survived totally. Based on experience with 37 flaps, fluorometric indices have been established that accurately predict necrosis. Serial dye injections have been used to document transient flap ischemia in the early postoperative period. Representative cases illustrating the advantages of fluorometry in flap assessment are presented.

A prospective study of endotracheal tube cytology in head and neck cancer patients.

A prospective study was undertaken to determine the incidence of endotracheal tube contamination by malignant cells in patients with head and neck cancer undergoing bronchoscopy. In 67 consecutive patients, bronchoscopy was performed with a flexible instrument, through or beside the endotracheal tube. Following the procedure, the inside and outside of the tube were washed and the specimens examined cytologically. Fifteen positive (class III to V) cytologic specimens were obtained, all from the outside of the tube. All washings from inside the tube were negative (class I and II). Twelve of the positive cytologic specimens were found in patients with hypopharyngeal and laryngeal carcinoma, two with carcinoma in the tongue base, and the other primary site was unknown. Two patients with normal chest roentgenograms had positive bronchial and endotracheal tube washings. In both the bronchoscope was passed beside the endotracheal tube. This study provides additional evidence that contamination of the bronchoscope can occur when it is passed directly over a carcinoma of the head and neck.

Monitoring free flap perfusion by serial fluorometry.

An efficient method to evaluate the patency of microvascular anastomoses and to predict flap viability is crucial when free flaps are used in reconstructive surgery. We report a study of 60 neurovascular island flaps in rats where the nutrient artery and/or vein were transected and anastomosed. Fluorescein dye was injected immediately after anastomosis, and the uptake and elimination of dye were quantified at 5-minute intervals with the fiberoptic perfusion fluorometer. Analysis of dye delivery clearly identified six hypofluorescent flaps presumed to be ischemic. In five of these flaps, revision was attempted. Three evidenced improved fluorescein uptake and elimination on reinjection of dye. These flaps survived, whereas the other two necrosed. Of the 54 flaps deemed patent after the first injection, two evidenced poor fluorescence on reinjection 3 hours later. These flaps necrosed and evidenced venous thrombosis (which probably occurred during the 3 hours between the first and second injections). Fiberoptic fluorometry can be employed to assess a free flap immediately after vascular anastomosis and throughout the critical hours postoperatively. Assessment of uptake and elimination after single or serial injections reflects flap perfusion and predicts viability with a high degree of accuracy.

Acinic cell carcinoma of the oral cavity.

A rare case of acinic cell carcinoma of minor salivary gland origin within the oral cavity is reported in a 62-year-old woman. These tumors most commonly arise in the parotid gland and follow an insidious course requiring long-term follow-up. The gross and histologic features of the patient's tumor include pseudoencapsulation, mixed solid and acinar architecture, microcyst formation, and the presence of conspicuous diastase-fast and PAS-positive cytoplasmic granules, characteristic of lesions that have been called acinic cell carcinoma by a variety of authors. Surgical excision is the treatment of choice. However, following an incisional biopsy, the patient refused further surgical treatment and has remained clinically disease-free three years postoperatively.

Complications of intubation.

Endotracheal intubation with current inert low-pressure, high-volume cuffed tubes is a safe procedure associated with few complications in the vast majority of patients. However, complications related to mechanical difficulties and mucosal injury can occur even under ideal circumstances. Immediate complications are primarily associated with problems during intubation and extubation while early and late complications represent the short- and long-term effects of epithelial trauma.