Feasibility and outcome of endoscopic staple-assisted esophagodiverticulostomy for Zenker's diverticulum.

OBJECTIVES/HYPOTHESIS: Endoscopic staple-assisted esophagodiverticulostomy (ESED) is a newly described method of surgically correcting Zenker's diverticulum. Initial reports on the ease and success of the surgery have been quite enthusiastic, making it seem the procedure of choice. We initiated the procedure in an algorithm of treatment of Zenker's diverticulum, to further explore the feasibility and outcome of this new technique. STUDY DESIGN: This is a case series of 23 patients with Zenker's diverticulum who have undergone surgical repair. For each patient, an attempt at ESED was made. If unsuccessful, an open approach was then taken. RESULTS: Seven of 23 patients (30%) were unable to be treated with ESED because of inability to expose the diverticulum or unfavorable anatomy of the diverticulum itself. Of the remaining 16 patients, ESED was successful in resolving the symptoms of diverticulum in 14 (87%). Two patients (13%) were somewhat improved but had persistent dysphagia. No significant complications occurred. All patients resumed oral diet within the first 24 hours after surgery. CONCLUSION: Esophagodiverticulostomy is an excellent method of surgically correcting Zenker's diverticulum in many patients, but anatomical considerations may prevent its use, making open approaches of continued importance in a surgeon's armamentarium.

Granulocyte transfusion in the management of fulminant invasive fungal rhinosinusitis.

Usually, fulminant, invasive fungal rhinosinusitis is observed in the immunocompromised patient and is associated with significant morbidty, and mortality. A high index of suspicion and early diagnosis is imperative for optimizing outcome. Mainstays of treatment include antifungal agents and radical resection of necrotic tissue. Reversal of the underlying medical condition, when possible, is a critical part of the management. In the neutropenic population, granulocyte transfusion may represent an adjunct to current therapy. We provide the first report of a case of invasive fungal rhinosinusitis in which this intervention was used.

Complications of frontal sinusitis and their management.

Because of the anatomic location and venous drainage pattern of the frontal sinus, complications commonly involve intracranial structures but can involve the orbit and adjacent bony and soft tissue structures also. Evaluation of patients by a thorough history and physical examination, culture of purulent discharge or infected bone, and axial and coronal CT scanning with contrast is important for diagnosis and treatment planning. Treatment of complications uniformly involves the use of intravenous antibiotics and appropriate drainage procedures to arrest the infection and allow for resolution of the inflammatory complication. Significant morbidity and mortality from complications can occur despite aggressive medical and surgical treatment.

Preoperative imaging to predict orbital invasion by tumor.

BACKGROUND: Our purpose was to examine the accuracy of preoperative imaging in assessing tumor invasion of the orbit and nasolacrimal system. METHODS: Nineteen preoperative CT and 17 preoperative MR images from patients at risk for orbital invasion were retrospectively reviewed. Invasion was corroborated by pathologic and intraoperative assessment. RESULTS: Tumor adjacent to the periorbita was the most sensitive predictor of orbital invasion (90%) for both CT and MRI. Extraocular muscle involvement on MRI (100%) and orbital fat obliteration (80% MRI, 86% CT) had the highest positive predictive values of the criteria evaluated. Extraocular muscle displacement and enhancement were less accurate (<65%) predictors. No one criterion was >79% accurate in predicting orbital invasion. Six or more positive criteria predicted invasion with 67% sensitivity and 80% specificity (accuracy, 72%). CT was more accurate than MRI in seven of nine criteria. Invasion of the nasolacrimal system was predicted accurately (89%). CONCLUSIONS: Although preoperative imaging can aid in surgical planning, it should not replace intraoperative assessment in ambiguous cases of orbital invasion.

Objective and subjective outcomes in surgery for chronic sinusitis.

Endoscopic and radiological findings in patients with chronic sinusitis do not always correlate with symptoms. Studies suggest that postoperative endoscopic examination of the sinonasal cavity provides prognostic information regarding the potential for future episodes of sinusitis and the need for revision surgery. It is recommended that findings on nasal endoscopy be included in future outcomes studies on sinusitis.

Nuchal fibroma: a clinicopathological review.

Nuchal fibroma, or collagenosis nuchae, is a benign soft tissue tumor that arises from the posterior cervical subcutaneous tissue, with a predilection for the interscapular and paraspinal regions. Because of its benign clinical course and its close histopathologic similarity to other benign head and neck lesions, this lesion may be misdiagnosed and underreported. The purpose of this paper is to review the histopathologic and radiologic findings unique to nuchal fibroma, and compare and contrast it to the other soft tissue neoplasms within the clinical differential diagnosis. These include several benign (elastofibroma, lipoma, fibrolipoma, nodular fasciitis) and rare malignant entities (fibrosarcoma, liposarcoma, fibromatosis).

Clinical care pathways: decreasing resource utilization in head and neck surgical patients.

In this era of decreasing reimbursement, health systems have been forced to become more efficient and decrease resource utilization to remain financially viable. One of the methods of internal cost control has been the use of clinical pathways. Given the complexity of treatment of head and neck cancer patients, clinical pathways can help to standardize decision making and introduce uniformity in resource utilization. The objective of this study is to compare resource utilization and outcomes before and after implementation of a clinical pathway for head and neck surgical patients. We observed significant decreases in hospital costs as well as shorter lengths of stay after pathway implementation. It is our belief that a uniform management tool is beneficial in this complex disease.

Chronic rhinitis: a manifestation of chronic lymphocytic leukemia.

Chronic rhinitis is a condition that occasionally reflects underlying systemic disease. In such cases, physical examination, nasal endoscopy, and computed tomography may be nonspecific. Diagnosis and treatment of the underlying illness may improve nasal symptoms, which may prove refractory to standard rhinitis therapy. A case of chronic rhinitis secondary to nasal involvement of chronic lymphocytic leukemia (CLL) is presented. Biopsy was important in clarifying the cause of the rhinitis. Treatment of the CLL with chlorambucil was successful in alleviating nasal symptoms, and systemic effectiveness was reflected by a decrease in the patient's white cell count. Chronic rhinitis as a manifestation of CLL can be successfully managed through systemic treatment of the underlying disease. Biopsy can be helpful in confirming the cause of rhinitis and should be considered in refractory cases of rhinitis.

Quantitative evaluation of the upper airway during nasopharyngoscopy with the Müller maneuver.

OBJECTIVE: To quantitatively examine changes in the upper airway caliber of normal subjects at graded negative inspiratory pressures generated during nasopharyngoscopy with a Müller maneuver. STUDY DESIGN: Eighteen normal subjects prospectively underwent nasopharyngoscopy with Müller maneuvers. Subjects performed graded and maximal effort Müller maneuvers while sitting upright, and maximal-effort Müller maneuvers in the supine position. Two regions of the upper airway--the retropalatal and retroglossal--were examined. METHODS: Images from the endoscopic examination were objectively analyzed by adjusting manually traced airway contours using full-width, half-maximum edge detection algorithm software. The adjusted tracings' area and dimensions through the airway centroid were measured. RESULTS: Müller maneuvers performed at -40 cm H2O resulted in a 64%+/-17% (P = .0001) reduction in upper airway area that consisted of a 51%+/-20% (P = .0001) reduction in the lateral dimension and a 21%+/-24% (P = .0026) reduction in antero-posterior dimension. Müller maneuvers in the retroglossal region did not significantly reduce airway area (P = .575), but demonstrated an altered airway conformation that consisted of lateral narrowing and an increase in antero-posterior dimension. Changes in body position did not result in significant differences in either airway caliber or airway dimension. CONCLUSIONS: Airway caliber during forced inspiration is mediated primarily through changes in the lateral pharyngeal walls. This study has also shown that antero-posterior and lateral airway structures are largely independent in their response to Müller maneuvers. Similarly, the retropalatal and retroglossal regions of the upper airway respond differently to forced negative intraluminal pressure.

Endoscopic management of sinonasal inverted papilloma.

Since 1992, 42 patients at the University of Pennsylvania have been treated for inverted papilloma (IP). Thirty-three patients were managed endoscopically with or without a Caldwell Luc approach (CLA) and retrospectively analyzed. The CLA, which involves a gingivobuccal incision for access to the maxillary sinus, is distinguished from a formal Caldwell Luc procedure. These 33 patients with histologically confirmed IP were without evidence of malignancy. They also did not have evidence of intracranial, orbital, or frontal sinus IP. Seventeen of 33 patients (17/33) were without prior treatment (primary). Sixteen of 33 (16/33) presented from an outside institution with recurrent IP (secondary). The recurrence rate using this method to treat primary IP was 6% (1/17), and for secondary IP was 25% (4/16). Scheduled postoperative endoscopic surveillance permitted early detection of recurrence and continued endoscopic control of IP. All 33 patients were endoscopically free of disease at the end of the study. These preliminary data are encouraging for the use of intranasal endoscopy with and without CLA as a means of managing and controlling IP in selected cases.

Identifying the patient with sleep apnea: upper airway assessment and physical examination.

Since the final common pathway for obstructive sleep apnea is obstruction of the upper airway during nocturnal respiration, examination and assessment of the anatomy of the upper airway plays a central role in patient evaluation. Since the upper airway begins at the nose and lips and ends at the larynx, a complete assessment of the upper airway evaluates this entire length of this anatomic region including the bony framework and soft tissue. Though office assessment of these structures does not necessarily mimic the appearance of behavior of these structures during physiologic sleep, the office examination can give important information as to the site of obstruction during sleep that can help direct therapy.

Upper airway assessment: radiographic and other imaging techniques.

Upper airway imaging is a powerful technique to study the mechanisms underlying the pathogenesis and biomechanics of sleep apnea and the mechanisms underlying the efficacy of therapeutic interventions in patients with sleep disordered breathing. The primary upper airway imaging modalities include nasopharyngoscopy, cephalometrics, CT scanning, and MR imaging. Imaging studies using these modalities have provided important insights into the static and dynamic structure and function of the upper airway and surrounding soft-tissue structures during wakefulness and sleep. Such imaging studies have highlighted the importance of the lateral pharyngeal walls in mediating upper airway caliber. These imaging modalities have also been used to study the effect of respiration, weight loss, mandibular repositioning devices, and upper airway surgery on the upper airway. Three-dimensional reconstruction of the airway and surrounding soft-tissue structures can be performed with MR imaging and CT scanning. Clinical indications for upper airway imaging are evolving such that imaging studies should be considered in patients with sleep apnea who are being treated with dental appliances or upper airway surgery.

Pleomorphic adenoma of the parotid.

Pleomorphic adenoma of the parotid is the most common tumor of salivary gland origin, accounting for 60 to 70 percent of all benign salivary gland tumors. This lesion usually presents as a slow-growing painless mass inferior to the pinna of the ear. The diagnosis is based on clinical presentation, magnetic resonance imaging or computed tomography, and fine-needle aspiration biopsy. The treatment is wide excision in which the entire capsule is removed but the facial nerve is spared. Proper diagnosis and treatment are necessary to prevent the complications of tumor recurrence and malignant transformation. Carcinoma expleomorphic adenoma arises in longstanding tumors and has a five-year recurrence rate of 75 percent.

Sudden sensorineural hearing loss after general anesthesia for nonotologic surgery.

Sudden sensorineural hearing loss (SNHL) is a well-recognized phenomenon that is attributed to a variety of etiologies. Sudden SNHL after cardiopulmonary bypass surgery has been well reported and is thought to be due to microemboli. However, a review of the English literature revealed only 15 cases of SNHL after general anesthesia for nonotologic surgery. Several etiologies for this loss have been suggested, but no proven pathogenesis is yet available. This report adds to the literature three additional cases of sudden SNHL after general anesthesia for nonotologic surgery. The literature is reviewed and proposed mechanisms of injury are discussed.

MR evaluation of frontal sinus osteoplastic flaps with autogenous fat grafts.

PURPOSE: To investigate the MR findings in patients who have had osteoplastic frontal sinus flaps placed for inflammatory sinonasal disease. METHODS: The MR images of 13 patients who had improvement of symptoms after osteoplastic frontal sinus flap placement with fat autograft were prospectively evaluated for the presence of high intensity on T2-weighted scans, contrast enhancement, and replacement of frontal sinus fat by lower-signal soft tissue. All studies were performed on a 1.5-T unit using a 5-in round surface coil placed over the nasion. Sagittal T1-weighted, axial and coronal fast spin-echo T2-weighted, and precontrast and postcontrast axial and coronal T1-weighted images were obtained through the operative bed. The T2-weighted and postgadolinium sequences were done with a fat-suppression technique. RESULTS: Hyperintensity within the frontal sinuses on T2-weighted images and enhancement (peripherally and/or centrally where fat was replaced with soft tissue) were found to some degree in all patients. The degree of replacement of frontal sinus fat with soft tissue ranged from 4% to 85% (mean, 43%). Five patients with persistent symptoms had no distinguishing MR features when compared with asymptomatic patients. CONCLUSIONS: Although increased T2-weighted intensity, fat replacement, and enhancement are findings compatible with inflammation, these changes may be seen in patients who are asymptomatic after placement of osteoplastic frontal sinus flaps; they may represent the normal granulation process. MR findings after flap placement are nonspecific and have limited utility in distinguishing symptomatic patients with recurrent inflammatory disease from asymptomatic patients whose imaging findings are related to postoperative scar tissue.

Carotid artery invasion by head and neck masses: prediction with MR imaging.

PURPOSE: To determine the value of magnetic resonance (MR) imaging in predicting resectability of head and neck neoplasms around the carotid arteries. MATERIALS AND METHODS: Forty-nine patients (28 male patients and 21 female patients aged 17-79 years; mean, 57.3 years) with head and neck masses and clinical evidence of carotid wall invasion underwent MR imaging. T1-weighted, T2-weighted, and gadolinium-enhanced T1-weighted images were analyzed to determine circumferential involvement of 53 arteries by tumor. RESULTS: More than 270 degrees of circumferential involvement was considered suggestive of unresectability of the malignant neoplasm; 270 degrees or less was considered lack of invasion. The sensitivity of MR imaging for determination of unresectable disease was 100% (12 of 12 cases), specificity was 88% (36 of 41), and accuracy was 91% (48 of 53). Accuracy was 100% for squamous cell carcinoma (n = 29). CONCLUSION: Tumor that encompasses more than 270 degrees of the carotid artery probably cannot be removed from the artery. Tumor that involves 270 degrees or less of the artery can be removed.

Kaposi's sarcoma of the head and neck in acquired immunodeficiency syndrome.

Kaposi's sarcoma has emerged from obscurity to become a common treatment problem. Otolaryngologists can play a key role in diagnosis and treatment of the victims of AIDS given the frequency of involvement of the head and neck. Kaposi's sarcoma involvement of the head and neck is often the presenting symptom of AIDS, making accuracy in diagnosis critical if intervention is to begin early. KS is rarely the cause of death in these patients, although it can cause significant morbidity. Treatment is currently directed toward palliation for pain, bleeding, dysphagia, airway obstruction, severe disfigurement, and prophylaxis for rapidly progressive tumor. The choice of treatment is dependent on the symptoms, location, and extent of the lesion. Radiation, chemotherapy, and alpha interferon form the core of treatment, with the former two more commonly used. The general medical condition of the patient must be considered, particularly when systemic treatment is contemplated. Future directions of therapy may be directed toward optimizing combination therapy and modification of the underlying immunodeficiency to allow the body's own compromised immunity to cause regression of the tumor.