The rhinology laboratory.

OBJECTIVES: This study seeks to develop a rhinology lab model and to assess its effectiveness for physicians-in-training. STUDY DESIGN: We established a rhinology lab at our institution with simple and affordable modifications to our temporal bone lab. Residents attended a seven-part lecture series and received a list of endoscopic and open procedures to perform on computed tomography (CT)-scanned, vessel-injected cadaver heads. METHODS: After 2 years we asked participating residents to rate their lab experience on a 1-to-10 (disagree-agree) scale. RESULTS: Cumulative scores indicated that residents enthusiastically perceived this additional training as worthwhile (micro=10), while increasing their efficiency (micro=9.5), safety (micro=9.875), and anatomic knowledge (micro=9.875). The lab has opened opportunities for rhinology research, as evidence by one resident publication and another project in progress. Survey feedback has helped develop guidelines for instructor participation in the lab as well as for assigned reading and independent study. CONCLUSIONS: Based on our preliminary experience, we recommend the rhinology lab to all residency programs as an important yet cost-effective means of maintaining education in step with rapidly changing technologies.

Timing of percutaneous endoscopic gastrostomy tube placement in head and neck cancer patients.

Percutaneous endoscopic gastrostomy (PEG) is an effective method for providing alimentation in patients with upper aerodigestive tract carcinoma. Multiple complications of this procedure have been reported, ranging from leakage around the tube to tumor seeding of the abdominal cavity. This study was undertaken to determine whether the timing of PEG tube placement with respect to primary tumor extirpation led to a difference in the number and severity of observed complications. The medical records of 43 patients with head and neck carcinoma who had PEG tubes placed from 1995 to 1996 were retrospectively reviewed. Comparisons of timing of PEG tube placement, complication, location, and stage of the primary tumor were performed. In addition, the use of adjuvant therapy with respect to the time of PEG tube placement and complications was evaluated. Of these, 23% were done before and 30% during surgery at the time of primary tumor resection (9 of 13 were after primary removal). One patient had an intraabdominal abscess. Minor complications occurred in 15 of 43 patients (35%) and included granulation tissue at the PEG site, leakage, and tube displacement. Eight of the 9 patients who underwent intraoperative PEG after tumor resection had no complications. Patients who underwent PEG during or after surgery had significantly fewer complications than those who underwent preoperative PEG or had unresectable tumors (P = 0.038). The largest number of complications occurred in patients who underwent preoperative PEG (57%) followed by patients whose tumors were unresectable (31%). There was no statistical difference with regard to tumor location or postoperative x-ray therapy in PEG complications. This study demonstrates that PEG tube placement after tumor resection has the lowest incidence of postoperative complications. Performing PEGs intraoperatively after tumor resection can prevent the need for additional anesthesia to provide alimentation in patients with upper aerodigestive tract carcinoma.

Flow cytometry and squamous cell carcinoma of the maxillary sinus: A possible prognostic indicator for multimodality intervention.

Malignant tumors of the paranasal sinuses constitute less than 1% of all malignancies. Unfortunately, few prognostic factors have been identified regarding the efficacy of interventional therapy. Patients with carcinoma of the maxillary sinus frequently present with an advanced stage of disease and multimodality therapy is often proposed. Although some tumors appear to be more sensitive to preoperative chemotherapy and radiation therapy, a method of predicting and evaluating tumor behavior has not been recognized. Introduced as a means of identifying cell populations with abnormalities in total DNA content, flow-cytometric DNA analysis provides a quick and reliable means of tumor characterization for many malignancies. Although nuclear DNA content has been implicated as a prognostic factor in an increasing number of tumor types, current data on the role of DNA content in head and neck carcinoma is conflicting and incomplete. To evaluate the role of flow-cytometric DNA analysis in predicting therapeutic alternatives, 22 patients with squamous cell carcinoma of the maxillary sinus were reviewed. Patient outcome and histopathologic grade were retrospectively compared with flow-cytometric evaluations of paraffin-embedded formalin-fixed tumor specimens. Four of sixteen tumors (25%) were found to be aneuploid and were also associated with an increased survival rate (p < 0.01). This initial data emphasizes the possible usefulness of DNA measurement for characterization of squamous cell carcinoma of the maxillary sinus and stresses the need for further evaluation.

Management of chronic sinusitis in the adult cystic fibrosis patient.

Cystic fibrosis (CF) is an autosomal recessive disorder affecting exocrine gland function. Although CF was formerly a deadly disease of infants and children, recent improvements in antibiotics, nutritional therapy, and supportive care have extended the median survival to adulthood. Patients with CF often present with sinusitis and nasal polyposis in addition to recurrent pulmonary infections. Although the effectiveness of endoscopic sinus surgery in children with CF has been documented, the treatment guidelines and efficacy in the adult CF patient are unknown. We present a series of 16 adult patients with CF and chronic sinusitis. The majority of patients presented with nasal polyposis and concomitant pulmonary complications. Endoscopic findings are reviewed, with an emphasis on improving pulmonary function following endoscopic sinus surgery. Preliminary findings suggest that endoscopic sinus surgery improves symptoms of sinusitis and exercise tolerance and may delay the progressive respiratory failure that often affects the adult CF patient.

Obstructive sleep apnea in women.

Obstructive sleep apnea is a complex disorder characterized by periodic cessation of breathing during sleep. Classically, men exclusively have been evaluated for mode of presentation or associated morbidity that accompanies obstructive sleep apnea; minimal investigation has been undertaken with regard to the female population. Recent literature indicates that obstructive sleep apnea is much more prevalent in women than previously recognized and is increasingly underdiagnosed. We present a review of a large cohort of women with obstructive sleep apnea, with specific attention to presenting symptoms, coexisting medical problems, and surgical efficacy. The study group comprised 58 women with the diagnosis of obstructive sleep apnea; we analyzed the group for presentation, polysomnographic findings, and therapeutic management. We reviewed cases for medical management or surgical intervention. In the surgery group, each patient was evaluated with polysomnography before and after surgery. Significant coexisting medical problems were identified in both groups. We address the success of surgical intervention.

The evaluation of ciliary function: electron versus light microscopy.

Diagnosing Primary Ciliary Dyskinesia can often be difficult. Physical findings suggest the disease, but definitive diagnosis should be made with a ciliary biopsy. Twenty biopsies were obtained from 16 patients and all underwent both light and electron microscopic examination. In 8/20 (40%) there was a discrepancy between the different imaging techniques. Therefore, light microscopy should be used to assess adequacy of biopsy and motion of the cilia along with electron microscopy to examine ultrastructure.

Acute laryngeal trauma in the pediatric patient.

We reviewed the evaluation and management of pediatric laryngeal trauma, focusing on the unique characteristics of the immature airway as they affect functional results. The study was based on 91 cases of acute laryngeal trauma managed by the senior author (E.S.P.) from 1973 to 1996. Patients over 15 years old were considered physically mature and excluded. The remaining 10 cases (mean age 9.7) were reviewed in detail and compared to the adult series. Intervention ranged from level I (observation) to level III (open repair with stent placement). Outcome measure was by functional evaluation of swallowing, voice, and airway. Injuries were rated from group 1 (minor trauma) to group 4 (massive laryngeal injury with multiple fractures). Sixty percent fell into group 1 or 2. Conservative management in these patients produced excellent results as measured by decannulation (100%), functional speech (100%), and normal deglutition (100%). Conversely, 2 of the 4 patients with group 3 or 4 injuries had persistent airway and/or voice complications despite more aggressive intervention. As the pediatric larynx is protected by pliable cartilage and a more craniad location in the neck, traumatic laryngeal injuries in children tend to be less severe than those in the adult population. Group 1 or 2 injuries respond well to conservative treatment. However, children with extensive laryngeal injuries may have more long-term sequelae.

Sickle cell disease and tonsillectomy. Preoperative management and postoperative complications.

BACKGROUND: Patients with sickle cell disease are recognized as having a relatively higher risk for postoperative complications, including fever, atelectasis, pneumonia, or sickle cell vas-occlusion. OBJECTIVE: To present a protocol for preoperative management of patients with sickle cell disease undergoing tonsillectomy, including the use of transfusions and intravenous hydration. DESIGN: Retrospective chart review. SETTING: Academic, tertiary care referral medical center. PATIENTS: Seventy-five patients with sickle cell disease who underwent tonsillectomy with or without adenoidectomy were included for review. Preoperative management was documented, and risk factors were assessed. Intraoperative management was reviewed, and postoperative complications were identified and compared with preoperative data and management. RESULTS: Preoperative management consisted of transfusions to a hemoglobin S ratio (hemoglobin S-total hemoglobin) less than 40% or a hemoglobin level greater than 100 g/L. Aggressive intravenous hydration of 1.5 times the maintenance fluid was given 24 hours before surgery. Increased complications were associated with a preoperative hemoglobin S ratio greater than 40% (P < .05) and an age younger than 4 years (P < .05). Operative time, technique, and blood loss were not statistically significant risk factors. The average length of hospitalization was 4.8 days. CONCLUSIONS: Children with sickle cell disease presenting for elective tonsillectomy should be given a transfusion to a hemoglobin S ratio less than 40% in an attempt to reduce postoperative complications. Additional factors, such as age and presence of obstructive sleep apnea, only increase the potential risks.

Detection of cervical metastasis. A meta-analysis comparing computed tomography with physical examination.

BACKGROUND: Despite extensive coverage in recent literature, controversy continues with regard to the relative sensitivities of computed tomography (CT) and physical examination (PE). OBJECTIVE: To identify a statistically significant consensus. DATA SOURCES: Initially, data were reviewed on 47 consecutive patients with head and neck cancer on whom a total of 53 neck dissections were performed. These data were combined with findings from a 15-year MEDLINE review of the English-language literature, including references. STUDY SELECTION: All publications that contained a direct comparison of CT with PE, with appropriate data availability, were included. DATA EXTRACTION: Multiple-observer independent extraction was used. A total of 647 neck dissections were included in the meta-analysis. The definition of metastasis varied minimally among studies as follows: (1) nodal size, greater than 10 to 15 mm; (2) multiplicity of 8- to 10-mm nodes; or (3) evidence of necrosis. Necks were compared for positivity or negativity rather than for the actual nodal staging. In all cases, a final determination was made by results of histopathologic examination of surgical specimens. DATA SYNTHESES: The results in this review favored CT over PE but were not statistically significant by use of the Fisher exact test. A combination of the present study's data with those of the literature review yielded the following meta-analysis results: sensitivity, 83% (CT) vs 74% (PE) (P = .002); specificity, 83% (CT) vs 81% (PE) (P = .7); and accuracy, 83% (CT) vs 77% (PE) (P = .006). Overall, PE identified 75% of pathologic cervical adenopathy; this detection rate increased to 91% with the addition of CT. The results of sensitivity analysis confirmed homogeneity across study designs. CONCLUSIONS: Computed tomography is a more sensitive indicator of cervical metastasis than PE. More importantly, these diagnostic modalities were additive, with CT significantly enhancing the detection rates of PE alone. All patients who are at risk for cervical metastasis should have CT or equivalent radiographic imaging performed prior to therapeutic intervention. Future studies correlating CT detection rates to the primary site and staging are needed before more specific conclusions can be drawn.

Management of subglottic foreign bodies.

Foreign body aspiration is not an infrequent encounter in the practice of otolaryngology and requires immediate attention. The vast majority of foreign body aspirations occur in children less than 3 years of age, and the actual event of aspiration is frequently not witnessed. Although inhaled foreign bodies most often lodge in the bronchi, laryngotracheal foreign bodies also occur and are potentially more dangerous. Specifically, subglottic foreign bodies present unique clinical challenges. The diagnosis of subglottic foreign bodies is often difficult and they are commonly confused with other causes of upper airway obstruction. We present our experience with the diagnosis and management of seven patients with subglottic foreign bodies, who presented with an abnormal airway and whose problems were initially misdiagnosed. The radiographic and clinical features are discussed with a review of our surgical management.

Branchial cleft cyst posterior to the carotid vessels.

Branchial cleft anomalies may appear as a sinus fistula or cyst. An understanding of the developmental embryology and anatomy can predict branchial cleft anomalies by the relationship of the corresponding branchial arches that form at the time of development. The second branchial cleft anomalies are the most common and may be found along a tract from the anterior border of the sternocleidomastoid muscle anterior to the carotid vessels and IX and XII. A cyst may form anywhere along this tract but most commonly is just lateral to the internal jugular vein anterior to the carotid vessels. We describe a patient with a second branchial cleft cyst that was posterior to the carotid vessels documented by computed tomography. The cyst was found intraoperatively to be clearly posterior to the common carotid artery. This case demonstrates the need for an understanding of developmental embryology, anatomical landmarks and variations.

Temporomandibular joint dehiscence after mastoid surgery: a case report.

This article reminds the otolaryngologist of a rare but real complication of mastoid surgery. Additionally, we have offered a straightforward method to repair the resulting defect.

Pilomatrical carcinosarcoma of the cheek with subsequent pulmonary metastases. A case report.

We report a case of malignant pilomatrixoma with a pronounced biphenotypic morphology. The lesion, which was excised from the cheek of a 36-year-old man, was composed of a large pilomatrixoma lying within a spindled, sarcomatoid stroma. Fourteen months later, the tumor metastasized to the right upper lobe of the lung. We describe the tumor's pathology, histology, and immunochemistry and discuss the differential diagnosis. We also speculate on its histogenesis.

The management of blunt fractures of the thyroid cartilage.

Our experience with 20 cases of blunt fractures of the thyroid cartilage encountered over the last 15 years were reviewed. These injuries were classified into one of three categories: nondisplaced with minimal associated laryngeal injuries (four cases), moderately displaced with intralaryngeal defects (12 cases), and severe fractures with intralaryngeal avulsion injuries (four cases). Treatment consisted of either surgical reduction of fracture (and associated intralaryngeal injuries) or conservative, nonsurgical management. Results were graded subjectively as good, fair, or poor for airway and voice.

Acute laryngeal trauma: a review of 77 patients.

Acute laryngeal trauma is a rare injury. In the past 18 years, 77 patients with acute laryngeal trauma have been evaluated at our institution. Each patient's care was overseen by the senior author (E.S.P.). The 61 patients who were seen within 48 hours of their accident are compared with those treated after 48 hours. All patients are classified by both injury (groups 1 through 5) and treatment (types I through III). Results are reported for voice, airway, and swallowing. Our methods of evaluation and treatment are outlined, and controversial aspects of patient management are addressed. We conclude that conservative treatment of group 1 and 2 injuries is 100% effective, expeditious repair of laryngeal injuries greatly reduces poor outcome, and the type of injury can be used to roughly predict patient outcome. Further, with use of current methods of diagnosis and management, almost all patients will be decannulated (98%) with functional speech (100%) and normal deglutition (100%).

Evaluation of immunocompetency in juvenile laryngeal papillomatosis.

The morbidity from juvenile laryngeal papillomatosis (JLP), a disease process characterized by recurrent growth of multiple epithelial papillomas, has greatly improved with the advent of immunomodulating agents used in combination with the surgical approach of CO2 laser vaporization. In prospectively evaluating the immunologic status of four pediatric patients with this disorder, one patient repeatedly demonstrated IgG2 subclass deficiency. One of two children found to have subnormal functional natural killer (NK) activity received thrice weekly intramuscular administration of 3,000,000 units/m2 body surface area of human leukocyte (alpha) interferon (IFN). Natural killer function normalized, but therapy was discontinued after 4 months; however, no clinical benefits from IFN administration were observed. Further in vitro evaluation of NK function and lymphokine production is needed, in order eventually to offer more effective immunomodulating agents to such patients. A brief review of the literature concerning JLP is also presented.