Geographic variation in allergic fungal rhinosinusitis.

Allergic fungal rhinosinusitis (AFRS) has a worldwide distribution. This survey of 20 otolaryngologic practices throughout the United States confirmed a variation in the frequency of AFRS relative to endoscopic sinus procedures performed for all other diagnoses. The highest incidence occurred in Memphis, Tennessee at 23%, with three other southern practices reporting a frequency of at least 10%. In the northern locations the frequency ranged from 0 to 4%. No correlation with mould counts was demonstrated, possibly because of incomplete mould data relative to most of the surgical locations.

Outcome-oriented managed care comparing efficacies of cefaclor and amoxicillin in acute and recurrent acute otitis media.

A study utilizing outcome-oriented cure is employed to show the effectiveness of a given medical treatment. A specific patient population is studied in order to determine the most effective treatment for a common clinical disorder. A total of 201 children were retrospectively studied to evaluate the efficacy and side effects of amoxicillin and cefaclor in the treatment of acute otitis media and recurrent acute otitis media. There were 456 episodes of acute otitis media; 245 episodes were treated with amoxicillin with an efficacy of 91%, while 211 episodes were treated with cefaclor with an efficacy of 97%. The dosage of 40 mg/kg/day, divided in three equal doses, was employed for both antibiotics in the treatment of acute otitis media, while half of this amount was given once daily for the chemoprophylaxis of recurrent acute otitis media. In the 87 courses of chemoprophylaxis with cefaclor for recurrent otitis media, the efficacy was found to be 53%; while amoxicillin was found to be effective in 30% of the 33 patients studied. There were fewer side effects noted in the cefaclor group than in the amoxicillin group (4% vs. 12%). Both drugs caused diarrhea, while cefaclor also caused a mild maculopapular rash in two patients (1.67%). While amoxicillin remains the drug of choice for acute otitis media (AOM), this study suggests that cefaclor may be a better selection in the chemoprophylaxis of recurrent acute otitis media.

Effects of guaifenesin on nasal mucociliary clearance and ciliary beat frequency in healthy volunteers.

STUDY OBJECTIVE: Mucociliary clearance is an important host defense function of the upper respiratory tract that requires the coordinated beating of cilia and results in the transport of mucus to the oropharynx. Guaifenesin is a commonly prescribed drug that is reported to improve the clearance of respiratory secretions. We hypothesized that guaifenesin increases nasal mucociliary clearance related to increases in ciliary beat frequency (CBF) and that a direct relationship exists between nasal CBF and nasal mucociliary clearance. DESIGN: Double-blind placebo-controlled crossover study. PARTICIPANTS: Ten healthy volunteers with a previous history of sinus disease. INTERVENTIONS: Subjects received guaifenesin or placebo on days 1 to 7 or days 14 to 21. MEASUREMENTS AND RESULTS: In vivo saccharine transit time (STT) was measured by noting the time in minutes required for the subject to taste a saccharin particle placed on the inferior turbinate of the naris. The CBF was determined by video microscopy on ten separate groups of beating ciliated nasal mucosal cells obtained by brushing immediately after each STT determination. We found that there was no significant change between the guaifenesin-or placebo-treated groups from baseline values of STT (p = 0.94) or CBF (p = 0.46). Regression analysis demonstrated no relationship between STT and CBF for repeated measures within subjects (mean r2 = 0.18; mean p = 0.66) and between STT and CBF when all paired measurements were combined across subjects (r2 = 0.47; p = 0.46). CONCLUSION: We conclude that guaifenesin exerts no measurable effect on in vivo nasal mucociliary clearance or ex vivo nasal ciliary motility in healthy volunteers with previous sinus disease. In addition, there appears to be no relationship between nasal STT measured in vivo and CBF measured ex vivo. The lack of correlation is most likely due to variations in CBF related to sampling artifacts introduced by the nasal brushing process.

Microvascular reconstruction of the head and neck cancer patient.

Surgical resection of cancer of the head and neck often results in significant functional and cosmetic deformity. Reconstruction of these deficits have often been inadequate to reintegrate these patients into daily life. Recent advances in microsurgical techniques, however, have ushered in a new era for reconstruction following head and neck cancer ablative surgery. Microvascular free tissue transfers have made possible the reconstruction of major head and neck defects that previously were not possible as well as markedly improving function and cosmesis. Successful reconstruction requires close cooperation between the head and neck ablative surgeon as well as the reconstructive surgeon. We describe four different microvascular flap techniques which we have used for head and neck cancer reconstruction to illustrate some of the many applications of these microvascular flaps.

Cerebrospinal fluid rhinorrhea: a review of the literature.

CSF rhinorrhea may be spontaneous or traumatic, the majority of cases being traumatic and presenting within the first three months. Spontaneous leaks imply an underlying abnormality which must be identified prior to treatment. Diagnosis and identification of the site of the leak is often inaccurate, even with meticulous care given to placing and removing the nasal pledgets. Once the leak is identified, medical or surgical treatment may be attempted. Recurrent leaks are common and serial operative procedures have been reported to stop even small leaks.

Complications of interstitial radioactive iodine implants for recurrent pituitary adenomas.

Three cases of recurrent pituitary adenoma elected to be treated with I125 implants are presented. The I125 implants caused significant delayed changes in the tissues surrounding the sella turcica which lead to the development of refractory cerebrospinal fluid (CSF) rhinorrhea. All three cases developed meningitis and two had pneumocephalus. This complication lead to the death of two patients and required intensive therapy in the third to achieve recovery.

Sinusitis--inspecting the causes and treatment.

In summary, sinusitis is a common disease caused by viruses, bacteria and the accumulation of excessive secretions and inflammatory mediators that impair the function of the mucociliary transport. Combination treatment is usually necessary to treat the cause and relieve the symptoms of sinusitis. Therapy aims at eliminating causative bacteria with antibiotics, decongesting edematous membranes, and thinning mucus with use of a mucolytic-expectorant. Improving the rheology of mucus by thinning abnormally thickened secretions may improve mucociliary transport and enhance penetration of antibiotics. Acute sinusitis usually responds to treatment within 2 weeks. However, if treatment is unsuccessful or a severe complication occurs, intravenous antibiotics may be necessary along with antral puncture and lavage. In resistant cases, an appropriate surgical procedure may enhance the drainage.

Surgical treatment of obstructive sleep apnea syndrome (OSAS)

Obstructive sleep apnea syndrome patients usually present with multiple areas of anatomic disproportions. The site or sites of obstruction must be accurately diagnosed preoperatively by a systematic means of examining the patient. This includes nasopharyngoscopy with Muller maneuver and sometimes cephalometrics. The surgical treatment is individualized to the site or sites of obstruction and can include tracheostomy, septoplasty, UPPP, geniohyoid advancement and suspension of the hyoid. For extreme cases advancement of the maxilla, mandible and hyoid bone are sometimes necessary.

Bell's palsy: a facial nerve paralysis diagnosis of exclusion.

Bell's Palsy is not synonymous with facial nerve paralysis. While it is a common cause of facial nerve paralysis, it is a diagnosis of exclusion and other causes of facial nerve paralysis should be ruled out by appropriate evaluation and follow-up. A case report is presented of a patient with a facial nerve paralysis, which was initially diagnosed as Bell's Palsy, but which was found to be a poorly differentiated parotid malignancy causing facial nerve paralysis. A review and discussion of Bells Palsy, evaluation and treatment is presented.

Heterotopic gastrointestinal cyst of the tongue.

A 6.5-month-old white male presented with a cyst involving the left posterior half of his tongue which partially compromised his airway. A computed tomography scan revealed that the mass also involved the left floor of the mouth. Surgical excision of the mass was performed, and the mass was demonstrated to be a gastrointestinal heterotopic cyst. The clinical and pathological features of this rare lesion are presented and the pathogenesis is discussed.

The management of the cleft lip and palate patient.

We believe that early closure of the hard palate defect with a palatal appliance and surgical closure of the lip and soft palate according to the rule of tens are very important. Delaying the hard palate closure allows for maximal growth of the palatal shelves. We also feel that pressure equalizing tubes placed in the ears at the initial surgical procedure allows for more normal function of the middle ear, less middle ear infections, better hearing, and ultimately better speech. We feel that early closure of the soft palate may decrease velopharyngeal incompetence by normalizing the position of the pterygoid plates. It may also help to reduce serous otitis media by improving eustachian tube function.

Computed tomography and magnetic resonance imaging of cervical metastasis.

Thirteen patients with head and neck cancer underwent staging by clinical examination, computed tomography (CT), and magnetic resonance imaging (MRI) in a standardized blinded fashion. All patients subsequently underwent radical neck dissection with subsequent pathologic staging. CT and MRI each predicted 93% of staging results correctly, with clinical examination correct 67% of the time. Staging of primary tumors had an accuracy of 90% by clinical examination, 40% by CT, and 50% by MRI when compared to staging the pathologic specimen. Understaging was seen in 50% of CT scans and 30% of MRI scans. We believe either CT or MRI should be considered for routine staging of the neck in all head and neck malignancies.

High-activity iodine-125 endocurietherapy for head and neck tumors.

Inoperable solid tumor recurrence within a surgical bed or within a previously irradiated field usually responds poorly to re-treatment with conventional external beam irradiation (EXRT) and/or chemotherapy. We present a new, alternative method of re-treatment used in two patients with recurrent head and neck cancer involving the parotid (adenocarcinoma) and neck nodes (squamous cell carcinoma). These patients were successfully re-treated with high-activity 125iodine (I-125) permanent implantation.

High activity iodine 125 endocurietherapy for recurrent skull base tumors.

Experience with endocurietherapy of skull base tumors is reviewed. We present our cases of recurrent pituitary hemangiopericytoma, radiation-induced recurrent meningioma, recurrent clival chordoma, recurrent nasopharyngeal cancer involving the cavernous sinus, and recurrent parotid carcinoma of the skull base which were all successfully retreated with high-activity 125iodine (I-125) permanent implantation.

Glycerol-induced positional nystagmus in human beings.

Direction-changing nystagmus has been seen after the ingestion of ethanol in both animals and man. The direction of the nystagmus is dependent upon the position of the head and is thus called Positional Alcohol Nystagmus (PAN). This article provides information about positionally dependent, direction-changing nystagmus in human beings after the ingestion of glycerol (1.5 g/kg). Electronystagmographic recordings were made and serum glycerol levels were repeatedly determined over a period of 7 hours. The resulting data compliment earlier work done with ethanol. These data provide support for a buoyancy hypothesis to explain positional nystagmus after ingestion of water-soluble molecules with differing specific gravities.

Outcome of locally advanced stage III and IV head and neck cancer treated by surgery and postoperative external beam radiotherapy.

An uncontrolled retrospective analysis of 76 patients with locally advanced Stage III and Stage IV squamous cell carcinoma of the oral cavity, oropharynx, pyriform sinus, supraglottic larynx, glottic larynx, and hypopharynx, who were treated in a uniform manner by surgical resection and 6,600 rad postoperative external beam radiotherapy, revealed relatively high 2-year and 4-year adjusted survival rates of 76% and 68%, respectively. Complication rates were acceptable (8%). The advantages of this treatment approach for locally advanced head and neck cancers compared to treatment by surgery alone are discussed.

Upper airway obstruction and the pharyngeal lymphoid tissue.

Enlarged tonsils and adenoids can cause chronic upper airway obstruction that may result in a spectrum of clinical findings ranging from sleep apnea to cor pulmonale and right heart failure. The clinical findings associated with this entity are reversible if the condition is identified early and removal of the obstructing tissue is performed before life-threatening changes occur.