Tympanic Plexus Neurectomy for Intractable Otalgia.

OBJECTIVE: The goal of this study was to analyze whether tympanic plexus neurectomy is a successful surgical option in patients with intractable otalgia. STUDY DESIGN: A retrospective single institution study from the experience of two surgeons was conducted. METHODS: Records of adult patients with intractable unilateral otalgia of likely glossopharyngeal origin were reviewed, with institutional review board approval. Patients who responded to a tympanic plexus block were considered for tympanic neurectomy. Twelve patients (13 ears) underwent the procedure. Surgical outcomes and the presence of persistent otalgia were evaluated. RESULTS: Persistent otalgia was present for 16.7 months ± 8.6 standard-error-of-the-mean months prior to an intervention. Narcotic medication was used in 41.7% of patients prior to surgery. Patients received tympanic plexus blocks (median: 1, range 1-3) prior to tympanic neurectomy to evaluate candidacy for surgery. Intractable otalgia resolved in six of 13 ears (46.2%) after one surgery, with an average follow-up of 25.5 months. A significant reduction in pain occurred in two of 13 ears (15.4%) after an initial surgery. One patient received no benefit from the initial procedure. Revision surgery occurred in four ears, resulting in pain relief in three of four cases. All together, nine of 13 ears received complete resolution of pain, and an additional two of 13 ears received partial benefit using our algorithm for treatment of intractable otalgia of tympanic plexus origin. CONCLUSION: Intractable otalgia treated with tympanic neurectomy is a viable treatment option in cases of failed medical management. These findings provide important information that will aid clinicians in counseling chronic otalgia patients. LEVEL OF EVIDENCE: NA.

Endoscopic transcanal removal of symptomatic external auditory canal exostoses.

Exostoses are bony outgrowths of the external auditory canal (EAC) that can lead to cerumen entrapment, recurrent infections, and conductive hearing loss. When surgical removal is indicated, a drill or osteotome may be used via a post-auricular, endaural, or transcanal approach. Studies suggest that exostoses removed by transcanal osteotome result in decreased morbidity when compared to open, drilled approaches; however, inadvertent injury to the facial nerve or inner ear is a theoretical concern given the restrictive geometry of the EAC and challenges of visualizing the tip of the chisel through the microscope. The endoscope provides superior visualization of the external auditory canal and tympanic membrane compared to the microscope. We sought to demonstrate the efficacy and safety of endoscopic exostosis surgery with an osteotome. We find that the endoscope provides improved wide angled views without blind spots. There were no intraoperative complications. Endoscopic canaloplasty for exostoses may be readily applied.

HPV positive tonsillar cancer in two laser surgeons: case reports.

A 53 year-old male gynecologist presented with human papillomavirus (HPV) 16 positive tonsillar squamous cell carcinoma. He had no identifiable risk factors with the exception of long term occupational exposure to laser plumes, having performed laser ablations and loop electrosurgical excision procedures (LEEP) on greater than 3000 dysplastic cervical and vulvar lesions over 20 years of practice. The second patient is a 62 year old male gynecologist with a 30 year history of laser ablation and LEEP who subsequently developed HPV 16 positive base of tongue cancer. He also had very few other risk factors for oropharyngeal cancer or HPV infection. HPV is a probable causative agent for oropharyngeal squamous cell carcinoma and has been reported as being transmittable through laser plume. This paper suggests that HPV transmitted through laser plume can result in subsequent squamous cell carcinoma.

Choriocarcinoma arising in a serous carcinoma of ovary: an example of histopathology driving treatment.

BACKGROUND: Choriocarcinoma within an ovarian carcinoma is exceptionally rare. Nevertheless, recognition of this mixed tumour is important for administration of appropriate chemotherapy. CASE: A 65-year-old woman underwent resection of an ovarian mass after presenting with a pelvic mass and breast tenderness. On pathologic examination the mass showed a choriocarcinoma in association with a serous carcinoma. This pathologic diagnosis led to a specific chemotherapy regimen with cisplatin, etoposide, and bleomycin, suitable for both types of malignancy. CONCLUSION: Both gynaecologists and pathologists should be aware that the histopathologic classification of ovarian epithelial carcinoma and its variants, such as this one, may have an increasing role in the management of this disease.

Minimizing the urological and psychological morbidity of urinary tract fistulae from VBAC.

BACKGROUND: Because of the relative rarity of the condition, there is no consensus for the timing of surgical repair of fistulae following vaginal birth after Caesarean section (VBAC). CASES: Three cases of urinary tract fistulae following VBAC are presented. Two patients had an early repair (24-48 hours after delivery), and the third had a repair at four months after delivery. The surgical approach and intraoperative findings for the early and late repairs are described, and the psychological effects of early and late repair are compared. The early repairs were not technically difficult and were associated with less psychological morbidity. CONCLUSION: In the absence of contraindications, early repair of urinary tract fistulae diagnosed within the first few days after VBAC delivery is preferred. If early repair is attempted, perioperative conditions must be optimized; urogynaecologic or urologic expertise and assistance should be considered.

Comparison of FEV6 and FVC for detection of airway obstruction in a community hospital pulmonary function laboratory.

The National Lung Health Education Program recommends that primary care providers perform spirometry tests on cigarette smoking patients 45 years or older in order to detect airways obstruction and aid smoking cessation efforts [Ferguson GT, Enright Pl, Buist AS, et al. Office spirometry for lung health assessment in adults: a consensus statement from the national lung education program. Chest 2000; 117: 1146-61]. An abbreviated forced expiratory maneuver that requires exhalation for 6s (FEV6) has recently been proposed as a substitute for forced vital capacity (FVC) to facilitate performance of such spirometry. We set out to assess the accuracy of diagnosis of obstruction and abnormal pulmonary function using FEV6 in comparison to FVC in a community hospital population. One hundred pulmonary function tests performed at a community hospital were randomly selected and retrospectively analyzed. Sixty-three of the 100 tests had satisfactory 6-s expiration and were subject to further analysis. We compared the spirometric interpretation using Morris predictive equations for FEV1/FVC and Hankison predictive equations for FEV1/FVC and FEV1/FEV6. The Hankison set of equations is the only published reference formulas for prediction of FEV6. We found that versus our Morris gold standard, Hankison based FEV1/FVC interpretation was 100% sensitive and 67% specific for the diagnosis of obstruction and 100% sensitive and 65% specific for the diagnosis of any abnormality. The Hankison based FEV1/FEV6 interpretation was 97% sensitive and 47% specific for diagnosing obstruction and 100% sensitive and 50% specific for identifying any abnormality versus the Morris FVC based gold standard. In conclusion, in our hospital based pulmonary function laboratory, FEV6 based interpretation has excellent sensitivity for detection of spirometric abnormalities. However, its moderate specificity may hinder its utility as a screening test. Further testing is necessary to determine its reliability in different patient populations with less highly trained operators.

The impact of image-guidance systems on sinus surgery.

Endoscopic treatment of diseases of the paranasal sinuses provides excellent visualization for minimally invasive surgery, and has evolved into a high-volume procedure with documented navigational risks to surrounding vital structures. Image-guidance systems use the data acquired during CT studies of the sinuses, which is processed through a workstation. Following a registration procedure, the coordinates of the tip of the surgical instrument being used are tracked and displayed in three views. The surgeon is then able to monitor the endoscopic work being done in the operative field and simultaneously document the precise location of the tip of the tracked instrument. Ideally, these systems will allow surgeons to accurately perform surgery with increased safety and improve long-term outcomes. Although the accuracies of these systems have been studied and reported [23,37], further large studies are needed to prove or disprove the impact of navigational systems on reducing surgical risk and improving surgical outcomes.Image-guidance systems employing optical and electromagnetic technologies have been clinically available for nearly 10 years, available during a time when there is an increased awareness of the risks of medical treatment and an emphasis on reducing errors. There is a need to prove that this technology, despite its added costs [39], ultimately improves safety and lowers the surgical risk of endoscopic sinus surgery. Only at that juncture can a mandate be made for including these systems in all procedures. There is universal agreement, however, that the use of this equipment can never bea substitute for surgical skill, training, or judgment.

Navigational risks associated with sinus surgery and the clinical effects of implementing a navigational system for sinus surgery.

OBJECTIVE: To evaluate the clinical effects of implementing the use of a navigational system in sinus surgery in a community hospital setting. STUDY DESIGN: Retrospective record review. METHODS: The hospital records of 800 patients who had undergone sinus surgery performed by 7 physicians at one institution over 11 years were reviewed and tabulated. The information was recorded in 2 groups of 400 with those in group A being treated before the availability of an electromagnetic sinus navigational system and those in group B being treated after the unit had been installed. The following data were collected: date, age, gender, informed consent, physician, additional procedures, sinuses entered, use of navigational system, revision status, setup time, operative time, and complications. The results of the two groups were analyzed statistically, and comparisons were made. RESULTS/CONCLUSIONS: The patient populations in groups A and B were determined to have similar demographic profiles. Significantly more sinuses, specifically in the frontal location, were entered in group B compared with group A. Adjusted for the number of sinuses treated, the median operative times did not differ significantly between groups. Major and minor complication rates were similar in both groups and were consistent with the published literature. In a community hospital setting, once an electromagnetic guidance system became available, it was used in 92% of the cases performed by sev-eral otolaryngologists.