The significance of Computed Tomography in invasive paranasal mucormycosis.

INTRODUCTION: Early diagnosis of acute invasive fungal rhinosinusitis (AIFR) is crucial for patients prognosis and may reduce the extent of surgical debridement. Initial evaluation usually includes paranasal Computed Tomography (CT), with an emphasis on bony erosion which is considered a specific but insensitive radiologic sign. Most studies made no distinction between Aspergillus and Mucor species while addressing CT findings. In this study, we seek to evaluate whether bony erosion on paranasal CT is a significant and reliable finding in the initial evaluation of invasive paranasal mucormycosis. METHODS: A retrospective review of pre-operative non-contrast craniofacial CT scans of patients diagnosed with acute invasive fungal rhinosinusitis (AIFR) caused by Mucor species for the presence of bony erosion. RESULTS: A total of 13 patients (9 males, 4 females) were included. Twelve patients were immunosuppressed due to various hematological malignancies. Six patients underwent debridement due to gross intraoperative findings of bony fungal invasion, but only one patient had evidence of bony erosion on the pre operative paranasal CT. CONCLUSION: Bony erosion on paranasal CT is an exceptionally insensitive radiologic sign for establishing or rejecting the diagnosis of Mucor induced AIFR. The mainstay of confirming or rejecting the diagnosis of AIFR is by physical examination, endoscopy and oriented biopsy of suspicious mucosal lesions.

Closed-suction compared with Penrose drainage after free flap reconstruction in the head and neck.

Microsurgical free flaps are common in head and neck reconstruction, and their techniques and outcomes have continuously improved during the past decades. However, there are variations in practice among surgeons between the use of closed-suction drainage systems and Penrose drains. The proponents of Penrose drains propose that the negative pressure generated by the closed-suction drainage system may harm the microvascular anastomosis. We know of no previous studies that have compared the two drains for microvascular free flap reconstruction, so our aim was to compare them in a single-centre, retrospective review of all patients who had microvascular free flap reconstruction of the head and neck region in our department between 1 November 2010 and 1 September 2017. During this period 84 patients had 87 free flap reconstructions in the head and neck, 43 of which had Penrose, and 44 closed-suction, drainage. We compared the number of complications between the groups including haematomas, seromas, wound infections, anastomostic thrombosis, anastomotic revision, and need for re-exploration. There were no significant differences between the groups, despite a trend toward fewer negative explorations in the closed-suction group. There were no differences in complications between suction and passive drainage systems after microvascular free flaps, which suggests that closed suction drainage could be safely used after free flap reconstruction in the head and neck.

PET/CT in the evaluation of patients with squamous cell cancer of the head and neck.

The purpose of this study was to compare the findings of positron emission tomography (PET) with fused PET and computed tomography (CT) in patients with suspected locoregional and distant head and neck cancer and to evaluate the impact of those findings on clinical management. Studies of 25 patients were retrospectively evaluated. PET findings were classified as malignant, benign or equivocal. PET/CT findings were then similarly classified and the PET-only results were amended accordingly. Comparison of findings was done on lesion and patient levels. A total of 45 foci of increased 18F-fluorodeoxyglucose (FDG) uptake were noted in 18 patients. PET/CT imaging defined anatomic localization of 41/45 lesions and clarified 6/10 equivocal PET findings. Additional information was provided by PET/CT regarding 9/45 (20%) of the lesions. PET/CT significantly affected patient management in 3/25 patients (12%) by limiting the extent of disease in one and excluding viable disease in two others. The accuracy of PET/CT was 88%, the sensitivity 100% and the specificity was 77%. The negative predictive value was 100% in this combined group of patients with locoregional and distant head and neck cancer. PET/CT is highly contributory for initial staging and in the evaluation of patients with suspected recurrent SCC of the head and neck, in whom anatomic imaging is inconclusive due to the locoregional distortions rendered by surgery and radiotherapy.

Midline versus paramidline mandibulotomy: a radiological study.

Mandibulotomy allows for wide exposure of deep oral cavity and oropharyngeal tumors and may be performed medial or lateral to the mental foramen. Medial mandibulotomy is divided into midline and paramidline. Midline mandibulotomy requires detachment of muscles which may lead to masticatory and swallowing problems and could potentially jeopardize the central incisors. Our study provides a basis for placement of bone cuts in mandibulotomy. The angles between the long axis of the two central incisors, the lateral incisor and canine bilaterally were measured in panoramic radiographs of 100 healthy patients. The distances between the roots were measured. The angle between the lateral incisor and the canine ranged from 1 degrees to 8 degrees compared to 1 degrees -4 degrees (P<0.001) between the central incisors. The distances between the lateral incisor and the canine were 1-6.2mm while the distances between the two central incisors ranged from 0.5 to 4.7mm (P<0.05). Although the measurements were taken from a younger group of patients compared to the usual age of presentation of oropharyngeal cancer, it shows that the paramidline mandibulotomy in which bony cuts are performed through a wider gap is the preferred approach.

The role of gamma-PET in the evaluation of patients with recurrent squamous cell cancer of the head and neck.

Squamous cell carcinoma (SCC) is the most common cancer of the head and neck (HNC). Advanced HNC warrants extensive ablative and reconstructive procedures, significantly altering locoregional anatomy, while radiation treatment further adds to the distortion. Anatomic imaging is therefore often inconclusive in suspected recurrent HNC. Functional imaging with fluorodeoxyglucose-positron emission tomography (FDG-PET) has been reported contributory in the evaluation of patients with SCC. While most reports are from dedicated PET systems, full ring PET is of limited availability and gamma-PET may offer a suitable compromise. The therapeutic impact of gamma-PET in patients with suspected recurrent HNC was retrospectively evaluated. Seventeen patients were evaluated. All had undergone surgery for HNC, 16 also received radiotherapy. gamma-PET scans were compared to anatomic imaging, histopathology and clinical follow-up. The impact of the FDG-PET scan on patient management was then evaluated. Eleven positive findings were confirmed. Two false positives were due to radiation changes, a recognized pitfall. There were no false negatives. Overall accuracy of the 18F-FDG gamma-PET scans was 88% with considerable effect on patient management. Gamma-PET with FDG appears valuable in the evaluation of suspected recurrent HNC, and may provide a suitable alternative when dedicated PET is unavailable.

Antibacterial properties of human amniotic membranes.

Amniotic membranes are widely used in a multitude of surgical applications and have been shown to reduce bacterial counts and promote healing in infected wounds. Antibacterial properties of amniotic fluid are well documented and the presence of many potentially antibacterial factors has been demonstrated. No such factors have yet been found in amniotic membranes. We have applied a direct disc-diffusion susceptibility test to try to establish the possible existence of such a factor. Amniotic membranes did not inhibit five bacterial species when tested at 3 X 10(6) and 3 X 10(8) colony forming units/ml. However, complete growth inhibition of all organisms was seen immediately under the amniotic membrane discs. These results support the hypothesis that the antimicrobial effect of amniotic membranes in vitro is due to their close adherence to the wound surface.

Uvulopalatopharyngoplasty: evaluation of postoperative complications, sequelae, and results.

A study of 71 patients with obstructive sleep apnea syndrome was performed to evaluate the effectiveness, complications, and late sequelae of uvulopalatopharyngoplasty. Postoperative immediate complications were of minor importance. In 96% of the patients, the snoring was improved; it was completely resolved in 48%. The postoperative apnea index remained pathologic in all patients who underwent postoperative polysomnography, although mild improvement was noted. Seventy-four percent of our patients felt a subjective postoperative improvement which was not always confirmed by the polysomnographic examination. A record of improvement was obtained in 64% of the operated patients. Our results establish the beneficial effect of uvulopalatopharyngoplasty, which is the recommended surgical procedure for obstructive sleep apnea syndrome.

The controversial treatment of anterior commissure carcinoma of the larynx.

There are two basic approaches to the appropriate therapy for carcinoma of the anterior commissure. The dilemma of whether to treat by primary irradiation or by conservative surgery is not yet solved. In this study, 67 patients were treated between 1967 and 1987 for anterior commissure carcinoma of the larynx. Radiation was used with 47 patients and conservation surgery with 20 patients. Initial lesion control was achieved with 72% of the patients treated by primary irradiation. Conservation surgery, when used as a primary treatment modality, achieved local control in 90% of the patients. The new techniques of reconstruction of the larynx enhance the surgeon's ability, strengthen his conviction to proceed to enlarged partial laryngectomies, and thus improve the oncologic control of the anterior commissure carcinoma as well.

Ionized serum calcium levels following combined treatment for cancer of the head and neck.

Thyroid function may be reduced after treatment of cancer of the head and neck, and hypothyroidism is much more common after combination therapy. Whether hypoparathyroidism and subsequent hypocalcemia also occur after such treatment is unknown. Few related studies have been published in which changes in total serum calcium have been studied after cancer treatment with radioactive iodine or external radiation. Twenty-two disease-free head and neck cancer patients were studied, 1 to 3 years after multimodal treatment, to determine if changes in serum ionized calcium levels or thyroid function were present. Our results suggest that parathyroid function, as represented by ionized calcium levels remains normal after multimodality (surgery, radiation and/or chemotherapy) combined treatment.

Care of the terminal head and neck cancer patient in the hospice setting.

The ratio of incidence to mortality is somewhat less than 3:1 for head and neck cancer, and the 5-year relative survival rate is 50%. Despite the high mortality rate, few reports have focused on patients with terminal head and neck cancer. A growing number of these patients end their lives in a hospice facility. A retrospective analysis was undertaken of 67 patients with terminal head and neck cancer who were admitted to the Tel Hashomer Hospice between 1988 and 1992. Patient data were reviewed and analyzed, and the particular characteristics of this population were defined. This study found that terminal head and neck cancer patients seem to receive better support in a hospice than in a general hospital or some family settings.

Laryngotracheal anastomosis: primary and revised procedures.

OBJECTIVES: Acquired upper airway stenosis is usually associated with a complex of pathological conditions at the high tracheal and the subglottic levels. Reported reconstructive techniques include widening by incorporation of grafts, segmental resection, and anastomosis or combined procedures. The management of recurrent stenosis after reconstructive surgery is a major challenge and has rarely been discussed in the literature. The purposes of the present study are to compare the clinical course of primary versus revised reconstructive procedures and to analyze the effect of age, diabetes, chronic lung disease, grading of stenosis, extent of resection, and revised procedures on the operative rate of success. STUDY DESIGN: A cohort study in a tertiary referral medical center. METHODS: The clinical course of 23 consecutive patients undergoing laryngotracheal anastomosis was studied comparing a group of 13 primary with 10 revision procedures. Seventeen patients underwent cricotracheal and six patients thyrotracheal anastomoses. All patients but one were tracheotomized before the definitive reconstructive procedure. Suprahyoid release was routinely performed except for two cases, and only one patient required sternotomy. The Wilcoxon test was used to examine the relationship between preoperative clinical parameters and the postoperative success (i.e., airway patency). RESULTS: Twenty-two of 23 patients (95.6%) had successful decannulation. Four patients required a revision procedure because of repeat stenosis at the site of the anastomosis (2) or distal tracheal malacia (2). Residual airway stenosis of less than 50% was noted in six patients, although only three complained of dyspnea during daily-activity exertion. There was no associated mortality. Complications included subcutaneous emphysema (4), granulation tissue formation (3), pneumonia (2), cardiac arrhythmia (2), and one each of pneumomediastinum, neck hematoma, and urosepsis. Protracted aspirations were noted in one patient who had revision surgery. Age was the only parameter that correlated with postoperative airway patency (P <.07), whereas the presence of chronic obstructive lung disease and diabetes, grade of stenosis, type of surgery, and revision surgery were found to be insignificant. CONCLUSIONS: The clinical course of laryngotracheal anastomosis in primary and revised procedures was similar in our group of patients. The operation can be performed safely, with an expected high rate of success and acceptable morbidity.

Elevated arginine vasopressin levels in squamous cell cancer of the head and neck.

The reported effectiveness of single tumor markers (TMs) associated with squamous cell cancer of the head and neck ranges from 15% to 71%, with most studies reporting sensitivity no higher than 50%. An increased incidence of the syndrome of inappropriate secretion of antidiuretic hormone or arginine vasopressin (SIADH) in patients with head and neck cancer has been reported. Serum arginine vasopressin (AVP) was studied as a possible TM in these patients. Sixty-three patients with squamous cell carcinoma of the head and neck determined as potentially curable were prospectively evaluated before treatment and compared to 17 patients with apparent cure of head and neck squamous cell cancer who served as controls. Serum AVP levels were obtained and determined by radioimmunoassay in the preoperative period and 1 week postoperatively in 15 patients. Thirty-four patients were staged as T4, 26 as T3, and 3 as T2. Twenty-one (33%) of the 63 patients had no neck involvement. Twenty-four (38%) of 63 patients had elevated serum AVP levels corrected for serum osmolarity. Of the 15 patients evaluated before and after surgery, 8 (53%) had elevated serum AVP levels preoperatively. Of these 8 patients, 3 had reduction in AVP levels and 5 had complete normalization after 1 week. The result obtained for serum AVP do not exceed results of other TMs reported. AVP may also not be as specific as other TMs for cancer of the head and neck. Our group with AVP sampled postoperatively is too small for us to draw conclusions, but reduction of its levels after treatment in all patients may be significant. These preliminary results indicate that further evaluation of AVP during the posttreatment course in a larger number of cases, and perhaps with other TMs as well, is warranted.

Use of human amniotic membrane in otolaryngologic practice.

Human amnion is a readily available allograft with low antigenicity, high antimicrobial potential, and the ability to foster epithelialization. We have used human amniotic membrane in our department for replacing nasal mucosa in Rendu-Osler-Weber disease, as tympanic membrane grafts, and for covering head and neck sites after flap necrosis. Our experience shows moderate success for management of severe epistaxis and excellent results in covering surfaces after flap necrosis. Use of amnion in eardrum perforations was unsuccessful and was discontinued. Properties of human amniotic membrane are listed and its application in the otolaryngologic practice is reviewed.

Study of the normal and insufficient velopharyngeal valve by the "Forced Sucking Test".

A thorough assessment of the velopharyngeal (VP) closure dynamics is important for therapeutic planning in patients with nasal speech. An additional diagnostic tool to the standard endoscopic examination of the VP valve, the "Forced Sucking Test" (FST) is presented. In this study, 110 patients with a normal VP valve and 40 patients with VP insufficiency were subjected to a comprehensive endoscopic examination. When existent, Passavant's ridge clearly appears in 80% of these cases during the FST. This is advantageous, since the ridge is often unseen during routine nasendoscopy. Passavant's ridge appears indistinguishable in shape and level during speech and FST. During FST, the bulge of the uvular ridge is clearly seen on the flat or concave nasal surface of the velum. In cases of diastasis of the velar musculature, the midline V-defect of the velum is clearly seen. The test is particularly important in children with concomitant adenoid hypertrophy. The findings are discussed in terms of their implications for the anatomy and physiology of the VP valve. FST is recommended as an additional and complementary part of the endoscopic examination of the VP valve.

Postsurgical prevertebral abscess of the cervical spine.

OBJECTIVES: Prevertebral abscess formation is an uncommon occurrence following cervical spine fusion surgery. Abscesses may present early or in a delayed fashion and require surgical drainage and long-term antibiotic treatment. The issues of osteomyelitis and the need for plate removal remain unresolved. STUDY DESIGN: A case series of six tetraplegic patients admitted for rehabilitation to the Chaim Sheba Medical Center (Tel Hashomer, Israel) is presented. METHODS: Five patients were trauma patients; one patient underwent repeated procedures and irradiation for tumor of the cervical spine. All patients developed prevertebral abscesses after a mean period of 30 days from their fusion surgery. Computed tomography scan was used in all patients to establish the diagnosis and define the extent of the infective process. All patients underwent one or more drainage procedures. The plate was removed in two patients at 1 and 4 months. RESULTS: Infection completely resolved in four patient and was refractory in one patient with malignant tumor, and a chronic small fistula remained in one case. Staphylococcus aureus was the main infective organism, but mixed infections were the rule. Even for a protracted course of infection, no significant osteomyelitis was encountered. CONCLUSIONS: Abscess formation after instrumentation of the neck may be more common than formerly recognized. Despite the prolonged course of disease and treatment, osteomyelitis is not a major concern. There is no automatic indication for plate removal to control infection, although plating may be safely removed after 10 to 12 weeks if the neck is explored and the cervical spine is stable. A high index of suspicion is warranted, and early recognition and diagnosis, prompt surgical drainage under general anesthesia, and long-term antibiotic treatment are key for eradication of the infective process. Prophylactic antibiotics may be of value. Meticulous antisepsis and surgical technique should be maintained to reduce the incidence of these severe complications.

An objective method for evaluation of the patulous eustachian tube by using the middle ear analyzer.

Patulous eustachian tube is more common than is usually presumed. The symptoms of this condition can paradoxically simulate an obstruction of the eustachian tube. The characteristic eardrum movements synchronized with breathing can be overlooked or be absent altogether and, therefore, the diagnosis in many cases is missed. We suggest using the middle ear analyzer for diagnosis and objective evaluation of the patent eustachian tube by adjusting it as for acoustic reflex testing. Our method is more sensitive than the more common method of tympanometry. Information is supplied for the patient's evaluation before and after treatment.

Adult-onset otitis media with effusion.

OBJECTIVE: To document the prevalence of adult-onset otitis media with effusion (OME), and to determine its causes, diagnostic approach, and therapeutic management. DESIGN: A prospective study of 167 consecutive patients with adult-onset OME. Endoscopic examination of intranasal and nasopharyngeal structures with special attention to the eustachian tube orifices was performed in all patients. In 65 patients computed tomography of the skull base, neck, and paranasal sinuses was also performed. RESULTS: Paranasal sinus disease, predominantly of the ethmoid system, was found to be the dominant causal factor in 110 patients (66%). Smoking-induced nasopharyngeal lymphoid hyperplasia and adult-onset adenoidal hypertrophy, two entities herein described, were the cause of OME in 15 patients (19%). Various other causes were found in 31 patients. Head and neck tumors, mainly nasopharyngeal carcinomas, were found in only eight patients (4.8%). The cause of adult-onset OME could not be determined in three patients (1.8%). CONCLUSIONS: Contrary to common belief, adult-onset OME is not an uncommon disease. Nasendoscopy is the mainstay of diagnostic evaluation in most patients. Computed tomography is also an important tool in most selected cases. Appropriate treatment of sinusitis resulted in resolution of OME in most patients. Sinusitis is the most common causal factor of adult-onset OME, but nasopharyngeal and parapharyngeal space-occupying lesions should be ruled out in all cases.

The otolaryngologist and the patient with velocardiofacial syndrome.

Velocardiofacial syndrome is the most common syndrome associated with clefting of the secondary palate. The endoscopically diagnosed occult submucous cleft palate is the most common palate anomaly associated with this syndrome. Patients with velocardiofacial syndrome present a special challenge to the otolaryngologist, who must be familiar with the diagnostic and therapeutic aspects of this syndrome. We report the findings in 21 patients with velocardiofacial syndrome. Only 11 (52%) had the typical manifestations, and others had only partial phenotype. Adenoidectomy must be avoided in these patients, since undiagnosed occult and overt submucous cleft palate are the most common cause of velopharyngeal insufficiency after adenoidectomy. Three patients had aberrant carotid arteries. This anomaly must be excluded by nasoscopy and computed tomographic scanning before pharyngeal flap surgery is considered in these patients. Criteria for exclusion of high-risk patients from adenoidectomy are presented and discussed.

Reduction of salivary flow with transdermal scopolamine: a four-year experience.

Scopoderm transdermal therapeutic system (TTS) is applied to prevent nausea and vomiting associated with motion sickness. Dry mouth is the most common side effect, appearing in up to two thirds of the patients treated. We have used this side effect to the benefit of patients with sialorrhea or with difficulties swallowing normally secreted amounts of saliva. More than 100 patients with tumors of the aerodigestive tract before and after surgery, and patients after parotidectomies, after tracheotomies, with peritonsillar abscesses, tonsillitis and pharyngitis, and neurologic disorders were thus treated. Reduced secretion of saliva was seen in 50% to 100% of the treatment groups. Other side effects were minimal and we recommend the use of scopoderm TTS for reduction of salivary flow.

The riddle of the uvula.

Since ancient times, the uvula has been a subject of interesting and contradictory observations. On the one hand, it was regarded as having a functional role in speech and in immunology, but on the other hand it was regarded as a potentially hazardous organ, possibly responsible for sudden infant death syndrome. None of these hypotheses, however, has been proved. In a previous study on patients undergoing uvulopalatopharyngoplasty, we suggested that the most important function of the uvula is connected with the muscularis uvula. Its function could be related to drinking while bending over. This previous assumption was that the uvula is a phylogenetic remnant from mammals that drink while bending their neck downward. In the present study, the soft palate of eight different mammals was macroscopically and microscopically studied and compared. Of all animals in the study, a small underdeveloped uvula was found only in two baboons. We found that the human uvula consists of an intermix of serous and seromucous glandular masses, muscular tissue, and large excretory canals. The serous and seromucous glands are absent in the other mammals. Thus, the uvula is a highly sophisticated structure, capable of producing a large quantity of fluid saliva that can be excreted in a short time. Both uvula and speech serve to differentiate human beings from animals. Our conclusion is that the uvula is possibly an accessory organ of speech, and may be another marker of human evolution that differentiates man from other mammals.