Endoscopic Transnasal Study of the Infratemporal Fossa

Objective

1)Introducing a new endoscopic orientation to the medial portion of the infratemporal fossa (ITF) which is not infrequently involved in sinonasal and related skull base pathologies. 2) Describing the anatomical details and measurement variations of some key ITF landmarks from the unique transnasal endoscopic perspective.

Methods

Using an extended endoscopic approach, the pterygopalatine and infratemporal fossae were dissected in 10 sides of 5 adult cadaver heads. After an extended transethmoid and transmaxillary approach, a plane of dissection along the pterygoid base and the infratemporal surface of the greater sphenoid wing was developed. The related masticatory muscles were dissected through the endoscopic approach. High quality images have been produced by coupling the video camera to a digital recording system.

Results

The foramen rotundum, ovale and spinosum were identified and new landmarks were described from the surgical endoscopic point of view. The sphenomandibularis muscle, recently named in anatomic literature, was also highlighted. Along with various neurovascular structures, the maxillary and mandibular divisions of the trigeminal nerve as well as the middle meningeal artery were identified. Columellar measurements to the foramen rotundum and ovale ranged from 6.1 to 8.0 cm for the former and 7.0 to 9.1 cm for the latter, with a mean of 6.75 cm and 7.78 cm respectively.

Conclusions

The current study provides a novel endo-scopic orientation to the medial ITF. Such knowledge should provide an anatomic basis for experienced surgeons to endo-scopically address this complex region with more safety and efficacy.

Endoscopic endonasal study of the maxillary nerve: a new orientation

BACKGROUND

Endoscopic endonasal procedures for advanced lesions involving the pterygopalatine fossa (PPF) and its various communications are increasingly performed. The maxillary division of the trigeminal nerve (V2) passes through the foramen rotundum and crosses the upper part of the PPF, with a risk of partial or complete injury during surgery in this complex region. Despite the available knowledge of the sinonasal anatomy, the endoscopic orientation of the V2 remains unclear and requires further analysis from this unique view.

METHODS

Using an extended endoscopic approach, the PPF was dissected in 20 sides of 10 adult cadaver heads. The V2 also was followed anteriorly from the trigeminal ganglion, toward the infraorbital canal. The course and the neurovascular relationships of the V2 were studied. High-quality endoscopic images have been produced by coupling the video camera to a digital video recording system.

RESULTS

The endoscopic course and relations of the V2 were carefully described. Important landmarks to identify and avoid injury of the nerve were discussed in relation to this unique view.

CONCLUSION

This study updates our understanding of the V2 anatomy from an endoscopic perspective. The medial to lateral inclination and drooping of the V2, as well as different relationships of the V2 with the vascular structures are important findings to be taken into consideration while endoscopically addressing related lesions.

Endoscopic reconstruction of large anterior skull base defects using acellular dermal allograft

BACKGROUND

Endoscopic repair of small- to medium-sized anterior skull base (ASB) defects using bone, cartilage, fascia, fibrin glue, lipolized dura, and, more recently, acellular dermal allograft have all been described with equal efficacy. The purpose of this study was to review our experience with the use of acellular dermis as the sole graft material in endoscopic reconstruction of large ASB defects.

METHODS

A retrospective chart review of all patients who underwent endoscopic repair of ASB defects at the University of Miami between the years of 2001 and 2006 was conducted. Fifty-six patients were identified who met these criteria. All repairs were performed by a transnasal, endoscopic approach. Outcome measures included success of graft take and incidence of major and minor complications. Dural defect size was defined as small (<0.4 cm), intermediate (0.4-2.0 cm), and large (>2.0 cm).

RESULTS

AlloDerm (AlloDerm. LifeCell Corp. Woodlands, TX) was used as the primary graft material in 30/55 (55%) cases; 16/55 (29%) of the repaired defects were classified as large. Graft success was 97% in the AlloDerm group and 92% in the non-AlloDerm group. The incidence of major and minor complications in the AlloDerm group was 0 and 3.3%, respectively. In the non-AlloDerm group, the incidence of major and minor complications was 4 and 12%, respectively. There were no statistical differences in the complication rates based on the type of repair or defect size.

CONCLUSION

Alloderm can be used successfully to repair ASB defects, including large defects that are >2 cm in size with little or no morbidity.

Endoscopic endonasal study of the internal carotid artery course and variations

BACKGROUND

With the advance in endoscopic sinus surgery, more procedures are being performed to address challenging lesions and, of particular concern, those around the internal carotid artery (ICA). Despite the current progress in the understanding of endoscopic paranasal sinus anatomy, little information is available about the course and variations of the closely related ICA as seen endoscopically. In this study, we show an endoscopic analysis of the ICA course in a series of advanced endoscopic dissections

METHODS

Ten cadaver heads (20 sides) have been endoscopically dissected. Using an extended approach, a wide sphenoidotomy has been performed as far laterally as the pterygoid base. The latter also has been drilled posteriorly and the ICA was fully exposed from its petrous part up to its termination below the anterior perforated substance of the brain. High-quality endoscopic pictures were produced by coupling the video images with a digital recording system.

RESULTS

The ICA course, landmarks, and segments have been defined and analyzed. The ICA was found to have a variable course that was well appreciated using the multiangled, magnified endoscopic view. The importance of such variation was established in relation to the nearby anatomic structures as well as possible lesions involving this area.

CONCLUSION

The results of this study provide the endoscopic sinus and skull base surgeon with a better understanding of the endoscopic course and variations of the ICA. In experienced hands, such endoscopic orientation should allow safer as well as more effective management of closely related lesions.

The voice and laryngeal dysfunction in stroke: a report from the Neurolaryngology Subcommittee of the American Academy of Otolaryngology-Head and Neck Surgery

OBJECTIVE

Stroke is the third leading cause of death in the United States, behind heart disease and cancer. It affects as many as 5% of the population over 65 years old, and this number is growing annually due to the aging population. A significant portion of stroke patients that initially survive are faced with the risk of aspiration, as well as quality-of-life issues relating to impaired communication. The goal of this paper is to define the scope of practice in otolaryngology for these patients, and to review pertinent background literature.

STUDY DESIGN

Consensus report and retrospective literature review.

RESULTS

Otolaryngology involvement in these patients is critical to their rehabilitation, which often requires an interdisciplinary team of specialists. This committee presentation explores epidemiological data regarding the impact of stroke and its complications on hospitalizations. A pertinent review of neuroanatomy as it relates to laryngeal function is also discussed. State-of-the-art diagnostic and therapeutic procedures are presented.

CONCLUSION

There is a well-defined set of diagnostic and therapeutic options for laryngeal dysfunction in the stroke patient.

SIGNIFICANCE

Otolaryngologists play a critical role in the interdisciplinary rehabilitation team.

Surgical outcomes and safety of transnasal endoscopic resection for anterior skull tumors

OBJECTIVE

To report the surgical outcomes and safety of transnasal endoscopic resection (TER) for anterior skull base (ASB) tumors.

STUDY DESIGN AND SETTING

A retrospective chart review to identify patients undergoing TER for ASB tumors at a tertiary care medical center between September 1997 and June 2006.

RESULTS

Nineteen patients underwent TER for ASB tumors without open craniotomy. There were 17 malignant and two benign lesions. Olfactory neuroblastoma was the most common pathology, occurring in 53 percent of patients. One patient recurred locally, resulting in an overall local control rate of 94.7 percent for all neoplasms and 94.1 percent for malignant disease. It should be noted that the tumor control rate may be premature given the small sample size and limited follow-up. Overall, there were 16 complications, but only two of these, an orbital hematoma and a frontal lobe abscess, were considered major complications directly attributable to surgery.

CONCLUSIONS

TER for ASB tumors appears to be safe in properly selected patients. In light of the small sample size and limited follow-up, the major complication rate directly attributable to surgery was 11 percent, and the overall local control rate was 95 percent. A larger multi-institutional series with longer follow-up is warranted.

Frozen-section biopsy analysis for acute invasive fungal rhinosinusitis

OBJECTIVE

To evaluate sensitivity and specificity of frozen-section biopsy in the diagnosis of acute invasive fungal rhinosinusitis (AIFRS).

STUDY DESIGN AND SETTING

Retrospective chart review of all patients treated for AIFRS at the University of Miami between 1993 and 2005. Twenty patients with the clinical diagnosis of AIFRS were identified. Histopathological data were collected to evaluate the use of frozen-section biopsy to diagnose the disease.

RESULTS

Permanent pathology sections were positive for AIFRS in all specimens. Frozen-section biopsies were positive for fungal features in all but five cases (four with Mucor and one with Aspergillus). High positive predictive values were found for both fungal types and for both sets of patients (bedside and intraoperative).

CONCLUSION

Frozen-section biopsy is a useful tool for rapid and effective diagnosis in patients with suspected AIFRS. A positive frozen-section result is highly predictive of invasive disease and merits prompt surgical intervention.

Sphenoid sinus chondromyxoid fibroma mimicking a mucocele

We report the case of a 44-year-old man who presented with a chondromyxoid fibroma (CMF) of the sphenoid sinus, which filled the sinus and clinically and radiologically resembled a mucocele. Chondromyxoid fibromas are the least common cartilaginous neoplasms of bone, typically occurring in the metaphysis of long bones. They have occasionally been described in the facial bones, usually the mandible and maxilla, and rarely involve the paranasal sinuses. Chondromyxoid fibroma displays a relatively unique histological appearance, with characteristic lobulation, with spindle to stellate cells embedded in a myxoid or chondroid matrix. The periphery of the lobules tends to be more cellular than the center. Despite having been described nearly 60 years ago, the histogenesis of CMF remains controversial. Although CMFs are generally regarded as benign neoplasms, they may show an infiltrative pattern and may recur, particularly when they are in locations where complete surgical excision may be difficult or impossible.

Reliability of the University of Miami chronic rhinosinusitis staging system

BACKGROUND

The aim of this study was to determine the interrater reliability and correlation between computed tomography (CT) and endoscopic components of the University of Miami (UM) Chronic Rhinosinusitis Staging System (UMCRSS), a comprehensive staging system for chronic rhinosinusitis (CRS).

METHODS

A prospective analysis of 55 patients undergoing endoscopic sinus surgeryfor CRS was performed. The population consisted of 28 men and 27 women, with a mean age of 45.9 years. All patients underwent staging, via the CT and endoscopic components of the UMCRSS in the operating room, by three examiners. The reliability of the system and all of its components was determined by kappa-coefficient analysis, comparing the data from all three examiners. Correlation between the CT and endoscopic arms was analyzed by Pearson's product moment coefficient.

RESULTS

Interrater reliability for the CT arm (kappa = 0.83) and endoscopic arm (kappa = 0.74 for the revision population, and kappa = 0.72 for the primary surgery population) were found to be significant. Endoscopic staging established significant correlation with CT staging (Pearson's r2 = 0.40; p < 0.0001 overall, 0.57, p < 0.0001 for revision, and 0.42, p < 0.0001 for primary cases).

CONCLUSION

The UMCRSS is a comprehensive and reliable staging system with very strong and positive correlation between the CT and endoscopic components.

Microdebriders used in functional endoscopic sinus surgery: secondary analysis and validation of a new tissue model

OBJECTIVES/HYPOTHESIS

To validate a previously reported in vitro tissue model for microdebrider comparison and determine which microdebrider, tissue type, blade type, and suction strength is most efficient. Specifically, the goal of the secondary analysis is to expand on the results of the preliminary analysis by increasing the sample size, and introduce an aspiration efficiency score (AES) to facilitate microdebrider comparison.

STUDY DESIGN

Prospective randomized comparison.

METHODS

A prospective randomized comparison of the Diego Powered Dissector and XPS 3000 Powered ENT System was conducted using a soft tissue and a firm tissue model. In addition to evaluating tissue aspiration with straight and angled blades, clogging rates and clearance times were measured. Both standard wall suction and liposuction were used. Basic statistical analysis, a one-way analysis of variance, and a post hoc Student's t test were performed to compare outcomes.

RESULTS

With standard wall suction, the microdebriders were equivalent for the overall microdebrider comparison. For the ''head to head'' comparison with standard wall suction, the devices were also equivalent when using the straight blades, but the XPS 3000 aspirated more tissue when using the angled blades. With liposuction, the XPS 3000 and liposuction independently aspirated more tissue but clogged more often compared with the Diego PD and regular suction. The aspiration efficiency of soft tissue (oysters) and straight blades was superior compared with firm tissue (scallops) and angled blades. For the ''head to head'' comparison with liposuction, the XPS 3000 aspirated more tissue regardless of tissue type, but the Diego PD clogged less with firm tissue (scallops). Overall, the AES favored the XPS 3000, soft tissue (oysters), straight blades, and liposuction.

CONCLUSION

Our tissue model represents a reliable and reproducible means of microdebrider comparison. Statistically significant differences between the Diego PD and XPS 3000, as well as between tissue types, blade types, and suction strengths, are reported. Using these results, microdebrider manufacturers can adopt similar tissue models, expand on the current AES, and include other commercially available microdebrider devices to test and report product performance to the consumer. Perhaps an optimal open to closed ratio or liposuction pressure can be determined that yields the greatest tissue aspiration with the fewest number of clogs.

The role of atypical bacteria in chronic rhinosinusitis

OBJECTIVE

This study examines the presence of atypical bacteria in chronic rhinosinusitis (CRS) by utilizing the polymerase chain reaction (PCR).

STUDY DESIGN AND SETTING

Eleven patients with CRS were prospectively enrolled. DNA was isolated from the mucosa samples and subjected to PCR using oligonucleotides specific for identification of atypical bacteria including: Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila. Also, routine aerobic and anerobic cultures were processed. Sinus tissue samples from 6 fresh corpses without evident sinus disease served as controls.

RESULTS

No atypical bacteria were identified in the 11 patient samples by PCR. One of 6 cadaver controls was positive by PCR for M pneumoniae. The most common organism obtained from routine culture was coagulase negative staphylococci.

CONCLUSION

Using sensitive PCR techniques, CRS mucosa did not reveal DNA from M pneumoniae, C pneumoniae, or L pneumophila.

SIGNIFICANCE

Atypical bacteria were not identified in patients with CRS despite highly effective PCR methods and they may not play a significant role in the cause of CRS.

Endoscopic sinus surgery for benign and malignant nasal and sinus neoplasm

PURPOSE OF REVIEW

Endoscopic sinus surgery has become widely accepted as the standard of treatment for chronic inflammatory diseases of the paranasal sinuses unresponsive to medical treatment. With increased skill with endoscopic surgical technique, advanced technologies such as intraoperative imaging systems, and a better understanding of the complex anatomy of the paranasal sinuses and surrounding vital structures, many otolaryngologists have increasingly applied their expertise in endoscopic sinus surgery to the resection of nasal and sinus neoplasms. The following represents a review of the recent literature on the latest trends regarding endoscopic resection of nasal and paranasal sinus neoplasms.

RECENT FINDINGS

There has been an increasing popularity in the removal of nasal and paranasal sinus neoplasms through an endoscopic approach. In the recent literature, emphasis has been on the endoscopic surgery of benign tumors, especially inverted papilloma and nasopharyngeal angiofibroma. Other benign neoplasms have also been reported, but only in small case reports. There have been a few recent reports supporting endoscopic removal of malignant neoplasms as well. However, the follow-up is too short and study groups too small to make definitive conclusions.

SUMMARY

In the hand of experienced and skilled surgeons, complete endoscopic removal is attainable in most cases. Especially for the more common benign neoplasms, such as inverted papilloma and early stage angiofibroma. En bloc resection is not necessary to achieve oncologic cure. However, several factors have to be considered before selection of this surgical approach. Large tumor size, intracranial or orbital extension, and extensive frontal or infratemporal fossa involvement are relative, but not absolute limitations.

Endoscopic management of anterior skull base tumors

Anterior craniofacial resection has become a standard procedure for management of lesions of the anterior skull base. During the last 2 decades, modifications of the classic anterior craniofacial resection have been reported. With the introduction of endoscopic sinus techniques and instrumentation, surgeons have begun to use endoscopic approaches for management of anterior skull base lesions. This article describes endoscopic modifications of anterior craniofacial resection.

Can Maximum Phonation Time Predict Voice Outcome after Thyroplasty Type I?

BACKGROUND

Thyroplasty type I, as introduced by Isshiki and colleagues almost 30 years ago, has become the gold standard of improving glottal incompetence caused by unilateral vocal fold paralysis. Intraoperative assessment of the adequacy of glottal closure is subjective and based on the perceptual judgment of vocal quality and degree of improvement in glottal gap size.

OBJECTIVE/HYPOTHESES

The primary purpose of this study was to investigate whether the intraoperative measurement of maximum phonation time (MPT) is an adequate predictor of voice outcome after thyroplasty type I. To assess this possibility, it was necessary to evaluate the effect of body posture (seated vs. supine) and anesthesia (none vs. light sedation) on the measure of MPT.

STUDY DESIGN

A prospective study of 20 individuals with unilateral vocal fold paralysis was undertaken.

METHODS

Subjects were assessed at three time points: pre-, intra-, and postoperatively across parameters of breathiness rating, glottal gap size, glottal flow rate, and MPT.

RESULTS

Results indicated that MPT was significantly lower in the supine versus seated position. In addition, light sedation resulted in a trend toward lower MPT that was not statistically significant. Finally, the intraoperative measurement of MPT, although lower than a 1-month postoperative measurement, was significantly predictive of the outcome.

CONCLUSIONS

The intraoperative measure of MPT appears to be an adequate predictor of the postoperative outcome.

Tissue Model and Preliminary Analysis of Microdebriders Used in Endoscopic Sinus Surgery

Objectives: In 1999, Ferguson reported the first and only quantitative analysis of microdebriders used in ESS. The purpose of our study was to establish a standardized in vitro model and compare the newer “next-generation” microdebriders to determine which device and combination of tissue type, blade, and suction strength was most efficient for this model.

Methods: The Gyrus-Diego-Powered-Dissector and Xomed-XPS-3000-Powered-ENT-System were compared using a soft tissue model consisting of raw oysters (nasal polyps) and a firm-tissue model consisting of scallops mixed with eggshells (nasal/sinus tissue). In addition, the effect of blade type (straight/60) and suction strength (wall-suction/liposuction) on aspiration efficiency was evaluated. Aspiration efficiency was quantified by 3 outcomes (tissue aspiration, clog-frequency, and clearance time).

Results: For the “head-to-head” comparison, Xomed was statistically superior for soft tissue/oyster aspiration when using the straight blade regardless of suction strength and when using the angled blade with liposuction. Although not statistically significant, several trends were observed in our analysis. First, Gyrus appeared to be superior to Xomed for firm-tissue/scallop aspiration, clog-frequency, and clearance time. In addition, straight blades appeared to be superior to angled blades for overall tissue aspiration, clog frequency, and clearance time. Finally, liposuction appeared to be superior for both soft tissue/oyster and firm tissue/scallop aspiration, but wall-suction demonstrated less clogging and clearance time.

Conclusion: The tissue model presented appears to be both reliable and reproducible. Only 2 statistically significant results were observed, however, several trends toward significance were noted. A second study with a larger sample size and more advanced statistical analysis is needed to better delineate these trends.

Spastic/spasmodic vs. tremulous vocal quality: motor speech profile analysis

Strained, strangled, and tremulous vocal qualities that are typically seen in adductor spasmodic dysphonia (ADSD), voice tremor (Tremor), and the spastic dysarthria of amyotrophic lateral sclerosis (ALS) may sound similar and be difficult to differentiate. The purpose of this study was to determine if these vocal qualities of neurologic origin could be differentiated on the basis of acoustic and motor speech parameters. Three groups of subjects (ADSD, ALS, and Tremor) were analyzed by the Motor Speech Profile System (Kay Elemetrics, Lincoln Park, NJ) for fundamental frequency (Fo), standard deviation of Fo, diadochokinetic rate (ddk), standard deviation of ddk, mean intensity and standard deviation of ddk, frequency and amplitude variability in connected speech, and speaking rate in connected speech. Profiles of the three groups are presented with the significant features that differentiated one from the other.

Early results of transcutaneous injection laryngoplasty with micronized acellular dermis versus type-I thyroplasty for glottic incompetence dysphonia due to unilateral vocal fold paralysis

Medialization thyroplasty (type I) has become the gold standard to improve glottic closure due to unilateral vocal fold paralysis. A newer injection method utilizing homologous collagen from cadaveric human tissue has been described as an attractive alternative as no donor site is required, there is a very low risk of hypersensitivity, and the intact, acellular collagen fibers may suffer a reduced long-term reabsorption rate. Preliminary results on eight patients comparing presurgical and postsurgical parameters (perceptual, stroboscopic, acoustic, and aerodynamic) revealed comparable results when compared with a control group of individuals, age- and sex-matched, that had undergone standard medialization thyroplasty (type I). Further study is needed to assess the long-term results with this minimally invasive method of vocal fold medialization.

Endoscopic resection of inverted papilloma: University of Miami experience

BACKGROUND

The aim of this study was to evaluate the efficacy and safety of endoscopically resecting paranasal sinus inverted papillomas at a tertiary medical center.

METHODS

Over a 9-year period, 51 patients with a diagnosis of inverted papilloma underwent endoscopic resection at the University of Miami/Jackson Memorial Medical Center. The study group consisted of 14 women and 37 men with a mean age of 59 years (range, 20-88 years) enrolled in a clinical data base. All of the patients were followed endoscopically at regular intervals on an outpatient basis.

RESULTS

Endoscopic evidence of extensive papillomas involving the anterior and posterior ethmoid sinuses and at least one (usually the maxillary) dependent sinus was found in 60% of the cases. Extensive radiological disease (varying degrees of mucoperiosteal thickening or opacification of all five cavities) was evident in 50% of the cases. All but two had unilateral disease. An association with chronic inflammatory polyps (clinically and pathologically) was observed in 25 of 51 patients (49%). Follow-up ranged from 6 to 99 months (mean, 30 months). There have been seven recurrences (14%). Four of these have been managed in the office under topical anesthesia. Three recurrences were managed surgically in the operating room. All of the patients have been free of disease. Complications included an intraoperative CSF leak (three patients); temporary infraorbital hypesthesia (three patients); periorbital ecchymosis, hematoma, or cheek edema (four patients); and orbital symptoms (two patients). Carcinoma was found in four patients (8%) who received postoperative radiotherapy and remain free of disease.

CONCLUSION

The endoscopic approach continues to provide at least equivalent short-term results as compared with external techniques for the removal of paranasal sinus inverted papilloma. The final cavity should allow for adequate postoperative surveillance and potential resection of recurrences in the office setting, without the need for a return to the operating room in most patients. The association of inverted papilloma with chronic inflammatory polyps and tobacco use warrants additional study.

Cough and paradoxical vocal fold motion

OBJECTIVES

The differential diagnosis and treatment of patients with chronic cough, paradoxical vocal fold motion, and disordered breathing can be a challenge to most practicing otolaryngologists. Tracheobronchial (ie, asthma, bronchitis, and tracheal stenosis), laryngeal (ie, vocal fold paralysis and neoplasms), and rhinologic (ie, allergies and rhinosinusitis) etiologies are commonly diagnosed and treated effectively. However, occasionally one is faced with patients who are refractory to medical treatment and have no obvious rhinologic, laryngeal or pulmonary cause.

STUDY DESIGN AND SETTING

We conducted a review of the literature.

METHODS

We present a thorough review of the current medical literature exploring the complex neurologic mechanisms involved in the production of cough and the relationship between gastroesophageal reflux disease, vagal neurapathy, and paradoxical vocal fold motion.

RESULTS

The diagnosis and successful treatment of chronic cough can be complex. It requires a thorough understanding of the neurologic mechanisms behind cough excitation and suppression. Successful treatment strategies include aggressive management of the patient's reactive airway disease, gastroesophageal reflux disease, and, in select cases, paradoxical vocal fold motion. This may involve a well-coordinated effort among pulmonologists, otolaryngologists, gastroenterologists, and speech pathologists.

CONCLUSION

Gastroesophageal reflux disease, vagal neuropathy, and paradoxical vocal fold motion are additional causes of chronic cough and disordered breathing that need to be considered, in the absence of obvious laryngotracheal and/or rhinologic pathology. A high index of suspicion is essential in making the diagnosis and formulating an effective multidisciplinary treatment plan for these patients.

Management of common voice problems: Committee report

OBJECTIVE

This report provides the reader with a state-of-the-art update on a number of common voice problems that require phonosurgical intervention.

STUDY DESIGN AND SETTING

This multiauthor review is not a position statement of the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) and may reflect institutional preference and/or bias. It arose from a panel discussion at the AAOHNS meeting in 2000.

RESULTS

We provide a review of the genesis and management of papillomatosis, dysplastic glottal epithelium, arytenoid granulomas, Reinke's edema, and vocal-fold paralysis.

CONCLUSIONS AND SIGNIFICANCE

In the past decade, there has been a dramatic expansion of knowledge regarding a variety of voice disorders and associated treatment. There has been a convergence of basic science investigations in anatomy, physiology, and pathology with clinical trials of treatment, both surgical and nonsurgical. This information should provide the reader with current insight into critical management issues of the aforementioned disorders.

Comparison of antral tap with endoscopically directed nasal culture

OBJECTIVES/HYPOTHESIS

The diagnosis of acute bacterial rhinosinusitis continues to generate controversy in critically ill patients. The efficacy of endoscopically directed cultures in these patients is unknown. We compared antral tap (AT) with endoscopic tissue culture (ETC) of the osteomeatal complex in an intensive care unit (ICU) setting.

METHODS

Twenty patients admitted to a surgical/trauma ICU were evaluated by AT and ENB for the presence of rhinosinusitis. All patients had 1) a fever of unknown origin without resolution on empiric antibiotic therapy for > or =48 hrs; 2) other sources of fever ruled out; 3) computed tomography scan evidence of mucoperiosteal thickening +/- sinus air/fluid levels; and 4) attempt at conservative treatment with topical decongestants and removal of all nasal intubation. Microbiologic data were collected and analyzed for any statistical difference between groups.

RESULTS

A total of 29 sides underwent simultaneous tap and endoscopically directed tissue culture. The mean age was 40 years (range, 23-77 y) with 85% being males. Fifteen of 20 (75%) patients in the AT group were culture-positive. Of the 49 isolates from the AT, 55% yielded Gram-negative bacilli (Acinetobacter sp. 37%) and 45% yielded Gram-positive cocci. The ETC group was culture-positive in 18 of 20 (90%) patients. Of the 52 isolates from the ETC, Gram-negative bacilli were found in 58% (Acinetobacter sp. 33%) and 42% yielded Gram-positive cocci. The ETCs were culture-positive in all but 1 patient with positive taps. There appeared to be a concordance between AT and ETC in 60% of the patients. In five instances (25%), results of the AT or ETC changed ICU management. Two patients ultimately required sinus surgery.

CONCLUSIONS

Sinus taps and/or endoscopically directed tissue cultures led to a change in ICU care in 25% of ICU patients studied. In patients with fever of unknown origin and computed tomography evidence of sinusitis, an antral tap continues to provide important information concerning maxillary sinusitis. However, ETC may give as good a representation of the microbiology and secondary inflammatory changes responsible for bacterial ICU rhinosinusitis causing fever of unknown origin. Further study on a larger group of patients is needed.

Endoscopic resection of esthesioneuroblastoma

Esthesioneuroblastoma (olfactory neuroblastoma) is a rare malignant neoplasm originating from neuroepithelial cells. Treatment for this tumor has traditionally required a craniofacial resection through an external approach. The safety and efficacy of transnasal endoscopic resection is uknown. A series of five patients with Kadish stage A or B lesions of the anterior skull base were resected and immediately reconstructed endoscopically over a nine-year period. There were 2 males and 3 females with a mean age of 64 years. Three patients were treated primarily and two were treated secondarily for recurrences after failing a traditional external craniofacial resection and postoperative radiotherapy. All primary lesions received adjuvant radiotherapy. The mean follow-up time was 31 months. All patients were discharged within 4 days or less. Operative complications included temporary postoperative infraorbital anesthesia (1 patient), unplanned cerebrospinal fluid leak (1 patient), and can orbital hematoma (1 patient). None of these complications resulted in any permanent sequelae. Two patients had prolonged nasal crusting for up to one year due to a variety of factors; large cavities, radiation therapy, and exposed lyophilized dural graft. However, all skull base defects healed without any short- or long-term sequelae. There have been no local recurrences. Two patients (1 primary and 1 secondary) developed regional metastasis to the orbit or cervical lymph nodes managed with primary transorbital excision or modified neck dissection, respectively. All but one patient remain free of disease by clinical, endoscopic, and radiographic (CT or MRI) surveillance. The remaining patient recurred distally as an undifferentiated carcinoma in his temporal bone and lungs 12 months after the initial resection. In experienced hands select cases of esthesioneuroblastoma can be safely excised and reconstructed endoscopically with comparable degrees of tissue removal as with external approaches. Short-term oncologic results in this mall series of patients appear to be comparable to traditional methods. Longer follow-up on a larger series of patients is warranted.

A stepwise surgical technique using the medial orbital floor as the key landmark in performing endoscopic sinus surgery

HYPOTHESIS

The medial orbital floor (MOF) and adjacent bony ridge of the antrostomy, when combined with columellar measurements, are easily identifiable and consistent anatomic reference points from which critical orbital and skull base structures can be found during endoscopic sinus surgery.

METHODS

Two examiners, with varying endoscopic sinus surgery experience, performed endoscopic and direct measurements from the columnella and medial orbital floor to critical orbital and skull base structures on 11 human cadaver heads (18 sides). The distances to four critical skull base or orbital structures and to the anterior and posterior wall of the sphenoid sinus were measured. The mean, ranges, and standard deviations for all measurements (endoscopic and direct) were calculated and simple regression analysis was performed.

RESULTS

The mean and range of values for each of the variables correlated well between examiners, and between endoscopic and direct measurements. There was slightly more variability in measurements when the MOF was used. However, the differences were no more than a few millimeters and did not appear to affect the overall clinical use of these values.

CONCLUSIONS

The MOF and adjacent bony ridge of the antrostomy, when combined with columellar measurements, are easily identifiable and consistent anatomic landmarks that are not affected by the presence of significant inflammatory disease or previous surgery. These reference points provide even the most inexperienced surgeon with precise anatomic localization within the paranasal sinuses. They also determine the correct anteroposterior trajectory into the sphenoid sinus, whereby inadvertent intracranial or intraorbital complications may be avoided.

Endoscopic sinus surgery in previously irradiated patients

PURPOSE

Our purpose was to evaluate the safety and efficacy of endoscopic sinus surgery in irradiated patients with absolute indications for sinus surgery.

PATIENTS AND METHODS

During 5 years at a tertiary referral center, more than 200 patients received irradiation to a field that included the paranasal sinuses. Complaints related to the sinuses are common in such patients and often include crusting and increased mucus drainage. Six patients presented with significant sinus infections in the absence of tumor recurrence and failed medical management. Additional problems included epiphora and nasal obstruction caused by cicatricial choanal stricture. Surgical interventions included ethmoidectomy, multiple osteotomies, debridement of scarred or devitalized tissue, and dacryocystorhinostomy. Outcome measures included intraoperative findings and complications, length of hospital stays, endoscopic assessments of the healing over 6 months post-operatively, and improvement or persistence of symptoms over 2 to 3 years of follow-up.

RESULTS

Surgery can be technically difficult because of derangements of normal anatomy and dehiscence of important structures. Although bleeding problems, prolonged admission, and delayed healing were noted in certain cases, they did not result in long-term morbidity.

CONCLUSIONS

Endoscopic sinus surgery has become an invaluable tool in the treatment of refractory sinusitis. Our literature review has revealed no information, however, regarding endoscopic sinus surgery in previously irradiated patients. Theoretically, such patients are at risk for healing problems and anatomic derangements, which could lead to complications. There is, nevertheless, a theoretical benefit to avoiding external approaches in patients who might heal poorly.

A fine-cut technique for permanent laryngeal sectioning

BACKGROUND

A new technique for permanent sectioning of the human spinal cord has provided superior images over those produced with traditional methods. Application of this technique for sections of the human larynx may yield cost-effective, efficient, and accurate laryngeal anatomic dissections.

STUDY DESIGN AND METHODS

This study was designed to evaluate this technique for dissections of the human larynx. Laryngeal sections from cadavers were submerged in a celloidin solution, a derivative of wallpaper plaster, and frozen to -15 degrees C. After preparation, axial and coronal cuts of 100 microm were made with a Macrocut Tome sectioning system.

RESULTS

Sections were completed in approximately 30 hours. Digitized photographs of the laryngeal sections provide detailed images of precise anatomic relationships.

CONCLUSION

Celloidin-based sectioning of the human larynx yields precise anatomic information beyond standard radiographic imagining and previous permanent laryngeal sectioning techniques in a cost-efficient and timely manner. Black and white fine-section photographs are provided.

Acoustic analysis of the singing and speaking voice in singing students

The singing power ratio (SPR) is an objective means of quantifying the singer's formant. SPR has been shown to differentiate trained singers from nonsingers and sung from spoken tones. This study was designed to evaluate SPR and acoustic parameters in singing students to determine if the singer-in-training has an identifiable difference between sung and spoken voices. Digital audio recordings were made of both sung and spoken vowel sounds in 55 singing students for acoustic analysis. SPR values were not significantly different between the sung and spoken samples. Shimmer and noise-to-harmonic ratio were significantly higher in spoken samples. SPR analysis may provide an objective tool for monitoring the student's progress.

Efficacy of transoral intraluminal Wallstents for tracheal stenosis or tracheomalacia

OBJECTIVES

The efficacy and safety of intraluminal Wallstent Endoprosthesis (Boston Scientific/ Medi-Tech, Quincy, MA) placement to restore airway patency in patients with tracheal stenosis or tracheomalacia are unknown.

STUDY DESIGN

Retrospective review in setting of tertiary, referral, and academic center.

METHODS

A retrospective review of 13 consecutive patients over a 2-year period who underwent transoral resection of tracheal stenosis and immediate transoral Wallstent placement. One patient had tracheomalacia. All of the patients were considered at high risk for transcervical surgery or had failed prior traditional open procedures.

RESULTS

The average patient age was 54.2 years, with nine male and four female patients. All had Cotton/Myer stenoses (grades II to IV) with moderate to severe degrees of inspiratory stridor. Four patients were tracheotomy dependent. The length of stenosis varied from 1 to 4 cm. One patient had a 10-cm segment of tracheomalacia. At the time of writing, none of the patients has had a problem with significant migration or extrusion and most of the patients have incorporated the stent well without any short-term obstructive granulation tissue. After a mean follow-up of 15 months (range, 4-24 mo). 10 of the 12 patients with stenosis (83%) have remained free of any inspiratory noise during breathing. The one patient with tracheomalacia also has remained free of symptoms.

CONCLUSIONS

Transoral Wallstents appear to be safe and may be a reasonable alternative in the restoration of airway patency in select patients with tracheal stenosis or tracheomalacia.

Treatment of acute and chronic rhinosinusitis

Rhinosinusitis is a common health complaint that is often seen by primary care physicians and otolaryngologists in the United States. The complicated anatomy of the paranasal sinuses, as well as the multiple etiologies, contributes to the complexity that one often faces in trying to ameliorate or eradicate this disease in affected individuals. A full understanding of the fundamentals of rhinosinusitis, as well as the treatment options available for the different types, is important. It is very important for the physician to take an organized, step-by-step approach to the management of each patient with this complicated disease. As most cases of rhinosinusitis presenting to the generalist's office will be of viral origin, antibiotics should not be given unless the patient has purulent rhinorrhea or worsening symptoms lasting more than 5 days, or total symptoms lasting longer than 10 days. When medical treatment fails or is incomplete, adjunctive surgical treatment becomes an option. Generally, the symptoms that are most helped by surgery include persistent headaches, nasal obstruction, and recurrent or persistent purulent rhinorrhea unresponsive to medical management. Appropriate and timely referral for specialty care will result in the definitive management of recalcitrant rhinosinusitis when medical management alone fails or in cases where a complication or malignancy is suspected. This article reviews the current understanding of the anatomy, pathophysiology, classification, diagnosis, and potential complications of rhinosinusitis. It also describes the current approach to the treatment of both acute and chronic rhinosinusitis.

Efficacy of computed tomographic image--guided endoscopic sinus surgery in residency training programs

OBJECTIVE

To determine the efficacy of computed tomographic image-guided endoscopic surgery in the hands of inexperienced surgeons.

STUDY DESIGN

Four second-year otolaryngology residents, with no prior experience performing ethmoidectomies, performed endoscopic sinus surgery (ESS) on formalin-fixed human cadaveric specimens with and without the aid of computer-assisted surgery (CAS).

METHODS

Each resident was asked to identify critical sinus, orbital, and skull base structures while performing a total ethmoidectomy and multiple sinusotomies. Their surgical accuracy (percentage of correctly identified structures), total operative time, and incidence of major complications were recorded for each side. A total of 16 sides were evaluated (8 with and 8 without CAS). Statistical significance between groups was determined by means of Pearson's chi2 analysis.

RESULTS

Statistical analysis showed a significant difference (P = .001) in the mean accuracy of identifying critical anatomical landmarks between the CAS (97%) and non-CAS (76.8%) groups. Although not statistically significant, operative time appeared to be longer in the group using CAS (average of 67 vs. 80 min). Three major intracranial complications were documented only in the group not using CAS.

CONCLUSIONS

Although, unquestionably, a thorough knowledge of the anatomy remains essential for performing ESS, CAS improves surgical accuracy and reduces the risk of major intracranial or intraorbital complications for residents. In additional, our data suggest that this technology may enhance surgical efficiency and improve the learning curve by reducing operative time (below one's normal baseline) while maintaining a greater than 90% accuracy in identifying critical anatomical landmarks.

Relationship between aerodynamic measures of glottal efficiency and stroboscopic findings in asymptomatic singing students

Singing requires exquisite coordination between the respiratory and phonatory systems to efficiently control glottal airflow. Asymptomatic singing students underwent pulmonary function testing (PFT), videostrobolaryngoscopic examination, and measures of glottal efficiency (maximum phonation time [MPT], glottal flow rate [GFR], and phonation quotient [PQ]) performed in both a sung and spoken tone. Pulmonary function and glottal efficiency values were within reported normative data for professional singers. However, sung tones were made with significantly higher GFR and PQ and lower PQ than spoken tones. The mean GFR was not related to the degree of glottal closure (by videostrobolaryngoscopy) or underlying pulmonary support.

Thyroplasty type I: short- versus long-term results

OBJECTIVE

After thyroplasty type I, significant improvement has been reported in objective measures of vocal function. The purpose of this investigation was to compare the short- and long-term results in patients undergoing thyroplasty type I.

METHODS

Data on 26 patients who had undergone thyroplasty type I for management of unilateral vocal fold paralysis were compared from before surgery to the short-term (1-month) and long-term (>1-year) postoperative assessment points. Statistical analysis included paired tests to assess the significance of between-group differences.

RESULTS

Significant differences were found between the preoperative and both postoperative evaluations for the measures of mean glottal flow rate, maximum phonation time, jitter, shimmer, and harmonic-to-noise ratio. However, no significant differences were found between the 1-month and >1-year assessment points.

CONCLUSIONS

The results for the parameters studied appeared to reach maximum improvement within 1 month after surgery. It is possible that the effects of time, including the normal aging process, hormonal changes, or other alterations in general health, may require longer follow-up to better address these issues.

Diagnosis and management of allergic fungal sinusitis with orbital involvement

PURPOSE

Allergic fungal sinusitis (AFS) is a noninvasive disease characterized by recurrent sinusitis. This condition is commonly treated with surgical debridement and several months of systemic corticosteroids. The treatment of AFS is examined in this study.

METHODS

A retrospective case series of three patients with AFS.

RESULTS

All three patients were treated with surgical debridement and less than one month of systemic corticosteroids. The patients then were treated with intranasal corticosteroids and monitored closely. Antifungal therapy was not used. All three patients remained disease-free during follow-up ranging from 12 months to 36 months.

CONCLUSIONS

Surgical debridement and systemic corticosteroids for less than four weeks followed by intranasal corticosteroids may provide long-term control of AFS. Additional study is recommended to examine further the optimal treatment for AFS.

Endoscopic cerebrospinal fluid rhinorrhea repair: is a lumbar drain necessary?

OBJECTIVES

To determine the necessity for lumbar drains during endoscopic cerebrospinal fluid (CSF) rhinorrhea repair.

METHODS

Thirty-three patients underwent endoscopic repair of CSF rhinorrhea without a lumbar drain during a 7-year period. The size of the dural defect ranged from a microleak (less than 1 mm dural defect) to a 3-cm dural defect of the anterior skull base.

RESULTS

All of the procedures in patients with smaller defects (<5 mm) were performed on an outpatient basis. Thirty-two patients (97%) had complete resolution of their CSF leak after 1 procedure without any recurrence (average follow-up 29 months).

CONCLUSION

A lumbar drain is not routinely necessary for successful closure of CSF rhinorrhea of any size. Smaller dural defects may be safely performed on an outpatient basis without complications.

Failure of cricopharyngeal myotomy to improve dysphagia following head and neck cancer surgery

OBJECTIVE

To determine whether cricopharyngeal myotomy can improve dysphagia associated with head and neck cancer surgery.

DESIGN

Prospective, randomized, multicenter trial.

SETTING

Twelve clinical sites across the United States.

PATIENTS

Between 1989 and 1994, 125 patients undergoing combined modality therapy for head and neck cancer, including resection of the tongue base or supraglottic larynx, were prospectively entered into the trial.

INTERVENTION

Cricopharyngeal myotomy on a randomized basis.

MAIN OUTCOME MEASURES

Videofluoroscopic examination to determine oropharyngeal swallowing efficiency, which is defined as the ratio of percentage of the bolus swallowed to total swallowing time using 3 different bolus consistencies.

RESULTS

No significant difference in oropharyngeal swallowing efficiency between myotomy vs no myotomy was seen at 6 months of follow-up regardless of bolus consistency.

CONCLUSIONS

In this prospective test of cricopharyngeal myotomy, the procedure fails to significantly improve dysphagia associated with head and neck cancer surgery. The efficacy of this surgical procedure in other disease entities should also be rigorously explored.

Incidence of abnormal laryngeal findings in asymptomatic singing students

OBJECTIVE

Abnormalities in the mucosal lining of the vocal folds may interfere with the normal vibratory patterns and result in vocal limitations, especially for singers whose demands are great. A prospective, longitudinal study was undertaken to investigate the incidence of laryngeal abnormalities in asymptomatic singing students.

METHODS

Sixty-five singing students at the school of music underwent videostroboscopic evaluation and completed a comprehensive questionnaire. Videos were rated by 3 experienced clinicians, and interrater reliability was calculated. Results were correlated with demographic factors, background medical history, and singing history.

RESULTS

Five students (8.3%) exhibited early signs of benign vocal fold lesions (2 with nodules and 3 with cysts). A high incidence of posterior erythema (n = 44; 73.4%), suggesting possible reflux, was found.

CONCLUSIONS

A surprisingly high number of otherwise asymptomatic singing students demonstrated abnormal laryngeal findings. Their relationship with vocal performance will be addressed as well as implications for preventative measures.