The evolution of tonsil surgery and rethinking the surgical approach to obstructive sleep-disordered breathing in children

Within the last 10 to 15 years, a significant amount of research in tonsil surgery has focused on reduction of post-operative pain and recovery time. In order to minimize or avoid morbidity, a number of otolaryngologists in the United States and Europe have revived a historical procedure, previously known as ‘tonsillotomy’, specifically for those patients with obstructive sleep-disordered breathing (OSDB) due to adenotonsillar hypertrophy. More recently, surgeons have used terms such as partial tonsillectomy, partial intracapsular tonsillectomy or subtotal tonsillectomy to describe their procedure and have employed a variety of modern instrumentation. This return to a ‘partial’ procedure has generated a debate similar to that which occurred amongst tonsil surgeons about 100 years ago, when tonsillotomy was the most commonly performed procedure. Today, concerns about regrowth and problems with infection of the remaining tonsillar tissue have been raised. Such concerns, combined with an incomplete understanding of why the ‘partial’ procedure was abandoned in the early twentieth century, may explain why tonsil surgeons hesitate to change their approach to patients with OSDB due to adenotonsillar hypertrophy. These issues can be addressed in a meaningful way only through a detailed review of the evolution of tonsil surgery, which is presented here. This information, along with a summary of the last 10 years' experience with these techniques, supports the use of a ‘partial’ procedure in children with OSDB due to adenotonsillar hypertrophy. Future areas of research are also discussed.

Cervical presentations of thymic anomalies in children

OBJECTIVE

To better define the clinical manifestations, radiologic imaging and the surgical management of cervical thymic lesions in children.

STUDY DESIGN

Multi-center retrospective case review.

METHODS

The charts of all children with pathologically confirmed thymic lesions at six children's hospitals (1990-2002) were reviewed for demographics, physical findings, X-ray findings, operative outcomes and pathology.

RESULTS

There were a total of 15 children, 2 of whom had ectopic cervical thymus and 13 who had thymic cysts. They ranged in age from 1 month to 18 years. Thymic lesions were more common in males. Ectopic cervical thymus was best defined by MRI whereas thymic cyst had a more consistent appearance on CT. All children had successful surgical resection with no recorded complications or recurrences.

CONCLUSIONS

Cervical thymic lesions are rare. Ectopic cervical thymus tends to be found primarily in infants whereas thymic cysts occur in a wider age range. Radiologic imaging is important but is not histologically specific. Definitive diagnosis and cure requires complete surgical excision.

Rigid fixation of facial fractures in children

This article presents a retrospective analysis of a selective use of rigid fixation among 62 children with facial fractures, treated at a Level I trauma center over a 5-year period (1986-1991). There were 21 mandible fractures, 11 orbital fractures, 11 zygomaticomalar complex fractures, 7 nasal fractures, 5 maxillary fractures, 3 pan-facial fractures, 2 nasal-orbital-ethmoidal complex fractures, and 2 frontal sinus fractures. Only 18 children had rigid fixation of their injuries. Complications of Le Fort upper facial fractures repaired with rigid fixation involved perioperative sinusitis; one case required oral antibiotics, the other ethmoidectomy and maxillary antrostomy. One child with a Le Fort fracture had delayed exposure of a zygomaticomalar buttress plate, which required surgical removal. Permanent enophthalmos occurred in two children with Le Fort fractures. The authors conclude that traditional conservative management is appropriate in most cases. However, in children aged 13 and older with mandible fractures and children with complex mid- and upper facial fractures, a judicious use of rigid fixation has advantages over the traditional techniques.

The impact of airbags and seat belts on the incidence and severity of maxillofacial injuries in automobile accidents in New York State

OBJECTIVE

To evaluate the effect driver-side and passenger-side airbags have had on the incidence and severity of maxillofacial trauma in victims of automobile accidents.

DESIGN

Retrospective analysis of all automobile (passenger cars and light trucks) accidents reported in 1994.

SETTING

New York State.

PATIENTS

Of the 595910 individuals involved in motor vehicle accidents in New York in 1994, 377054 individuals were initially selected from accidents involving cars and light trucks. Of this subset, 164238 drivers and 62755 right front passengers were selected for analysis.

MAIN OUTCOME MEASURES

Each case is described in a single record with approximately 100 variables describing the accident, eg, vehicle, safety equipment installed and utilized or deployed, occupant position, patient demographics, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses, and procedural treatments rendered. A maxillofacial trauma severity scale was devised, based on the ICD-9-CM diagnoses.

RESULTS

Individuals using airbags and seat belts sustained facial injuries at a rate of 1 in 449, compared with a rate of 1 in 40 for individuals who did not use seat belts or airbags (P<.001). Those using airbags alone sustained facial injuries at the intermediate rate of 1 in 148, and victims using seat belts without airbags demonstrated an injury rate of 1 in 217 (P<.001).

CONCLUSION

Use of driver-side airbags, when combined with use of seat belts, has resulted in a decrease in the incidence and severity of maxillofacial trauma.

Comparison of power-assisted adenoidectomy vs adenoid curette adenoidectomy

OBJECTIVE

To compare the safety and efficacy of power-assisted adenoidectomy (PAA) vs adenoid curette adenoidectomy (ACA).

DESIGN

A prospective randomized study.

SETTING

Children's hospital of a tertiary care medical center.

PATIENTS

Ninety patients (aged 1-13 years) underwent PAA, and 87 patients (aged 1-12 years) underwent ACA.

MAIN OUTCOME MEASURES

The parameters evaluated were operative time, blood loss, completeness and depth of resection, injuries to surrounding structures, short- and long-term complications, surgeon satisfaction with the procedure, and parents' assessment of the patient's postoperative recovery period.

RESULTS

The PAA was 20% faster (P<.001) and had 27% less blood loss (P<.001) than the ACA. It provided a more complete resection(P<.001) and better control of the depth of resection (P<.05). Surgeon satisfaction was greater with PAA (P<.001). There was no difference in the recovery period or parent satisfaction. One patient in the PAA group returned to the operating room for control of postoperative bleeding, and 1 child in the ACA group returned to the hospital for postoperative dehydration.

CONCLUSION

The PAA provides a faster, dryer, more complete, and more surgically satisfying resection than the ACA.

Familial occurrence of acinic cell carcinoma of the parotid gland

We report the familial occurrence of acinic cell carcinoma involving the parotid gland, the first such report of which we are aware. The familial occurrence of any salivary gland neoplasm is rare. Several reports are present in the literature, including pleomorphic adenoma, Warthin tumor, carcinoma of the submandibular gland, and malignant lymphoepithelial lesion. We report the case of a 35-year-old man who underwent excision of a left parotid gland acinic cell carcinoma. Eight years later, his daughter presented at the age of 16 years with a nontender parotid gland mass that was excised and found also to be acinic cell carcinoma. The histologic features of both neoplasms were typical of acinic cell carcinoma. While this may represent a coincidental event, the possibility that this familial occurrence is a manifestation of common genetic or environmental risk cannot be excluded.

Evaluation of orbital stress dissipation in pediatric and adult skulls using electronic speckle pattern interferometry

OBJECTIVES

To measure and quantitatively compare the degree of force dissipation in pediatric and adult skulls subjected to similar dynamic forces.

DESIGN

An anatomical study using electronic speckle pattern interferometry, which allows generation of displacement vectors after application of a force.

SUBJECTS

Five human skulls (3 pediatric and 2 adult).

INTERVENTION

Each skull was subjected to a reproducible and quantifiable force created by a steel ball pendulum striking a precise periorbital focus: (1) infraorbital foramen, (2) supraorbital notch, (3) malar eminence, and (4) nasofrontal suture. Electronic speckle pattern interferometry was used to construct interferogram fringe patterns to determine skull regions with the greatest degree of displacement.

RESULTS

Interferogram analysis revealed that the adult skull has a tendency to dissipate force with minimal resultant displacement. In contrast, the pediatric skulls demonstrated greater displacements (ie, increased fringe density) at the same periorbital foci.

CONCLUSIONS

The pediatric skull dissipates periorbital stress differently than the adult skull, as illustrated by quantitative interferogram analysis. This finding parallels clinical data that demonstrate a varying pattern of fractures in pediatric and adult skulls related to craniofacial development.

Pediatric mandibular fractures

Over the last 20 years, a revolution in the management of facial fractures has taken place. Refinements in biocompatible materials of great delicacy and strength along with advances in our understanding of biomechanics of the face, have rendered complex injuries consistently amenable to accurate 3-dimensional reconstruction. Furthermore, with the availability of education in the techniques of internal rigid fixation, these advanced techniques have become routine practice in adults. However, the suitability of rigid internal fixation for children remains controversial. There are many concerns about the effect of implanted hardware in the mandible of a growing child. In addition, some evidence suggests that the elevation of functional matrix off of bone may result in alterations in development. The goal is to restore the underlying bony architecture to its pre-injury position in a stable fashion, with a minimal of aesthetic and functional impairment. However, in children the treatment of bony injuries is most easily accomplished by techniques that may adversely effect craniofacial development. While it is not entirely possible to resolve this dilemma, there exists an extensive body of experimental and clinical information on the appropriate management of pediatric mandibular fractures which can be used to formulate a rational treatment plan for most cases. This paper presents an overview of the contemporary understanding and application of these treatment principles.

Starplasty: a new technique of pediatric tracheotomy

OBJECTIVE

To report a new technique of pediatric tracheotomy that reduces the problems of pneumothorax and recannulation after accidental decannulation in a recently performed tracheotomy.

DESIGN

Retrospective chart review for 1990-1997.

PATIENTS

Sixty-eight children aged between 2 days and 14 years.

METHOD

The starplasty procedure is based on the geometry of a 3-dimensional Z-plasty. The technique of the procedure is described and illustrated in detail.

RESULTS

There were 27 short-term complications, including 4 accidental decannulations. There were no instances of pneumothorax or tracheotomy-related deaths. There were 25 long-term minor complications. There were no instances of tracheotomy-related death, suprastomal collapse, or tracheal stenosis. Thirty-eight children remain tracheotomy tube dependent, 17 underwent decannulation, 7 died of primary disease, and 6 were lost to follow-up. All 17 children who underwent decannulation have a persistent tracheocutaneous fistula.

CONCLUSIONS

I conclude that starplasty reduces the incidence of major complications and death. Its only drawback seems to be persistent tracheocutaneous fistula.

Safety of powered instrumentation for adenoidectomy

A recent study established the utility of an endoscopic shaver for adenoidectomy in children by the transoral approach and showed that power assisted adenoidectomy (PAA) was significantly faster with a trend toward decreased blood loss. The purpose of this study was to demonstrate the safety of power assisted adenoidectomy in a large cohort of patients. A retrospective review was performed of 329 patients who had adenoidectomy by powered instrumentation. Postoperative complications were documented and compared with a similar group that had curette adenoidectomy. Complications watched for included prolonged recovery, postoperative hemorrhage, readmission for dehydration, velopharyngeal insufficiency, and nasopharyngeal stenosis. No postoperative complications were seen in the power assisted adenoidectomy group. This review confirms the safety of power assisted adenoidectomy.

First branchial cleft anomalies: a study of 39 cases and a review of the literature

OBJECTIVES

To identify the clinical and anatomical presentations and to discuss the guidelines for surgical management of anomalies of the first branchial cleft.

DESIGN

Retrospective study.

SETTING

Three tertiary care centers.

PATIENTS

Thirty-nine patients with first branchial cleft anomalies operated on between 1980 and 1996.

INTERVENTION

All patients were treated surgically. Complete removal of the lesion required superficial parotidectomy with facial nerve dissection in 36 cases. The relationship of the facial nerve and anomalies is discussed.

RESULTS

Anatomically, 3 types of first branchial cleft anomalies are identified: fistulas (n=11), sinuses (n=20), and cysts (n=8). Clinically, 3 types of presentation are noted: chronic purulent drainage from the ear (n=12), periauricular swelling in the parotid area (n=18), and abscess or persistent fistula in the neck located above a horizontal plane passing through the hyoid bone (n=21). A membranous attachment between the floor of the external auditory canal and the tympanic membrane was observed in 10% of cases. The facial nerve was located lateral to the anomaly in 39% of cases.

CONCLUSIONS

Before definitive surgery, many patients (n=17) underwent incision and drainage for infection owing to the difficulties in diagnosing this anomaly. Wide exposure is necessary in most cases, and a standard parotidectomy incision allows adequate exposure of the anomaly and preservation of the facial nerve. Complete removal without complications depends on a good understanding of regional embryogenesis, a knowledge of the circumstances surrounding discovery, an awareness of the different anatomical presentations, and a readiness to identify and protect the facial nerve during resection.

Power-assisted adenoidectomy

OBJECTIVE

To quantify that the use of powered instrumentation for adenoidectomy is an improvement over traditional techniques.

DESIGN

Retrospective case series of 40 consecutive children undergoing power-assisted adenoidectomy compared with 40 consecutive children undergoing conventional transoral adenoidectomy with a curet.

SETTINGS

Tertiary care center.

MAIN OUTCOME MEASURES

Operative time, blood loss, length of hospitalization, and complications.

RESULTS

With power-assisted adenoidectomy, the mean operative time was significantly faster (11 minutes vs 19 minutes for the conventional method), mean blood loss was not significantly different (22 mL vs 32 mL for the conventional method), mean length of hospitalization after the procedure was not significantly different (2.95 hours vs 2.8 hours for the conventional method), and there were no surgical complications with either technique.

CONCLUSION

In comparison with conventional techniques, power-assisted adenoidectomy provides significant advantages that are subjectively apparent but can also be objectively measured.

p53 protein expression in benign lesions of the upper respiratory tract

OBJECTIVE

p53 is a tumor suppressor gene that is lost or mutated in most forms of human malignancy. There are, however, very few studies evaluating p53 expression in normal epithelium or benign lesions.

DESIGN

We screened for p53 protein expression in a variety of benign epithelial lesions of upper respiratory tract using monoclonal antibody DO-1 on paraffin-embedded material.

SUBJECTS

We studied a total of 109 cases: 16 cases of juvenile and 36 cases of adult laryngeal papillomatosis, 10 cases each of laryngeal nodules and laryngeal polyps, 17 cases of inverted papilloma, and 20 cases of nasal polyps.

RESULTS

Nuclear immunoreactivity for p53 protein was demonstrated in 14 (88%) of 16 cases of juvenile laryngeal papillomatosis, 33 (92%) of 36 cases of adult laryngeal papillomatosis, 4 (40%) of 10 cases of laryngeal nodules, 8 (80%) of 10 cases of laryngeal polyps, 7 (41%) of 17 cases of inverted papilloma, and 2 (10%) of 20 cases of nasal polyps. These results pertained only to the basal epithelial layer in all cases of laryngeal nodules, laryngeal polyps, and nasal polyps. Intermediate layer cells were also positive for p53 in the majority of the cases of both juvenile (69%) and adult (75%) laryngeal papillomatosis and in a minority of the cases of inverted papilloma (18%).

CONCLUSIONS

Overexpression of p53 protein is commonly demonstrable in benign epithelial lesions of the upper respiratory tract. This observation suggests that p53 protein accumulation may occur in the absence of mutation of the p53 gene and may correlate with epithelial proliferative activity.

Management of facial trauma in children

In today's fast-paced society, many children sustain severe maxillofacial injuries that require surgical reconstruction. The factor that differentiates the treatment of pediatric facial fractures from those of adults is facial growth. Anticipation of mandibular growth facilitates repair because most injuries can be treated with intermaxillary fixation. Midfacial injuries, on the other hand, may be more sensitive to alterations of facial growth, and complex cases require more sophisticated correction. The techniques of three-dimensional reconstruction of complex facial fractures has been facilitated greatly by the use of a rigid plating system, wide craniofacial exposure, and bone grafting. These techniques have sound theoretic and practical applications in severe pediatric facial trauma.

Orbital fractures in children

OBJECTIVE

To determine if the pattern of orbital fractures may be influenced by the changing craniofacial ratio of the growing child, as the orbit is the boundary between the face and the cranium.

DESIGN

Retrospective case series of 40 patients between the ages of 1 year and 16 years with orbital fractures.

SETTING

The Albany (NY) Medical Center Hospital, a tertiary level 1 trauma center.

OUTCOME MEASURES

The sex, age, site, and mechanism of injury, associated injury, and treatment methods for children admitted to the Albany Medical Center Hospital with orbital fractures between July 1986 and June 1992.

RESULTS

Fourteen children had fractures of the orbital roof, 10 children had fractures of the orbital floor, 14 children had mixed fractures, and two children had fractures of the medial wall. The mean age (4.8 +/- 3.3 years) of the 14 patients with roof fractures was significantly less than the mean age (12.0 +/- 4.2 years) of the 26 children with other orbital fractures. Logistic regression demonstrated that the age at which the probability of lower orbital fractures exceeds the probability of orbital roof fractures is 7.1 +/- 1.0 years. Orbital roof fractures had a significantly greater likelihood of associated neurocranial injuries. The need for surgical repair was significantly lower among children with roof fractures as well as among children 7 years of age and younger.

CONCLUSIONS

Orbital roof fractures are a type of skull fracture that occur primarily in younger children as a consequence of the proportionally larger cranium and the lack of frontal sinus pneumatization. Lower orbital fractures are a type of facial fracture that occur primarily in older children as a consequence of the increased vulnerability of the face due to growth and the pneumatization of the paranasal sinuses.

Treatment of experimental frostbite with pentoxifylline and aloe vera cream

OBJECTIVE

To compare the therapeutic effects of systemic pentoxifylline and topical aloe vera cream in the treatment of frostbite.

DESIGN

The frostbitten ears of 10 New Zealand white rabbits were assigned to one of four treatment groups: untreated controls, those treated with aloe vera cream, those treated with pentoxifylline, and those treated with aloe vera cream and pentoxifylline.

MAIN OUTCOME MEASURES

Tissue survival was calculated as the percent of total frostbite area that remained after 2 weeks.

RESULTS

The control group had a 6% tissue survival. Tissue survival was notably improved with pentoxifylline (20%), better with aloe vera cream (24%), and the best with the combination therapy (30%).

CONCLUSION

Pentoxifylline is as effective as aloe vera cream in improving tissue survival after frostbite injury.

Transsphenoidal hypophysectomy through the external rhinoplasty approach

The external rhinoplasty approach is a refinement of the well-recognized sublabial transseptal technique for transsphenoidal hypophysectomy first introduced by Cushing in 1910. This article relates our experience with 111 cases of transsphenoidal hypophysectomy performed during a 10-year period (1982-1992) and includes a detailed description of our use of the external technique. Fifty-one patients were male, and 60 were female. Ages ranged from 12 years to 80 years, with an average of 46 years. One hundred one patients had pituitary adenomas, four had craniopharyngiomas, two had inverting papillomas, and there was one each of lymphoma, metastatic prostate cancer, pituitary abscess, and posttraumatic cerebrospinal fluid leak. Nine of the operations were for recurrent adenomas. Complications included 8 symptomatic anterior septal perforations and 13 asymptomatic posterior perforations. Five had transient cerebrospinal fluid rhinorrhea, five had perioperative hemorrhages, two had minor postoperative columellar deformities, and one had injury to the internal carotid artery requiring embolization. We have found the external technique for transsphenoidal hypophysectomy to be a reliable and facile means for nasal exposure of the sphenoid sinus and pituitary gland without loss of nasal tip projection or significant cosmetic deformity.

Effects of air pollution on the upper respiratory tract of children

The impact of the environment on the upper respiratory tract of children has become an issue of recent interest. Sulfur dioxide causes nasal congestion in children as well as an increase in both mast cells and lymphocytes in nasal lavage fluids. Chlorpheniramine blocks the effect of sulfur dioxide on the nasal mucosa. Ozone exposure results in nasal congestion, increased levels of histamine, neutrophils, eosinophils, and mononuclear cells in nasal lavage fluid. No data are available on the effects of nitrogen dioxide or wood-burning stoves on the upper respiratory tracts of children. Formaldehyde in sufficient concentrations causes upper airway irritation; however, no data are available on its long-term effects. Detriments in air quality cause adverse changes in the lower respiratory tracts of susceptible individuals. The effects on the upper respiratory tract are more difficult to document. There may be a causal relationship, but definitive proof of whether air pollution results in significant increases in pediatric otitis media, sinusitis, rhinitis, and pharyngitis has yet to be demonstrated.

Lateral cervical radiographs and adenoid size: do they correlate?

Clinicians have questioned the value of lateral soft tissue neck x-ray (LSTN) in assessing adenoid size. Elaborate cephalometric assays have been devised to measure degree of nasopharyngeal obstruction secondary to adenoid hypertrophy. This study prospectively studied 73 children, aged 11 months to 13 years, with clinical evidence of adenoid hypertrophy to assess how well a LSTN correlates with direct intraoperative observation of adenoid size and nasopharyngeal obstruction. We found a relatively weak correlation (Pearson coefficient r = 0.34) between x-ray and operative observations. We conclude that LSTN is an appropriate examination in the preoperative assessment of children being considered for adenoidectomy. However, this test must be interpreted by recognizing the inherent limitations of evaluating a dynamic structure, such as the nasopharynx, through a non-dynamic modality.

The external rhinoplasty approach for rhinologic surgery

The technique of external rhinoplasty has enjoyed a renaissance over the last ten years, primarily for cosmetic and functional septorhinoplasty, and we have found this to be an effective method for nasal reconstruction. Moreover, we have recognized the versatility of this approach for a variety of rhinologic problems and have utilized it for transsphenoidal hypophysectomy, sphenoidotomy, unilateral choanal atresia, septal perforation, nasal valvuloplasty and rhinophyma. We describe our technique and the rationale for employing it. We conclude that the enhanced exposure provided by the cutaneous decortication of the nose facilitates surgery of both the soft tissues and the supportive architecture of the nose.

Swallowing disorders in a population of children with cerebral palsy

One of the disabilities in patients with cerebral palsy (CP) is dysphagia. To establish the prevalence of dysphagia in a population of children with CP, and to determine if any factors are related to dysphagia, we studied 56 CP patients, 5-21 years, enrolled in a primary school for the disabled. Fifteen patients (27%) had either radiographic or clinical evidence of dysphagia. These 15 patients were compared to the remaining 41 patients without dysphagia. Using data obtained from chart review and interviews with speech pathologists, several factors that contributed to dysphagia were found. These included: bite reflexes, slowness of oral intake, poor trunk control, inability to feed independently, anticonvulsant medication, coughing with meals, choking, and pneumonia. We also noted trends in the following factors: presence of tongue thrusting, presence of drooling, severity of CP, poor head control, severity of mental retardation, seizures, and speech disorders. Factors not related to the presence of dysphagia include: subject age, cause of CP, and type of CP. Early, aggressive work-up and identification in CP patients with the risk factors outlined above can reduce the associated pulmonary complications.

Tracheal agenesis

Tracheal agenesis is a catastrophic congenital anomaly that invariably results in death. Forty-seven cases have been previously reported in the literature. We add five additional cases, including two type 1 cases, two type 2 cases, and one type 3 cases, based on Floyd's classification scheme. We describe the features of this unusual anomaly at the time of diagnosis. We discuss a rational approach to the management of this difficult problem on an emergent basis that allows for the maintenance of the infant's life until all of the implications of this fatal condition can be assessed. While we do not advocate reconstructive surgery for this anomaly, which has been universally fatal, we discuss the potential rearrangement of the anatomy, which may offer some hope in future cases. The concomitant congenital anomalies associated with these cases are reviewed, and autopsy specimens are presented for their anatomic interest.

The external rhinoplasty approach for rhinologic surgery in children

The external rhinoplasty is a versatile approach for exposing nasal anatomy in children and has been utilized for a variety of rhinologic problems (N = 35). These have included septal deviation (11), cleft lip nasal deformity (10), unilateral choanal atresia (five), nasal dermoids (four), and problems of the sphenoidal sinus (five). For children with septal deformities, the external approach allows complete intranasal visualization, providing access for careful and conservative reconstruction. In children with cleft lip nasal deformity, decortication allows for direct sculpting of the alar cartilages. For unilateral choanal atresia, the external technique provides exposure of the posterior vomer as in the transpalatal approach, but without the risk to palatal growth. For nasal dermoids, the open rhinoplasty offers wider exposure with more control over the medial osteotomies, a better view of the cribriform plate, and enhanced cosmesis. For problems of the sphenoid, the external route utilizes the guiding midline intranasal structures for rapid and direct entry into the sinus. In our study, the age range of the children was between 7 months and 18 years. The range of follow-up was between 6 months and 5 years. The techniques for the individual procedures are described, along with a rationale for their employment. There were no postoperative complications, and no long-term problems associated with the use of the external technique. In conclusion, the enhanced exposure provided by the external rhinoplasty approach in children facilitates rhinologic procedures on the soft tissues of the nose and the nasal architecture, as well as in the central core of the face.

Chlamydia trachomatis in the etiology of acute otitis media

In an effort to show that Chlamydia trachomatis (CT) may be involved in the causation of acute otitis media (AOM), we performed three experiments. In the first, we inoculated the tympanic bullae of 6 chinchillas with CT. Five of the 6 inoculated animals developed CT AOM. In the second experiment, we sprayed the nasopharynx of 10 chinchillas with CT. Of these, 8 developed both pharyngitis and AOM, and in 6, live CT was cultured from the middle ear and pharynx. In the third experiment, 5 chinchillas had their conjunctiva inoculated with CT. Three developed CT conjunctivitis. Of these, 2 developed CT pharyngitis and 1 developed CT AOM. We concluded that CT will cause AOM in the chinchilla by direct inoculation into the middle ear as well as indirectly by infection of the nasopharynx and conjunctiva.

Applied nasal anatomy & embryology

The embryology & anatomy of the nose as it is applied to rhinoplasty is surveyed so that the surgeon in training can develop a basis from which to review the literature. This review demonstrates the need for the consolidation and clarification of the nomenclature associated with the complex anatomy of the nasal pyramid.

The external rhinoplasty for the correction of unilateral choanal atresia in young children

The external rhinoplasty approach has been utilized in three young children for the correction of unilateral choanal atresia. It has been demonstrated to be technically feasible to utilize this technique in young children. It provides excellent exposure of the atresia plate with the ability to correct the atresia in a precise and confident way. This technique is an elegant alternative to transnasal puncture and transeptal resection.

External rhinoplasty approach to transsphenoidal hypophysectomy

The external rhinoplasty approach is a modification of the well recognized transseptal transsphenoidal hypophysectomy technique first introduced by Cushing in 1910. Our approach has been used successfully in 75 cases over a six year period, demonstrating its efficacy and safety. It provides a simple, reliable, rapid technique for exposing the septum and the floor of the nose with excellent exposure to the sphenoid sinus and pituitary gland. There has been no loss of nasal tip projection or other cosmetic deformity.

Endoscopic repair of supraglottic laryngeal clefts

We describe the technique of endoscopic diagnosis and endoscopic surgical repair used in the management of supraglottic interarytenoid laryngeal clefts in 11 children seen between 1981 and 1988 at the Hospital for Sick Children, London, England. Six of the children had primary type I clefts that required endoscopic repair. The symptoms included inspiratory stridor, choking during eating, and aspiration. Five of the children had previous transcervical repair of type II clefts that had partial breakdown in the interarytenoid area causing symptoms of aspiration, which required secondary repair endoscopically. All the patients had successful microlaryngoscopic closure; in two children, however, the breakdown of the repair necessitated repeated endoscopic correction. The only complication occurred in a case of postoperative supraglottitis, which was successfully managed with intubation and antibiotics. We conclude that endoscopic repair is a useful and reliable technique and an elegant alternative to the open transcervical approach for the closure of supraglottic laryngeal clefts.

Early complications of airway management in head-injured patients

Head-injured patients are frequently young, healthy individuals whose excellent medical condition is suddenly altered by trauma. The purpose of this study is to evaluate the early complications of airway management which occur in head-injured patients and to determine if these are different from what has been reported in patients with chronic illnesses (i.e., diabetes, atherosclerosis, or immunosuppression). Chart review of 52 head-injured patients reveals an early complication rate of 61% for endotracheal intubation and 20% for tracheotomy. Discriminant analysis shows that increasing duration of intubation is the most significant factor in predicting airway management complications (P less than 0.008). The incidence of complications seen in head-injured patients is similar to that of the chronically ill. Complications of endotracheal intubation are judged to be more severe than those of tracheotomy. Data from this study supports the early tracheotomy of severely head-injured patients who are likely to require prolonged airway management.

Bacterial antigens and neutrophil granule proteins in middle ear effusions

Otitis media with effusion is a significant cause of hearing loss in young children. We hypothesized that persistent bacterial antigens in middle ear effusions (MEEs) might act as chronic inflammatory stimuli causing release of neutrophil proteins. Concentrations of neutrophil lactoferrin and a 37-kd cationic bactericidal protein (CAP 37) were measured in 47 MEEs collected from 27 children at the time of tympanostomy tube placement. Antigens of Streptococcus pneumoniae were detected by latex particle agglutination and those of Haemophilus influenzae by dot-blot assay. Bacterial antigens were detectable in 24 (51%) of MEEs: S pneumoniae in 10 (21%), H influenzae in 12 (26%), and both antigens in 2 (4%). Concentrations of lactoferrin and CAP 37 in H influenzae antigen-positive MEEs were significantly higher than in either S pneumoniae antigen-positive or antigen-negative MEEs. We conclude that H influenzae antigen causes a greater middle-ear inflammatory response, as judged by neutrophil products, than does S pneumoniae antigen.

Predictive value of the Glasgow Coma Scale for tracheotomy in head-injured patients

Patients with severe head trauma often require prolonged intubation and subsequent tracheotomy. The Glasgow Coma Scale (GCS), an indicator of the severity of head injury, may help identify that subpopulation of trauma victims who will ultimately undergo tracheotomy. This retrospective study demonstrates through discriminant analysis that the likelihood of tracheotomy is significantly greater in patients with a GCS rating less than or equal to 7 than it is in patients with a GCS rating greater than 7 (p = .0001). Conversely, the presence of thoracoabdominal or maxillofacial injury is associated with but not predictive of eventual tracheotomy. In the hope of minimizing complications and enhancing the utilization of hospital resources, this study argues for early tracheotomy in patients with a GCS score less than or equal to 7 who do not undergo craniotomy and are otherwise stable.

Sternomastoid tumor of infancy

Sternomastoid tumor of infancy (SMTI) is the most common cause of neck mass in the perinatal period. We present seven children with this disorder, six studied prospectively. Ages at presentation ranged from 1 week to 4 weeks. Five had a history of birth trauma. Torticollis with facial asymmetry was seen in two. In six the diagnosis of SMTI was made clinically, and these patients were managed conservatively with massage and controlled stretching of the neck. Resolution of the neck mass, the torticollis, and the facial asymmetry occurred in all patients. Pathologic and radiographic findings are presented. We conclude that careful clinical assessment precludes the necessity of biopsy and emphasize the importance of conservative management of this transient problem.

Comparison of computed tomography and magnetic resonance imaging in chronic otitis media with cholesteatoma

We prospectively studied 10 patients with chronic otitis media suspected of having cholesteatoma with computed tomography and magnetic resonance imaging to assess which imaging modality would be most specific in predicting the presence of cholesteatoma. The interpretation of images was then correlated with the operative findings. In 9 of the 10 cases, computed tomography accurately predicted the extent and destructiveness of the disease but did not consistently differentiate between cholesteatoma and associated granulation tissue. In 2 of the 10 cases, the T1-weighted magnetic resonance imaging demonstrated high signal, suggestive of cholesteatoma. In one case, magnetic resonance imaging predicted cholesteatoma on the basis of bony destruction. However, in 7 of 10 cases the scan was nonspecific for cholesteatoma. We conclude that high-resolution computed tomography remains the primary imaging modality for chronic otitis media.

Noninvasive imaging of the normal temporal bone. Comparison of sagittal surface coil magnetic imaging and high-resolution computed tomography

High-resolution computed tomography (HRCT) is a noninvasive technique for evaluating the middle ear for primary and recurrent cholesteatoma. However, a limitation of HRCT is that it cannot differentiate between cholesteatoma and granulation tissue. Magnetic resonance imaging (MRI) is a noninvasive, nonradiologic technique that has been effective in demonstrating histochemical differences between various soft tissues. We present images from a normal living subject's temporal bone in the sagittal plane obtained with both HRCT and MRI. Anatomic correlates in the same cut planes are presented. The HRCT provided excellent detail of the bony landmarks within the temporal bone and was used as the reference for the MRI. The soft-tissue structures such as cranial nerves, cochlea, vestibule, and semicircular canals were identified.

Airway complications from laryngoscopy and panendoscopy

Laryngoscopy and panendoscopy can cause airway complications. To determine the risk to the airway from reintubation following general anesthesia in otolaryngology patients, we examined recovery room and anesthesia records at the Albany Veterans Administration Medical Center covering a 10-year period. From this information we determined the incidence of recovery room reintubation and studied airway risk factors associated with otolaryngologic endoscopy. From 1975 to 1984, 10,060 surgical patients were intubated at the Albany VA Medical Center. Only 17 patients (0.17%) required reintubation. Of 1,365 otolaryngology patients intubated during the same period, 324 had laryngoscopy and 302 had panendoscopy. Significantly, four laryngoscopy patients (1.2%) and nine panendoscopy patients (3%) required recovery room intubation. Nine endoscopy patients needed reintubation within 1 hour of extubation. We conclude that the risk of postoperative airway compromise is significantly greater among patients who underwent diagnostic laryngoscopy and panendoscopy than among patients who had general anesthesia for other reasons.

Three dimensional CT reconstruction for the evaluation and surgical planning of facial fractures

Despite advances in radiology--including CT scanning--the three-dimensional (3D) nature of facial fractures must still be inferred by the spatial imagination of the physician. A computer system (Insight Phoenix Data Systems, Inc., Albany, N.Y.) uses CT studies as substrate for 3D reconstructions. We have used the Insight computer for the evaluation and surgical planning of facial fractures of 16 patients with complex injuries. We present five illustrative cases, directly photographed from the computer monitor. Images can also be manipulated in real time by rotating or planar sectioning (functions best appreciated on video). The ability to cybernetically extract the facial skeleton from living subjects provides precise anatomic data previously unobtainable. The images are valuable for an accurate assessment of the relationship between the injured and uninjured sections of the face. We conclude that 3D reconstruction is an important advance in the treatment of facial fractures.

External rhinoplasty approach to transsphenoidal hypophysectomy

The history of transsphenoidal hypophysectomy demonstrates the soundness of the basic concept of approaching the sella turcica in a midline fashion through the nose. Conceptually, it has not been eclipsed since first evolved by Cushing in the early part of this century. The surgical advances since Cushing's time have been major refinements in instrumentation and minor refinements of his basic technique. The external rhinoplasty approach is such a refinement. We have used this technique in a two-year period between June 1982 and June 1984 on 14 patients. We have found this technique for transsphenoidal hypophysectomy to be a simple, reliable, rapid technique for exposing the septum and the floor of the nose. It provides excellent exposure to the sphenoid sinus and pituitary gland without loss of nasal tip projection or other cosmetic deformity.

The pectoralis myocutaneous flap for salvage of necrotic wounds

The authors have utilized six pectoralis major myocutaneous flaps in attempts to salvage extensive necrotic wounds of the pharynx and neck. The flap was employed in the following situations: massive necrosis of the entire neck skin with both carotid artery systems exposed, radiation necrosis of the neck skin with exposure of carotid artery, dehiscence of gastric pull-up from pharynx with resultant carotid exposure, failed trapezius flap in a radionecrotic oral cavity, and two cases of pharyngocutaneous fistula with extensive soft tissue necrosis. These flaps achieved healing in all cases. One death occurred 3 weeks following complete cutaneous healing secondary to a ruptured carotid pseudoaneurysm. One flap underwent total skin loss but the entirety of the muscle survived and the fistula was successfully closed with the back of the muscle being subsequently skin grafted. One case of dehiscence of the flap from oral mucosa resulted in a minor exposure of mandible with limited osteoradionecrosis controlled by topical means. This flap has performed extremely well in these precarious and difficult situations that previously may not have been salvageable. It has also been effective in abbreviating the required hospitalization and wound care. We conclude that the pectoralis myocutaneous flap should be the primary choice for the management of extensive postsurgical wound necrosis.

Pseudomonas aeruginosa in chronic maxillary sinusitis

Pseudomonas aeruginosa (Ps. Au.) infection of the maxillary sinus has been reported as an incidental finding on routine antrostomy; however, it has also been noted in several studies as the significant organism in the etiology of chronic sinusitis. Four case reports of culture verified Ps. Au. maxillary sinusitis are presented. The therapeutic modality used in two of the cases was a Caldwell-Luc operation and in two, an intranasal antrostomy. In all cases, multiple irrigations through the surgically created nasoantral windows were done postoperatively, as was the instillation of gentamicin ophthalmic drops intranasally. In all four cases the infection cleared with this combined surgical and medical therapy.

Evaluation of three cyanoacrylate glues for ossicular reconstruction

We evaluated and compared the separate effects of ethyl, isobutyl, and fluoroalkyl cyanoacrylate on the promontory mucosa and surgically disarticulated incudostapedial joint in the adult cat middle ear. The animals were sacrificed at 10-, 30-, and 60-day intervals after glue application. All three cyanoacrylates elicited a chronic inflammatory response when placed directly on the promontory mucosa. The use of ethyl and isobutyl cyanoacrylate resulted in persisting discontinuity of the incudostapedial joint with erosion of the incus. Fluoroalkyl cyanoacrylate maintained incudostapedial continuity without ossicular erosion. Ethyl and isobutyl cyanoacrylate are probably not appropriate for middle ear surgery. The less toxic fluoroalkyl cyanoacrylate may be useful as an ossicular adhesive in selected cases. Our findings are further contrasted with those obtained in similar studies with methyl and butyl cyanoacrylate. The effects of each of the five cyanoacrylates are reviewed in the continuing search for a safe and effective ossicular adhesive.

Dermal graft for protection of the pharyngeal suture line in cancer surgery of the head and neck

We studied the effect of free buried dermal grafts to primary pharyngeal closures among 24 nonirradiated patients undergoing radical head and neck surgery to determine if this technique would reduce the incidence of postoperative pharyngocutaneous fistula. For a control group we selected 23 patients who had undergone similar operations as the patients in the study group, but who did not have dermis used for pharyngeal protection. Our results indicate that dermal grafts do not alter the incidence of fistulization following cancer surgery of the head and neck.

A first branchial cleft anomaly within the parotid gland

Although the parotid glands are affected more frequently by cysts and congenital lesions than other salivary glands, the benign multigerminal cyst arising from a duplication anomaly of the first branchial cleft within the parotid gland is extremely rare. Forty-two cases of this unusual cause of parotid swelling have been reported in the literature. An example of a first branchial cleft anomaly appearing clinically as a parotid tumor is reported.