Abstract
6:30 to 7:45 AM (breakfast provided)
Grand Hyatt Washington: Independence
A
Supported by:
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J David Osguthorpe MD (moderator); James A Stankiewicz MD; John Fornadley MD
Charleston SC; Maywood IL; Palmyra PA
Educational Objectives: To understand how practice parameters in general are developed and to understand how the specific parameters of allergic rhinitis and rhinosinusitis are developed.
Description of Symposium: The federal Agency for Health Care Policy and Research and the American Medical Association are involved in the development of practice parameters for the treatment of various medical conditions. The American Academy of Otolaryngology-Head and Neck Surgery, the American Academy of Otolaryngic Allergy, and the American Rhinologic Society have promulgated practice parameters on allergic rhinitis and on rhinosinusitis. Symposium attendees will be provided an overview on how practice parameters are developed and then specific recommendations for managing patients with allergic rhinitis or rhinosinusitis (acute and chronic).
6:30 to 7:45 AM
(breakfast provided)
Grand Hyatt Washington: Constitution B
Supported by:
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James A Hadley MD (moderator); Jack B Anon MD; Michael D Poole MD PhD
Rochester NY; Erie PA; Houston TX
Educational Objectives: With resistance rates rising for current antibiotics, knowledge of surveillance data, pharma-cokinetics, and pharmacodynamics in antimicrobials should assist the physician's appropriate choice of therapy.
Description of Symposium: The rational utilization of antibiotics for respiratory tract infections including otitis, rhinosinusitis, and pharyngitis has been scrutinized due to the increasing incidence of resistant bacteria. Surveillance studies continue to demonstrate a rise in the number of infections produced by resistant bacteria.
MICs and MBCs are the common parameters used to identify the activity of an antibiotic against a specific bacteria. They may determine the potency of the drug to the infecting organism, but they provide no information regarding the time course of antimicrobial activity.
Pharmacokinetics describes the absorption, distribution, and elimination of drugs. Pharmacodynamics describes the relationship between serum concentrations and the pharmacologic effect of the antimicrobial agent. Knowledge of the mechanisms of resistance of bacteria along with utilization of current surveillance studies of bacterial isolates assists the clinician otolaryngologist in the appropriate choice of antibiotic therapy for respiratory tract infections.
8:00 to 9:30 AM WCC Room 30
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William R LaMear MD; Toni M Ganzel MD (moderators)
8:00 AM
Renee A Hillhouse DO (presenter); Zubair A Syed MD Joplin MO
Objectives: Tonsillectomy with or without adenoidectomy is one of the most common surgical procedures, particularly in a pediatric population. Many techniques have been described in the literature. The ultrasonic dissector coagulator (Harmonic Scalpel [HS]; Ethicon Endo-Surgery Inc, Cincinnati, OH) has been well studied in the general surgery literature. Using quality-of-life criteria, this pilot study prospectively evaluates whether the HS's unique properties offer advantages over traditional electrocautery (EC) tonsillectomies in regards to postoperative pain, return to regular diet, and bleeding complications.
Methods: A prospective study involving 146 tonsillectomies within a 5-month period was performed. Eighty-nine patients had EC tonsillectomies, and 57 had HS tonsillectomies. Parameters, such as return to regular diet, return to activity, and use of postoperative pain medications, were monitored for each patient with a brief questionnaire. Complications, such as increased perioperative and postoperative bleeding, were monitored by the surgeon and by chart review.
Results: In total, 146 questionnaires were sent, and 81 were returned, 40 from the HS patients and 41 from the EC patients. The age range was 2 to 18 years (mean 6.8 years). The mean ages of the HS and EC groups were 6.5 and 7.3 years, respectively. Seventy percent of the HS patients returned to a regular diet in 24 to 72 hours, compared to 54% of the EC group. This was statistically significant (P < 0.01). Seventy-three percent of the EC patients took the prescribed pain medication every 4 to 6 hours versus 67% of the HS patients (P < 0.007). Regular activity in 24 hours was greater for the HS group (33% vs 15%). In the population group younger than 7 years, 54% returned to a regular diet in 24 hours versus 36% of EC patients (P < 0.004). Forty-three percent (n = 12) of the HS group returned to regular activity within 24 hours versus 16% (n = 4) of the EC group (P < 0.05). There were 2 late postoperative bleeding episodes in the EC group.
Conclusion: It appears from this early pilot study that the HS tonsillectomy offers advantages of early return to diet and activity over standard EC tonsillectomies. This is particularly advantageous in our group aged 7 years and younger. We report no increase in perioperative or postoperative bleeding with the use of the HS. Additional studies are needed to further evaluate this new device for tonsillectomies.
8:08 AM
Michael G Stewart MD MPH (presenter); Rhoda Wynn; Spiros Manolidis MD
Houston TX
Objectives: To study the practice patterns and adherence of practicing physicians to an evidence-based practice guideline (PG) on pediatric otitis media, which was developed by the Agency for Health Care Policy and Research using a rigorous data-driven methodology and multidisciplinary approach, including otolaryngologists, pediatricians, audiologists, etc. The results and recommendations from this PG have been disseminated to physicians, the media, and the public in multiple independent publications and on the Internet, and the findings have also been referenced in other manuscripts and publications. However, it is not clear that the recommendations from this PG are being followed by practicing physicians. We performed this study to assess the current knowledge base and adherence to this PG among practicing otolaryngologists and pediatricians.
Methods: A survey study of 1000 physicians was performed; 500 otolaryngologists and 500 pediatricians were randomly selected from the memberships of the AAO-HNS and the American Academy of Pediatrics. Each physician was sent a demographic questionnaire and a 6-item survey asking about their practice patterns and treatment preferences in young children with otitis media with effusion (OME); we did not inform physicians that they were being tested against an evidence-based PG. Survey items covered the accuracy of diagnostic testing, medical and surgical treatments for OME, and appropriate timing of treatment. Correct responses to the 6 items were taken from the summary recommendations of the PG, and were all evidence based. We performed frequency analysis of correct responses and compared responses between different specialties.
Results: The survey response rate was 45%. Overall, none of the 445 physicians answered all 6 items correctly (ie, congruent with the PG). Items with the highest frequency of correct responses were related to treatment of early OME (86%) and diagnostic testing for OME (78%). Items with the lowest number of correct responses were related to audiologic testing in prolonged OME (23%), medical treatment for OME (47%), and use of antihistamines in OME (47%). Overall, pediatricians and otolaryngologists had similar total scores, but on some treatment items pediatricians were more frequently correct than otolaryngologists (P < 0.001). Physicians younger than 45 years were correct on at least 5 items more frequently than older physicians (21% vs 11%, P = 0.009), and academicians scored higher than nonacademicians (27% vs 13%, P = 0.003).
Conclusion: These results indicate that the practice patterns of otolaryngologists and pediatricians differ—in some cases significantly—from the recommendations of an evidence-based PG. In particular, 2 items covering key treatment recommendations were answered in agreement with the PG by less than half of the physicians. Overall, physicians were correct more often on items related to diagnostic testing, but pediatricians scored significantly better than otolaryngologists on 2 treatment-related items. It is not clear from this study whether these discrepancies were due to poor dissemination or lack of knowledge concerning the PG, or disagreement with its findings and recommendations. These data indicate significant problems with the current state of adherence to a PG for otitis media in otolaryngology and pediatrics.
8:16 AM
Sujana S Chandrasekhar MD (presenter); Natarajan Venkatayan MD; Yolanda L Troublefield MD; Mahmoud El-Sherif M Ammar MD
Newark NJ; Newark NJ; Maplewood NJ; Hackensack NJ
Objectives: Surfactants are known to reduce surface tension in the lining layer of the mucosal surface of the eustachian tube (ET), thereby reducing the pressure needed for passive opening of the ET. Reduction in passive opening pressure of the ET permits effective drainage of the middle ear into the nasopharynx. The potential for treating otitis media with effusion (OME) with intranasal surfactant instead of antibiotics or myringotomy, therefore, exists. This experiment was designed to compare the effectiveness of treatment of OME in gerbils using intranasal metered-dose aerosolized surfactant with and without additives. Treatment efficacy was determined for drug and dose regimen, and both control and placebo groups were used.
Methods: OME was developed in 65 gerbils (Meriones ungulatus) by transtympanic injection of 10 mg lipopolysac-charide derived from Klebsiella pneumoniae. Initial in vivo tympanometry and otomicroscopy were performed to establish a disease-free middle ear. Observations via otomicroscopy and tympanometry were performed every other day for 30 days following the transtympanic injection. Either nothing (control), normal saline solution (placebo), surfactant, surfactant with betamethasone, or surfactant with phenylephrine was used. The study groups were further stratified into once a day and twice a day drug regimens. The drugs were sprayed intranasally with an aerosolized metered dose inhaler, beginning at the third day after the development of OME and continuing until resolution of effusion.
Results: In the once a day drug regimen group, resolution of OME was observed by otomicroscopy at day 16 (+1) in both the control and placebo groups, day 10 (+1) in the surfactant group, day 8 (+1) in the surfactant with betamethasone group, and day 16 (+1) in the surfactant with phenylephedrine group. In the twice a day drug regimen, resolution of OME was observed by otomicroscopy at day 16 (+1) in both the control and placebo groups, day 8 (+1) in the surfactant group, day 6 (+1) in the surfactant with betamethasone group, and day 18 (+1) in the surfactant with phenylephedrine group. There was no recurrence of effusion over a total evaluation time of 30 days.
Conclusion: OME resolved at least 50% as quickly as the natural course in the animals treated with intranasal surfactant alone and with steroid. The twice-daily dosing regimen is statistically superior. There was no recurrence of effusion. This study demonstrates the effectiveness of an aerosolized synthetic surfactant with and without steroid in causing resolution of OME. The scope for patient treatment is potentially outstanding.
8:30 AM
Eric A Mair MD (presenter); Thomas M Fitzpatrick MD; J David Lane MD
Derwood MD; Washington DC; Washington DC
Objectives: Tracheobronchial airway stents are used with increased frequency to treat major airway obstruction in children and adults for both benign and malignant processes. Although careful and judicious stent placement has provided significant and possibly lifesaving airway improvement in many patients, there are notable potential complications. This is the first paper focusing on airway stent complications and how to manage them.
Methods: From October 1997 to January 2000, 20 patients (aged 6 months to 79 years) underwent endoscopic placement of a total of 25 airway stents. Stents were placed for both benign (n = 14) and malignant (n = 11) tracheobronchial diseases. Stents were placed in the operating room under general anesthesia by rigid bronchoscopy combined with flexible bronchoscopy and fluoroscopy as needed. Stents were placed either as sole therapy or in combination with adjuvant therapy such as radiotherapy, brachytherapy, chemotherapy, laser ablation, photodynamic therapy, balloon dilatation, or cryotherapy. Migration resistance, granulation induction, stent structural integrity, and ease of removal were evaluated by serial bronchoscopy (fiberoptic and virtual). Complications are analyzed based on stent type (metallic vs plastic) and disease type (benign vs malignant).
Results: Seven complications were reported. The majority (6/7) were associated with benign airway pathology and included stent migration (Dumon and Ultraflex stents), stent breakage (Ultraflex stent), excessive granulation (Palmaz and Ultraflex stents), and poor patient tolerance due to persistent dysphagia and chest pain (Rusch Y stent). Only 1 complication was associated with malignant disease (Wallstent migration). Stents were endoscopically removed in 5 of 7 complications, whereas the remaining 2 required endoscopic stent manipulation. Endoscopic stent removal is difficult with metal stents because the stents become epithelialized in the airway. Plastic stents are easier to remove but are associated with more migration and granulation. There was no lasting morbidity or mortality associated with stent therapy.
Conclusion: Tracheobronchial stents provide a minimally invasive adjunct to manage significant airway obstruction. Stents are very successful as palliation for obstructive malignancies in the major airway not responding to conventional therapy. The majority of complications are noted in longterm treatment of benign conditions. When considering airway stents for treatment of benign processes, one should carefully consider all alternatives prior to placement. Stents can be removed successfully with the endoscope if complications arise, but the longer a metal stent is in place, the more difficult it is to remove. We not only present our experience with airway stents and their complications but also offer effective management strategies should stent complications arise.
8:38 AM
Brian Rubinstein MD (presenter); E Bradley Strong MD; Craig W Senders MD
Elk Grove CA; Sacramento CA; Sacramento CA
Objectives: The incidence of occult malignancy in routine tonsillectomy and adenoidectomy (T&A) specimens is extremely low. Recent otolaryngology and pathology literature has suggested that histopathologic analysis of routine T&A specimens may be unnecessary. The goal of this study is to (1) better define the current national standard of care regarding histopathologic analysis of routine T&A specimens, (2) determine any changes in specimen-handling practices from 1989 to present, and (3) perform a retrospective analysis of occult malignancy in routine T&A specimens at the University of California-Davis Medical Center (UCD).
Methods: Surveys were sent to 4715 members of the American Academy of Otolaryngology-Head and Neck Surgery across the United States. The surveys assessed (1) practice type (private, academic, salaried, and other); (2) pathologic processing practices in 1989, 1994, and 1999 (for pediatric and adult populations); and (3) reasons for change in practice. In addition, we performed a retrospective analysis of routine T&A specimens at UCD between 1984 and 1999 looking for the incidence of occult malignancy.
Results: The surveys were returned by 1243 individuals (26%). Practice types were 80% private, 12% academic, 6% salaried, and 2% military. The pediatric handling practices were as follows: 1989—52% full pathology, 23% gross only, and 4% no pathology; 1994—46% full pathology, 36% gross only, and 8% no pathology; and 1999—38% full pathology, 41% gross only, and 20% no pathology. The adult handling practices were as follows: 1989—66% full pathology, 10% gross only, and 2% no pathology; 1994—68% full pathology, 19% gross only, and 3% no pathology; 1999—66% full pathology, 23% gross only, and 9% no pathology. A X 2 analysis of specimen handling practices revealed a significant (P < 0.001) increase in respondents ordering gross only and no pathology. The retrospective analysis found that 1583 patients underwent routine T&A. There were no occult malignancies found.
Conclusion: There is a statistically significant increase in the number of otolaryngologists sending routine T&A specimens for gross only or no pathology in both the pediatric and adult age groups. There is no correlation between the type of practice and the changes in pathologic analysis performed. The retrospective analysis performed at UCD supports the reduced need for histopathologic analysis of routine T&A specimens. However, the incidence of occult malignancy is not zero, and the need for histopathologic analysis must be determined on a case-by-case basis.
8:46 AM
Pete S Batra MD (presenter); Nancy M Young MD; Santhanam Suresh MD
Chicago IL
Objectives: Postoperative pain management in children undergoing tympanomastoid surgery can be a challenging task. The great auricular nerve block (GANB) has been successfully used in pain management for otoplasty without any side effects. This study prospectively evaluated the efficacy of the GANB for postoperative pain management after tympanomastoid surgery in children.
Methods: Forty patients undergoing tympanomastoid surgery were randomized in this double-blind study. Twenty patients underwent GANB, and 20 patients were treated with intravenous morphine. The two groups were compared for incidence of postoperative pain and nausea and vomiting.
Results: Based on the objective pain scale criteria, there was no difference in the incidence of postoperative pain and requirement for rescue pain medication in the two groups (P = 0.527). The postoperative incidence of nausea and vomiting was significantly lower in the GANB group (P = 0.011).
Conclusion: GANB provides equivalent pain relief as intravenous morphine in children undergoing tympanomastoid surgery. Patients undergoing GANB also have a lower incidence of postoperative nausea and vomiting. GANB can serve as an important adjunct in pain management for tympanomastoid procedures in children.
9:00 AM
Robert L Folmer PhD (presenter)
Portland OR
Objectives: Myringotomy with insertion of pressure equalization tubes has proven to be extremely effective in treating persistent serous otitis media. This study compares the advantages and disadvantages of this procedure when performed in the operating room or with laser in an office setting.
Methods: Traditional myringotomy with tube insertion (M&T) was compared to laser office ventilation of ears with insertion of tubes (LOVE IT). Subjective and objective data evaluated included patient/parent satisfaction, time and cost of procedure, time interval from diagnosis to treatment, complications, and results. Objective data were obtained by chart review. Subjective data were obtained by survey and personal communications.
Results: Based on collected data, overall patient/parent satisfaction was greater with LOVE IT. M&T required less time to perform. LOVE IT cost significantly less. Time interval from diagnosis to treatment was less with LOVE IT. Complications and results were similar.
Conclusion: LOVE IT appears to offer a realistic alternative to traditional M&T. Although specific new skills must be diligently learned by the operating otolaryngologist, LOVE IT offers subjective and objective advantages to the patient/parent. It also represents marked cost savings, decrease in antibiotic use, and potential decrease in middle ear disease.
9:08 AM
Robert Thome PhD (presenter); Daniela Curti Thome MD; Rodrigo A C De la Cortina MD
Sao Paulo Brazil
Objectives: To report the results of subglottic stenosis treated using 2 different posterior cricoid augmentation (PCA) surgical techniques—the variables were the type of graft and duration of stenting—and to discuss the potential advantages and disadvantages of each one.
Methods: Seventy-two patients with subglottic and/or posterior glottic stenosis were treated using 2 different PCA surgical techniques. Fifty-six patients were adults and 16 children, ranging in age from 8 months to 68 years. The procedures included thyrotomy, vertical midline division of the cricoid lamina starting below the interarytenoid area, lateral retraction of the cricoid halves, placement of a graft between the hemilaminas, and insertion of an endolaryngeal stent. Patients were divided into 2 groups depending on the graft and duration of stenting: group 1, costal cartilage graft and stenting for 4 weeks (16 patients, 2 children and 14 adults); and group 2, buccal mucosa graft and stenting for 8 to 12 weeks (56 patients, 14 children and 42 adults). The factors evaluated included rate and time of decannulation and morbidity.
Results: The PCA with mucosa graft resulted in a decannulation rate of 93% and with cartilage graft of 87.5%. Three adult patients with cartilage graft had the stent in place for an additional 8 weeks as a result of resorption. Cartilage graft had more donor-site morbidity, increased surgical time, and shorter decannulation time.
Conclusions: When the 2 types of PCA surgical techniques were compared for correcting subglottic stenosis, the results were not different. Both techniques have the disadvantage of requiring an additional operative site. Cartilage graft has an unpredictable degree of graft resorption. In mucosa graft, potential morbidity is almost nonexistent. In children good results can be achieved with both techniques; however, in adults buccal mucosa, despite needing a longer duration of stenting than cartilage to obtain a lateral stabilization of cricoid halves, has proved to be safer and have lower morbidity.
9:16 AM
Jay Granzow MD (presenter); Daniel K Lee MD; Uttam K Sinha MD
Santa Monica CA; Los Angeles CA; Los Angeles CA
Objectives: Controversy continues to surround the acute management of peritonsillar abscess. Using both subjective and objective criteria, this study prospectively investigates the effects of intravenous (IV) steroids on patient discomfort, residual pus, and disease resolution. The study also compares the use of needle aspiration versus incision and drainage (I&D) of peritonsillar abscesses on patient pain, the presence of residual pus, and the ultimate resolution of disease.
Methods: Of 81 patients presenting with acute peritonsillar abscess, 57 patients received 10 mg IV Decadron prior to treatment, and 24 patients received no IV steroids. Forty patients were treated with I&D, while 41 underwent needle aspiration for treatment. Patients were asked to subjectively rate pain at several times during and after initial abscess drainage. The presence of pus at initial presentation and on follow-up was recorded. These results were statistically collated and compared.
Results: The group of patients receiving IV steroids was compared with the group not receiving steroids. No statistical difference was found in patient pain during or after abscess drainage, and no significant difference was noted in the rate of residual pus between these two groups on all follow-up days. The difference in persistent disease was not statistically significant (P > 0.05) on follow-up day 1 for needle aspiration (15%) versus I&D (23%). Residual pus was significantly different (P < 0.05) on follow-up day 2 for needle aspiration (12%) versus I&D (0%). Subjective ratings of patient pain revealed no significant difference between both groups during the procedure or on follow-up.
Conclusion: IV steroids appear to offer no benefit in the treatment of peritonsillar abscess. Both I&D and needle aspiration of peritonsillar abscesses are ultimately equally successful in the treatment of the disease process. However, since there is no significant difference between the treatment modalities in patient discomfort, I&D appears to result in faster disease resolution. Peritonsillar abscesses preferably should be treated with I&D when instruments and equipment are available but can be adequately be treated with needle aspiration and additional patient follow-up if necessary.
8:00 to 9:30 AM WCC Room 32
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Eduardo M Diaz MD Jr; Stanley E Thawley MD
(moderators)
8:00 AM
Roberto A Lima MD (presenter); Jacob Kilgerman MD; Fernando Luis Dias MD; Geraldo M Sa MD
Rio de Janeiro Brazil
Objectives: In order to assess whether near-total laryngectomy could successfully reach the cure and preserve the voice in advanced laryngeal cancer, we studied 33 patients with T3/T4 squamous cell carcinoma of the larynx treated in our institution who had undergone a near-total laryngectomy.
Methods: A retrospective analysis of 33 patients with T3/T4 unilateral laryngeal carcinoma was carried out from 1990 to 1994. The mean age was 61 years (range 44 to 76 years), 88% were male, and 82% were smokers. Fourteen patients had glottic lesions, 17 patients had transglottic lesions, and 2 had supraglottic lesions. Using the TNM classification of the International Union Against Cancer (UICC-1992), we classified 27 patients as T3N0M0, 2 patients as T3N1M0, 1 patient as T3N2bM0, and 3 patients as T4N0M0. Twenty patients had bilateral selective lateral neck dissection, and 13 had unilateral selective lateral neck dissections. Survival was analyzed using the Kaplan-Meier actuarial method.
Results: Thirty patients (94%) achieved the voice with this procedure. Eight patients (24%) had metastatic lymph nodes in the neck. One patient had local recurrence, and 4 patients had recurrence in neck nodes. One patient had the recurrence treated with completion laryngectomy and is alive without disease. Three patients with neck recurrence died of the disease, and 1 patient was salvaged with modified radical neck dissection. One patient had a second tumor in the esophagus and died of disease. The 3-year disease-specific survival was 93% for the bilateral neck dissection group and 60% for the unilateral neck dissection group.
Conclusion: Survival was comparable to that of patients undergoing total laryngectomy, regarding the extent of the lesion. The voice can be achieved in most cases. Our data suggest that the near-total laryngectomy should be carried out with bilateral neck dissection.
8:08 AM
Stephen Y Lai MD PhD (presenter); Ara A Challan MD; Gregory S Weinstein MD; Randal S Weber MD
Philadelphia PA
Objectives: Aggressive nonmelanoma skin cancer (ANMSC) of the head and neck is difficult to manage given its propensity for regional metastasis, perineural invasion, direct parotid invasion, and bony destruction. Management of these tumors demands awareness of characteristics contributing to their recurrence. We reviewed our experience of patients with ANMSC to determine risk factors for local-regional tumor progression and to evaluate effectiveness of treatment.
Methods: Between 1996 and 1999, 54 patients (median age 69.5 years) were treated for ANMSC. We reviewed the presentation, management, and outcome of these patients.
Results: The majority of ANMSCs presented in the periauricular area (19/54), the frontozygomatic area (10/54), and the nose (9/54). Squamous cell carcinoma was present in 32 patients, and basal cell carcinoma was present in 22 patients. Twenty-five patients presented with recurrent lesions. Factors that were statistically significant (P < 0.05) in determining tumor recurrence included preoperative facial weakness, recurrence following previous treatment, regional metastasis, status of surgical margins, and tumor histology. Despite postoperative radiation therapy administered to 26 patients, 12 patients sustained local-regional failures. Disease-specific and overall survival rates were 86% and 78%, respectively, at 24 months.
Conclusion: Management of ANMSC requires a precise understanding of its behavior. Treatment strategies should include en bloc resection of the primary tumor with parotidectomy for deep invasion of the gland or regional metastasis. Neurotropic spread to the facial nerve must be given special consideration. An algorithm for the treatment of ANMSC based upon its presenting characteristics will be presented.
8:16 AM
Mohamed Rifai MD (presenter); Hany Khattab MD
Cairo Egypt
Objectives: To study the behavior of anterior commissure (AC) carcinoma regarding its tendency for cartilage invasion and consequently the application of subtotal laryngectomy as a treatment modality.
Methods: Supracricoid laryngectomy (SCL) with cricohyoidopexy (CHP) or tracheohyoidopexy (THP) was performed for 69 cases of recurrent AC carcinoma. The procedure involves excision of the thyroid cartilage with the tumor-bearing mucosa and subsequent anastomosis between the thyroid and cricoid cartilage. The epiglottis may be preserved and included in the anastomosis as well. Histopathologic examination of the region of the AC was performed using whole-organ sectioning in 32 randomly selected specimens. Serial sections were prepared and examined histopathologically for evidence of microscopic cartilage invasion in the region of the AC.
Result: The local control rate obtained at 2 years was 88.4% for SCL with CHP and 71.4% for SCL with THP. The overall laryngeal preservation rate (preservation of both respiratory and phonatory functions) was 94.2% and 81.2% for CHP and THP, respectively. Microscopic involvement of the thyroid cartilage was detected in the 32 sections studied.
Conclusion: Whether recurrence was de novo or initiated by residual malignant cells, it is mandatory to excise the anterior portion of the thyroid cartilage with the tumor-bearing mucosa. Subtotal laryngectomy with CHP or THP is a suitable alternative to total laryngectomy in this respect.
8:30 AM
Mark T Agrama MD (presenter); Brian A Neff MD; David Reiter MD DMD
Philadelphia PA; Philadelphia PA; Narberth PA
Objectives: The ultimate outcomes for cancer treatment are cure rate, survival after treatment, and quality of life after treatment. For outcomes research to demonstrate relationships between treatment choices and any of these parameters, episodes of care in each treatment group must be standardized. Radical neck dissection (RND) has a specific anatomic definition; however, nodal yield for procedures reported as RND varies greatly. The nature and strength of any relationship between nodal yield and outcomes must be established before meaningful outcomes research can be done in this area.
Methods: The nodal yields for all unilateral procedures reported as RND for carcinoma of the oropharynx in our institution from 1989 to 1993 (n = 61, no prior treatment) were analyzed and compared with similar data from the National Cancer Institute (NCI) SEER registry for the same disease and period (n = 1499). Statistical analysis was done to determine the probability that our sample parameters are representative of population parameters, assuming the descriptive statistics for the large NCI sample reflect population parameters for all patients with carcinoma of the oropharynx.
Results: Our mean nodal yield from 61 radical neck dissections was 32 versus 27 in the NCI data. Our standard deviation was 15.3 compared to 17.2 in the NCI data. Values ranged from 2 to 66 nodes, while the NCI range was from 1 to 97 nodes. We calculated a 2% probability that our sample parameters are no different from those of the large NCI population. Therefore no relationship between what the medical record states was an RND and the outcomes of treatment can be demonstrated.
Conclusion: As our nodal yield is highly unlikely (98%) to represent that of the general population of patients undergoing RND, outcomes research based on these data would be faulty. Until correlation of nodal yields with outcomes is examined, we cannot know how to relate neck dissection to outcomes. We are studying the nature of the relationship (if any) among nodal yield, cure rate, and survival. We are also studying the distribution of yield variance among surgeons, pathologists, and the population. Only after the strength of these associations is determined can outcomes research really help to improve the quality of care in head and neck cancer patients. We urge head and neck surgeons to use Academy-recommended definitions for neck dissections and to accurately record the nature of each procedure for later analysis.
8:38 AM
Ara A Challan MD (presenter); Allan Gottschalk MD PhD; Sarah H Kagan PhD; Ann Marie Dakunchak RN
Philadelphia PA
Objectives: This paper analyzes the influence of transmandibular resection, total laryngectomy/total pharyngectomy, and bilateral neck dissection on variance among 3 intraoperative pathways. Patients undergoing laryngopharyngectomy (TLP) resection, transmandibular (TM) resection, or transcervical (TC) resection with radial forearm free flap reconstruction are placed on intraoperative pathways. Procedure and case (out of room) length are the indicators monitored for performance improvement. Surgical approach and extent of resection were accounted for in pathway design. Pathway variance analysis will assess clinical impact and design success for procedure variation.
Methods: Our academic medical center uses 3 intraoperative clinical pathways to manage resource use and time for patients undergoing head and neck resections with radial forearm free flap reconstruction. These pathways were designed as timed schematics by an interdisciplinary team. Bilateral neck dissection is allotted an additional hour in each pathway. The goals of the pathways were to reduce case length by 3 hours for TC (19%) and for TLP (18%) and by 4 hours for TM (21%) and to achieve labor savings in cost per case. Eleven TC cases, 9 TM cases, and 5 TLP cases are analyzed using descriptive statistics. They were compared within for variance and between pathways to establish clinical influence of TM approach, total laryngectomy/total pharyngectomy, and bilateral neck dissection on case length.
Results: TC pathway procedure and case length averaged 640 and 740 minutes, respectively; TM pathway procedure and case length averaged 675 and 794 minutes, respectively; and laryngeal pathway procedure and case length averaged 774 and 808 minutes, respectively. TLP case length accounted for the greatest variance, with a standard deviation of 148 minutes and a range of 620 to 975 minutes. However, even the outlier time of 975 minutes is only 15 minutes over goal time. TM approach average procedure length compared favorably with aggregate mean time of 680 minutes and presented no clinical challenge to pathway goals. A design accommodation of 1 hour for bilateral neck dissection proved clinically adequate and did not influence procedure length. Labor savings have not yet been analyzed. They are, however, clearly linked to time efficiencies.
Conclusion: Time savings goals of 19% to 21% improvement over historical averages for all 3 pathways and procedure variations have been uniformly met. Labor savings and operating room hours saved for other cases are clearly attached to this achievement. Our experience suggests intraoperative pathways and design accommodations are successful in achieving demonstrable savings and particularly important in a scarce resource environment such as the one faced by academic medical centers today.
8:46 AM
Christopher Hampson MD (presenter); Guy J Petruzzelli MD PhD
Glen Ellyn IL; Maywood IL
Objectives: Alcohol withdrawal is frequently encountered in patients undergoing surgery for head and neck cancer. Experience at one institution warranted an investigation of outcomes of patients with a history of alcohol abuse undergoing head and neck cancer surgery in order to understand the effects of alcohol on postoperative course and recovery. Data were also collected to compare postoperative costs in relation to non-alcohol-dependent head and neck cancer patients to assess the overall use of health care resources in this patient population.
Methods: This was a retrospective review of 20 head and neck cancer patients treated with surgery at Loyola University Medical Center from 1995 through 1999 by the senior author (G.J.P.). Ten of the patients experienced alcohol-withdrawal syndrome postoperatively. Data were collected in areas of staging, complications, length of intensive care unit (ICU) stay, and length of hospital stay. Cost data were collected in areas of ICU charges, pharmacy charges, and total hospital charges.
Results: In total, there were 27 complications for 10 patients in the alcohol-withdrawal group versus no reported complications in the non-alcohol-withdrawal group. No mortalities occurred. The alcohol-withdrawal group had an average of 4 more days in the ICU and 12 more days in the hospital. There was a greater than 600% average increase in ICU charges compared to the non-alcohol-withdrawal group. Total hospital charges for the alcohol-withdrawal group averaged a greater than 250% increase over those of non-alcohol-withdrawal patients.
Conclusion: Patients with head and neck cancer experiencing postoperative alcohol withdrawal have a significant increase in postoperative complications, ICU stay, and hospital admission. There exists a 2-fold increase in total postoperative costs. This information displays a need to further evaluate the care of alcohol-dependent head and neck cancer patients in order to develop strategies to even the outcomes.
9:00 AM
Marta Garcia-Pallares MD (presenter): Eduardo Morera Serna
MD; Javier Gavilan MD; Ricardo Bernaldez Millan MD
Madrid Spain
Objectives: Near-total laryngectomy provides a functional alternative to total laryngectomy. Oncologically, it is a radical surgical procedure in which a permanent tracheal stoma is always required, but the patient almost always obtains a natural voice. Most of the larynx is resected, and a speaking shunt is created using the remaining tissue from the posterior half of the larynx on the opposite side to the tumor. The preserved structures include the arytenoid and a posterior portion of the vocal cord on the uninvolved side. This study presents our experience with near-total laryngectomy analyzing the functional and oncologic results.
Methods: Seventy-eight patients with squamous cell carcinoma of the larynx and hypopharynx were treated with this technique from 1991 to 1997. Sixty-three patients underwent neck dissection. The patients ranged in age from 36 to 87 years (mean 62 years). Seventy-six patients were men, and 2 were women. Survival was analyzed under the Kaplan-Meier method.
Results: The most frequent tumor location was supraglottic in 36 cases. T3 and T4 cancers were the most common in this series, in 40 and 26 patients, respectively. Regarding the oncologic results. 5% had local recurrence, 15% neck node recurrence, and 10% distant metastases. Pharyngocutaneous fistula was the most frequent postoperative complication (47% of cases). Speech was acquired in 75% of the patients. Symptomatic aspiration was noticed in 13% of cases. The 3-year overall survival, cause-specific survival, and relapse-free survival were 53.3%, 74.2%, and 70.6%, respectively.
Conclusion: Near-total laryngectomy is a successful surgical procedure for selected patients with laryngeal and hypopharyngeal cancer; it does not replace total laryngectomy but does reduce its indications. Voice preservation can be achieved in most cases.
9:08 AM
Jagdish K Dhingra MD (presenter); Ann Kearney MA; Nora V Laver MD; Stanley M Shapshay MD FACS
Boston MA; Brookline MA; Boston MA; Boston MA
Objectives: A pulsed-dye laser (PDL) at a wavelength of 585 nm is absorbed by oxyhemoglobin in the erythrocytes within the blood vessels. The pulse duration of this laser is sufficiently short so that the temperature increases capable of causing thermal damage are confined to the walls of blood vessels and adjacent perivascular tissue. The sparing of damage to the overlying mucosa and the vibratory segment of the vocal fold makes this laser a potentially useful tool in microlaryngeal surgery. There have been clinical reports of the efficacy of this laser in treatment of laryngeal papillomas and vocal fold ectatic lesions. However, the safe dosages of the PDL in preservation of vocal cord function remain to be established. The present study was carried out to determine the effect of varying powers of PDL on vocal cord function in a canine model.
Methods: A PDL at increasing power settings from 10 through 14 J/cm2 was used to treat the right vocal fold in a group of 7 canines. In the control group, 2 canines underwent treatment with a CO2 laser, whereas microlaryngeal surgery was performed using cold instruments on a third animal. Videostroboscopic findings were recorded preoperatively and at 6 to 12 weeks posttreatment. Subjective analysis of the voice quality was made, and videostroboscopic data were analyzed by a speech pathologist in a blinded fashion. The canines were euthanized, and the larynges were harvested for histology. Four histologic features were carefully studied: epithelial integrity, inflammatory cell infiltrate in subepithelial layers, collagen deposition in lamina propria, and state of vasculature.
Results: Following the PDL treatment at fluences of 10 J/cm2, there was no obvious change in the appearance of the vocal fold except immediate obliteration of blood vessels in the submucosal layer. At higher fluences of 12 and 14 J/cm2, subtle punctate submucosal bleeding was observed. Glottal dynamics of the animals treated by PDL were near normal. There was complete glottic closure, normal mucosal wave, phase symmetry, and normal phase closure. None of the vocal cords treated with PDL showed disruption of epithelial continuity on histologic examination. There was minimal submucosal reaction with no evidence of increased collagen deposition.
Conclusion: This experimental study clearly demonstrates that at the dosages tested, 585-nm PDL offers a minimally traumatic alternative to the standard cold surgery or CO2 laser in treatment of certain laryngeal lesions. The normal glottal waveform in larynges treated with PDL signifies preservation of vocal fold cover and its relationship to the body. This was corroborated by the absence of any significant histologic changes in the epithelium and superficial lamina propria. Clinical trials are currently under way to test the efficacy of this technique in the treatment of recurrent laryngeal papillomatosis with encouraging results.
9:16 AM
Tulio Alberto Valdez MD (presenter); Elie Rebeiz MD; Stanley M Shapshay MD FACS
Boston MA
Objectives: Laryngeal cancer accounts for approximately one third of all upper aerodigestive tract malignancies. Histologic diagnosis of laryngeal carcinoma requires direct laryngoscopy and biopsy under general anesthesia. Fluorescence spectroscopy is a noninvasive method with the ability to analyze the biochemical and histomorphologic characteristics of tissue. It has been used to study cancerous and precancerous lesions in various organs with promising results. Laser-induced autofluorescence may provide an alternative for the diagnosis of laryngeal cancer.
Methods: Twelve patients with suspected premalignant and malignant lesions of the larynx were enrolled in the study. Fluorescence spectra were obtained using a fiberoptic-based portable spectrofluorometer capable of measuring fluorescence at 337-nm excitation wavelength and white light reflectance. Under general anesthesia using a rigid laryngoscope for exposure, the fiberoptic probe was placed in contact with the mucosal lesion. A contralateral clinically normal site was used as control. A mathematical algorithm using fluorescence and white light reflectance was developed to obtain the intrinsic fluorescence and to diagnose malignant lesions.
Results: Using our intrinsic fluorescence algorithm, we were able to distinguish cancerous lesions from normal controls in 10 of 10 patients with laryngeal carcinoma. The other 2 patients who presented with a hemorrhagic polyp and leukoplakia, respectively, were correctly diagnosed as having benign conditions.
Conclusion: This pilot preliminary study demonstrates that laser-induced intrinsic autofluorescence may provide a nonsurgical procedure to effectively diagnose laryngeal carcinoma. This technique also has the potential to be performed in an office setting with local anesthesia using a flexible fiberoptic laryngoscope.
8:00 to 9:30 AM
WCC Room 38
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Scott A Estrem MD (moderator); Sherri M Jones PhD; Timothy A Jones PhD; Joel A Goebel MD
Columbia MO; Columbia MO; Columbia MO; Saint Louis MO
Educational Objectives: (1) To learn a rapid yet effective examination of patients with vestibular disorders suitable for the practicing general otolaryngologist. (2) To learn the appropriate clinical situations when electronystagmography, platform posturography, and rotary chair testing are indicated. (3) To learn about cutting-edge vestibular testing equipment currently in use in select vestibular laboratories. (4) To learn about vestibular testing equipment currently in research laboratories. (5) To learn about the latest research into otolith function testing.
Description of Symposium: This seminar will include the current state of the art for the diagnosis of vestibular disorders for the practicing general otolaryngologist and the otologist, the cutting-edge vestibular testing technology currently available and its applicability, and a look into the future of vestibular testing.
A succinct yet effective history and physical examination coupled with suggested vestibular testing modalities for the busy general otolaryngologist will serve as the basic platform. We will build on this with additional clinical examinations that have specific diagnostic relevance. Discussion will involve indications for the standard vestibular testing modalities, electronystagmography, platform posturography, and rotary chair testing. Other specialized vestibular testing methods currently available in today's marketplace and vestibular testing in the research phase will be described. Finally, a sneak peek into the latest research involving otolithic function testing and its application in the realm of the future clinical laboratory will demonstrate the vitality of research efforts into the assessment of patients with balance disorders.
On completion of this seminar, novice to experienced otologists will have gained valuable information for their practices.
8:00 to 9:30 AM
WCC Room 40
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Gordon J Siegel MD (moderator); Charles D Bluestone MD; Richard M Rosenfeld MD MPH; Michael D Poole MD PhD
Chicago IL; Pittsburgh PA; Brooklyn NY; Houston TX
Educational Objectives: Many new options have recently become available in the treatment of otitis media (OM). The goal of this program is to present an array of treatment options to stimulate debate and further growth in the area.
Description of Symposium: Each presenter will be given 5 minutes to present an overview of his thoughts on an appropriate treatment protocol for OM. The moderator will ask 2-3 questions for debate, followed by open questioning from the audience. Possible moderator questions include the following: (1) Routine tympanocentesis for acute OM: is it necessary? (2) Laser office ventilation of ears: does it work? (3) Antibiotics in acute OM: what is the proper role? (4) Immunotherapy in OM: will it make a difference? 5) What role should adenoidectomy play in the treatment of OM?
8:00 to 9:30 AM
WCC Room 39
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Steven M Zeitels MD (moderator); Norman D Hogikyan MD; Roy R Casiano MD; James A Koufman MD; Glendon M Gardner MD; Clark A Rosen MD
Boston MA; Ann Arbor MI; Miami FL; Winston Salem NC; Bloomfield Hills MI; Pittsburgh PA
The evaluation and treatment of voice disorders have changed dramatically in the last 10 years. These changes are in part due to increased knowledge of laryngeal function, diagnostic advances, and new surgical methods. This seminar is aimed at highlighting some of these advances as they apply to several common voice disorders. New surgical approaches for the treatment of unilateral vocal fold paralysis will be presented. Advances in adjunct therapy for laryngeal papilloma disease and the role of laryngopharyngeal reflux disease in patients with vocal fold granuloma will be discussed. Evaluation and management of Reinke's edema and white lesions of the vocal fold will also be reviewed. Each presentation will include, when appropriate, the role of the otolaryngologist-head and neck surgeon, speech pathologist, and consulting specialists in the management of the selected voice disorder.
9:30 to 10:15 AM
WCC Room 38
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(with Spanish translation)
9:30 to 10:24 AM
WCC Room 15
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James H Boyd MD; Michael D Poole MD PhD (moderators)
9:30 AM
Kwok Seng Loh FRCS (presenter); Dong Fang PhD; Luke Kim-Slan Tan MD FRCS
Singapore Singapore
Objectives: Kikuchi's disease (KD) is a benign necrotizing lymphadenitis that is diagnosed on histology. The etiology remains unclear, although viral infection has been postulated. It is thought to be associated with the development of systemic lupus erythematosus (SLE). The aim of this study was to describe our patients with cervical lymphadenopathy diagnosed as KD and to determine whether there were any distinguishing factors from nonsuppurative lymphadenitis.
Methods: Cervical lymph node biopsies from 1995 to 1999 diagnosed histologically as KD or nonsuppurative lymphadenitis were included in the study. Clinical and pathologic parameters were collected. Statistical analysis was performed for the two groups of patients using 2-sample t test, χ2 test, or Fisher's exact test.
Results: There were 14 patients with KD and 47 with nonsuppurative nodes. The characteristic patient profile of KD was a nonsmoking woman, with a mean age of 28 years (SD 7.5). The mean duration of symptoms was 6.1 months (SD 15.5). Multiple painful cervical lymphadenopathies were common, with level 5 nodes being most frequently affected. The total and differential white cell counts were within the normal range. None of the patients with KD developed SLE. No significant differences were found between KD and nonsuppurative nodes.
Conclusion: In our series, patients with KD were likely to be young adult female nonsmokers with multiple tender lymphadenopathy in level 5 neck nodes. No association between KD and SLE was noted. No differences were noted in the clinical pattern between patients with KD and nonsuppurative cervical lymphadenitis. This may suggest an infectious cause for KD.
9:38 AM
Marise Da Penha Costa Marques MD (presenter); Shiro Tomita MD; Pedro Luiz Oliveira Medeiros MD
Rio de Janeiro Brazil
Objectives: Surgery in patients of homozygous sickle cell disease can be a problem because of the potential for sickling events in the perioperative period. The purpose of this study was to standardize medical and surgical perioperative protocols for management of these patients in otolaryngologic surgery.
Methods: A total of 6 patients were included, 1 boy and 5 girls, whose ages ranged from 8 to 18 years. The surgical procedures were under general anesthesia. The body temperature and oxygen saturation were monitored, with avoidance of hypoxia, acidoses, hypotension, and hypothermia. The operative technique for tonsillectomy was modified, and a total closure of the tonsil's place was performed.
Results: All patients had homozygous sickle cell disease and were already on a chronic exchange transfusion regimen to have S-hemoglobin lower than 15% and a hemoglobin level greater than 10 mg/dL. Tonsillectomy and adenoidectomy were performed in 6, myringotomy in 2, and turbinoplasty in 4. There were no perioperative complications.
Conclusion: It is extremely important to have effective communication between the surgeon, anesthesiologist, and hematologist. This protocol minimizes the risk of hemorrhage and sickling crises. Using these guidelines in 6 otolaryngologic cases, we have had no complications at our institution.
9:46 AM
Anthony J Cornetta MD (presenter); David Reiter MD DMD
Philadelphia PA; Narberth PA
Objectives: To describe a new method for piercing the otitis media ears of individuals with metal hypersensitivity and allowing them to wear earrings with minimal risk of reaction.
Methods: Thirty-one patients with histories of hypersensitivity to metallic jewelry (62 ears) underwent earlobe piercing with a 20-gauge intravenous infusion catheter set. The hub of the catheter was cut off to protrude 1 mm from either surface of the lobe. Smooth 14-karat gold ball stud earrings were placed through the catheter shafts, and their backs were snapped on. The catheter-shaft-over-earring-stud units were changed after 30 days. Patients were given several shortened catheter shafts to use over their earring posts for the next 6 months.
Results: No patient experienced an infection or hypersensitivity reaction in the first 6 months of earring use as above. No lobe developed a cleft, and no patient experienced a complication of the procedure or subsequent earring use. None of the 18 patients still in contact at 2 years had reported complications.
Conclusion: Using the distal shaft of a PTFE intravenous catheter as an earring post sheath can allow hypersensitive individuals to wear earrings in pierced ears on a limited basis. If a millimeter of the shaft is left covering the earring post beyond each surface of the pierced lobe, the ornament and back of the earrings seem not to have sufficient contact with the lobe skin to provoke a reaction.
10:00 AM
Solaiman Juman MD MBBS FRCS (presenter); Austin I Trinidade MB ChB FRCS; Collin S Karmody MD; Steve C Medford FRCS; Dexter Shim FRCS; Wendell Dwarika FRCS; Mirza Asraph MD
Couva Trinidad & Tobago; San Fernando Trinidad & Tobago; Boston MA; Miami FL; Port of Spain Trinidad & Tobago; Port of Spain Trinidad & Tobago; San Fernando Trinidad & Tobago
Objectives: The comparative incidence of otitis media (OM) has long been difficult to ascertain because almost all previous epidemiologic studies were performed in comparatively homogeneous populations. In an attempt to answer the question of racial variation in the incidence of OM, a study was undertaken on the island of Trinidad, the most southerly of the West Indian islands, with a population of 1.2 million. About 40% of the population is of African ancestry (Afro-Trinidadians), 41% is of East Indian ancestry (Indo-Trinidadians), and 20% is a mixture of European stock with a liberal sprinkling of Chinese, Middle Eastern, and mixed races.
Methods: All patients who presented with acute OM (AOM), middle ear effusion (MEE), or chronic suppurative OM (CSOM), of either the tubotympanic or atticoantral types, during the period from November 1998 to July 1999, were included in the study. The 3 national ORL departments participated in the study, suggesting that our results were representative of the whole population. A questionnaire was devised that documented ethnic and other demographic factors. This was completed once an experienced physician diagnosed the patient with one of the above conditions.
Results: In total, 252 patients were enrolled in the study. There were 128 males and 124 females, and the age range was 4 months to 83 years. Sixty patients presented with AOM, 88 with MEE, and 104 with CSOM. The most interesting result was the ethnic distribution of the patients with OM: 138 (54.7%) were Indian, and 71 (28.1%) were African in origin, a ratio of nearly 2:1. The ratios of Indians to Africans in the different types of OM are as follows: AOM, 1.6:1; tubotympanic CSOM, 3.9:1; and atticoantral CSOM, 5:1. However in MEE the ratio is 1:1.
Conclusion: This study involved the 3 national ORL departments as well as the private practice of the Trinidadian researchers, representing at least 95% of the ORL practices in Trinidad, suggesting the data obtained are truly national figures for the time period studied. The populations of the East Indians and the Africans are approximately equal nationally, but in those presenting with OM, the East Indians nearly doubled the Africans. The Indians significantly outnumbered the Africans in all types, with the exception of the MEE group. As this study is ongoing, we anticipate analyzing a larger cohort in the coming months but do not expect the ratios to change.
10:08 AM
Mansoor Madani DMD (presenter)
Bala Cynwyd PA
Problem Addressed: Seventy years ago, radiofrequency (RF) energy was first used as a cauterizing device in general surgery. More recently, RF energy has been used to treat cardiac arrhythmias, to reduce muscle contractions in neurology, and for many other applications in medicine and surgery, including treatment of snoring and nasal congestion. While highly useful and effective, some of the standard electrocautery devices generate extreme heat that produces collateral damage to surrounding tissue. Somnoplasty and Coblation are the latest methods to treat chronic nasal congestion and snoring. Coblation enables volumetric removal of target tissue while producing minimal necrosis of collateral tissue.
Methods: Ninety patients were treated with Coblation for chronic nasal congestion with a follow-up time of 2 to 6 months after surgery. Coblation is a bipolar system and requires no grounding pads. It replaces the thermally damaging vaporization and pyrolysis of standard electrosurgery with molecular disintegration via a cold ablative process. A molecular dissociation occurs that produces volumetric tissue reduction. Coblation is performed with the patient under local anesthesia. A specialized surgical wand connected to the RF generator is placed into the inferior turbinate in 2 locations, and RF energy is applied for 10 to 15 seconds.
Results: Patients experience minimal discomfort following the treatment. Within 4 to 6 weeks following surgery the nasal passages open significantly, allowing patients to breathe better and at the same time reducing nasal congestion and postnasal drip. Reduction of nasal snoring and improved sense of smell are expected following the treatment. A comparison of Coblation to other available systems was addressed.
Conclusions: Coblation is a new method using RF to reduce nasal soft tissue volume. It may be associated with several surgical and clinical advantages, including better operative results, reduced surgical time, and less postoperative pain. RF treatment is used in oral and nasal surgery to remove and shrink tissue for correcting and improving snoring, nasal congestion, and sleep apnea. Simultaneous with volumetric tissue removal and collagen shrinkage, Coblation can coagulate smaller blood vessels adjacent to the zone of ablation. This is effected by the residual current flow in the tissue, which extends beyond the plasma/tissue boundary. Use of RF has demonstrated promising results, while reducing patients' pain and improving their breathing with a speedy recovery compared with standard techniques.
10:16 AM
Yuri Petroviche Uliyanov MD PhD (presenter)
Moscow Russia
9:30 to 10:24 AM
WCC Room 20
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Serge A Martinez MD; Stanley E Thawley MD (moderators)
9:30 AM
Fernando Luis Dias MD (presenter); Jacob Kligerman MD; Roberto A Lima MD; Geraldo M Sa MD
Rio de Janeiro Brazil
Objectives: The dimension of the adverse impact of histopathologic factors in advanced laryngeal cancer is controversial. The aim of this study is to determine the prognostic significance of various histopathologic features in advanced laryngeal squamous cell carcinomas (SCC).
Methods: This was a retrospective study of 136 previously untreated patients with stage III and IV SCC of the larynx, treated between 1992 and 1994. For the purposes of this study, patients were divided in 4 groups: I, pT3N0M0; II, pT4N0M0 with cartilage invasion (CI); III, pT4N0M0 with extralaryngeal spread (ELS); and IV, pT3-4N1-3M0. All patients underwent radical surgery plus postoperative radiotherapy. Results were obtained using a uni-multivariate analysis regarding the incidence of locoregional recurrence rates, distant metastases, and disease-specific survival rates.
Results: There were 29 (21.3%) patients in group I, 34 (25%) in group II, 31 (22.7%) in group III, and 42 (30.8%) in group IV. All had negative margins at frozen section. Radiotherapy doses varied between 5000 and 6500 cGy. The 36-month disease-specific rate was 70.9%. At the end of this study 86.2% of group I were alive and free of disease in comparison with 88.2% of group II, 61.2% of group III, and 48% of group IV. Comparison of pT3N0M0 and pT4N0M0 with CI patients revealed statistically significant results (P = 0.32), but comparing these two groups with pT4N0M0 with ELS and pT3-4N1-3M0 patients, we found statistically significantly different results (P = 0.02 and P = 0.002 respectively).
Conclusion: Evaluation of prognostic factors by comparing groups of patients on the basis of different histopathologic features revealed no statistically different outcome between patients with stage IV SCC of the larynx (based on CI criteria) and patients with stage III SCC. The presence of ELS and regional lymph node metastases, particularly with extracapsular spread, significantly affected the outcome of patients and emerged as the most important negative factors in our group of patients.
9:38 AM
Roberto A Lima MD (presenter): Jacob Kligerman MD; Fernando Luis Dias MD; Geraldo M Sa MD
Rio de Janeiro Brazil
Objectives: In order to analyze the factors influencing lymph node metastasis in parotid cancer and the impact of prognostic factors on disease-free survival, we analyzed the files of 82 patients with malignant parotid tumors.
Methods: We retrospectively reviewed the files of 82 patients treated at our institution and by the authors, from 1974 to 1994. All patients were treated with surgery, and 47 patients had postoperative radiotherapy. Ten patients were treated with parotidectomy plus neck dissection. The mean age was 49 years (range 5-92 years). Forty-one patients were male. According the UICC/1992 TNM classification, we classified 27 patients as stage I, 19 as stage II, 21 as stage III, and 15 as stage IV. The influence of age, sex, histology, stage, grade, and presence of neck metastasis on the 10-year disease-free survival was analyzed using the Kaplan-Meier actuarial method and the Mantel-Haenszel test. The influence of those factors on the presence of neck metastasis was analyzed using the χ2 method.
Results: Thirty patients had mucoepidermoid carcinoma, 18 patients had adenocarcinoma, 14 patients had acinic cell carcinomas, 9 patients had malignant mixed tumors, 7 patients had adenoid cystic carcinomas, and 4 patients had other tumors. Twenty-two patients had recurrences, 6 patients had local recurrences, 4 patients had neck recurrences, and 12 patients had distant metastases. The presence of neck metastasis was influenced by 4 factors: stage, grade, age, and histology (P = 0.003, P = 0.02, P = 0.03, and P = 0.03, respectively). Three prognostic factors negatively influenced the prognosis: histology, grade, and stage (P = 0.0001, P = 0.0001, and P = 0.0001, respectively). The 10-year disease-free survival was 94% for stage I, 73% for stage II, 30% for stage III, and 16% for stage IV.
Conclusion: Stage, grade, and histology were independent prognostic factors. The grade of the tumor was the most important prognostic factor. The stage was an important factor to predict the presence of neck metastasis.
9:46 AM
Luis Lassaletta MD (presenter): Eduardo Morera Serna MD; Ricardo Bernaldez Millan MD; Javier Gavilan MD
Madrid Spain
Objectives: The optimal management of the N0 neck remains controversial. Options include watchful waiting, radiation therapy, and elective neck dissection. Functional neck dissection (FND) consists of the removal of the lymphatic tissue of the neck, dissecting along facial planes. For laryngeal and hypopharyngeal cancer the operation includes the removal of nodal groups II to V. This study evaluates the effectiveness of FND in providing regional control of metastatic disease to the clinically negative neck.
Methods: A case series of 153 patients with 218 dissected necks treated by surgery for N0 laryngeal or hypopharyngeal cancer at La Paz University Hospital (Madrid, Spain) is presented. Primary tumor location included 139 laryngeal (103 supraglottic, 19 glottic, 15 transglottic, and 2 subglottic) and 14 hypopharyngeal (pyriform sinus) tumors. Sixty-five patients underwent a bilateral FND, while ipsilateral FND was performed in 88 patients. All patients were followed up for a minimum of 5 years or until death. The site of recurrence was considered to be at the most proximal site. Survival and neck recurrence-free rates were determined using the Kaplan-Meier method.
Results: Occult metastasis was observed in 30% of patients. The 5-year survival rate was 75% in the pN- group (median = 146 months) and 36% in the pN+ group (median = 24 months). The 5-year neck recurrence-free rate was 93.5%. There were 9 neck recurrences (5.8% of patients, 4.2% of dissected sides), which occurred in 6 dissected and 3 undissected sides. Four recurrences occurred in pN- cases. Of the 9 patients who developed neck recurrences, only 3 were alive after 5-year follow-up. One was treated with surgery alone and 2 by surgery and radiation therapy.
Conclusion: The high occult metastatic rate supports the performance of elective surgery in the clinically negative neck. FND is an oncologically effective procedure that provides control of neck metastasis from laryngeal and hypopharyngeal tumors. Recurrences in pathologic negative necks raise the controversy about surgical extension and the possibility of nondetected micrometastases.
10:00 AM
Jeffrey M Zimmerman MD (presenter): Marlon Maus MD; William M Keane MD; David Andrews MD; H Warren Goldman MD
Havertown PA; Philadelphia PA; Philadelphia PA; Philadelphia PA; Philadelphia PA
Objectives: The surgical expertise of various surgical specialties can be combined to approach lesions located in the posterior orbit, parasellar region, anterior cranial fossa, and nasal cavity. We will show how otolaryngology, oculoplastic, and neurosurgical specialists work as a team at Thomas Jefferson and Wills Eye Hospitals, developing novel surgical approaches that result in minimally invasive surgery.
Methods: A transorbital craniotomy is performed via a suprabrow incision, including the frontal bone and orbital roof in a single piece, exposing the superior, medial, and lateral orbits, along with the perichiasmal and chiasmal areas and the anterior fossa. Extending the incision medially allows an external approach to the ethmoid and frontal sinuses. In addition, when necessary, transnasal endoscopy allows visualization of the paranasal sinuses.
Results: We present 25 cases of tumors of the skull base and orbit that were addressed using transorbital craniotomy through a suprabrow approach. In some cases, it was necessary to add the use of transnasal endoscopy to adequately approach the lesions. Using this technique, the lesions were well visualized and resected with minimal brain and orbital manipulation.
Conclusion: Transorbital craniotomy through an extended suprabrow incision allows for wide access to the posterior orbit, parasellar region, anterior cranial fossa, and nasal cavity. Minimizing brain retraction and using a single bone flap decrease postoperative morbidity and reduce recovery time. In addition, placing the incision in the brow achieves a superior cosmetic result.
10:08 AM
Jacquelyn Reilly MD (presenter): David J Myssiorek MD
Bronx NY; New Rochelle NY
Objectives: To evaluate the association of intraoperative facial nerve stimulation and postoperative facial nerve paresis/paralysis.
Methods: Seventy-eight consecutive patients who underwent parotidectomy by a single surgeon were retrospectively analyzed for age, sex, side, and size of tumor; tumor histology; and use of a facial nerve stimulator (0.7 mA). Any intraoperative use of a nerve stimulator was considered a positive finding. Facial paresis was diagnosed if present at any time after surgery up to 10 days. Eighteen patients were excluded because the facial nerve or one of its branches was intentionally cut or a parotidectomy had previously been performed. The Fisher exact test was performed on these data.
Results: Facial paresis developed in 20% (8/41) of the patients who were stimulated and 21% (4/23) of the nonstimulated patients. These results were not statistically significant (P = 1.00001). There was no permanent paralysis in either group. The type, size, and side of the tumor and the sex and age of the patient did not affect the outcome.
Conclusion: There was no difference in the incidence of postoperative facial nerve paresis or paralysis between the stimulated and nonstimulated patients. Routine use of a stimulator is not necessary during parotid surgery as its use does not prevent or promote facial nerve injury.
10:16 AM
Vu T Ho BS (presenter); Diego Preciado MD; George L Adams MD
Minneapolis MN
Objectives: Previous studies using aggressive surgical management have suggested a universally poor outcome from squamous cell carcinoma (SCC) metastatic to the salivary glands. Our objective was to examine our experience with the surgical management of this disease based on the clinical impression that we had several long-term survivors.
Methods: A retrospective study of 11 cases at our institution over the last 10 years with SCC metastases to the parotid glands was performed. All cases were of presumed dermal origin. Eight of the 11 patients had undergone previous renal transplantation. Four patients underwent superficial parotidectomy (SP), 4 underwent total parotidectomy, and 3 underwent radical parotidectomy (RP) with facial nerve sacrifice. Appropriate surgery for complete oncologic resection of disease was performed. All patients had postoperative radiation.
Results: Patients who underwent SP had small SCC foci in the lateral aspect of the gland. Patients who underwent total parotidectomy had larger node involvement in the deep lobe of the gland. Positive perineural extension on frozen section dictated RP in the remaining cases. Six of 11 patients are currently alive (3 > 3 years). Six patients developed locally recurrent disease and/or distal metastases. Of the 4 patients treated with SP, 2 recurred locally and 1 remains alive. Of 3 RP patients, 1 recurred locally and 2 remain alive. Interestingly, the 3 nontransplant patients are alive and disease free.
Conclusion: We propose that metastatic SCC to the parotid gland should be treated like other more common primary parotid malignancies. In our experience, complete oncologic resection, for certain cases, offers good local control and improved survival, in contradistinction to other reports. Transplant-related immune suppression may portend a poorer outcome and perhaps provided a negative skew to this series.
9:30 to 10:24 AM
WCC Room 21
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John F Hoffmann MD; William R LaMear MD (moderators)
9:30 AM
John P Leonetti MD (presenter); Sam J Marzo MD
Maywood IL
Objectives: The purpose of this paper is to present a series of 7 patients with facial paralysis due to a parotid or temporal bone malignancy after having been misdiagnosed as having idiopathic facial paralysis (Bell's palsy).
Methods: The record of 7 patients with facial paralysis, who were thought to have Bell's palsy but were found to have malignant parotid tumors with facial nerve invasion, were retrospectively reviewed. Presenting manifestations, tumor histology, and treatment outcomes were assessed.
Results: Three patients had squamous cell carcinoma, 2 patients had adenoid cystic carcinoma, 2 had adenocarcinoma, and 1 had an osteogenic sarcoma. Two tumors originated in the temporal bone, 3 lesions were of parotid origin, and 2 tumors were too extensive to identify the site of origin. Surgical extirpation was achieved through the use of a variety of lateral skull base techniques, and all patients received postoperative radiotherapy. One patient is alive without disease, 1 patient is alive with active progressive disease, and the remaining 5 patients died of local or distant metastatic disease.
Conclusion: Malignant tumor invasion of the facial nerve can mimic Bell's palsy. A delay in diagnosis will likely affect long-term successful treatment. Five of 7 patients in this series died of their disease within 2 years of diagnosis. We must warn our medical colleagues to be skeptical of the diagnosis of atypical idiopathic facial paralysis.
9:38 AM
Alexander Ramirez MD (presenter); Joseph L Hegarty MD; Robert K Jackler MD
Son Francisco CA
Objectives: We hope to alert clinicians that chronic meningeal inflammation caused by idiopathic hypertrophic pachymeningitis may present as asymmetric hearing loss.
Methods: A retrospective review of 2 illustrative cases is used to exemplify the spectrum of this disease. The first patient is a 51-year-old woman who presented with suddenonset right-sided hearing loss, tinnitus, vertigo, and severe headaches. An audiogram revealed a profound unilateral sensorineural hearing loss. MRI showed massive thickening of the meninges in the prepontine area, originating near the clivus and extending to the porus acusticus. The second patient is a 27-year-old man presenting with sudden-onset left-sided hearing loss, vertigo, and a history of diplopia. An audiogram showed severe down-sloping unilateral sensorineural hearing loss. MRI revealed diffuse dural enhancement of the posterior fossa and the tentorium, extending into the left internal auditory canal.
Results: Both patients had extensive workups to rule out known causes of hypertrophic pachymeningitis, including RPR, ACE, PPD, and multiple cultures. MRI revealed meningeal thickening ranging from thin linear enhancement to massive thickening. These findings were not seen with either precontrast T1 or T2-weighted MRI scans. Biopsies revealed dense fibroconnective tissue with a chronic inflammatory infiltrate and necrotizing granulomatous inflammation. All meningeal cultures were negative for bacteria, fungus, and AFB. Treatment with steroids improved symptoms and radiographic findings.
Conclusion: Idiopathic hypertrophic cranial pachymeningitis is a rare disorder characterized by thickened fibrotic dura. It typically presents as headaches and cranial neuropathies, most commonly hearing loss, due to fibrous entrapment. It is a diagnosis of exclusion often requiring biopsy to exclude meningioma, chronic infection, or granulomatous disease. The spectrum of radiographic findings spans from thin but brightly enhancing dura to massive thickening that may simulate tumors. Inflammatory meningeal disease is yet another example of a pathologic entity that can be discovered on MRI only with contrast administration. As noncontrast (FSE T2) MRI screening for acoustic suspects becomes more widespread, clinicians must be aware that these limited studies may miss important sources of pathology.
9:46 AM
Samuel H Selesnick MD (presenter); Teri Nguyen BA
New York NY
Objectives: The role of the neurotologist in treating extra-axial tumors of the posterior fossa continues to grow. In the past neurotologists focused their efforts on the treatment of acoustic neuromas, but increasingly neurotologists are involved in the treatment of posterior fossa meningiomas. The majority of posterior fossa meningiomas involve the ventral petrous apex or petroclival region. This ventral location and the intervening cranial nerves and vasculature make these lesions a challenge to treat. Meningiomas located posterior to the internal auditory canal yet anterior to the sigmoid sinus compose a distinct subgroup of posterior fossa meningiomas on the posterior petrous face. The objective of this study is to identify the presentation of patients with posterior petrous face meningiomas, describe their treatment, and analyze their outcomes.
Methods: A retrospective analysis of posterior fossa extra-axial tumors treated by the senior author was undertaken. Meningiomas located posterior to the internal auditory canal yet anterior to the sigmoid sinus, on the posterior petrous face, were identified. The clinical presentation, surgical treatment, and outcomes of these patients were reviewed.
Results: Seven patients met the inclusion criteria for this study. These patients with posterior petrous face meningiomas had subtle findings on presentation, despite in some cases, the presence of large tumors significantly compressing the cerebellum. Uniformly, patients with tumors in this favorable location had uncomplicated surgeries and postoperative courses. There was no correlation between tumor size and outcome in patients with posterior petrous face meningiomas, as all did well.
Conclusion: The site of origin of intracranial meningiomas arising from the temporal bone dictates their clinical presentation and their ultimate postoperative course. Posterior petrous face meningiomas arising between the internal auditory canal and the sigmoid sinus have a particularly favorable outcome after surgery, regardless of tumor size. These outcomes can be attributed to the absence of significant direct brain stem and cranial nerve compression.
10:00 AM
Lorne S Parnes MD (presenter)
London Canada
Objectives: Tourette syndrome is a neurologic disorder manifested by both vocal and complex motor tics. The disorder, which almost always starts in childhood, is much more common than originally believed. Due to oversight, the diagnosis is often delayed. In that many of the presenting symptoms involve the head and neck, the otolaryngologist is often called on to assess these patients. However, to date, there have been no previous reports of this disorder in the American otolaryngology literature.
Methods: Three patients ultimately diagnosed with Tourette syndrome are presented to demonstrate the pertinent otolaryngologic features of this disorder.
Results: Case 1 is a 9-year-old boy, referred for assessment of eustachian tube dysfunction. For 3 years he complained of pressure in both ears necessitating almost continual autoinsufflation and lower jaw movement. Tympanostomy tubes had failed to alleviate his symptoms. Further history revealed other complex vocal and motor tics. Case 2 is a 9-year-old boy under care for enlarged vestibular aqueduct syndrome. During one routine follow-up visit, he displayed lip licking and stretching, eye blinking, and arm and shoulder tics. On further questioning, we found that these and other tics had been waxing and waning for more than 1 year. Case 3 is an 11-year-old boy referred for assessment of nasal stuffiness. Related symptoms included chronic sniffing and throat clearing, but unrelated findings included eye tics, vocal tics, and hyperactivity.
Conclusion: Patients with Tourette syndrome, most commonly young males, may be referred to the otolaryngologist for assessment of various phonic/vocal or oral/facial motor tics. The disorder may also be diagnosed coincidentally. Many of these individuals also have comorbid disorders including attention deficit-hyperactivity disorder and obsessive-compulsive disorder. Awareness and recognition are extremely important, allowing for prompt diagnosis and earlier intervention. As well, it will avoid multiple referrals to various specialists, an all too common occurrence for these individuals.
10:08 AM
Kwai Onn Chan MBBS (presenter); Yoke Pang MD; Kuan Kiang
Tan MBBS FRCS
Singapore Singapore
Objectives: Most studies on acute epiglottitis come from countries in the northern hemisphere, and they usually report a large proportion of pediatric patients. This study retrospectively reviews a tropical population to determine epidemiologic and clinical variables and attempts to identify factors associated with airway intervention.
Methods: Thirty-two patients diagnosed with acute epiglottitis during a 7-year period were studied. Data collected included epidemiologic, clinical, diagnostic, therapeutic, and outcome parameters. Statistical analysis was used to identify factors associated with airway intervention.
Results: Ninety-six percent of patients were adults. There was only 1 child in the group. The mean age was 45 years. The most common presenting symptom was sore throat (93%), and 50% had dyspnea. None of the 22 patients who were initially treated conservatively required airway intervention later. Eleven patients required airway intervention (9 intubations and 2 tracheostomies). The risk factors for airway intervention that were statistically significant were a presenting symptom of dyspnea (P < 0.05) and the clinical assessment of a narrowed airway (P < 0.05).
Conclusion: In the tropics, acute epiglottitis is predominantly an adult problem. Dyspnea is a very important symptom as a high proportion have airway compromise requiring airway intervention. However, only selective intubation is recommended as patients without airway compromise do very well with close monitoring and appropriate antibiotics.
10:16 AM
Hieu-Hanh Ngo MD MSc (presenter); Julie Loslier MD; Caroline Pesant MD; Fanny Aubin MD
Sherbrooke Canada
Objectives: Utility refers to the preference or desirability for a particular health state. It is used in estimation of quality-adjusted life-years (QUALYs) and in health economics such as the costs of gains in QUALYs in certain treatment programs. The objective of the following study is to evaluate the perception of the general public regarding the value of life of different health states affected by deficits in hearing, vision, speech, taste, and smell by measuring the utility values assigned to these conditions.
Methods: From the general public, 118 persons were randomly chosen for an interview using the time-tradeoff method to measure utility values regarding the above health conditions. A standardized questionnaire on physical health and socioeconomic status was used to establish independent variables. Parametric and nonparametric statistical tests were used to explore influential factors on utility values assigned.
Results: The median values for life with loss of taste and smell, hearing loss, blindness, and aphasia were 0.83, 0.71, 0.45, and 0.23, respectively. The following factors have some influence on these preferences: gender, age, marital status, associated illnesses, and types of work and leisure activities.
Conclusion: The time-tradeoff method nicely collapses considerations of quantity of life directly into the measure of health-related quality of life. Measures from the general public may help direct funding programs to the most cost-effective health programs for the general population by using cost-utility analyses.
10:24 AM
Francis Marchal MD (presenter); Annemarie Kurt MD; Pavel Dulguerov MD; Prof Willy Lehmann
Geneva Switzerland
Methods: Sialolithiasis was diagnosed, either by sialography or by ultrasound, in 48 patients. Indications for submandibular gland removal were (1) recurrent infections lasting more than 12 months, and (2) chronic infection lasting longer than 2 months despite antibiotic therapy. For each gland 8 slides were stained with hematoxylin-eosin. The degrees of inflammation, fibrosis, and atrophy were analyzed and scored in 3 grades of increasing abnormality. All these pathologic data were correlated to the clinical history (age, duration of symptoms, number and frequency of infectious episodes, delay between the last infection and the surgery) and statistical significance, as analyzed by 1-way analysis of variance.
Results: Three pathologic groups were defined: I (normal)—absent or moderate inflammation, absence of fibrosis and atrophy; II (subnormal)—moderate inflammation, moderate fibrosis, and absent or moderate atrophy; and III (abnormal)—massive inflammation and/or fibrosis and/or atrophy. Groups I, II, and III had 9, 14, and 25 patients, respectively. Thus 48% of patients had normal or subnormal submandibular glands removed. For groups I, II, and III, respectively, the mean age was 39, 35, and 52 years; the mean duration of symptoms 2.4, 4.7, and 2.2 years; the average number of episodes 3.8, 3.6, and 3.0; the frequency of episodes 2.3, 1.6, and 4.4 per year; and the delay 1.8, 1.9, and 2.4 months. There was no statistically significant correlation between pathologic and clinical data, except the age of the patient.
Conclusions: A new pathologic grading of sialadenitis is proposed. Although the indications of submandibular gland removal seem adequate, close to 50% of the removed glands are histopathologically normal or subnormal. Numerous episodes of sialadenitis and long-lasting symptoms are not synonymous with salivary gland destruction. Further studies are needed to correlate this pathologic grading system to salivary function.
9:30 to 10:24 AM
WCC Room 22
•
William H Slattery III MD; Patrick J Antonelli MD (moderators)
9:30 AM
Eric W Sargent MD (presenter)
Saint Louis MO
Objectives: Stapedotomy has supplanted total- or near-total footplate stapedectomy for many otologic surgeons and is perceived to result in better high-frequency hearing with fewer complications. To determine whether the outcome of stapedotomy changes with experience, the results of consecutive operations by a fellowship-trained otologist in an academic otologic practice were reviewed.
Methods: The first 40 consecutive patients who underwent primary KTP laser stapedotomy by the author for otosclerosis were studied in this retrospective case review. Preoperative and postoperative audiograms for both the operated ear and the opposite ear (control) were compared. Results over time were analyzed.
Results: There were no major complications or loss of hearing among the 40 patients. Minor complications included 1 middle ear infection, 2 torn flaps, 3 partial footplate removals, and 1 tympanic membrane perforation. Hearing for the entire group improved from a speech reception threshold of 57 dB (SD 20) to 29 dB (SD 21) (P > 0.001). Complete closure of the air-bone gap was achieved in 20% of the first 10 patients and 40% of the last 10 patients. The duration of operative time decreased with experience.
Conclusion: The results of stapedotomy improve with experience, although in my hands, the learning curve was more rapid than has been reported for total- or near-total footplate removal.
9:38 AM
Elias M Michaelldes MD (presenter); Jack M Kartush MD
Southfield MI; Farmington Hills MI
Objectives: Exposure to loud noise can result in sensorineural hearing loss. In otology, a wide variety of devices are used that have significant noise output to both the operator and the patient. This study quantifies and compares the sound pressure levels (SPLs) of a variety of otologic instruments.
Methods: Using a calibrated SPL meter, the peak and impulse SPLs of several otologic instruments were determined at 1 cm from their application to human temporal bones. Devices measured were an air-powered drill with a cutting burr, an electric microdrill, and KTP, CO2, and erbium lasers.
Results: Impulse SPLs for the KTP laser, CO2 laser, microdrill, air-powered drill, and erbium laser were 67, 71, 90, 105, and 105 dBA, respectively. Peak SPLs were 81, 89, 102, 118, and 132 dBA, respectively.
Conclusion: Use of the KTP laser, CO2 laser, and microdrill results in impulse levels of less than 100 dBA. Although the impulse levels of the erbium laser and the air-powered drill were equivalent, the peak SPLs of the erbium laser were significantly higher. These high SPLs may increase the chance for hearing loss. Like any tool, lasers and drills have benefits and risks. The results of this study demonstrate significant differences in SPL of common otologic lasers and drills. While noise-induced hearing loss is a function of both SPL and duration of exposure, surgeons should consider these differences when selecting and applying these tools, especially when used on or adjacent to the ossicular chain and stapes footplate.
9:46 AM
Jayson S Greenberg MD (presenter); Spiros Manolidis MD
Houston TX
Objectives: To examine the incidence and nature of complicating factors in surgery for chronic otitis media in a metropolitan public hospital setting.
Methods: We performed a retrospective review of surgery for chronic ear disease in a metropolitan public hospital during a 15-month period to identify cases of complicated chronic otitis media (CCOM). This disease classification was defined by the presence of one or more of the following complicating factors: intracranial or extracranial abscess, labyrinthine fistula, dura and/or brain herniation, facial nerve involvement, or middle ear tympanosclerosis combined with cholesteatoma. Secondary features, including revision surgery and cholesteatoma extent, were also identified. Operative management was also reviewed.
Results: One hundred eleven surgical cases were reviewed. Forty-nine (44%) met criteria for CCOM. Complicating factors included 27 dural herniations, 8 encephaloceles, and 20 labyrinthine fistulas. There were 5 infectious complications including 4 intracranial abscesses and 1 mastoid abscess. Twenty facial nerves were involved by cholesteatoma, including 4 patients with preoperative facial paralysis. There were also 4 cases of combined obliterative tympanosclerosis and cholesteatoma. Twenty-six cases were revision operations, while 23 were primary surgeries. Forty-three (88%) had cholesteatoma involvement, the majority of which were extensive. Most patients (92%) were managed by an extended modified radical mastoidectomy. There was no iatrogenic sensorineural hearing loss or facial paralysis.
Conclusion: The incidence of CCOM in a large, metropolitan public hospital is high. CCOM in this setting represents a challenging and often neglected entity, which requires significant surgical effort to control. Maintaining functional hearing is possible but difficult, and it should be considered of secondary importance. Primary surgical goals should focus on prevention of further complications and eradication of disease.
10:00 AM
Marta Sandoval MD (presenter): Pedro Viladrich PhD; Carmen Cabello PhD; Rafael Vera MD; Francisco Gudiol PhD; Manuel Dicenta MD PhD
Barcelona Spain; Llobregat Spain: Llobregat Spain; Barcelona Spain; Llobregat Spain; Barcelona Spain
Objectives: To analyze the otologic clinical aspects in those adults patients with otogenic pneumococcal meningitis (PM) and to review the general characteristics of otogenic PM.
Methods: From 175 patients with PM whose clinical data were prospectively collected from 1977 to 1999, we describe 63 cases of otogenic PM (36% of all the PM in adults). The diagnosis of PM was done by a compatible clinical picture and blood culture and/or cerebrospinal fluid culture.
Results: The clinical characteristics of otogenic PM were similar to those of PM from other foci. Six patients had recurrent meningitis. Neurologic complications were present in 35% of the cases. Most of the patients had unilateral acute otitis media. In 50% of cases the otorrhea was present at the diagnosis of the PM. Almost 50% of the patients had histories of otologic symptomatology. Surgery was performed promptly in very few cases; myringotomy and ventilation tube insertion was the most frequent procedure. The mortality rate was 18%. More than 50% of the patients have been contacted and have no further PM, but 1 woman in 1999 had her third otogenic PM.
Conclusions: We have determined 3 types of otitis media that are associated with PM: otitis media diagnosed in the emergency department without clinical features (6%), acute otitis media that starts 5 to 7 days prior to admission (33%), and the most frequent type, which rapidly evolves in less than 2 days (46%). Chronic otitis media is a rare focus of PM. The characteristics of the otologic manifestations in otogenic PM have never been reported before, to our knowledge.
10:08 AM
Leopoldo Jose Cordero MD (presenter)
Capital Federal Argentina
Objectives: To identify surgical technique similarities and differences between cochlear implants and the Vibrant Soundbridge. The Vibrant Soundbridge is a partially implanted hearing device intended for patients with symmetrical, bilateral, moderate to moderately severe sensorineural hearing loss. Otologists with cochlear implant experience will clearly see the similarities in implantation.
Methods: A personal comparison was made from experience with more than 100 cochlear implant patients to our first experiences with the Vibrant Soundbridge. This condensed session will compare the following: skin flap, mastoidectomy, preparation of the implant bed, posterior tympanotomy, and implant placement.
Results: In our experience the key differences were found to be the posterior tympanotomy and obviously the implant placement of the Vibrant Soundbridge.
Concision: With so many similarities between cochlear implantation and the Vibrant Soundbridge implantation, it is essential to identify the key differences to obtain optimal results for each patient. Our first experience has been positive, with favorable comments from our first patient.
10:16 AM
Thong Le MD (presenter); Eric W Sargent MD
O Fallon IL; Saint Louis MO
Objectives: Migraine-associated vertigo has been described as a diagnostic entity characterized by unsteadiness, dysequilibrium, or episodic vertigo occurring alone or as an aura to headache. We reviewed a group of patients accrued over l year suspected of having migraine.
Methods: Thirty-two patients referred to a tertiary-care neurotology clinic for evaluation of dizziness (dysequilibrium, vertigo, unsteadiness, lightheadedness) were identified as possibly having a variant of migraine. Criteria used to identify this group included (1) symptoms atypical of known labyrinthine disease, (2) lack of objective findings on examination, and (3) normal balance testing.
Results: The mean age was 41.2 years, 84% were female, and 63% described their dysequilibrium as a sensation of rocking, swaying, staggering, shifting, swimming, floating, or leaning. Fifty-nine percent had associated headaches, 53% had visual distortions, 53% had nausea, and 69% had aural or head fullness, tinnitus, and/or subjective hearing changes. Forty-one percent had a history of migraine or migraine variant in the past, and 44% had previously failed medical or surgical treatment for their symptoms. One patient had undergone vestibular nerve section without relief for presumed vestibular hydrops. Patients were treated with antimigraine regimens (diet modification, Midrin, verapamil, β-blockers, tricyclic antidepressants, etc) or were referred to a neurologist for migraine evaluation and treatment.
Conclusion: Migraine may be a cause of symptoms in patients previously described as psychogenic or undiagnosable. Its protean presentation may be confusing, and currently published diagnostic criteria may not be broad enough.
10:30 AM to 12:00 NOON
WCC Room 30
•
William H Slattery III MD; Patrick J Antonelli MD
(moderators)
10:30 AM
Elizabeth H Toh MD (presenter); John W House MD; Alejandro Perez MD
Los Angeles CA; Los Angeles CA; Santiago Chile
Objectives: Much controversy exists concerning the risk of inner ear barotrauma following stapes surgery in scuba and sky divers. No uniform consensus has been established regarding poststapedectomy barorestrictions. The purpose of this study was (1) to determine the incidence of adverse auditory or vestibular sequelae in poststapedectomy patients related to scuba and sky diving, and (2) to offer recommendations on barometric exposure after stapes surgery.
Methods: Survey questionnaires were mailed to 2222 patients who had undergone stapedectomies at a single tertiary otologic referral center between 1987 and 1998. We found that 208 of the initial 917 respondents (22.7%) had snorkeled or scuba or sky dived after stapes surgery. Of these 208 patients, 140 responded to a second questionnaire detailing dive protocols, otologic symptoms, and their relationship to the diving activities. Data obtained from 29 of the latter respondents, who only scuba or sky dived, were analyzed, and their medical records were reviewed.
Results: Four of the 23 scuba divers (17%) experienced otologic symptoms at the time of diving. These included otalgia on descent (3/23; 13%), tinnitus (1/23; 4.3%), and transient vertigo on initial submersion (1/23; 4.3%). One patient developed sensorineural hearing loss 3 years after scuba diving, which was attributed to noise exposure. Of the 9 patients who sky dived, only 1 patient (11%) reported otalgia during the dive. No significant diving-related long-term effects indicative of labyrinthine injury were seen in any of the 29 patients.
Conclusion: Stapedectomy does not appear to increase the risk of inner ear barotrauma in scuba and sky divers. These activities may be pursued with relative safety following stapes surgery, provided adequate eustachian tube function has been established.
10:38 AM
Fatthi Abdel-Baki MD (presenter); Mohamed M Badreldine MD; Mostafa k Bakry Mbbch; Ibrahim M Elsaid PhD
Alexandria Egypt
Objectives: The sinus tympani, a hidden area in middle ear surgery, is known to be a common site for residual cholesteatoma. Surgical access to this space is a real challenge for otologic surgeons in cholesteatoma patients irrespective of the surgical technique used. Many approaches were described in the literature in an attempt to overcome this difficulty. The increased use of the endoscope in middle ear surgery during the past few years had encouraged us to study and describe the endoscopic surgical anatomy of the sinus tympani and its implication in cholesteatoma surgery.
Methods: Thirty temporal bones constituted the material of our anatomic study. The sinus tympani was examined and photographed using endoscopes (of different angles) introduced transmeatally. Frontal saw cuts were made in the temporal bones so that the cutting line passed across the bony eustachian tube. Using the microscope and looking from anterior, the sinus tympani was examined, photographed, and compared to the endoscopic findings. In the clinical part of our study, 92 patients with acquired cholesteatoma were operated either with canal up or canal down technique. The involvement of sinus tympani by cholesteatoma was reported as observed by microscope. Blind microscopic cleaning of cholesteatoma from sinus tympani (if present) was attempted. Then the endoscope was used to report the presence or absence of cholesteatoma remnants.
Results: Our temporal bone endoscopic evaluation of sinus tympani correlated significantly with the direct anterior microscopic findings. Taking into consideration that accurate direct anterior microscopic examination of the sinus tympani can only be performed in sectioned temporal bone, endoscopy proved to be a valuable tool giving true impressions in real-life situations. In the present clinical part of the study, the sinus tympani was found to be involved in 63 of 92 patients with cholesteatoma (68%). After blind microscopic cleaning of the sinus tympani, endoscopic examination revealed the presence of residual cholesteatoma remnants in sinus tympani in 23 patients (36%). These were then removed using endoscopic techniques.
Conclusion: Our work demonstrates clearly the superiority of the endoscope over the microscope in assessing and cleaning sinus tympani. Therefore the endoscope should be considered a valuable tool to complement the microscope in ear surgery. It is recommended that the endoscope be used as a part of any training program or temporal bone course for the otologic surgeon.
10:46 AM
Carsten Dalchow MD (presenter): Detiev Grun MD; Heinz F Stupp PhD
Duesseldorf Germany; Duesseldorf Germany; Duesseldorf NRW Germany
Objectives: Since 1994 more than 1100 titanium implants were used to reconstruct the ossicular chain of the middle ear for chronic otitis media. This presentation discusses the extrusion rate and hearing results for 2 types, partial and total titanium prostheses, commercially available from 2 different companies, used in patients who were followed up from 6 to 72 months.
Methods: A wide variety of patients aged 5 to 82 years received a tympanoplasty type III. Those patients whose ossicular chains had been reconstructed with titanium implants since 1994 were evaluated. As implants from one company are fixed in size; implants of a second company are trimmable in length. All prostheses are lightweight and made of pure titanium, fitting most anatomic situations.
Results: Earlier results already showed a very low complication rate. Extrusion occurred only in cases of middle ear atelectasis with resorption of interposed cartilage (<1%). No adverse reaction to the prostheses could be seen, even in histologic reviews. An average air-bone gap less than 20 dB (A) for all calculated frequencies of 0.5, 1, 2, and 4 kHz was achieved for more than 70% of cases. Almost 40% of cases showed a calculated air-bone gap of less than 10 dB (A), only less than 10% higher than 30 dB (A).
Conclusion: All implants used offer the proven benefits of titanium, namely high biocompatibility and high stability at a very low complication rate with excellent hearing results for the patients. Titanium implants can be highly recommended to reconstruct the ossicular chain of the middle ear.
11:00 AM
Muaaz Tarabichi MD (presenter)
Kenosha WI
Objectives: Large problematic cavities, an unpredictable healing pattern, fibrosis, and closing of the meatus are commonly associated with postauricular canal wall down procedures and often prevent further ossicular reconstruction. An endoscopic technique allows transcanal exploration of the attic and antrum and provides a “what you see is what you get” open cavity; this in turn allows a better framework for ossicular and partial tympanic membrane reconstruction.
Methods: Fifty-one ears with acquired cholesteatoma underwent endoscopic transcanal tympanotomy and extended atticotomy to access and remove the sac. Partial reconstruction of the TM up to the level of the horizontal segment of the facial nerve was performed along with ossicular reconstruction. The extended atticotomy cavity was packed open. Office-based endoscopic surveillance and follow-up were performed.
Results: Forty-nine procedures were performed on an outpatient basis. There were no iatrogenic facial nerve injuries. Bone thresholds were stable, except in 1 patient with perilymphatic fistula. Mean follow-up was 42 months. Two ears required revision surgery. Nine required office-based minor procedures. Closure of air-bone gap to within 20 dB (average of 500, 1000, 2000 Hz) was accomplished in 23 ears.
Conclusion: The transcanal endoscopic open cavity approach allows minimally invasive management and surveillance of cholesteatoma with results that compare well to those of postauricular methods. This technique produces a predictable, safe, and easily manageable cavity, and it also provides for a better framework for ossicular reconstruction.
11:08 AM
Karen Borne Teufert MD (presenter); John W House MD
Los Angeles CA
Objectives: The purpose of this study is to re-evaluate hearing results and rates of extrusion using partial (PORPs) and total (TORPs) ossicular replacement prostheses for ossicular reconstruction. We examined results of reconstruction by PORPs and TORPs with variables including type of surgery (primary vs revision, with/without mastoidectomy), and we analyzed extrusion rates.
Methods: The charts for patients who received a PORP/TORP between 1990 and 1998 were examined. The type of surgery and complications were collated. Hearing tests were given preoperatively and 3 months postoperatively, and the change in 4-frequency pure-tone average (PTA) was examined. In addition, patients had a follow-up hearing examination an average of 1 year after surgery, with some returning more than 2 years after surgery.
Results: There were approximately equal left and right side cases, and the proportion receiving a PORP was nearly 50/50. There was a 3.0% extrusion rate of the PORP/TORP, with 14.9% experiencing postoperative complications. Preoperative 4-frequency PTA was 54 dB, and 3-month postoperative PTA was 35 dB, a statistically significant decrease in PTA (P < 0.001). The final follow-up PTA averaged 36 dB, nearly the same as the 3-month follow-up. For those patients with a follow-up visit at 2 years or more following surgery, the PTA remained stable (3-month average, 29 dB; ≥2-year average, 32 dB).
Conclusion: The extrusion rate of 3% is lower than reported in 1984 and 1991, and the overall level of hearing impairment decreased preoperative to postoperative. The preservation of hearing at 3 months was maintained in a subsample of patients who were followed up more than 2 years after surgery. This demonstrates that the continued use of this type of ossicular reconstruction is successful and preserves long-term hearing improvement in this sample of patients.
11:16 AM
Sam J Marzo MD (presenter); John P Leonetti MD
Maywood IL
Objectives: Intratympanic gentamycin injection is a new and promising technique for management of vertigo secondary to Meniere's disease. By performing a partial chemical vestibulectomy, the injections can allow control of vertigo and preservation of hearing. We recently have been using injections to control vertigo in patients with Meniere's disease and Meniere's syndrome who have failed prior surgical treatment.
Methods: Of 193 patients seen between July 1999 and January 2000 in our balance clinic for vertigo, 7 had prior ear surgeries for unilateral Meniere's disease or Meniere's syndrome. These surgeries included 5 prior endolymphatic sac decompressions and 2 prior perilymphatic fistula repairs. All of these patients failed medical management and were candidates for intratympanic gentamycin injections. These injections were administered over a several-week time period via a standard protocol.
Results: Six of 7 (86%) of these patients had control of their vertigo with intratympanic gentamycin therapy. The 1 patient who failed intratympanic gentamycin therapy underwent a vestibular neurectomy with ultimate control of his vertigo. Side effects were few and included worsening of a unilateral sensorineural hearing loss in 2 patients (29%).
Conclusion: Patients with persistent vertigo in Meniere's disease or Meniere's syndrome who have failed prior surgical treatment usually require a destructive procedure such as a vestibular neurectomy if there is serviceable hearing or if a labyrinthectomy in the hearing is nonserviceable. Intratympanic gentamycin therapy produces a partial chemical vestibulectomy, can be titrated to the patient's symptoms, and might have a role in controlling vertigo in patients who have failed prior surgical therapy.
11:30 AM
Herbert Silverstein MD FACS (presenter); William B Lewis MD; Seth I Rosenberg MD FACS; William S Conlon MD
Sarasota FL
Objectives: To study the trends of surgical procedures used to treat Meniere's disease in the United States during the last decade.
Methods: A questionnaire was sent to all members of the American Otological Society and the American Neurotology Society to learn the frequency, results, and complications of surgical procedures used to treat Meniere's disease. The setting was a tertiary treatment center. Patients living in the United States who had a surgical procedure for Meniere's disease since 1990 were included in the study. There were no interventions. The data were collected on an Excel spreadsheet and statistically analyzed.
Results: This paper describes the experiences of surgeons treating Meniere's disease from 1990 to 1999. Seventy-eight percent of respondents were fellowship trained; 80% perform vestibular neurectomy, 88% labyrinthectomy, 84% endolymphatic sac surgery, and 70% intratympanic gentamicin therapy. Although endolymphatic sac surgery was more common as a first-line therapy, 73% believed intratympanic gentamicin to be on the rise, and 56% believed they were treating more Meniere's patients due to the ease and noninvasiveness of intratympanic gentamicin.
Conclusion: Conventional surgical therapy for Meniere's disease is still common; however, intratympanic treatment with aminoglycoside antibiotics is on the rise, and more Meniere's patients are receiving treatment because of the ease and lack of invasiveness of its application.
11:38 AM
Michael J Ruckenstein MD MSc FRCSC (presenter): Jeffrey P Staab MD; David Solomon MD PhD; Douglas C Bigelow MD; Neil T Shepard PhD
Philadelphia PA; Philadelphia PA; Philadelphia PA; Philadelphia PA; Newtown Square PA
Objectives: To validate that a rapidly administered, objective, quantitative psychological screening test, the Basic Symptom Index-53 (BSI-53), can accurately identify patients with complaints of dizziness and imbalance secondary to psychological pathology.
Methods: Patients referred to our tertiary care balance center were evaluated by a neurotologist, underwent balance function tests and MRI scan (when indicated), and completed the BSI-53 questionnaire. Patients suspected of suffering from psychogenic dizziness based on clinical evaluation or responses on the BSI-53 were referred for formal psychiatric assessment (SCID). The diagnostic impression of the neurotologist, the results of the BSI-53, and the results of the psychiatric assessment were then compared.
Results: To date, a total of 42 patients have participated in the study. Based on neurotologic assessment, 29 patients were diagnosed with psychogenic dizziness and 13 with primary vestibular disorders. There was a strong, statistically significant association between the neurotologist's diagnosis, the results of the BSI-53, and the ultimate psychiatric diagnosis. In 2 patients with primary vestibular pathology, the BSI-53 suggested a secondary psychiatric diagnosis, ultimately determined to be major depression.
Conclusion: Psychological disorders are common etiologies for nonspecific complaints of dizziness/imbalance. The BSI-53 offers the otolaryngologist an easily administered and valid screening questionnaire that provides him or her with quantitative data that then can be used to counsel the patient and arrange for appropriate referrals for psychiatric assessment. Furthermore, the BSI-53 appears useful in detecting psychopathology in patients with underlying chronic vestibular pathology. These patients may benefit from adjunctive psychiatric intervention.
11:46 AM
Joseph L Hegarty MD (presenter); Richard M Irving MD FRCS; Lawrence H Pitts MD; Robert K Jackler MD
San Francisco CA
Objectives: To propose a management algorithm for patients presenting with bilateral acoustic neuromas based on tumor size and residual auditory function.
Methods: A retrospective analysis of 750 patient records with a diagnosis of acoustic neuroma from a University neurotology referral center revealed 47 patients with NF-2. Twenty-seven of these patients presenting with bilateral acoustic neuromas between 1983 and 1999 and managed at this institution were included for analysis. Data including tumor size, surgical approach, preoperative and postoperative audiometric evaluation, facial nerve outcome, and synchronous central nervous system tumors were evaluated.
Results: Of the 27 patients managed, 12 underwent staged bilateral tumor excision, while an additional 11 underwent unilateral tumor excision with continued observation of the contralateral tumor. Four patients were managed nonsurgically, one of whom received unilateral treatment with fractionated radiotherapy. Hearing preservation was attempted in 15 tumors. Successful hearing preservation was achieved at or near preoperative levels in 0% of patients (0/7 tumors) when a retrosigmoid approach was used and in 75% (6/8 tumors) when using a middle fossa approach.
Conclusion: The management philosophy of bilateral acoustic neuromas remains different from that of sporadic acoustic neuromas due to the predicted progressive bilateral hearing impairment and a tendency toward metachronous tumor development. Primary treatment goals include preservation of existing neurologic function and relief of brain stem compression. Strategies such as continued observation or early intervention have been successful in maintaining hearing for as long as possible. An algorithm for the management of bilateral acoustic neuromas is described that comprises observation, stereotactic radiotherapy, and microsurgical excision.
10:30 AM to 12:00 NOON
WCC Room 32
•
Linda Gage-White MD PhD; Stilianos Kountakis MD PhD (moderators)
10:30 AM
Simon James Watts MD FRCS (presenter); Hermanus D Vuyk MD PhD; Bippon Vindayak
Newcastle upon Tyne United Kingdom; Blaricum Netherlands; Reading Bershire United Kingdom
Objectives: Revision rhinoplasty is one of the most taxing procedures within the remit of the ENT surgeon as it involves operating on scarred tissues in an area of the face that allows little margin for error. This presentation will demonstrate the relative frequency of deformities in the various nasal subdivisions and compare the findings with those of previously published texts on the subject.
Methods: This is a retrospective analysis of 110 patients who have undergone revision rhinoplasties (44 male, 66 female; age range 20-69 years). The abnormalities detected and their relative incidence in each patient are placed into the categories of the upper, middle, and lower thirds of the nose. These are then compared to findings in previous papers by Parks (1992) and Kamer (1988).
Results: One hundred ten patients collectively demonstrated 407 deformities at 3.7 per case. Tables will demonstrate the deformities found in each of the upper, middle, and lower thirds. These will be represented as both numbers and percentages within the subset and as percentages of the total number of deformities. The commonly encountered deformities will then be demonstrated for each specific subdivision. Finally, the incidence of these commonly found deformities will be compared to those findings demonstrated by Kamer and Parks in their respective papers.
Conclusion: The analysis of 110 revision rhinoplasty cases revealed a recurring pattern of deformities. Recognition of this pattern and conceptualization of their etiology will help to form individualized management strategies for the prevention and management of these deficiencies in the future.
10:38 AM
Babak Azizzadeh MD (presenter); Keith E Blackwell MD; Mr Carlos Ayala; Jeffrey D Rawnsley MD
Los Angeles CA; Los Angeles CA; Brownsville TX; Los Angeles CA
Objectives: To document the reliability, incidence of complications, and cost of therapy for patients older than 80 years who undergo microvascular head and neck reconstruction.
Methods: Thirteen octogenarians underwent free flap reconstruction of defects resulting from the treatment of head and neck cancer at an academic tertiary care medical center. The incidence of medical and reconstructive complications and the cost of hospitalization were compared to findings in 99 younger patients treated during the same time period.
Results: There were no cases of free flap failure or significant reconstructive complications in the octogenarians. The incidence of medical complications was 62% in the octogenarians and 15% in the younger patients. The average cost of therapy was $54,702 per patient in the octogenarians, compared to $30,397 in the younger patients. The increased incidence of medical complications and increased cost arose primarily from an increased severity of preoperative systemic illness in the octogenarians. However, controlling for comorbidity did not eliminate the discrepancy in medical complications between the octogenarians and the younger patients.
Conclusion: While microvascular head and neck reconstruction in the elderly is very reliable, the incidence of medical complications and the cost of therapy are significantly increased in octogenarians.
10:46 AM
Karen M Kost MD (presenter)
Westmount Canada
Objectives: Percutaneous tracheostomy is now widely practiced by intensive care unit physicians and anesthetists in many North American centers. The procedure, however, has been slow to gain acceptance by the otolaryngology community because of early reports of serious complications. Increasing evidence indicates that endoscopic percutaneous dilatational tracheostomy using multiple dilators is at least as safe as conventional tracheostomy in the operating room. Recently, a single dilator was introduced in an attempt to further simplify the procedure. The objectives of this presentation are to acquaint the audience with the use of this new instrument through a discussion of the indications, contraindications, and important technical details of the procedure. Results in the first 60 patients will be reviewed.
Methods: The new single dilator is being evaluated in terms of safety and complications as part of an ongoing prospective study. Thus far, the procedure has been performed in 60 consecutive adult, intubated, intensive care unit patients requiring tracheostomy between June 1998 and August 1999 at the McGill University teaching hospitals.
Results: Of the 60 patients, 28 were male and 32 were female, with a mean age of 66 years. Procedure time ranged from 5 to 15 minutes. Shiley tracheostomy tubes were used in all cases, with 43 patients receiving a No. 8 tube, and 15 patients receiving a No. 6 tube. Blood loss was less than 20 cc in 56 cases and less than 50 cc in the remaining 4. Complications occurred in 5 (8%) of 60 patients. One patient briefly desaturated to 81% intraoperatively. Postoperatively, 1 patient was accidentally decannulated 2 weeks after the procedure, requiring reintubation followed by reinsertion of the tracheostomy tube. Postoperative bleeding occurred in 3 patients, all of whom had severe coagulopathies. Control was achieved with local measures and by correcting the coagulopathy. None of the patients required transfusions as a result of the bleeding.
Conclusion: Endoscopic percutaneous dilatational tracheostomy using multiple dilators is at least as safe as conventional tracheostomy in the operating room. Using the same basic principles, the new single dilator was introduced as a means of further streamlining the procedure. Early results in 60 patients indicate that the single dilator further simplifies the technique without compromising safety.
11:00 AM
Oscar Kujawski MD (presenter); Jean Fasel MD
Geneva Switzerland
Objectives: Chronic eustachian tube dysfunction is related to frequent middle ear pressure drops associated with transmission deafness, tinnitus, otalgia with vertigo, tympanic membrane atelectasis, and recurrent otitis media. After the failure of repeated antibiotic prescriptions, the insertion of a ventilating tube in the tympanic membrane is at present the single most effective treatment. This study prospectively evaluates the first endoscopic transnasal CO2 laser-assisted eustachian tube surgery, called laser eustachian tuboplasty (LETP), developed for directly treating these common eustachian tube pathologies when all conservative measures have failed or in the case of recurrence after myringotomy.
Methods: Thirty-eight patients suffering from chronic eustachian tube dysfunction symptoms were selected for this surgical procedure. Clinical examination involved otoscopy, tympanometry, and dynamic tuboscopy. Average transmission deafness was analyzed by audiometry before and after surgery. Failure of initial conservative measures based on topical cortisone treatment associated with logopedic therapy led to surgical indication. A total of 72 LETPs were provided. Twenty-five patients (66%) also presented case histories of recurrent otitis media or ventilation tube insertion. The surgical procedure consists of selectively vaporizing the mucosa and the cartilage of the roof and the posterior wall of the eustachian tube using CO2 laser nasal fiber probes.
Results: Subjective improvement was noted after an average of 2 weeks. The initial deafness was reduced in 27 patients (71%), remained the same in 10 patients (26.3%), and worsened in 1 patient (2.7%). The initial tinnitus was reduced in 23 patients (60.5%), remained the same in 13 patients (34.2%), and worsened in 2 patients (5.3%). Recurrent otalgia, often accompanied by vertigo, was reduced in 33 patients (86.8%), and remained the same in 5 patients (13.2%). None of the treated patients complained of intensified otalgia. The average hearing gain analyzed by audiometry was 52.5%. No significant complication was observed. None of the 25 patients who also presented case histories of recurrent otitis media or ventilation tube insertion experienced a recurrence after surgery.
Conclusion: LETP appears to be an effective tool for treating chronic eustachian tube dysfunction. It reduces transmission deafness, tinnitus, and recurrent otalgia. Reduction of recurrence of otitis media with effusion that was also observed in our study seems to confer to this surgery a new prophylactic approach in order to prevent this common middle ear pathology. This new 1-day surgery seems to be safe and easy. It may be applied in the future to wider indications, such as treating otologic complications of rhinopharynx oncology or congenital deformity. By enhancing middle ear ventilation, it may be associated in the treatment of Meniere's disease that responds to myringotomy.
11:08 AM
Gordon J Siegel MD (presenter)
Chicago IL
Objectives: To identify and describe the similarities between the perception of chronic tinnitus and the perception of pain. The goal of this study is to contribute to the understanding of tinnitus and to contribute to the development and implementation of effective treatments for severe forms of this symptom.
Methods: A total of 321 men and 115 women (mean age 50.6 years) who visited the Tinnitus Clinic at Oregon Health Sciences University filled out detailed questionnaires that were mailed to them prior to their initial appointments. These questionnaires requested information about patients' medical, hearing, and tinnitus histories. For the present study, a subset of 12 of these questions were evaluated because of their relevance to tinnitus severity. In addition, patients' responses to 2 questions about depression, 1 about insomnia, and the State Trait Anxiety Inventory were analyzed.
Results: Responses to questions about tinnitus severity from 121 patients who reported current depression were compared to responses from 285 patients who reported no history of depression. Patients with current depression scored significantly higher than nondepressed patients on all 12 questions relating to tinnitus severity. Reported loudness and severity of tinnitus were significantly greater for patients who often experience insomnia than for groups of patients who reported that they never or only sometimes have difficulty sleeping. Tinnitus severity was also greater for patients with higher levels of anxiety as measured by the State Trait Anxiety Inventory.
Conclusion: Many patients with chronic tinnitus experience insomnia, anxiety, and depression. According to results from the present study, depression and tinnitus severity are linked in some patients. Insomnia and anxiety are also associated with greater perceived severity of tinnitus. These findings underscore the importance of identification and successful treatment of insomnia, anxiety, and depression for patients with tinnitus. Treatment of these coincident symptoms—with medications or psychotherapy—is likely to reduce tinnitus severity for many of these patients. Because of the similarities between patients with chronic tinnitus and patients with chronic pain, it might be useful for clinicians to treat tinnitus patients as they would treat pain patients. For some patients, tinnitus can be considered phantom auditory pain.
11:16 AM
Steven R Mobley MD (presenter); Soham Roy MD; Craig A Buchman MD
Miami Beach FL: Miami FL: Miami FL
Objectives: The Internet has been identified as the fastest growing information medium of the modern era. Within the field of otolaryngology there have been an expanding number of both educational courses and Internet-based businesses aimed at the development of Internet pages for physicians in the academic and community settings. However, to our knowledge, there are no data in the otolaryngology literature that quantify patients' use or interest in the Internet when seeking otolaryngologic care. In this study we set out to establish the usage patterns and interest in the Internet for patients in a tertiary otolaryngology outpatient setting.
Methods: A voluntary survey of all new adult patients in a university-based outpatient otolaryngology clinic was performed. Patients answered 50 questions regarding their current or past use of the Internet for researching physicians, hospitals, symptoms, and other medical information. In addition, respondents provided feedback about information they would like to have available from their otolaryngologist via the Internet. Complete demographic information was obtained from respondents. These data are a preliminary subset of an ongoing evaluation.
Results: The survey was completed by 116 patients; 70% of respondents had regular access to the Internet. Internet use was not associated with age, but there was a significant association with increased income. On average, the Internet was used to research health care information 1.9 times within the past year; 41% of patients used the Internet to research a specific symptom or diagnosis. The most common diagnoses researched were cancer and sinusitis; 21% of patients attempted to find a physician on the Internet, but 30% were unsuccessful. Patients were interested in learning about their otolaryngologist's education, experience, and malpractice record. While a significant number of patients were interested in performing basic office functions over the Internet (getting laboratory results, making appointments), 85% had concerns about the reliability of information over the Internet.
Conclusion: While the interest of physicians to develop Internet-based web pages is increasing steadily, little has been done to investigate the use and interests of patients for whom these Web pages are designed. Our data confirm that almost half of new otolaryngology outpatients are using the Internet to research information regarding their own health care. From our survey data, otolaryngologists can learn more about the information that is of interest to patients and may use these data to better educate patients in their clinical practices and over the Internet. As the information technology era continues to expand, it is critical that otolaryngologists continue to provide information to patients that is reliable, secure, and useful.
11:30 AM
Fatthi Abdel-Baki MD (presenter); Diaa A Riad MD; Mohamed M Badreldine MD; Ahmed S Eldaly MD
Alexandria Egypt; Alexandria Egypt; Alexandria Egypt; Pittsburgh PA
Objectives: Dizziness, a common symptom in clinical practice, may be caused by a variety of lesions ranging from trivial to life-threatening conditions. MRI is an excellent tool for diagnosing such conditions. The main MRI limitation is its high cost, which cannot be afforded by many patients. The aim of the present study is to check the positive and negative predictive values of certain selection criteria which were established in our practice as a baseline for referral of dizzy patients to MRI.
Methods: Two hundred thirty-seven dizzy patients were routinely subjected to basic audiologic evaluation, electronys-tagmography (ENG), videonystagmoscopy, and auditory brain stem response (ABR) testing. Patients were referred for MRI if showing at least 1 of the following criteria: (1) abnormal ABR or if it cannot be performed due to severe hearing loss, (2) abnormal central vestibular tests by ENG, (3) patients not responding to proper medical treatment or vestibular rehabilitation for a maximum period of 3 months, and (4) abnormal symptoms despite normal findings. For every patient with positive criteria evaluated by MRI, 4 consecutive patients with negative criteria were sent for MRI as well to constitute our control in a randomized manner.
Results: Of 237 dizzy patients, 22 met the selection criteria needed for referral to MRI. On performing such imaging, 20 patients showed positive findings: vascular loops (7), acoustic tumors (4), MS (3), chordoma (1), brain atrophy (1), brain infarction (1), ependymoma (1), cholesteatoma (1), and pineal body tumor (1). However, 2 patients had completely free MRI scans. Abnormal ABR was the most common cause for referral (9), followed by the patient not responding to treatment (8), then abnormal central vestibular test by ENG (3), and profound hearing loss preventing ABR performance (3). The least indication was abnormal symptoms (1). MRI done in 88 patients with negative selection criteria (control group) failed to show any significant findings.
Conclusion: Although MRI ideally should be performed as an initial diagnostic step in every dizzy patient, the present study showed that by performing routine audiovestibular tests and following the above-mentioned selection criteria, the need for MRI will be significantly reduced without jeopardizing diagnostic accuracy in dizzy patients. The present work stressed the value of performing ABR routinely in every dizzy patient, even in individuals with normal hearing as a cost-effective alternative to routine MRI.
11:38 AM
Phillip Chang FRACS (presenter); Nicola Quaranta MD; David M Baguley MSc; David A Moffat BSc MBBS FRCS
Cambridge United Kingdom; Parma Italy; Cambridge United Kingdom; Cambridge United Kingdom
Objectives: Cholesteatomas of the cerebellopontine angle (CPA) account for 6% to 7% of lesions in this region. Their slow growth rate along with their malleable capsule means that with time they have the ability to engulf neurovascular structures in the CPA and the clefts within the brain cortex. They tend to grow along pathways of least resistance. For all these reasons, they present late and large, presenting both diagnostic and surgical challenges. A new staging system is proposed and the unit's experience is reported.
Methods: Fifteen consecutive cases of CPA cholesteatoma were reviewed. These cases were managed at a tertiary neurosurgical referral unit between September 1985 and April 1999. The study population, consisting of 7 men and 8 women, had a mean age of 44 years (range 21-69 years) at the time of surgery. The clinical, audiologic, and radiologic presentations were examined. The tumors were classified according to the newly proposed Moffat classification of CPA cholesteatomas. The results of surgical management, based on postoperative neurologic deficits, degree of resection, complication rate, and recurrence rate on follow-up, were also evaluated.
Results: Using the new staging system, spread of these lesions occurred most commonly in the anterior and superior directions. In two thirds of cases the presenting symptom was related to the vestibulocochlear nerve. The average duration of symptoms was 23 months (ranging from 1 month to 10 years). The hearing-preservation surgical approaches were used the most, while the translabyrinthine approach alone or in association with a middle fossa craniotomy was performed in selected cases. The lesion removal was total in 12 cases and subtotal in 3 cases. Unsteadiness was the most common postoperative symptom. The postoperative complications included aseptic meningitis, pulmonary embolism, and temporary cerebrospinal fluid leak, all of which were managed conservatively.
Conclusion: Surgical removal is the only available therapy. The surgical approach should optimize resection while minimizing morbidity. The ability to optimize an approach only comes with the teamwork of a neurotologist and a neurosurgeon. By following this management philosophy, the unit was able to completely remove the CPA cholesteatoma in 80% of cases, with minimal morbidity and no mortality.
11:46 AM
In-Seok Seo MD (presenter); Yang-Sun Cho MD PhD; Myung-Koo Kang MD; Sung Hwa Hong MD PhD
Seoul South Korea; Seoul South Korea; Pusan South Korea; Seoul South Korea
Objectives: External ear resonance (EER) can normally increase the sound pressure level at the tympanic membrane by as much as 20 dB between 2 and 4 kHz. EER depends on the characteristics of the external ear canal (EAC) and tympanic membrane. Tympanic membrane perforation (TMP) in chronic otitis media (COM) can alter the EER, and surgeries such as tympanoplasty and various types of structural modifications of EAC may further change the resonance characteristics. This study was designed to identify (1) the EER characteristics in patients with TMP, (2) postoperative changes in EER with 3 types of operation, (3) EER changes according to the postoperative periods. These changes should be considered in the fitting of hearing aids as needed for COM patients with sensorineural hearing loss who underwent surgery.
Methods: This study was composed of 107 ears with TMP that underwent tympanoplasty with canal wall up mastoidectomy (CWU), 40 ears that underwent epitympanoplasty (EPI), 24 ears that underwent canal wall down mastoidectomy (CWD), and 96 control ears. We measured the gain and frequency of the first peak of EERs by using a real ear analyzer. EPI was designed to preserve the posterior canal wall while exposing the sinus tympani and epitympanum widely by EAC widening, scutum removal, and epitympanic obliteration. At first, preoperative EERs were checked and compared with those of the control group. Subsequently, postoperative EERs were measured and analyzed in 3 types of surgery. In the CWU group, EERs were measured at postoperative 3, 6, 9, 12 and more months and compared during the follow-up periods.
Results: The gain and frequency of the preoperative group were not different from those of the control group. However, peculiar negative peaks appeared around 1500 Hz in half of these ears. After mastoidectomy and tympanoplasty had been performed using the temporalis fascia, the peak gain increased remarkably in all 3 postoperative groups. The CWD and EPI groups showed significantly lower frequencies than the CWU and control groups, but the difference was not demonstrated between the CWD and EPI groups. In the CWU group, the increments in gain diminished over time, but the peak gain did not equalize to that of the control's data even after 2 years.
Conclusion: Some additional gain should be considered in the frequencies around 1.5 kHz for hearing aid users with TMP. The gain of peak increased after all types of surgery. The procedures that increase the volume of EAC (EPI, CWD) push the first peak to the lower frequencies while losing some gain in the high frequencies. However, EPI enabling the use of CIC-type hearing aids have more advantages in overcoming the above problems than CWD. We could expect alterations of EER after surgeries in chronic otitis media patients, suggesting that these changes should be considered in the fitting of the hearing aids.
11:54 AM
Jyoti Dabholkar MD (presenter)
Mumbai India
Objectives: A prospective study of 240 patients presenting with unsafe chronic suppurative otitis media (CSOM) was performed. The study included age and sex at presentation, complication as a presenting feature, type of surgery done (radical/modified radical mastoidectomy), and reconstruction of the hearing mechanism if not staged.
Methods: This is a prospective study of 240 patients presenting with unsafe CSOM in a teaching hospital from October 1995 to August 1999. The following details were recorded: age, sex, complications at presentation, and type of mastoidectomy done (radical vs modified radical); if canal wall reconstruction or reconstruction of the hearing mechanism was done, the frequency and the choice of material used were also recorded.
Results: Most patients presenting were 11 to 30 years old, with 67.5% being male. About 15.42% of patients were in the pediatric age group (<14 years). Forty-three patients presented with complications of unsafe CSOM. The total complication rate was 17.9%. About 75% of cases presented with cholesteatoma, 32% with granulations, and 7% with both. Only 2.5% were radical mastoidectomies, and 97.5% were modified radical mastoidectomies. The incidence of tuberculosis as an etiological factor was seen in about 3%. Canal wall with lateral attic wall reconstruction was done in 10.8%, and the material of choice was autocartilage. Of the 240 cases, hearing mechanism was reconstructed in about 59.2%, with the material of choice being autoincus (auto-ossicle) if present or homo-ossicle. In 38.33%, the surgery was staged.
Conclusion: The incidence of complications as an initial presenting symptom, although thought to be reduced in the era of antibiotics, is still high. In addition, the number of patients presenting in the pediatric age group is very high. Controversies about canal wall up and canal wall down surgery will continue eternally; however, we think that for the Indian setup, canal wall down surgery is the procedure of choice because education, financial status, poor medical help in rural areas, and poor follow-up are important factors in managing the disease.
10:30 AM to 12:00 NOON WCC Room 40
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Rodney P Lusk MD (moderator); Reuben C Setliff III MD; Dale H Rice MD
Saint Louis MO; Sioux Falls SD; Los Angeles CA
Educational Objectives: To discuss the historical rationale for middle meatal antrostomy (MMA); explore the advantages, disadvantages, indications, and contraindications for MMA; and review the anatomy and physiology of the maxillary sinus and associated pathophysiology.
Description of Symposium: Creation of an MMA has been a cornerstone of functional endoscopic sinus surgery for the past 10 years. The theoretical basis for the surgical MMA has recently been challenged as our understanding of maxillary sinasophysiology broadens and new models to explain the pathogenesis of sinusitis emerge. As a result, controversy surrounds this early tenet of endoscopic sinus surgery as the need for and benefit derived from the once routine MMA are being redefined. To this end, the panelists will openly debate the relevant issues responsible for the current controversy and present their clinical experience and surgical model to support their position.
10:30 AM to 12:00 NOON WCC Room 31
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Karen H Calhoun MD (moderator); Ronald B Kuppersmith MD; Jo A Shapiro MD; Marvin P Fried MD; Lawrence P A Burgess MD COL USA MC; Robert H Ossoff MD
Galveston TX; Seattle WA; Boston MA; Bronx NY; Triplr Army Mdcl HI; Nashville TN
This presentation explores the impact of technology on residency training and education, including such issues as Online Educational Resources; Technology, Residents, and the ABO; Electronic Teaching for Medical Students and Residents; Residency Training and Surgical Simulators; and Telementoring.
10:30 AM to 12:00 NOON WCC Room 38
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(with Spanish translation)
Ramon M Esclamado MD (moderator); David J Adelstein MD; James H Boyd MD FACS; James I Cohen MD PhD; Gregory K Hartig MD; James T Parsons MD
Cleveland OH; Cleveland OH; Saint Louis MO; Portland OR; Madison WI; Gainesville FL
Educational Objectives: Treatment approaches for patients with head and neck squamous cell cancer continue to focus on improving disease-specific and overall survival, while attempting to minimize functional and treatment morbidity that affects the patient's subsequent quality of life. The participant in this seminar will be able to identify both surgical and nonsurgical treatment options designed to be oncologically effective while preserving functional integrity in speech and swallowing. The participant will understand the advantages and limitations of the different therapeutic strategies and apply these principles toward appropriate treatment recommendations.
Description of Symposium: This seminar will present several case scenarios in a tumor-board format that are commonly encountered by the otolaryngologist-head and neck surgeon in clinical practice. Case presentations of patients with squamous cell cancer of the oropharynx, larynx, and hypopharynx will be discussed. A multidisciplinary panel will discuss the appropriate diagnostic and staging evaluation; treatment considerations, options, and principles; and expected oncologic and functional outcomes. Particular emphasis will be placed on surgical and nonsurgical organ preservation approaches, appropriate management of neck disease, and the effect of these strategies on distant metastatic disease.
10:30 AM to 12:00 NOON WCC Room 39
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(with Spanish translation)
Regina P Walker MD (moderator); Samuel A Mickelson MD; Tod C Huntley MD; Nelson B Powell MD
Hinsdale IL; Atlanta GA; Indianapolis IN; Palo Alto CA
The consequences of sleep-disordered breathing (SDB) can be very serious and even life-threatening. Pathologic daytime sleepiness, which results from SDB, can lead to deterioration of neurobehavioral function. Recent attention to the potential increased risk of motor vehicle accidents in the sleep apnea population has important implications for the treating physician. New evidence suggests that the sleepy driver is as dangerous as the intoxicated driver.
The purpose of this miniseminar is to review the medical, social, and legal consequences of SDB with an emphasis on obstructive sleep apnea syndrome (OSAS). The more common medical consequences of OSAS, such as hypertension and cardiovascular disease, will be reviewed. The social consequences include the known increased rate of motor vehicle accidents in the sleep apnea population. Emphasis will be placed on comparing patients with OSAS to intoxicated drivers.
Finally, there is growing concern among treating physicians as to what their legal role is for reporting sleepy drivers to government agencies. A review of regulations and guidelines dealing with fitness to drive for sleep apnea patients will be presented.
