Annals of Otology,Rhinology & Laryngology

Severe subglottic stenosis in children is best managed by laryngotracheal reconstruction or cricotracheal resection (CTR). We describe clinical outcomes with CTR and end-to-end anastomosis in pediatric patients with severe subglottic stenosis in a tertiary-care pediatric teaching hospital in Mexico City. We prospectively followed up all consecutive patients younger than 18 years of age with a Myer-Cotton grade 3 or 4 subglottic stenosis who underwent CTR between May 1, 2000, and March 31, 2003. The frequency of each clinical outcome was calculated. Twenty-two patients (16 boys [72.7%] and 6 girls [27.3%]) were included. The mean age at operation was 4.6 years (range, 11 months to 16 years). Eighteen patients (81.8%) required primary CTR, and 4 (18.2%) required extended CTR. Seventeen (77.3%) had grade 3 stenosis, and 5 (22.7%) had grade 4 stenosis. Six (27.3%) had associated clinical conditions, and 3 (13.6%) had associated vocal cord mobility defects. All were tracheostomy-dependent at presentation, and none had undergone previous airway surgery. Ten (45.5%) underwent one-stage surgery, and 12 (54.5%) had a concomitant temporary tracheotomy. No intraoperative complications occurred. Seventeen patients (77.3%) developed postoperative granulation tissue requiring endoscopic resection. The mean follow-up was 1.2 years (range, 2 months to 2.8 years). No deaths occurred. Fifteen children (88.2%) with grade 3 stenosis and 5 (100%) with grade 4 stenosis were decannulated, for an overall decannulation rate of 90.9%. Partial cricoid resection with end-to-end anastomosis has been a feasible procedure with reproducible successful results among our patients. We conclude that CTR performed as a primary procedure is an effective treatment for the management of severe subglottic stenosis in children.

More than 16,000 vagal nerve stimulators (VNSs) have been implanted for refractory epileptic seizures. The most commonly reported side effect is hoarseness. This study examines the effects of VNS placement on vocal fold function. Eleven patients who had undergone VNS placement at our institution were recruited. Subjective evaluation by a panel of speech and language pathologists of both connected speech and videolaryngoscopy recordings were used both at rest and during VNS activation. Additional subjective evaluation included use of the Voice Handicap Index for the study group. These results were compared to data from age- and sex-matched controls. Objective data included maximum phonation time in the study and control groups, as well as laryngeal electromyography performed on the VNS-implanted patients only. Motor unit potential morphology and recruitment, as well as spontaneous activity, were analyzed bilaterally for the cricothyroid and thyroarytenoid muscles. Significant differences were found between the study and control groups subjectively for vocal quality and videolaryngoscopy parameters. Vocal fold tension, supraglottic muscular hyperfunction, and reduced vocal fold mobility were the most common findings during VNS activation. Two of 10 patients had immobile left vocal folds in the absence of active stimulation. The maximum phonation time was generally reduced in the subject group, but this reduction did not reach statistical significance. Finally, 6 of 10 patients had abnormal electromyographic results, including large-amplitude polyphasic motor unit potentials and decreased recruitment. We conclude that implantation of a VNS can affect vocal fold function. The effects are magnified during periods of active stimulation. There is the potential for nerve degeneration after prolonged repetitive stimulation, and there may be a trend toward greater vocal fold dysfunction with higher stimulation parameters.

Case reports in the literature on conjoined twins discuss the difficulties with anesthesia and surgical separation; however, the role of airway endoscopy as a means of evaluating the respiratory tract has not been described. This case of thoraco-omphaloischiopagus laterally conjoined twins demonstrates the importance of videoendoscopic airway evaluation in the management of conjoined twins. Direct laryngoscopy and bronchoscopy was used to evaluate ventilator dependence and demonstrated tracheal anomalies that were partially responsible for difficulties with weaning and endotracheal tube placement. Knowledge of the airway anomalies assisted in ventilator management of the twins, and the neonatalogists were able to proceed with greater confidence because no surgically correctable airway obstruction was found. Direct laryngoscopy and bronchoscopy offer valuable information about thoracopagus conjoined twins and should be included in the preoperative evaluation of planned separation of conjoined twins, as well as being used for conjoined twins who are ventilator-dependent.

Several authors have eloquently described the characteristics of vocal fold scar, a long-term consequence of vocal fold injury. However, events in the acute stage of mucosal injury, which lead up to fibrosis, have been largely overlooked. The current study describes acute events with regard to mucosal re-formation in a rabbit model. Vocal fold injury was induced surgically. A fibrinous clot was present 1 day after injury. Massive cellular infiltration was noted on day 3, and complete epithelial coverage was achieved by day 5. Also, neo-matrix deposition was noted as early as 5 days after injury, and more mature collagen was seen by day 7. The general timetable described in the current study can contribute to the experimental foundation for the development of regenerative models of healing in the vocal folds. Most notably, the proliferation phase of wound healing appears to occur approximately 3 days after injury, indicating a critical time for intervention. Manipulation and/or alteration of naturally occurring neo-matrix deposition and organization may yield improved biophysical function of the injured vocal fold.

On the basis of a retrospective review of an inception cohort of 135 patients, with an isolated, previously untreated, moderately differentiated to well-differentiated invasive squamous cell carcinoma of the pyriform sinus and a minimum of 3 years of follow-up, consecutively managed with a supracricoid hemilaryngopharyngectomy (SCHLP) at a single tertiary referral care center and locally controlled, the authors review in detail the surgical technique, highlight the potential technical pitfalls, and document the complications and long-term functional outcome. The overall postoperative mortality rate was 3.7%. The overall mortality rate directly related to the SCHLP was 1.5%. A significant surgical complication directly related to SCHLP completion was noted in 9.6% of cases. The mean lengths of time to removal of the tracheotomy and feeding tubes were 9 and 19 days, respectively. The mean duration of hospitalization was 25 days. Normal swallowing without aspiration by the first postoperative month was noted in 64.6% of patients. Temporary grade 1–2 aspiration and grade 3 aspiration were noted in 26.9% and 8.5% of patients, respectively. Overall, in our series, successful oral alimentation without gastrostomy or completion total laryngectomy was achieved in 91.9% of patients by the first postoperative year, and the incidences of permanent gastrostomy, completion total laryngectomy, and aspiration-related death were 0.7%, 1.5%, and 0.7%, respectively. A significant late complication related to the use of postoperative radiotherapy was noted in 26.5% of cases. From a functional point of view, such results suggest that SCHLP should be integrated among the various conservation treatment options available to patients with selected invasive squamous cell carcinoma of the pyriform sinus.

Eosinophilic angiocentric fibrosis (EAF) is a rare specific inflammatory condition that affects the nose and upper airways and is characterized by distinctive histopathologic features. We report the clinical, histopathologic, and radiologic features of EAF in an elderly woman who presented to us with complete stenosis of the left nostril, nasal swelling, and granuloma faciale (GF) of the overlying nasal skin. The histopathologic spectrum of the early, intermediate, and late stages of EAF in the deeper nasal tissues is illustrated along with the adjacent changes of GF in the overlying nasal skin. Quantification of immunohistochemically stained lymphocyte cell subsets in the perivascular inflammatory component was performed by using software to compare the proportions of lymphocyte subsets in the two conditions. The results showed similar proportions of perivascular CD4 T lymphocytes in EAF and GF. We believe that both EAF and GF may represent unusual tissue responses. Similar analysis in other cases will help confirm these findings. A review of the literature suggests that the condition, if localized, is amenable to surgical treatment. In progressive late stages, EAF causes fibrotic stenosis of the affected site with localized extension.

Use of contrast-enhanced color-coded Doppler (ultra)sonography (CCDS) in evaluating enlarged lymph nodes has been subject to numerous attempts to define criteria for differentiation between benign and malignant lesions. Evaluation of dynamic perfusion patterns with contrast-enhanced CCDS in cervical lymph nodes offers new possibilities of differential diagnosis. A total of 28 patients with clinically enlarged lymph nodes were included in this study. Contrast-enhanced CCDS was performed on each patient. The color signals from nodes <15 mm in diameter were analyzed with a specialized computer program. Each node was later examined through immunohistochemical staining. Vascularization as shown by unenhanced CCDS was significantly greater in metastatic lymph nodes than in reactively enlarged lymph nodes (8.66% versus 2.81%; p = .01). The maximum vascularization area after contrast injection did not show any significant change (26.61 % versus 28.63%; p = .75). Comparison of values obtained before and after contrast enhancement showed the largest relative increase in vascularization in inflammatory lymph nodes, from a factor of 19.55 to a factor of 10.03 (p = .025). Dynamic values such as contrast enhancement, behavior of dynamic values referred to time, and the evaluated vascularized area did not show any significant difference. The metastatic lymph nodes (5.46 versus 3.33; p = .007) predominantly consisted of large blood vessels. The increased vascularization in the unenhanced CCDS examination of metastatic lymph nodes seems to be associated with the increased number of large blood vessels. An increased vessel density, due to a greater number of total vessels, is related to an inflammatory process. Color Doppler mapping has been proven to depict useful aspects distinguishing benign from malignant lymph nodes of the neck; however, a definitive differentiation between lymph nodes involved with malignancy and inflammatory changes remains difficult.

This retrospective study was undertaken to assess balance recovery and dizziness handicap in 32 patients after a vestibular and balance rehabilitation program. Outcomes were compared between 12 patients with peripheral vestibular disorders and 20 patients with central or mixed balance disorders. The patients were tested with posturography (sensory organization test [SOT]) and the Dizziness Handicap Inventory (DHI) before and after their therapy program. The vestibular SOT, composite SOT, and functional DHI scores obtained before and after exercise were significantly improved in both the peripheral and central groups. The visual SOT mean scores obtained before and after therapy were significantly different only for the group with central or mixed vestibular disorders. Changes in SOT scores were not directly correlated with changes in DHI scores. Outcome measures of vestibular rehabilitation protocols confirmed objective and subjective improvement of balance and dizziness handicap in patients with peripheral and central vestibular disorders.

Lymphoma, which represents about 5.4% of all neoplasms and, more significantly, 19% to 28% of malignant neoplasms, is the most common nonepithelial malignancy of the head and neck area in Koreans. Natural killer T-cell (NK/T-cell) lymphoma is a lymphoma of putative natural killer cell lineage. NK/T-cell neoplasms are generally rare, but they are more common in people of East Asian, Mexican, or South American descent. These neoplasms are highly aggressive and show a strong association with Epstein-Barr virus. The preferential site of extranodal NK/T-cell lymphoma is the nasal cavity, and there has been no report of NK/T-cell lymphoma developing from the tongue. We encountered a rare case of NK/T-cell lymphoma of the tongue, which we report with a review of the literature.

Approaches to the infratemporal fossa and nasopharynx are difficult because of the anatomic complexity of these regions. We describe our experience with osteoplastic maxillotomy, with our own modifications, and evaluate oncological outcomes and postoperative quality of life. Ten patients underwent osteoplastic maxillotomy, 3 of whom had a diagnosis of malignancy, and 7 of whom had nasopharyngeal angiofibromas (NPAs). A Weber-Fergusson incision was made to develop facial flaps and preserve the vascularity of the maxilla. Osteotomies were performed through the facial aspects of the maxilla, on the orbital rims, and on the malar eminence for the medial variant of the procedure. The anterolateral variant involved descent of the temporalis muscle with preservation of the facial nerve, and a zygomatic osteotomy. Four craniotomies were done. Two patients had the medial variant of the procedure, and 8 had the anterolateral variant. The complications were transient and mild. The patients who had malignancies are alive with no disease, and there was 1 recurrence among the 7 patients with NPAs. We found excellent aesthetic results in 8 of the 10 patients, and no change in basic functions in 8 patients. Osteoplastic maxillotomy allows resection of massive NPAs with no significant bleeding. Resection of malignant lesions with good results is feasible.

We report what is, to our best knowledge, the first case of chronic recurrent multifocal osteomyelitis (CRMO) in which the frontal and sphenoid bones were involved. Characterized by a prolonged and fluctuating course of osteomyelitis at different sites, CRMO is self-limited, although sequelae can occur. The diagnosis is one of exclusion. It is important to publish cases like this, because the recognition of CRMO can prevent aggressive surgical and medical treatment.

Neurofibromatosis 2 (NF2) is characterized by bilateral vestibular neurofibromas. Although the facial nerve, the cochlear nerve, and the superior division of the vestibular nerve can be evaluated before surgery, whether the inferior division of the vestibular nerve is affected remains undetermined without an operation. A total of 7 patients with NF2 (2 men and 5 women) underwent pure tone audiometry, caloric testing, vestibular evoked myogenic potential (VEMP) testing, and magnetic resonance imaging. Audiometry revealed mean hearing levels of less than 26 dB for 1 ear, 26 to 70 dB for 8 ears, 71 to 90 dB for 3 ears, and more than 90 dB for 2 ears. Caloric testing revealed an absent response in 71% of the 14 ears. Seven ears underwent VEMP testing, and only 1 ear (14%) displayed absent VEMPs. Magnetic resonance imaging depicted space-occupying lesions in all 14 auditory canals: small tumors in 3 ears, medium tumors in 7 ears, and large tumors in 4 ears. The tumor size of NF2 is related to the caloric response, but is unrelated to the mean hearing level or VEMPs. In conclusion, NF2 originates from the superior vestibular nerve more often than the inferior vestibular nerve. It more often infiltrates the cochlear nerve than the inferior vestibular nerve.

Rhinitis and sinusitis concern roughly a quarter of the population in the Western world. They are associated with a wide range of symptoms: nasal obstruction, anterior and posterior nasal discharge, sneezing episodes, facial pain or congestion, and taste and smell disorders. The aim of this prospective study was to evaluate the clinical significance of these various symptoms as a function of the topographic diagnosis of chronic rhinosinusitis. The study involved 474 patients with signs of chronic perennial and persistent rhinosinusitis. The disorders of the nasal cavities and paranasal sinuses were classified into three main diagnostic categories: chronic rhinitis, localized sinusitis (mainly, anterior sinusitis), and diffuse rhinosinusitis (ie, nasal polyposis). A principal components analysis was performed. The symptom patterns of the three main clinical entities differed greatly. Most of the following clinical signs — nasal obstruction, anterior and posterior nasal discharge, sneezing, and facial congestion — are found in all diagnostic categories and hold no specific clinical significance. By contrast, four symptoms seem to have a substantial differentiating potential: anosmia and complete loss of flavor for diffuse rhinosinusitis, cacosmia for localized anterior sinusitis, and severe facial pain for localized sinusitis. This study proposes a new analysis of the relationship between symptoms of chronic rhinosinusitis and findings on a sinus computed tomography scan.

No case of synovial sarcoma of the nasal septum has so far been reported. We present a patient with synovial sarcoma of the nasal septum and review the related literature. The patient underwent local excision without adjuvant therapy. There was no local recurrence or distant metastasis in the 18-month follow-up period.