Speciality
Spotlight

 




 

Otolaryngology


 

    

  




  • Vasama
    J-P, Linthicum FH Jr. (House
    Ear Inst,Los Angeles)


    Meniere’s Disease and
    Endolymphatic Hydrops Without
    Meniere’s Symptoms:Temporal Bone Histopathology


    Acta Otolaryngol (Stock)
    119:297-301,1999

     


    This
    is a good article from another
    authentic 
    study of T.Bare Sections
    studied in 21 yrs. Wherein
    E.Hydrops is noted 
    without any symptoms of
    Meniere’s .This study
    therefore is interesting in
    comparing histopathological
    finding in so-called 
    “normal” EARS with
    those of of patients with
    Meniere’s Disease.
    Nevertheless it is an
    established fact that E. Hydrops
    is the most important
    pathological finding correlating
    Meniere’s disease patients.

      


  • Yazawa
    Y,Suzuki M,Kitano H,et al
    (Shiga Univ,Otsu , Japan)


    Intraoperative Mitomycin C in
    Endolymphatic Sac Surgery for
    Meniere’s Disease : A pilot  Study.


    ORL J Otorhinolyngol Relat
    Spec 61:188-194,1999

      


    The
    use of mitomycin –C to prevent  postoperative fibrosis is the basis in this sac surgery done
    in 14 patients who in 6 months
    follow-up has shown no vertigo
    ,10db improvement in hearing in
    5 patients and reduction of
    tinnitus.

      


    This
    may be of benefit in sac surgery
    provided long-term results are
    available .Long-term results of
    sac surgery 
    without mitomycin show
    definitely unsatisfactory
    results hence use of mitomycin
    in sac surgery may prove long
    term 
    results.

       

  • Yotsuyanagi T, Nihei Y, Yokoi K, et al (Hirosaki Univ, Japan)

    Functional Reconstruction Using a Depressor Anguli Oris Musculocutaneous Flap for Large Lower Lip Defects, Especially for Elderly Patients.

    Plast Reconstr Surg 103: 850-856, 1999

        


    The most common lesion of the malignant lesions of oral cavity is lower lip squamous carcinoma

         


    In planning the reconstruction of large excision defect the following factors should be kept in mind.

        


    – Maintenance of sphineteric action

    – Retention of sensation

    – A large enough opening for the mouth

    – Acceptable cosmetic appearance.

        


    In surgical technique described – Nerve supply and Blood supply is well preserved.

          

  • Raulin C, Schroeter CA, Weiss RA, et al (Laserklinik, Karlsruhe, Germany; Med Centre, Maastricht, The Netherlands; Johns Hopkins Univ, Baltimore, Md; et al)

    Treatment of Port-Wine Stains With a Noncoherent Pulsed Light Source: A Retrospective Study.

    Arch Dermatol 135: 679-683, 1999

       


    Thirty-seven patients with 40 port-wine stains between 1994 to 1997, aged 1 to 68 years were treated with intense pulsed light source (IPLS). Before and after treatment, photographs were taken. All side effects recorded. The treatment appears to be safe and effective.

        

  • Franceschi S, Levi F, La Vecchia C, et al (Centro di Riferimento Oncologico, Aviano, Italy; Registre Vaudois de Tumeurs, Lausanne, Switzerland; Instituto di Ricerche Farmacologiche “M Negri”, Milano, Italy; et al )

    Comparison of the Effect of Smoking and Alcohol Drinking Between Oral and Pharyngeal Cancer

    Int J Cancer 83: 1-4, 1999

       

    The relationship of exposure to alcohol and tobacco is established. However, the separate and combined effects of alcohol and tobacco between oral and pharyngeal cancer were compared in case-control investigation.

        

    274 patients with oral cancer and 364 with pharyngeal cancer, 1254 controls matched were studied. 

        

    Observation-Conclusion – Alcohol has a stronger effect on oral cancer than on pharyngeal cancer. This may help explain why oral cancer mortaility is rising in men from many developing countries after many years of declining.

        

  • Pritikin
    JB, Caldarelli DD, et al (Rusb-Presbyterian-St Luke’s Med Ctr, Chicago)

    Endoscopic Ligation of the Internal Maxillary Artery for Treatment of Intractable Posterior Epistaxis

    Ann Otol Rhinol Laryngol 107: 85-91, 1998

          

    Ten patients treated with ligation of internal maxillary artery branches, along with ligation of sphenopalatine artery in sphenopalatine fossa had success rate of 100%.

        

    This is another approach and has minimal morbidity. Problem is only verified with small number of patients. Appears to be a promising method.

         

  • Cheng D, Iriarte GC (Kaiser Permanente, Downey, Calif)

    The Paper Clip Nasal Dilator

    Laryngoscope 108: 1247-1248, 1998.

        

    A narrow nasal valve results in serve nasal obstruction.

         

    Plastic coated nasal clip shaped and inserted in rounded end of nostril, kept for one month serves the purpose very well.

          

  • Shoseyov D, Bibi H, Shai P, et al (Hadassa Med School, Jerusalem, Israel; Brazilai Hosp, Ashkelon, Israel; SHIRAM Asaf Harofe Med Ctr, Zerifin, Israel; et al)

    Treatment with Hypertonic Saline versus Normal Saline Nasal Wash of Pediatric Chronic Sinusitis.

    J Allergy Clin Immunol 101: 602-605, 1998.

         

    Thirty patients were studied randomly with double-blind study. 

         

    Instilling 1 -mL hypertonic saline (HS) 3 times daily for 1 month improves the clinical and radiological conditions of children with chronic sinusitis. This treatment is tolerable and inexpensive.

         

    This is an interesting study supporting the use of HS. The exact mechanism is not known.

       

  • Waridel F, Monnier P, Agrifoglio A (Univ Hosp, Lausanne, Switzerland)

    Evaluation of the Bone Resistance of the Sphenoid and Ethmoid Sinuses.

    Laryngoscope 107: 1667-1670, 1997

       

    This cadaveric study included 21 specimens. Resistance to breakage of these bony structures was determined critically by dynamometric assessment. 

         

    This anatomical study identified highly fragile sites which correlate with location of surgical complication of functional endoscopic sinus surgery.

        

    R. A. Otto comments: This simple study attempts to quantify bony resistances. It differs from Stankiewicz and Kainz and Stammberger, have stated that the weakest area is the area around the anterior ethmoidal artery, in the region of anterior base skull.

        

  • Metson R, Gliklich RE (Haravard Med School)

    Clinical Outcome of Endoscopic Surgery for Frontal Sinusitis

    Arch Otolaryngol Head Neck Surg 124: 1090-1096, 1998.

       

    Clinical results of this procedure was evaluated in 87 patients over a period of 2 yrs.

       

    To avoid surgical failures, authors now use bilateral drillout technique in all patients with frontal sinusitis after a Lynch procedure.

        

    R..A Otto comments:Though the results appear promising, long term follow-up are needed to determine it as a procedure of choice.

       

  • Casiano RR, Livingston JA (Univ of Miami, Fla)

    Endoscopic Lothrop Procedure: The University of Miami Experience.

    Am J Rhinol 12: 335-339, 1998.

       

    This 2 year study included 21 patients with persistent or recurrent frontal sinusistis. Lothrop procedure seeks to create a common frontal sinus ostium. Ostium patency rate of 75% was reported. This prospective study sought to pick up patients who will benefit from Endoscopic Lothrop procedure.

       

    A 57% patency rate was noted in recurrent sinusitis patients in whom conventional endoscopic tecnhiques failed. The chances of ostium patency was improved by maintaining a common frontal ostium of greater than 8mm in the anterioposterior dimension and 16 mm in the lateral dimension by Lothrop technique.

       

    Authors provide some useful information correlating ostia size and patency rates. The study is limited and has short-term follow-up – R.A. Otto.

        

  • Lawson W, Reino AJ (Moutn Sinai Med Ctr, New York)

    Isolated Sphenoid Sinus Disease: An Analysis of 132 Cases.

    Laryngoscope 107: 1590-1595, 1997.

        

    Sphenoid sinus disease raises difficult diagnostic issues. To distinguish from primary to secondary sinusitis or even primary to malignant disease is difficult. The 22 year study retrospectively was reviewed and signs and symptoms and radiographic findings were analysed.

         

    Headache was most common and visual disturbances being the next symptom.

        

    The key to diagnosis of isolated sphenoid disease is CT, with adjunct MRI as indicated. Findings of bone expansion, thinning and remodelling indicated Mucoceles and benign tumours. Bone erosion is pointed to malignant disease. A signal void in the sinus cavity on MRI is a sign of fungal sinusitis.

        

    Authors presented a CT algorithm to facilitate diagnosis and treatment selection.

        

  • Dolbie
    RA [Univ of Texas, San Antonio]

    A review of Randomized
    Clinical Trials in Tinnitus

    Laryngoscope 109: 1202-1211,
    1999



    Most patients with tinnitus have subjective cases associated with sensorineural hearing loss attributable to aging, noise exposure, head injury, and other causes. Many patients with tinnitus have no hearing loss at all.



    None of these treatments provided replicable long-term relief of tinnitus compared with placebo. Nonspecific support and counseling may help, as do trycyclic antidepressants in patients with severe cases.



    This author has done a very comprehensive study of the current state of the art in terms of randomized clinical trials regarding tinnitus. His study is quite appropriate and his conclusions quite relevant. As he mentions, non-specific supportive counseling helps, as do antidepressants in severe cases. I would add that behavioral listening seems to be the most important and useful method we have in dealing with these patients.

  • Veling
    MC, Windmill I, Bumpous JM [Univ
    of Louisville, Ky]

    Sudden Hearing Loss as a
    Presenting Manifestation of
    Leukemia

    Otolaryngol Head Neck Surg
    120: 954-956, 1999



    Sudden hearing loss is a rare initial manifestation of hematologic disorders. This report described a case in which sudden hearing loss was one of the presenting manifestations of leukemia.



    Woman, 65, was seen with acute-onset back pain. She reported a 6-day history of tinnitus and a 1-day history of sudden-onset bilateral hearing loss. Physical examination revealed bilateral serous middle ear effusions with intact tympanic membranes and clear external auditory canals. Laboratory tests revealed a white blood cell count of 33,200. Results of a bone marrow aspirate were consistent with acute lymphocytic leukemia. Audiologic examination revealed bilateral 

    profound sensorineural hearing loss. The patient received induction chemotherapy, with leukocytosis resolution. Audiologic examination results demonstrated significant improvement. The patient was discharged and has remained in remission. 



    This case was unusual in that deafness was one of the presenting symptoms of leukemia. 



    Typically, leukemia will cause deafness during its terminal stages. Leukemia can be seen as a presenting symptom of sudden deafness. The pathology of such patients, as seen from studies in temporal bones, suggests an immediate infiltration of pathologic leukemic cells throughout the labyrinthine spaces, followed by secondary degeneration of the sensory end organs and their cellular components.





  • Heiland
    KE, Goode RL, Asai M, el al [
    Stanford Univ, Calif; Ehime-Univ,
    Ehime 

    City, Japan; Universitasspital
    Zurich, Switzerland]

    A Human Temporal Bone Study
    of Stapes Footplate Movement

    Am J Otol 20 : 81-86, 1999



    Below the level 0f 2.0 kHz, stapes vibration was primarily pistonlike. Above 2.0 kHz, Anterior-posterior rocking motion rose logarithmically with frequency. Near the 4.0 kHz level, rocking and pistonlike motion were almost equal.



    Stapes footplate vibration was mostly pistonlike upto 2.0 kHz. The motion became more complex at higher frequencies because of a rise in anterior-posterior rocking motion. Hingelike motions were not seen. This information may be of use in the design of ossicular replacement prostheses that mimic or improve upon normal stapes vibration.



    It is interesting that they identify similar findings in that there is pistonlike action, but with higher frequencies, a more complex rocking motion takes place. Such studies are of interest not only from a physiologic point of view but also for those who do surgery in this area to repair pathologic structures

  • Chauvin
    K Bratton C, Parkins C
    [Louisiana State Univ, New
    Orleans]

    Healing large Tympanic
    Membrane Perforations Using
    hyaluronic Acid, 

    Basic Fibroblas Growth Factor,
    and Epidermal Growth Factor

    Otolaryngol Head Neck Surg
    121: 43-47, 1999



    Although 88% of tympanic
    membrane perforations heal
    spontaneously, the remainder
    require expensive

    tympanoplasty to avoid chronic
    problems. Use of epidermal
    growth factor [EGF] has improved
    nonsurgical closure rates

    dramatically in guinea pigs.



    Complete closure of the
    perforation occurred in all ears
    treated with HA and EGF There
    was no evidence of 

    cholesteatoma in any middle ear



    It could be nice to see such a
    study done in higher types of
    animals such as cats or monkeys.
    Perforations in animals such as

    guinea pigs have a remarkable
    propensity for self-healing.

  • Shea PF, Ge X, Shea JJ Jr [Univ of Tennessee, Memphis]

    Stapedectomy for Far-advanced Otosclerosis

    Am J Otol 20: 425-429, 1999, Pg.54

    Stapedectomy is indicated for those patients with far-advanced otosclerosis even in the absence of air conduction [AC]. 



    The negative Rinne test distinguished far-advanced otosclerosis from other types of hearing loss. Most patients with far-advanced otosclerosis benefited from stapedectomy. 



    These patients seem to be the most grateful because they are essentially deaf to begin with, but then achieve useful hearing. 

  • Bajaj Y, Bais AS, Mukherjee B [Lady Hardinge Med College, Delhi, India; SSK Hosp, Delhi , India: Kalawati Saran Children’s Hosp, Delhi, India]

    Tympanoplasty in Children : A Prospective Study

    J Laryngol Otol 112 : 1147-1149, 1998, Pg.89



    All children had a central perforation without cholesteatoma. Ears had to be dry for at least 6 weeks before surgery. Patients underwent type-I tympanoplasty with autograft temporalis fascia.



    Surgery is least successful in children with large or bilateral perforations. 

  • Golz A, Netzer A, Joachims HZ, et al [ Technion-Isreal Inst of Technology, Haifa; Westerman Research Associates Inc, Shrewsbury, NJ]

    Ventilation Tubes and Persisting Tympanic Membrane Perforations

    Otolaryngol Head Neck Surg 120: 524-527, 1999, Pg.90

    Myringotomy with ventilation tube insertion is the most common pediatric otologic operation. 



    A perforation was considered permanent if it persisted for more than 1 year after spontaneous extrusion or removal of tubes.



    Persistent perforations were also significantly more common among children under 5 years of age.

  • Eisenman
    DJ, Parisier SC [Lenox Hill
    Hosp, New York]

    Meatoplasty : The cartilage
    of the Floor of the Ear
    Canal 

    Laryngoscope 109: 840-842,
    1999



    An adequate meatal opening is
    important in postoperative ear
    care.



    The success of otologic
    procedures frequently depends on
    a adequate meatal opening,
    Excision of the cartilage of
    the 

    floor of the ear canal is an
    important part of successful
    meatoplasty.



    It is important to have good
    meatus in order to allow
    self-cleansing of the enlarged
    canal or mastoid cavity.

  • Soultan Z, Wadowski S, Rao M, et al [State Univ of New York, Brooklyn]

    Effect of Treating obstructive Sleep Apnea by Tonsillectomy and/or Adenoidectomy on Obesity in Children

    Arch Pediatr Adolesc Med 153: 33-37, 1999, Pg. 195



    Obese children with enlarged tonsils or adenoids can have obstructive sleep apnea, which may cause poor growth and a failure to thrive. Effects of obstructive sleep apnea in children are disturbed sleep and sleep deprivation with subsequent daytime hypersomnolence and decreased activities, Obesity may be caused by this decreased energy expenditure.



    Increased gain in height, weight, and body mass index is associated with treating obstructive sleep apnea by tonsillectomy or adenoidectomy in most children, including the obese.

  • Fitzpatrick
    RE [Univ of California, San
    Diego]


    Treatment of
    Inflamed Hypertrophic Scars
    Using Intralesional 6-FU


    Dermatol Surg 25: 224 -
    232, 1999, Pg 165.

      

    Intralesional
    injections of 5-FU in a
    concentration of 50 mg/ml were
    administered in doses ranging
    from 2 to 50 mg.

      

    Mixing 0.1 ml of Kenalog
    [Westwood Squib, Buffalo, NY]
    and 0.9 ml of 5-FU in the same
    syringe caused less pain and
    had greater efficacy.

       

    It was rare for a scar to not
    respond favorably. Scars with
    the greatest response were
    typically red, the most
    inflamed,
    the most symptomatic,
    and most firmly 
    indurated. The first
    signs of response were
    typically reduced pain and
    itching, followed by softening
    of the scar, then flattering
    and decreased redness.
    Hypertrophic scars were more
    responsive than keloids.

       

    The use of intralesional
    injections alone or in
    combination with Kenalog with
    pulsed dye laser is safe and
    effective in the treatment and
    prevention of hypertrophic
    scars and some small, isolated
    keloids.



  • Feder HM, Jr. Gerber MA, Randolph MF, et al [ Univ of connecticut, Farmington; Univ of connecticut, Hartford; Danbury, conn; et al]

    Once-daily therapy for Streptococcal Pharyngitis With Amoxicillin

    Pediatrics 103: 47-51, 1999, Pg. 199



    Patients with group A b-hemolytic streptococcal [GABHS] pharyngitis may be better able to comply with once-daily oral amoxicillin therapy than with treatment taken several times a day.



    Once-daily amoxicillin treatment is as effective as penicillin V therapy given 3 times daily in the treatment of GABHS
    pharyngitis.

  • Henriksson G, Westrin KM, et al (Huddinge Univ Hosp, Sweden; Karolinska Hosp, Stockholm)

    Recurrent Primary Pleomorphic Adenomas of Salivary Gland Origin: Intrasurgical Rupture, Histopathologic Features, and Pseudopodia.

    Cancer 82: 617-620, 1998.

        

    Retrospective study of 230 patients operated for benign salivary gland pleomorphic adenoma between 1974 to 1993 was done.

       

    Occurrence of pseudopodia (fingerlike extensions) appears to be important risk factor for local recurrences. This explains the lower recurrence rate in patients undergoing radical surgery, than those patients with enucleation and limited excisional surgeries with so called normal parotid tissue surrounding the tumour mass. If pseudopodia are present then long-term follow-up (to detect and treat recurrence) is required.

         

    The Authors reinforce the importance of appropriate surgical procedure because surgeon is not aware of presence of extensive pseudopodia at the time of surgery.

        

  • Goode
    RK, Auclair PL, et al (Armed Forces Inst of Pathology, Washington, DC: Natl Naval Dental Ctr, Washington, DC)

    Mucoepidermoid Carcinoma of the Major Salivary Glands: Clinical and Histopathologic Analysis of 234 Cases with Evaluation of Grading Criteria.

    Cancer 82: 1217-1224, 1998.

        

    High, intermediate and low grades have been reported. One study denotes the presence of cystic component of less than 10% is considered as high grade.

        

    In this study, 337 patients were analysed which included follow-up data. 84% were in parotid. 13% in submandibular gland and 3% in the sublingual gland. Four groups were formed Group I, survival free of disease. Group II, survival with local recurrence, Group III, survival with local metastases and Group IV, death of disease.

        

    This study identifies prognostic factors. Outcome varied significantly according to site and grade of the tumour. Metastases from submandibular glands were more frequent. The treatment should be based on clinical stage of the disease and histopathologic guide. Even low grade tumours in submandibular gland needs aggressive treatment and close follow-up.

        

  • Laskawi R, Rodel R, et al (Univ of Gottingen, Germany)

    Retrospective Analysis of 35 Patients with Acinic Cell Carcinoma of the Parotid Gland.

    J OralMaxillofac Surg 56: 440-443, 1998.

       

    This is a rare tumour, occurs in late middle age commonly in females. Retrospectively studied because of its rarity. The study included 35 patients treated between 1945 and 1994. Surgery is the therapy of choice. The response to radiation is not favourable either to prevent recurrences or increase in survival period. The latter part is of particular interest in management.

         

  • Yang CY, Andersen PE, et al (Oregon Health Sciences Univ, Portland)

    Nodal Disease in Purely Glottic Carcinoma: Is Elective Neck Treatment Worthwhile?

    Laryngoscope 108: 1006-1008, 1998.

       

    All patients were included with glottic cancer between 1984 to 1994. Ninety-two patients were identified who had at least 2 yrs of follow-up for T stage, cord mobility, CT scan, nodal disease, lesion extension, treatment modality and tumour pathology. Recurrences were reviewed.

        

    Occult nodal disease with NO glottic carcinoma was low with 0% incidence in T1 and T2 stage disease and 19% in T3 and T4 stage disease. Only paratracheal level II and III nodes were at high risk. Therefore, elective neck dissection should be performed for advanced disease in case with low morbidity. CT scanning was not useful for staging in these patients.

        

  • Asakage T, Yokose T, Mukai K, et al (Natl Cancer Ctr Hosp East, Chiba, Japan; Tohoku Univ, Miyagi, Japan)

    Tumor Thickness Predicts Cervical Metastasis in Patients with State I/II Carcinoma of the Tongue.

    Cancer 82: 1443-1448, 1998

           

    The retrospective study included 44 patients with previously untreated stage I/II carcinoma of tongue involving the anterior two thirds of the tongues. They were treated by partial glossectomy only. Twenty-one patients had cervical metastasis and 23 were without. Tumour thickness and other variables were compared.

           

    Tumour thickness more than 4mm thickness are at higher risk of cervical metastases and were regarded as having latent metastasis. Conservative supramyohyoid neck dissection, as performed for T1N1 or T2N1 carcinoma of the tongue may be suitable.

            

    This article confirms depth of invasion in more predictive of cervical metastasis than T classification. Spiro et al suggested this even for 2mm thickness and more.

        

  • Cruz
    IB, Snijders PJF, Meijer CJ, et al (Univ Hosp Vrije Universiteit, Amsterdam; Academic Centre for Dentistry, Amsterdam)

    p53 Expression above the Basal Cell layer in Oral Mucosa is an Early Event of Malignant Transformation and Has Predictive Value for Developing Oral Squamous Cell Carcinoma.

    J Pathol 184: 360-368, 1998.

        

    Majority of oral squamous cell carcinoma have mutations in the oncogene p53.

        

    To determine the relationship, immunohistochemical staining was performed on 11 premalignant lesions in which carcinoma developed. Therefore, p53 expression appears on early event in the carcinogenesis of premalignant lesions. 

       

    This combined with histologic criteria of dysplasia is danger sign. If more continued studies demonstrate this, it will be of great value in the management of patients with dysplastic biopsy specimens.

         

  • Int J Radiat Zakotnik B, Smid L, Budihna M, et al (Inst of Oncology, Ljubljana, Slovenia: Univ Dept. of Otorhinolaryngology and Cervicofacial Surgery, Ljubljana, Slovenia)

    Concomitant Radiotherapy with Mitomycin C and Bleomycin Compared with Radiotherapy Alone in Inoperable Head and Neck
    Cancer: Final Report.

    Oncol Biol Phys 41: 1121-1127, 1998.

        

    Sixty-four patients were randomly treated in 2 groups. One group received radiotherapy alone and other group received radiotherapy with concomitant above mentioned chemotherapy.

        

    Other group receiving radiotherapy with concomitant chemotherapy had significantly higher complete remission, disease free survival and better survival rates.

  • C.
    Gaelyn Garrett, MD, and Robert
    H, Ossoff, DMD, MD
    From the Department of
    Otolaryngology, Vanderbilt Voice
    The Otolaryngologic Clinics of
    North America

    Phonomicrosurgery II:
    Surgical Techniques


    Volume 33, Number 5, October
    2000, Pg. 1063-1070

      

    Vocal
    fold stripping almost always
    results in the removal of normal
    epithelium and a significant
    portion of the superficial layer
    of the lamina propria [SLLP].
    Frequently, the vocal fold heals
    with significant scarring within
    the lamina propria tethering the
    mucosal cover to the underlying
    vocal ligament.  Vocal fold vibration is hampered.

      

    In the treatment of
    benign nonneoplastic lesions,
    vocal fold stripping techniques
    should therefore be abandoned in
    favor of treatments that spare
    epithelial and mucosal tissue.

      

    Newer
    microlaryngeal techniques
    attempt adequate excision of the
    lesion without removing
    surrounding normal tissue.

      

    The CO2 laser causes
    tissue ablation to a depth of
    approximately 200
    mm
    at optimal laser settings.

      

    It has hemostatic properties for
    the microcirculation [vessels
    < 50
    mm],
    making it ideal for lesions such
    as palilloma that are highly
    vascular and involve the
    epithelium.

     

    Unfortunately, laser energy
    causes thermal damage to
    surroundings normal tissue,
    including the epithelial layer
    and deeper portions of the
    lamina propria, unnecessarily
    increasing the risk for
    postoperative scarring.

     

    Therefore, do not routinely use
    the laser for excision of benign
    nonneoplastic vocal fold lesions
    when sparing of the mucosal
    cover is indicated.

       

    Surgical Approach

       

    Phonomicrosurgical
    techniques have been developed
    to preserve as much as possible
    the cover-body vibration of the
    true vocal fold.
    These techniques have
    been described as microflap
    or mini-microflap
    approaches.

       

    They take advantage of a natural
    surgical plane within the mostly
    avascular Superficial  Layer of
    the Lamina Propria SLLP.

     

    Clinical reviews have
    reported excellent results with
    the microflap technique.
    The goal of the
    dissection is to excise the
    lesion within the SLLP without
    injuring the overlying
    epithelium and underlying vocal
    ligament.

     

    Postoperative Care

      

    Patients
    are placed on strict voice rest
    for 1 to 2 weeks gradual
    resumption of voice use under
    the guidance of the surgeon and
    a speech and language
    pathologist. 
    Most complaint patients
    can expect to achieve 90% or
    more of their premorbid voice by
    3 months following surgery.



        

  • Forrest LA, Schuller DE, Karanfilov B, et al (Ohio State Univ, Columbus)

    Update on Intraoperative Analysis of Mandibular Margins

    Am J Otolaryngol 18: 396-399, 1997

       

    In 61 patients with involvement of alvelous, the study of serial frozen section biopsy of the cancellous bone at the mandibular stump demonstrated 100% corelation, and thus the extent of resection of the mandibule could be decided accordingly.

        

    This article provides some evidence of the effectiveness of this technique in assessing resection.

        

  • De Stefani E, Boffetta P, Oreggia F, et al (Registro Nacional de Cancer, Montevideo Uruguay; Inernatl Agency for Research on Cancer, Lyon, France; Academia Nacional de Medicina, Montevideo, Uruguay, et al).

    Smoking Patterns and Cancer of the Oral Cavity and Pharynx: A Case-Control Study in Uruguay.

    Oral Oncol, Eur J Cancer 34: 340-346, 1998.

        

    Four hundred and twenty-five men with confirmed lesions and 427 hospitalized controls were studied.

       

    Smoking black tobacco cigarettes seems significant in oral and pharyngeal carcinogenesis. Risk was decreased with filter use and cessation of smoking. Black tobacco contained high tobacco-specific nitrosamines. A high tar content was noted in hand-rolled cigarettes thus combination has more risk of oral cancer.

        

    This interesting article can help physicians counseling their patients – particularly impact of tobacco type and use of filtered cigarettes.

        

  • Colletier
    PJ, Garden AS, Morrison WH, et al (Univ of Texas, Houston)

    Postoperative Radiation for Squamous Cell Carcinoma Metastatic to Cervical Lymph Nodes from an Unknown Primary Site: Outcomes and Patterns of Failure.

    Head Neck 20: 674-681, 1998.

       

    Out of 136 patients with cervical metastasis from unknown primary sites, 39 patients underwent excisional biopsy and rest of them various types of neck dissection. All received radiotherapy subsequently. 58 months follow-up was done.

       

    Excisional biopsy and radiotherapy offers excellent disease control and survival rates. Those with ECE (extracapsular extension) and multiple nodal involvement the results are not as good. Radiation should start within 3 to 4 weeks and should be of full required dose.

       

    Excisional biopsy did not have any reduction in disease control or survival rates. However, it should not be an argument in all cases. Detrimental effects of ECE and multiple nodal involvement is confirmed by this study further. R.A. Otto.

        

  • Simon D, Koehrle J, Reiners C, et al (Heinrich-Heine-Univ, Dusseldorf, Germany; Unvi of Wurzburg, Germany; Univ of Essen, Germany)

    Redifferentiation Therapy with Retinoids: Therapeutic Option for Advanced Follicular and Papillary Thyroid Carcinoma.

    World J Surg 22: 569-574, 1998.

       

    About 33% of differentiated thyroid carcinoma (DTC) show loss of differentiation during progression of disease and then become refractory to standard treatment.

       

    Retinoid treatment (13-cis-retinoic acid) reduces tumour growth and reinduces iodide uptake suggesting that redifferentiation in cancerous growth in (DTC). This is not so in on anaplastic cancer.

       

    A 65% response rate was shown among patients of advance DTC. Thyroglobulin levels always do not accompany this response. Therapy is well tolerated with few side effects. No conclusions as the survival rates have been drawn.

       

    This study has offered a ray of hope in the management of advanced DTC patients and further studies may offer better hopes. R.A. Otto.

      

  • Gimm O, Ukkat J, Dralle H (Martin-Luther-Univ Halle-Wittenberg, Germany)

    Determinative Factors of Biochemical Cure After Primary and Reoperative Surgery for Sporadic Medullary Thyroid Carcinoma.

    World J Surg 22: 562-568, 1998.

      

    Twenty-seven patients underwent total thyroidectomy and compartment based microdissection of nodes. Thirty-seven patients with continuously elevated serum calcitonin levels underwent 4-compartment lymphodectomy at reoperation.

       

    The report of 100% normalizaiton in serum of calcitonin levels in node negative and pT1 patients is notable. Postoperative calcitonic level is powerful prognostic factor. However, it is not clear whether the patients who are biochemically cured have better outcome. By correlating tumour size with the presence and location of lymph node metastasis, this study provides useful guidelines for the extent of nodal dissection necessary at the time of primary operation of Medullary Thyroid Carcinoma. R.A. Otto.

        

  • Dralle H, Gimm O, Simon D, et al (Martin-Luther-Universitat Halle-Wittenberg, Germany; Heinrich-Heine Universitat, Dusseldorf, Germany; Gemeinschaftspraxis Innere Medizin-Endokrinologie, Heildelberg, Germany; et al)

    Prophylactic Thyroidectomy in 75 Children and Adolescents with Hereditary Medullary Thyroid Carcinoma: German and Austrian Experience.

    World J Surg 22: 744-751, 1998.

        

    In 1993, the RET proto-oncogene was identified as responsible for hereditary medullary thyroid carcinoma (MTC), since then patients with MTC based genetic screening have achieved biochemical cure by undergoing prophylactic thyroidectomy which prevents MTC and lymph node metastasis from developing.

         

      A major breakthrough in the diagnosis and treatment with identification of this genetic defect in thyroid tumours. Biochemical estimation of serum calcitonin to screen in no longer required. 

        

    These authors provide a sensible algorithm for management of these patients. The achievement in 96% patients of a biochemical cure is remarkable. Time will tell if biochemically curing these patients is superior. R.A. Otto.

       

  • Nilsson O, Lindeberg J, Zedenius J, et al (Karolinska Hosp, Stockholm; Lund Univ Hosp, Sweden; Uppsala Univ Hosp, Sweden)

    Anaplastic Giant Cell Carcinoma of the Thyroid Gland: Treatment and Survival Over a 25-Year Period.

    World J Surg 22: 725-730, 1998.

        


    Between 1930 and 1970, 50% of patients with ATC died within 3 months mainly by suffocation from the local tumour growth. Now only one similar death has occurred since 1989. Local tumour control has been achieved with debulking and pre and post operative doxorubicin and hyperfractionated accelerated radiotherapy.

        

  • Patel PC, Pellitteri PK, Patel NM, et al (Penn State Geisinger Health System, Danville,Pa)

    Use of a Rapid Intraoperative Parathyroid Hormone Assay in the Surgical Management of Parathyroid Disease.

    Arch Otolaryngol Head Neck Surg 124: 559-562, 1998.

        


    During parathyroid surgery patients underwent neck exploration and the parathyroid hormone assay is done by preremoval of parathyroids and postoperative, during operative procedure, thus guiding whether enough functioning of parathyroid tissue is received. If adenoma is suspected then preoperative 99mTc-sestamibi scanning was used to localize.

       

    Thus combination of preoperative scanning and intraoperative parathyroid hormone assay can guide unilateral exploration of neck.

       

  • Dhingra
    JK, Zhang X, McMillan K, et al (Tufts Univ, Boston; Lahey Clinic Med Ctr, Burlington, Mass; Massachusetts Inst of Technology, Cambridge)

    Diagnosis of Head and Neck Precancerous Lesions in an Animal Model Using Fluorescence Spectroscopy.

    Laryngoscope 108: 471-475, 1998.

         


    This animal experiment using laser induced fluorescence spectroscopy demonstrated the utility in the diagnosis of premalignant lesions like leukoplakia or erythroplakia and histologically as metaplasia and dysplasia. 

       

    If this technique could be used to enhance over clinical skills (60%-80% reliability) such a tool could be very useful. G.R. Holt.

        

  • Shaari CM, Farber D, Brandwein MS, et al (Mount Sinai School of Medicine, New York; City Univ of New York)

    Characterizing the Antigenic Profile of the Human Trachea: Implications for Tracheal Transplantation

    Head Neck 20: 522-527, 1998.

         

    This study of 10 human tracheal wall detects Class I (Human leukocyte Antigens A,B and C) and Class II (human leukocyte antigen DR) histocompatibility antigens.

       

    Different areas of the trachea have greatly different antigenicity. Minor salivary glands in the wall are highly antigenic. Antigenicity of the perichondrium varies. Mucopolysaccharide matrix is nonantigenic but the chondrocytes have antigenic properties. These differences in antigenicity indicate that some tracheal grafts would be more immunogenic than others and therefore more prone to rejection.

       

    This article forms an important foundation upon which tracheal transplantation is an exciting possibility, if all the hurdles are overcome. R.A. Otto.

       

  • London SD, Park SS, Gampper
    TJ, et al (Univ of Virginia, Charlottesville)

    Hyperbaric Oxygen for the Management of Radionecrosis of Bone and Cartilage.

    Laryngoscope 108: 1291-1296, 1998.

       

    Sixteen patients included in this study suggests good results with HBO therapy for the management of radionecrosis of the head and neck. Subjective and objective outcomes improved greatly.

       

    HBO therapy has become an important portion of the equation in the prevention and treatment of osteoradionecrosis and
    chondroradionecrosis.

        

  • Davison SP, Sherris DA, Meland NB (Mayo Clinic, Rochester,
    Minn; Mayo Clinic, Scottsdale,
    Ariz)

    An Algorithm for Maxillectomy Defect Reconstruction.

    Laryngoscope 108: 215-219, 1998

       

    One hundred and eight patients over a period of 5 yrs underwent reconstruction of maxillary defects.

       

    The majority can be best reconstructed with a prosthesis,
    obturator. The guidelines are :-

        

    – First choose a technique that retains greatest residual hard palate without comprising growth excision. 

    – Second, position the resection in the socket of an extracted tooth, to preserve tooth adjacent to the defect. 

    – Third, consider a split thickness skin graft. 

    – Fourth, to avoid the influence with the obturator bulb, remove the inferior turbinate. 

    – Fifth, if possible, use a feasible preserve palatal disease free mucosa for tissue coverage.

       

    Finally consider the removal of residual adynamic soft palate if 50% or more has to be
    resected. Preoperative planning of the surgical approach is crucial, and the authors offer an algorithm to assist in this process.

       

  • KJ Doyle, Y
    Sininger, A Starr (Univ of California, Irvine; House Ear Inst, Los Angeles)


    Auditory Neuropathy in Childhood.



    Laryngoscope 108: 1374-1377, 1998


        


    Auditory neuropathy has the following clinical features: Hearing loss for pure tones, impaired word discrimination, abnormal auditory brain stem responses, and NORMAL outer hair cell function. The results of audiologic testing in 8 children with hearing deficits most likely caused by neuropathy of the eighth nerve were reported.

       


    The assessments suggested that, though cochlear outer hair cell function was normal, the lesion was located at the eighth nerve.

      

  • JK
    Thiringer, MA Arriaga (Lackland Air Force Base, Texas; Pittsburgh Ear Associates, Pa)


    Stapedectomy in Military Aircrew



    Otolaryngol Head Neck Surg 118:9-14, 1998.


       

    Stapedial surgery may pose a considerable risk for those in certain occupations e.g. military aircrews who challenge the function of the cochleovestibular system with each mission. Aircrew members who have had stapedectomies have been rejected for all flying duties by the Surgeon General of the Air Force. As additional clinical experience was gained, waivers for flight duty were granted on an individual basis. The aeromedical outcome for aircrew members who returned to flight duty after stapedectomy was reviewed.

       


    Before aircrew members returned to flight duty, patients were subjected to centrifuge and altitude -chamber testing, electronystagmography, rotational chairs, and actual test flights. In the entire group studied, no episodes of sudden hearing loss or vestibulopathic conditions occurred.

        

  • JP
    Leonetti, T Origitano, et al (Loyola Univ, Maywood, III)


    Intracranial Complications of Temporal Bone Osteoradionecrosis



    Am J Otol 18:223-229, 1997


      

    Osteoradionecrosis of the temporal bone may follow radiation to the brain, parotid gland, nasopharynx, or superior cervical area. Life-threatening intracranial complications may follow.

      


    In 4 patients studied, complications observed were multiple brain abscesses, aneurysm of the internal carotid artery; a cholesteatoma of the external auditory canal with extensive destruction of the mastoid bone leading to thrombosis and meningitis of the sigmoid sinus; meningitis with a small epidural abscess over the middle fossa dura; and prolonged infection of the ear canal, middle ear, and mastoid resulting in fatal otitic meningitis. The 3 patients who underwent surgery (mastoid) survived requiring careful and regular follow-up.

      

  • PA Fagan, JP Sheehy, et al (St. Vincent’s Hosp, Sydney, Australia)


    The Cerebellopontine Angle: Does the Translabyrinthine Approach Give Adequate Access?



    Laryngoscope 108: 679-682, 1998




    It was previously believed that the translabyrinthine approach provided inadequate access to the cerebellopontine angle. The authors after analyzing 33 patients undergoing translabyrinthine surgery and 13 undergoing the posterior fossa approach have concluded that the translabyrinthine approach enables superior visualization through a wider angle of surgical access with minimal cerebellar retraction.

  • HM
    Dunniway, DB Welling (Ohio State Univ, Columbus)


    Intracranial Tumors Mimicking Benign Paroxysmal Positional Vertigo.



    Otolaryngol Head Neck Surg, 118:429-436, 1998.




    Benign positional vertigo may not always be benign, as indicated in this study where intracranial tumors were identified in five patients who presented as “benign paroxysmal vertigo.”



    When patients of “benign paroxysmal vertigo” do not improve after particle repositioning manoeuver, further assessment is needed to rule out intracranial new growths.

       

  • RC O’Reilly, SB Kapadia, D.B. Kamerer (Univ of Pittsburgh, Pa)

    Primary Extracranial Meningioma of the Temporal Bone.

    Otolaryngol Head Neck Surg 118:690-694, 1998.



    Though meningiomas typically occur intracranially, they may rarely arise de novo in the temporal bone. Because of the invasive nature of this tumor, surgical resection is difficult, and postoperative surveillance is necessary.

  • AE-M
    Moussa, KA Abou-Elhmd (South Valley Univ, Sohag, Egypt)

    Wegener’s Granulomatosis Presenting as Mastoiditis

    Ann Otol Rhinol Laryngol 107:560-563, 1998.



    Wegener’s granulomatosis is an uncommon auto-immune disorder, which has a peak incidence in the fifth decade of life with a slight male predominance. Typically, nasal problems are the initial manifestation. Otologic symptoms are rare.



    The authors report 2 cases of Wegener’s granulomatosis manifesting as mastoiditis (a fourteen-year-old girl and a 20-year-old woman).

       

  • Harti DM, P Aidan, O Brugiere, et al (Universite Paris VII)

    Wegener’s Granulomatosis Presenting as a Recurrence of Chronic Otitis Media.

    Am J Otolaryngol 19: 54-60, 1998.





    This is a case report of Wegener’s Granulomatosis manifesting otitis media with facial palsy. Plasma antineutrophil cytoplasm antibodies were detected by means of immunofluorescence. After three weeks of immunosuppressive therapy, facial palsy disappeared, the ESR had normalized and the size of pulmonary nodules had decreased.



    This case report highlights the need to bear in mind non-infectious causes of chronic otitis media with
    otorrhea.

  • R
    Indudharan, T Arni, KK Myint, et al (Universiti Sains Malaysia, Kelantan; Hosp Tengku Ampuan Afzan, Kuantan, Malaysia)

    Lymphoblastic Lymphoma/Leukemia Presenting as Perichondritis of the Pinna.

    J Laryngol Otol 112: 592-594, 1998





    A patient treated for perichondritis of the pinna was eventually determined to have B-lineage lymphoblastic lymphoma evolving to a leukemic phase. There was no pre-existing immunodeficiency.



    Though lymphoma is the second most common malignancy of the head and neck region, the pinna as the extranodal site of lymphoma, has been previously reported only once. Hence the need to broaden one’s diagnostic horizon when inflammatory lesions do not heal within a reasonable period.

      

  • G
    Venkatraman, DE Mattox (Univ of Maryland Baltimore)

    External Auditory Canal Wall Cholesteatoma: A Complication of Ear Surgery.

    Acta Otolaryngol (Stockh) 117 :293-297, 1997.





    Large primary cholesteatomas of the external auditory canal are rare. Cases arising from previous surgery are even less common.



    This article presents five cases of cholesteatomas arising from the floor of the external auditory canal after ear surgery. In all these patients, the cholesteatomas were extensive enough to require surgery. The authors postulate that a careful surgical technique would help prevent canal wall cholesteatoma.

       

  • E
    Gur, A Yeung, M Al-Azzawi, et al (Univ of Toronto)

    The Excised Preauricular Sinus in 14 Years of Experience : Is There a Problem ?

    Plast Reconstr Surg 102: 1405-1408, 1998.





    A few of the patients having a congenital pre-auricular sinus suffer from recurrent infections. In such cases surgical excision of the sinus tracts is required. Recurrence is very likely if the tract is not excised completely.



    The authors have reviewed 165 primary preauricular excision procedures in 146 patients over a period of 14 years.



    The recurrence rate was higher (15.79%) in patients who had active infection during surgery than in patients who did not have active infection (8.22%). The recurrence rate was higher (16.7%) in patients who had surgical drainage of an abscess before the procedure, and 8.16% in those who did not.



    Recurrence rates can be reduced by excising a piece of cartilage at the base of the tract and by demonstrating the sinus with dye injection and/or probing at the time of surgery.

        



  • Steven
    M Zeitels, MD

    Phonomicrosurgery I :
    Principles and Equipment

    The Origin and Development of
    Endoscopic Laryngeal Surgery


    From the Department of Otology
    and Laryngology, Harvard Medical
    School; and the Division of
    Laryngology, Massachusetts Eye
    and Ear Infirmary, Boston,
    Massachusetts

    The Otolaryngologic Clinics
    of North America
    Volume
    33, Number 5, October 2000, Pg.
    1047-1062

        

    PHONOMICROSURGERY-

      

    Phonomicrosurgery is a means of
    maximally preserving the layered
    microstructure of the vocal
    fold, that is, the epithelium
    and lamina propria.

       

    Tissue Dissection : Laser
    Versus Cold Instruments.


    Unlike the laser, cold
    instruments provide tactile
    proprioception during delicate
    microdissection.

      

    Infusion into the superficial
    lamina propria is often helpful,
    whether a laser or cold
    instruments are used.

      

    Precise tangential
    dissection within the
    superficial lamina propria
    [i.e., subepithelial cyst
    dissection] is better
    accomplished with cold
    instruments.

      

    Cold instruments facilitate
    maximal preservation of the
    layered microstructure [lamina
    propria and epithelium] of the
    vocal folds.

       

    The CO2 laser is
    typically used for vocal fold
    surgery and enhances cold fd  
    instruments when the
    pathologic condition is vascular
    or is too large.

       

    The Rationales of
    Phonomicrosurgery.

    Phonomicrosurgical
    procedures are designed to
    improve aerodynamic efficiency
    and vocal quality by creating a
    smooth vocal fold edge that is
    not excavated with overlying
    flexible epithelium.

        

    There is a little difficulty in
    the growth and regeneration of
    normal epithelium, as occurs
    after a cordectomy that is left
    to heal secondarily.

         

    The subepithelial infusion of
    saline ad epinephrine into the
    superficial lamina propria has
    further enhanced the precision
    of microlaryngoscopic vocal fold
    surgery with the use of both
    laser and cold instruments.

       

    The author has used
    cold-instrument epithelial
    incision as a standard approach
    for the management of such
    pathologic conditions as cysts,
    epithelial atypia, and cancer.

       

    During the last 4 years, this
    approach has been extended to
    the management of nodules,
    polyps, ectasias, and varices,
    so a subepithelial resection of
    these traumatic lesions has
    become standard.

        

    Phonomicrosurgery has emerged as
    a physiologically based approach
    for benign and malignant
    disease.

          

  • T Hoshino, Y Ueda, H Mukohdaka, et al (Hamamatsu Univ, Japan)


    Acute Granulomatous Myringitis



    J Laryngol Otol 112: 150-153, 1998


       

    Acute and chronic myringitis seem to be caused by two different entities. 

        

    Acute myringitis manifests the following – otalgia, a granulomatous bulge along the malleus, and no middle ear infection.

        

    Chronic myringitis is characterized by erosion or thin granulation of the tympanic membrane – it can recur after debridement and cautery.

        

    Granulomatous changes of the tympanic membrane are rare. This article describes five causes of acute granulomatous
    myringitis.

  • NH Blevins, BL Carter (Tufts-New England Med Ctr, Boston)

    Clinical Forum: Routine Preoperative Imaging in Chronic Ear Surgery,

    Am J Otol 19: 527-538, 1998.

        

    Imaging studies, especially CT, can demonstrate the nature and extent of chronic otitis media, which may not be apparent on clinical findings per se. Such findings can affect operative treatment, especially in difficult and/or revision procedures. However, there is a view that routine radiography of the mastoid may suffice in being very helpful in most cases.

       

  • TS
    Karhuketo, HJ Puhakka (Tampere Univ, Findland)

    Middle Ear Imaging Via the Eustachian Tube With a Superfine Fiberoptic Videomicroendoscope.

    ORL J Otorhinolaryngol Relat Spec. 60: 30-34, 1998.

       

    With a fibreoptic videomicroendoscope inserted through the Eustachian tube, 56% of predetermined anatomical objects in the middle ear were visualized. 

       

    However, one may find obstructive sites or mucosal folds that may prevent a complete view of all the contents of the middle ear cleft.

        

  • RL Hebert II, GE King, JP Bent III (Med College of Georgia, Augusta)


    Tympanostomy Tubes and Water Exposure: A Practical Model.



    Arch Otolaryngol Head Neck Surg 124: 1118-1121, 1998.


       

    Myringotomy with tympanostomy tube placement is one of the very common otolaryngologic procedures done nowadays.

       

    Contrary to previous thinking, the authors have shown that entry of water into the middle ear is not promoted by showering, hair rinsing, or submersion of the head in clean tap water. The chances of water contamination increase by submersion in SOAPY water or swimming at a depth of more than 60 cms.

       

    Many of the previously advised water precautions are unnecessary in patients with tympanostomy tubes.

        

  • Rath
    T, Millesi W, Lang S, et al
    (Univ of Vienna)

    Mucosal Prelamination of
    a Radial Forearm Flap for
    Intraoral Reconstruction.

    Eur J Plast Surg 21:
    166-170, 1998.

       

    In 5 patients the use of a
    distal radial forearm flap
    to which buccal mucosal
    grafts were meshed in
    reconstructing oral defects
    after radical resection of
    squamous cell carcinoma is
    described. It was safe, easy
    to use and successful.
    Although the time is needed
    between creation of the flap
    and its insertion, this time
    can be used to deliver
    preoperative radiation and
    chemotherapy.

      

  • Yotsuyanagi
    T, Yokoi K, et al (Hirosaki
    Univ, Japan)

    A Supportive Technique
    Using a Splint to Obtain
    Definite Contour and
    Desirable Protrusion After
    Reconstruction of Microtia

    Plast Reconstr Surg
    101: 1051-1055, 1998

        

    The use of thermoplastic
    splint is used in 17
    patients directly to the
    newly constructed ear, to
    prevent deformity resulting
    from odema and scarring.
    Patients were monitored for
    3 yrs. The splints were used
    after the first and second
    stage of costal cartilage
    grafting.

        

    This technique is worth
    consideration. G.R. Holt.

          

  • Personelle
    J, de Souza Pinto EB, Ruiz
    RO (Sao Paulo, Brazil)

    Injection of Vitamin A
    Acid, Vitamin E, and Vitamin
    C for Treatment of Tissue
    Necrosis.

    Aesthetic Plast Surg
    22: 58-64, 1998.

       

    Experimental animals used
    were rats. Injection of ACE
    pool, composed of all-transretinoic
    acid, vitamin A, and vitamin
    E is useful for the
    treatment of necrosis after
    routine plastic surgery.

       

    The antioxidants and their
    general health effects were
    used orally in selected
    patients to better prepare
    their tissue for surgery by
    G.R. Holt and found this
    regimen to be useful. 

       

    Well controlled clinical
    trial is needed – G.R. Holt.

      

  • Abou
    Chebel N, Beziat J-L,
    Torossian J-M (CHU Lyon-Nord,
    Cedex, France)

    Le Lambeau Myo-Muqueux de
    Buccinateur Pedicule sur les
    Vaisseaux Faciaux: Interet
    Dans la Reconstruction du
    Plancher de la Cavite
    Buccale: A Propos de 10 Cas.

    Ann Chir Plast Esthet
    43: 252-257, 1998

       

    Ten patients were given the
    flap. The musculomucous
    buccinator flap described
    provided excellent-
    functional and esthetic
    results in the repair of the
    floor of the mouth. Its
    flexibility ensures good
    tongue mobility. However, it
    requires extraction of the
    mandibular molars and also
    must have intact facial
    artery that can be raised
    with the flap. The Doppler
    could also be used to
    identify the course of the
    facial artery intraorally.
    The flap must be placed
    anterior to the parotid duct
    and opening. The patient
    must now chew if the flap
    crosses alveolar ridge. G.R.
    Holt.

        

  • Kuhn
    J, Toohill RJ, Ulualp SO, et
    al (Med College of
    Wisconsin, Milwaukee)

    Pharyngeal Acid Reflux
    Events in Patients with
    Vocal Cord Nodules.

    Laryngoscope 108:
    1146-1149, 1998.

        

    This study with controls
    demonstrated patients with
    vocal nodules were
    significantly more likely to
    experience pharyngeal acid
    reflux and pharyngeal
    episodes were more frequent.
    These finding suggests a
    contributory role for GEPR
    in pathogenesis of vocal
    cord nodules. Given this
    association, the vocal cord
    nodules in some patients
    should follow antireflux
    precautionary steps like
    elevating the head while
    sleeping and avoiding food 3
    to 4 hrs before bedtime.

        

    Barium swallow is a poor
    indicator of reflux. It
    should also use empirical
    therapy of reflux in
    patients without any cause
    for development of vocal
    nodules. G.R Holt.

        

  • Rosenbower
    TJ, Morris JA Jr, Eddy VA,
    et al (Vanderbilt Univ,
    NashvilleTenn)

    The Long-term
    Complications of
    Percutaneous Dilatational
    Tracheostomy.

    Am Surg 64: 82-87,
    1998.

       

    Out of 237 patients admitted
    in trauma centre, 95
    patients underwent
    percutaneous tracheostomy.
    Fifty-five patients were
    available for final
    follow-up.

        

    The long-term complication
    rate of PDT is comparable to
    that of open tracheostomy.
    It is rapid, safe, easy,
    cost effective and is useful
    in patients requiring
    prolonged ventilatory
    support.

         

  • Ebraheim
    NA, Lu J, Skie M, et al (Med
    College of Ohio, Toledo)

    Vulnerability of the
    Recurrent Laryngeal Nerve in
    the Anterior Approach to the
    Lower Cervical Spine.

    Spine 22: 2664-2667,
    1997.

        

    This is cadaveric study.
    Anatomy demonstrated suggest
    danger of injury to
    recurrent laryngeal nerve
    more on right side because
    the nerve courses outside
    esophagotracheal groove and
    runs in oblique direction
    relative to the sagittal
    plane. Inferior thyroid
    vessel should be ligated as
    laterally as possible and
    the retractor should be
    blunt tipped to retract the
    longus colli muscle to
    provide intermittent
    retraction of the midline
    structures.

        

    This article highlights the
    rationale of using left
    sided approach to the spine
    when possible. If right
    sided approach is used then
    above precautions are
    necessary to prevent injury
    to recurrent laryngeal
    nerve.

        

  • Postma
    GN, Shockley WW (Naval Med
    Ctr, Portsmouth, Va; Univ of
    North Carolina, Chapel Hill)

    Transient Vocal Fold
    Immobility

    Ann Otol Rhinol
    Laryngol 107: 236-240, 1998

        

    Common causes of adult vocal
    fold immobility (VFI)
    include, thyroid surgery,
    nonlaryngeal malignancy and
    viral insult. The 3 patients
    had acute VFI, an unusual
    condition.

        

    This VFI lasts for 4 weeks
    or less. Anything lasting
    more than 12 months is
    called permanent. A variety
    of causes of transient and
    temporary VFI, have been
    identified: metabolic,
    traumatic, infectious or
    inflammatory, autoimmune,
    CNS, mechanical and
    neoplastic. Some cases are
    idiopathic.

       

    This is nice article about
    the temporal differences
    between transient, temporary
    and permanent vocal fold
    immobility. These are to be
    identified before any
    therapy is undertaken.

       

  • Filler
    RM, Forte V, Chait P (Univ
    of Toronto; Hosp for Sick
    Children, Toronto)

    Tracheobronchial Stenting
    for the Treatment of Airway
    Obstruction

    J Pediatr Surg 33:
    304-311, 1998

       

    A balloon expandable stent,
    the Palmaz stent, was
    inserted into 16 children
    with a variety of major
    airway obstructions. Thirty
    stents were inserted in 24
    separate procedures during
    the 5 yrs.

       

    Results showed they are
    extremely useful in the
    treatment of neonates and
    infants with localized
    tracheomalacia and
    bronchomalacia in those with
    airway obstruction caused by
    surgery for congenital
    tracheal stenosis, in
    patients with incurable
    congenital heart disease.
    The stents can be inserted
    easily and can be left for
    long periods if necessary.

        

    More clinical studies need
    to be performed using
    improved stent designs, to
    optimize the results – G.R.
    Holt.

       

  • Yumoto
    E, Sanuki T, Hyodo M, et al
    (Ehime Univ, Japan)

    Three-Dimensional
    Endoscopic Mode for
    Observation of Laryngeal
    Structures by Helical
    Computed Tomography.

    Laryngoscope 107:
    1530-1537, 1997.

       

    Helical scanning CT was used
    to produce high quality 3D
    endoscopic images of larynx.
    The method has been
    described. The method used
    was in 12 patients with
    normal and affected larynx,
    either by cancer, nerve
    palsy and atrophy. This
    method provided useful
    diagnositc and therapeutic
    information in patients with
    RLN palsy. In cancer
    patients axial images
    allowed better assessment of
    characteristic lesions than
    CT endoscopic images alone.

       

    This new technology can take
    3D data and through
    obstruction technique,
    produce an image than
    appears as the
    “New” of the
    larynx through an endoscope.
    G.R.Holt.

        

  • Riley
    RW, Powell NB, Guilleminault
    C, et al (Stanford Univ,
    Calif)

    Obstructive Sleep Apnea
    Surgery: Risk Management and
    Complicaitons

    Otolaryngol Head Neck
    Surg 117: 648-652, 1997.

        

    Patients who undergo surgery
    for obstructive sleep apnea
    syndrome (OSAS) are at
    increased risk for
    postoperative airway
    obstruction, hypoxemia,
    hypertension and death.

        

    In 182 patients with 210
    surgeries for OSAS, the risk
    factors were identified and
    were overcome.

        

    The use of fibre optic
    intubation can reduce
    intraoperative complications
    with OSAS who have large
    neck circumference and
    facial skeletal deficiency.
    Hypertension is a
    significant risk factor, and
    requires aggressive
    treatment. Nasal continuous
    positive airway pressure (CPAP)
    prevents hypoxemia.

        

    This article provides useful
    tips for the perioperative
    management of OSAS patients.
    R.A. Otto.

        

  • Osterlund
    A, Engstrand L (Univ Hosp,
    Uppsala, Sweden)

    An Intracellular
    Sanctuary for Streptococcus
    Pyogenes in Human Tonsillar
    Epithelium: Studies of
    Asymptomatic Carriers and In
    Vitro Cultured Biopsies.

    Acta Otolaryngol (Stockh)
    117: 883-888, 1997.

        

    Streptococcus pyogenes was
    found in epithelial cells
    for both symptomatic and
    asymptomatic patients. This
    intracellular reservoirs
    could serve as the source
    for reinfection. Perhaps
    antibiotics with good
    intracellular penetration
    should be used.

        

    This study provided the
    novel hypothesis that the
    inner harbor for S.pyogenes
    in the tonsils may be
    intracellular and therefore
    requires the antibiotics
    capable of penetrating and
    destroying this
    intracellular bacteria,
    thereby, completely
    eradicating the bacteria and
    the chances of reinfection
    or passing on the infection
    to others. G.R. Holt.

        

  • Ament
    PW, Paterson A (Latrobe Area
    Hosp, Penn)

    Drug Interactions with
    the Nonsedating
    Antihistamines

    Am Fam Physician 56:
    223-230, 1997.

        

    The nonsedating
    antihistamines – which
    include astemizole,
    fexofenadine, loratadine and
    terfenadine – are very
    commonly prescribed drugs.

       

    Terfenadine and astemizole
    cause serious adverse
    effects in interaction with
    macrolide antibiotics or the
    antifungal agents, quinine
    Such interaction appears to
    be less likely with
    fexofenadine and Loratadine.

        

    To avoid an adverse effect
    (drug-drug interactions) one
    must avoid prescribing any
    medication that may
    influence cytochrome P450
    system.

        

  • Iro
    H, Zenk J, Waldfahrer F, et
    al (Saarland Univ, Homburg,
    Germany; Univ of Erlangen-Nuremberg,
    Germany; Dr. Horst-Schmidt-Klinikum,
    Wiesbaden (EII) Germany) 

    Extracorporeal Shock Wave
    Lithotripsy of Parotid
    Stones: Results of a
    Prospective Clinical Trial.

    Ann Otol Rhinol
    Laryngol 197: 860-864, 1998.

        

    A total of 76 patients
    ranging form 2 to 80 yrs
    were treated. These patients
    were treated with routine
    treatment of sialogogues,
    bougienage, gland massage
    etc. with no resolution.

       

    This effective treatment
    gives reliable long-term
    results. With this
    treatment, parotidectomy and
    its accompanying
    complications can be
    avoided.

        

  • Marvez-Vals
    EG, Ernst AA, Gray J, et a
    (Louisiana State Univ, New
    Orleans; Vanderbilt Univ Med
    Ctr, Nashville, Tenn)

    The role of Betamethasone
    in the Treatment of Acute
    Exudative Pharyngitis.

    Acad Emerg Med 5:
    567-572, 1998.

        

    The double-blind clinical
    trial was performed over 3
    months. Forty-six patients
    were randomized to placebo
    and 46 to Betamethasone.

         

    Betamethasone, used as an
    adjunct to antibiotic
    therapy reduces the time to
    pain relief. Most effective
    in patients with
    streptococal positive.

          

  • Naumann
    M. Zellner M, Tokya KV, et
    al (Bayerische Julius -Maximilians
    Universitat, Wurzburg,
    Germany)

    Treatment of Gustatory
    Sweating with Botulinum
    Toxin.

    Ann Neurol 42:
    973-975, 1997.

        

    Gustatory sweating (Frey’s
    syndrome) has been treated
    with scopolamine or aluminum
    hydrochloride and tympanic
    nerve destruction.

        

    Intracutaneous injections of
    botulinum toxin (BTX) type A
    are more effective.
    Forty-five patients were
    treated. 50% patients
    reported complete relief and
    50% showed substantial
    improvement.

       

    This is safe and effective
    method. Long-term follow up
    is needed. G.R. Holt.

        

  • Adair-Bischoff
    CE, Sauve RS (Univ of
    Calgary, Alberta, Canada)

    Environment Tobacco Smoke
    and Middle Ear Disease in
    Preschool-Age Children.

    Arch Pediatr Adolesc
    Med 152: 127-133, 1998

        

    Six hundred and twenty-five
    eligible children for this
    study were reviewed.

        

    Conclusions: Exposure to
    environmental tobacco smoke
    (ETS) during the first 3yrs
    of life significantly
    increased the risk of middle
    ear diseases (MED) in these
    first-grade children.
    Greater exposure to (ETS)
    had greater risk for MED.

        

    Avoding ETS during the first
    3 years of life could have
    significant impact on MED
    and its associated
    morbidities.

         

  • Berrylin
    J Ferguson (Divn. Of
    Sino-nasal Disorders and
    Allergy, Dept. of
    Otolaryngology, Univ. of
    Pittsburgh School of
    Medicine, Pennsylvania)

    Mucormycosis of the Nose
    and Paranasal Sinuses

    Otolaryngo Clinics of
    North America, Vol.33(2),
    April 2000; 349-365

          

    It is uncommon and rarely
    affects healthy host. But
    for the afflicted patient,
    the speed with which it
    progresses and leads to the
    death, warrants immediate
    diagnosis and emergency
    treatment. It can be seen in
    diabetics and other
    immunocompromised patients.
    It starts in sinonasal
    region but rapidly
    progresses to rhinocerebral
    region and orbit producing
    proptosis and
    ophthalmoplegia.

         

    Aetiopathology

    It is a term used to refer
    to fungal infections of the
    order Mucorales which
    belongs to the class
    zygomycetes. These are
    termed as zygomycosis. This
    would also incorporate the
    other order of the class
    Entomophthorales. This
    latter is a tropical
    granulomatous infection of
    the subcutaneous tissues and
    paranasal sinuses by
    Basidiobolus and Delacroixia,
    which responds to local care
    in contrast to the order of
    mucorales.

        

    Most pathogenic species are
    members of the family.
    Mucoraceae, Rhizopus, Oryzae
    is the predominant pathogen
    and accounts for 60% of all
    forms of mucormycosis and
    90% of rhinocerebral cases
    of mucormycosis.
    Apohysomyces elegans is the
    most recently recognised
    agent and caused
    mucormycosis in an
    immunocompetent individuals.

        

    Diabetics in ketoacidosis
    are disproportionately
    affected. Out of 26 patients
    with rhinocerebral
    mucormycosis, 70% were
    diabetic.

        

    Other risk factors include
    neutropenia, systemic
    steroids, protein calorie
    nutrition, solid organ and
    bone marrow transplant,
    immunodeficiency, leukaemia,
    intravenous drug abusers who
    may inject spores of
    mucorales with their drugs
    and then present with
    space-occupying lesions of
    the central nervous system.
    The relative infrequency of
    mucormycosis in patients
    with AIDS probably reflects
    the ability of neutrophils
    to prevent growth of the
    fungus.

        

    Signs and symptoms reported
    in patients within 72 hours
    of onset of
    Rhino-Orbital-Cerebral
    Mucormycosis.

        

    ¨ Fever

    ¨ Nasal ulceration or
    necrosis

    ¨ Periorbital or facial
    swelling

    ¨ Decreased vision

    ¨ Ophthalmoplegia

    ¨ Sinusitis

    ¨ Headache

    ¨ Facial pain

    ¨ Decrease in mental status

    ¨ Nasal discharge or
    stuffiness

    ¨ Corneal cellulitis

    ¨ Orbital cellulitis

    ¨ Proptosis

    ¨ Palatal or gingival
    necrosis

    ¨ Afferent pupillary defect

    ¨ CN VII palsy

    ¨ Periorbital pain

    ¨ Chemosis (without orbital
    cellulitis)

    ¨ Epistaxis

    ¨ Facial numbness

    ¨ Diplopia

    ¨ Facial necrosis

    ¨ Hemiplegia/stroke

    ¨ Malaise

    ¨ Ptosis (without
    ophthalmoplegia)

    ¨ Decreased hearing

    ¨ Toothache

    ¨ Earache.

       

       

    Treatment

          

        1)
    Reversal of cause of
    immunocompromisation

          

        2)
    Systemic Antifungal
    Amphotericin B

           
    Systemic amphotericin can be
    administered 1 to 1.5mg/kg
    per day intravenously by
    monitoring patients

         

        3)
    Repeated and extensive
    surgical debridement

           
    External techniques like
    external ethmoidecormy or
    Caldwell-Luc procedure,
    preferred to endoscopic

           
    management

           
    Orbital exenteration was
    advocated but is now
    controversial.

             

        4)
    Topical application of
    amphotericin is 50mg vial
    and intravenous amphotericin
    B and 10mL of sterile

            
    water. This can be nebulized
    with a Rhinoflow device into
    the nose. The dosage is 4 mL
    in each

            
    nostril 2 to 6 times a day.

            

        5)
    Hyperbaric oxygen can be
    used. It helps reverse the
    ischaemic acidotic
    conditions that perpetuates

           
    fungal growth. Usually given
    at two atmospheres for 1 hr
    on a daily basis upto 30
    treatments. It then

           
    limits deformity by
    decreasing tissue of
    debridement.

              
      

  • Kenneth
    M Grundfast, Nicole Siparsky
    and Diana Chuong 

    Genetics and Molecular
    Biology of Deafness- Update

    The Otolaryngologic
    Cl. Of North America,
    Vol.33(6), Dec.
    2000,p.1367-1394

         

    Incidence of acquired types
    of hearing impairment
    diminished, but a growing
    proportion of all childhood
    hearing impairment is seen.

        

    Until recently only genes
    for HHI (Hereditary Hearing
    Impairment) were identified
    as syndromic causes. However
    in last 5 yrs many non-syndromic
    HHI were identified
    contributing to the HHI.
    Fifty-three loci have been
    identified for nonsyndromic
    HHI. Otolaryngologists,
    therefore, should have basic
    knowledge of HHI in order to
    diagnose, treat and prevent
    sensorineural hearing
    losses.

       

    Currently 25% of hearing
    impairment are congenital.
    50% of these are hereditary.
    2/3rd of these hereditary
    are nonsyndromic and 1/3rd
    are syndromic. 

        

    Apart from monitoring of
    infants at risk by OAE (otoacoustic
    emissions) and auditory
    brainstem response (ABR),
    newborn screening should
    include genetic testing
    (GJB2) as well, but is
    prohibitively expensive.

       

    Almost 50% of inherited
    deafness is caused by
    mutations in GJB2, which
    encodes connexin -26, a gap
    junction component on
    chromosome 13.

       

    In such early detection,
    early interventional
    programmes give larger
    benefit to these infants and
    children.

       

    Definition of Hearing
    loss vs Hearing Impairment

    Hearing loss means
    hearing was lost at birth

    Hearing Impairment means
    child was born with hearing
    impairment.

       

    Deafness versus hearing
    Impairment

    Deaf patient uses sign
    language primarily while
    hearing impaired patient
    uses speech as communication
    method.

        

    Congenital Hearing
    Impairment (CHI) versus
    Hereditary Hearing
    Impairment (HHI)

    CHI means deafness
    present at birth. It may be
    because of genetic mutation
    or pathologic process which
    occurs either during
    pregnancy or labour.

       

    HHI is the result of genetic
    mutation. It can manifest at
    birth or develop later in
    life.

        

    HHI present at birth is
    congenital hereditary
    hearing impairment, while
    HHI develops later is
    delayed onset hereditary
    hearing impairment. One of
    the most common types of HHI
    is autosomal dominant
    nonsyndromic delayed-onset
    of progressive hearing loss.
    Depending on the severity in
    the family, hearing loss
    will progress with the age.
    Several other family members
    affected helps it to
    differentiate this
    hereditary disorder from
    autoimmune inner ear
    disorder.

        

    Syndromic versus
    Hereditary Hearing
    Impairment

    The cause of a syndrome
    is either genetic or
    exogenous factors.

       

    Genetic examples are
    Usher’s, Pendred’s,
    Waardenburg’s,
    branchio-oto-renal
    syndromes. Exogenous
    examples are gene mutation
    caused cytomegalovirus,
    rubella or Goldenhar’s
    syndromes.

        

    It is important to remember
    that gene mutation can occur
    spontaneously so that a
    child affected may not have
    other relatives who are also
    affected.

        

    Syndromic versus Genetic
    Disorder

     It is important to
    note that syndromes which
    include hearing loss, may
    not manifest with it but can
    have other features. For
    example, Waardenburg’s
    syndrome only 17% have
    hearing loss. This is
    because of variability of
    gene expression.

       

       

    SYNDROMES AND
    NONSYNDROMIC HEARING LOSS

        


    There are 200 different
    syndromes with hearing
    impairment. Nearly,
    two-third is termed
    nonsyndromic which are
    associated with no other
    anomalies. Various modes of
    inheritance is seen in both
    viz autosomal recessive,
    autosomal dominant and
    X-linked transmission.
    Identification and location
    of many genes will further
    enhance understanding of
    this disorder.

       

    Inheritance Patterns

    Hereditary implies
    genetic basis of disorder.
    Three classical types being
    autosomal recessive,
    autosomal dominant or
    X-linked recessive. Though
    inheritance pattern varies
    in classical Mendelian
    patterns, the HHI is
    secondary to the interaction
    of several genes or the
    result of an interplay
    between genetic and
    environmental factors.

       

    (a) Autosomal Recessive

    Autosomal recessive
    comprises of 80% of
    hereditary deafness and the
    most common pattern. In the
    recessive transmission, the
    parents have normal or near
    normal hearing, inspite of
    possessing recessive gene.
    Typically there is a 25%
    chance that offspring might
    suffer. This is
    characterized by horizontal
    pattern. For offspring to
    exhibit, both parents must
    be carriers of the genetic
    disorder.

        

    (b) Autosomal Dominant

    Approximately 18% of
    cases. A vertical pattern of
    transmission. When one
    parent is a carrier, 50% of
    the offsprings suffer. If
    new mutation occurs in gene,
    it is inherited in dominant
    fashion. – thus offspring
    may be the first affected in
    the family.

       

    (c) X-Linked Recessive

    1% to 3% suffer. Genes
    located on X-chromosomes are
    involved. Affects males.
    This pattern of inheritance
    is similar to that of
    haemophilia, where mothers
    being the carriers but their
    male offspring are affected
    individuals.

        

    Abnormalities in
    Mitochondrial DNA

    This is another mode of
    inheritance of HHI. Maternal
    oocyte is the sole
    contributor of mitochondria.
    So any mitochondrial DNA
    mutation responsible for HHI
    in the mother will be
    transmitted to all of that
    mother’s offsprings. In some
    families, hearing loss may
    be the only mitochondrial
    disease.

        

    Mitochondrial DNA encodes
    mitochondrial proteins, tRNA
    and rRNA. Mutation in tRNA
    and rRNA are associated with
    nonsyndromic hearing loss.
    Another suspect in
    mitochondrial HHI is a
    mitochondrial import protein
    deafness/dystonia peptide (DDP).

       

    The expression of
    mitochondrial HHI varies
    greatly. Several other
    mitochondrial genes
    associated with nonsyndromic
    hearing loss and syndromic
    is already listed. Mutation
    in mitochondrial DNA
    encoding tRNA have been
    linked to HHI whereas
    mutation of Rrna is
    associated with
    susceptibility to
    aminoglycoside ototoxicity.
    DNA mutation mt3243 is
    associated with two
    syndromes (1) maternally
    inherited diabetes and
    deafness (MIDD) and (2)
    myopathy-encephalopathy-lactic
    acidosis stroke (MELAS).

          

          

    PENETRANCE, EXPRESSIVITY,
    AND GENETIC HETEROGENEITY

    The diagnosis of HHI
    inherited by autosomal
    recessive and autosomal
    dominant is not easy in some
    cases because of lack of
    manifestation of the
    features.

          

    The penetrance is the
    terminology used to indicate
    manifest expression of a
    gene. It is all-or-none
    phenomenon. So there are
    penetrant and non-penetrant
    genes. The expressivity is
    used to indicate the degree
    to which a penetrant gene
    will cause expression of
    abnormal function.

          

    Expression may be varied,
    even though the two
    individuals may possess the
    same gene. Recent research
    suggests that the sex of the
    parent from whom a gene
    mutation is inherited will
    influence the expression.
    This is termed as Genomic
    Imprinting.

        

    Genetic heterogenicity
    implies that different
    mutations involving
    different genes can result
    in an identical or similar
    phenotype. Not to be
    confused with a polygenic
    disorder, which is a
    phenotype that results from
    the interaction of multiple
    genes.

        

    Classification of
    Hereditary Hearing
    Impairment

         

    a) Syndromic
    Hereditary Hearing
    Impairment

    Syndromic are upto 30% of
    children with hereditary
    hearing impairment. There
    are many causative genes for
    these syndromes which have
    been identified. These are
    clinical syndrome. Hearing
    loss is conductive or mixed.

        

    b) Nonsyndromic
    Hereditary Hearing
    Impairment

    Almost 2/3rd in numbers. It
    is almost exclusively caused
    by mutations of single gene
    and these hearing
    impairments are not
    associated with any other
    abnormalities.

        

    There are several modes of
    inheritance of nonsyndromic
    HHI genes. Several genes
    have been isolated and
    cloned. The long list of
    genes, their loci and
    location on the chromosomes
    of autosomal recessive
    nonsyndromic HHI has been
    given and will be increasing
    as the research continues (Ref:
    Data from Van Camp G, Smith
    RJH: Hereditary Hearing Loss
    Homepage.)


        

    The list of syndromes out of
    few hundred, with inherited,
    gene, loci and location on
    chromosomes is prepared (Ref:
    Data from Van Camp G, Smith
    RJH: Hereditary Hearing Loss
    Homepage.)

        

    Hearing Loss Genes and
    Their Gene Products:

        

    Almost all genes implicated
    in HHI are identified in
    last 10 years. These genes
    encode related proteins
    which are studied in detail
    and include:

       

    a) Connexin genes

    b) Myosin genes

    c) POU genes

    d) Ion channel genes

        

    In addition number of genes
    have been identified (Ref:
    Data from Van Camp G, Smith
    RJH: Hereditary Hearing Loss
    Homepage.)


         

    (a) Connexin genes:

    This family is comprised of
    a group of genes that encode
    plasma membrane channel
    proteins of the alpha (A)
    and beta (B) types.

         

    (b) Myosin genes

    This family is related to
    the super family of myosin
    genes expressed throughout
    the body.

       

    (c) The POU genes

    Members of POU gene family
    encode transcription
    factors, some of which are
    expressed in the inner and
    middle ear.

       

    (d) The potassium
    channel gene super family
    includes genes that are
    expressed in the inner ear.

        

    One day genetic testing may
    be a useful diagnostic tool
    in the evaluation of Hearing
    Impairment.

        

    With growing understanding
    of genetic mutations and
    their effect on auditory
    function, scientists hope to
    develop treatments for many
    genetic disorders.
    Researchers explore the
    possibility of gene therapy
    for HHI and novel therapies
    to treat the deficiencies
    that arise due to genetic
    mutations. In the future,
    individuals carrying a
    genetic mutations
    responsible for progressive
    hearing loss may be able to
    receive a sufficient amount
    of normal gene product in
    order to prevent auditory
    dysfunction.

         

         

    CLINICAL APPROACH

    a) Family History -
    should be taken in details
    and should include all under
    age 30 with hearing
    problems.

        Certain
    hereditary traits should be
    inquired into.

        

    b) Physical Examination – to
    look at the patient as
    whole, to detect other
    abnormalities pointing to

       
    syndromes.

          

    c) Audiologic Testing -
    Cochlear and vestibular
    testing.

        

    d) Laboratory Testing 

       

    d) Radiologic Testing – CT
    and MR imaging

       

    e) Genetic Testing

        

        

  • Christopher
    J Hartnick, Robin T Cotton

    Congenital Laryngeal
    Anomalies

    Otolaryngologic Cl.of
    North Am. Vol.33(6),
    Dec.2000, pg.1293-1309

        

    Otolaryngologists face
    congenital laryngeal
    anomalies, which may be
    minor to severe. Such
    problems present at birth
    may require immediate
    attention. He should
    therefore have firm
    understanding of these
    aberrations in embryologic
    development. This article
    deals with pertinent
    embryology, relating to
    congenital laryngeal
    anomalies, reviews, the
    diagnosis and management in
    details.

       

    Embryology

    In 1885, His described
    the appearance of the
    respiratory primordium (RP)
    from an outpouching of the
    cephalic portion of the
    pharynx by the third week of
    gestation.

       

    The following description of
    the development occurs at
    different stages of
    development.

       

    According to Carnegie
    staging system for human
    embryologic development,
    there are two periods of
    development.

       

    The first period or the
    embryonic period is 8 weeks
    and comprises 23 stages.

    The second period is Foetal
    period spans the remaining
    32 weeks of gestation.

       

    The larynx begins to develop
    during stage II (at 25 to 28
    days) when RP appears as
    epithelial thickening on
    ventral aspect of the
    foregut.

       

    As the RP develops, outpouch
    of foregut lumen, the
    respiratory diverticulum
    (RD) grows into RP. As the
    RD develops from primitive
    pharyngeal floor at the
    level of adult glottis. The
    pharyngeal floor is
    separated from the primitive
    pharyngeal floor by
    primitive laryngopharynx
    which later becomes adult
    supraglottic region.

       

    Anomalies at this point can
    result into a number of
    larynotracheal anomalies.

    RD develops and extends
    inferiorly at stage 13 and
    14 and get separated from
    developing heart and hepatic
    primordium by the septum
    transversum (ST).

       

    The esophagus get separated
    from RD by tracheoesophageal
    septum. Anomalies of septum
    transversum leads to
    bronchobiliary fistula.
    Arrest of cranial (upward)
    development of
    tracheoesophageal septum
    leads to tracheoesophageal
    or laryngeal c lefting and
    tracheoesophageal fistula.
    Anomalies of the RD itself
    can cause tracheal agenesis,
    tracheal stenosis, or
    complete tracheal rings.

       

    During stage 15 the ventral
    lumen of primitive
    laryngopharyngeal region
    becomes obliterated and
    gives rise to epithelial
    lamina (EL). In stage 19 to
    23, EL recanalizes,
    reestablishing the
    connection between the
    ventral laryngeal portion
    and dorsal pharyngoglottic
    duct.

        

    Failure of recanalization of
    EL causes spectrum of
    disorder from laryngeal webs
    to laryngeal stenosis. With
    working knowledge, various
    anomalies can be adhered
    individually, starting from
    supraglottis to glottis,
    subglottis and upper
    trachea.

        

        

    LARYNGEAL WEBS

    Seventy-five percent
    webs occur at the level of
    the glottis. Severity of
    symptoms will depend on
    severity of webbing which
    are classified by Cohen as
    follows:-

       

    Type I – Anterior web
    involving 35% of glottis. 

              
    – The true vocal cords are
    visible. 

              
    – There is little or no
    subglottic extension, voice
    abnormal, slightly
    hoarseness.

       

    Type II – 35% to 50% glottic
    involvement. 

               
    – Thick anterior webbing
    with subglottic involvement.
    Cricoid abnormalities. 

               
    – Airway symptoms are
    uncommon, only during
    infection or intubation
    trauma. 

               
    – The voice is husky and
    weak.

       

    Type III – 50% to 70%
    glottic involved.

                
    – Web thick anteriorly

                
    – True vocal cords invisible

                
    – Cricoid abnormalities

                
    – Marked vocal dysfunction

                
    – Airway symptoms severe and
    require artificial airway.

        

    Type IV – 75% to 90% glottis
    involved

                
    – Uniformly thick anterior
    and posterior

                
    – True cords, not visible

               
    – Subglottis narrowed

               
    – Aphonic

               
    – Airway – immediate help.

      

    Diagnosis is either by
    flexible laryngoscopy, or by
    good quality lateral
    radiograph. It will also
    demonstrate cricoid
    abnormality.

        

    Management :

    – Type I membranous web
    observed until the child is
    3 to 4 years old and then
    web divided by a CO2 laser.

    – Type II cutting web on
    each side of the interval of
    2 weeks and dilation. Keel
    placement by endoscopy.
    Tracheostomy is necessary.

    – Type III & IV. Also
    delayed till 3 to 4 yrs with
    tracheostomy and later by
    various reconstructive
    procedures.

      

    Congenital supraglottic webs
    are unknown. They could be
    in anterior part or more
    rarely in posterior part.

        

    Laryngeal Stenosis and
    Atresia

    It is the most severe
    form of anomalies. Glottic
    or supraglottic atresia
    requires immediate
    trachneostomy in the labour
    room and has high mortality
    ratio. These are also many
    times associated with host
    of other anomalies like
    tracheoesophageal fistula,
    esophageal atresia, urinary
    tract abnormalities and limb
    defects.

         

    Congenital subglottic
    stenosis is associated with
    abnormally shaped cricoid
    cartilage first described by
    Hollinger in 1954. It is to
    be differentiated from
    acquired stenosis, by
    history only i.e. absence of
    infection and
    instrumentation.

       

    When lumen of cricoid is
    less than 4mm in newborn or
    less than 3mm in premature,
    it is congenital subglottic
    stenosis.

        

    Symptoms will depend on
    severity of stenosis. Myer-cotton
    Grading system uses
    endotracheal tubes to grade. 

        

    It is graded in 4 grades –

    Grades I – 0-50%
    obstruction,

    Grade II – 51% to 70%
    obstruction,

    Grade III -71% to 99%
    obstruction

    Grade IV – Total
    obstruction.

      

    Congenital S.G.S. also
    improves as the larynx
    grows. Less than 50% require
    tracheostomy. Dilation has
    little to offer in
    cartilaginous stenosis.

       

    In some patients, anterior
    cricoid split may be
    necessary to avoid
    tracheostomy. There are
    indications worked out by
    paediatric otolaryngologists:

       

    1. Extubation failure on at
    least two occasions because
    of subglottic malformation.

    2. Weight greater than 1500g

    3. No ventilator support for
    at least 10 days before
    procedure

    4. Supplemental oxygen
    requirement less than 30%

    5. No congestive heart
    failure for at least 1 month
    before the procedure

    6. No acute respiratory
    tract infection

    7. No antihypertension
    medication for at least 10
    days before the procedure.

        

    Grade I and Grade II lesion
    – Role of endoscopic laser
    treatment and short term
    stenting exists.

        

    Grade III and Grade IV -
    Open operative procedure of
    reconstruction are required.

        

    Laryngeal Clefts

       

    Posterior laryngeal clefts (PLCs)
    and laryngotracheal
    esophageal clefts (LTECs)
    derive from a common
    embryonic anomaly. 30% of
    these are associated with
    polyhydramnios. They are
    also associated with
    different syndromes with
    anomalies of other organs.

       

    Two classifications exists:

    A) Evan’s system. – LTEC,
    type I – supraglottic
    interaytenoid that extend,
    above the level of glottis.
    Cricoid is

        
    uninvolved. Type II -
    Cricoid and cervical trachea
    is involved. Type III -
    Extends to thoracic trachea.

        

    B) Benjamin’s Classification
    is modified Evans.

        Type I -
    cleft above vocal cord

        Type II -
    partial cricoid cleft and
    extends to vocal cords

        Type III
    – Total cricoid cleft with
    or without cervical tracheal
    cleft.

        Type IV -
    A cleft extending to
    thoracic trachea with or
    without involvement of
    bronchi.

         

    Symptom of Posterior
    Laryngeal Clefts (PLCs)
    -
    copious secretions,
    aspiration, cyanosis during
    feeding and recurrent
    pulmonary infecitons.

        

    Diagnosis : Flexible
    laryngoscopy

    Contrast esophagrams.

         

    Management : Repair
    of PLCs and LTECs requires
    control of the airway.
    Special instrument if any to
    be done endoscopically or by
    external operation procedure
    like laryngofissure or
    lateral pharyngotomy.

        

  • Hussam
    K, EL-Kashlan and Steven A
    Telian (Univ. of Michigan)

    Diagnosis and initiating
    treatment for peripheral
    system disorders: Imbalance
    and Dizziness with Normal
    hearing

    Otolaryng Clinics of
    N. America, vol.33(3), June
    2000

       


    Peripheral vestibular system
    consists of :

    (a) Vestibular
    labyrinth harbouring
    neuroepithelium responsible
    for identifying position and
    movements of head.

       

    (b) Vestibular nerve
    (part of cochlear vestibular
    nerve) carrying nerve fibres
    from labyrinth to CNS

       

    Disorder of Peripheral
    systems definitely affects
    hearing loss along with
    balance affected. However,
    certain following conditions
    cause dizziness without
    hearing loss.

      

    (1) Benign paroxysmal
    positional vertigo (BPPV)

    (2) Vestibular neuritis

    (3) Recurrent vestibulopathy

    (4) Familial vestibulopathy 

    (5) Bilateral idiopathic
    vestibulopathy.

       

    Detailed clinical
    interrogation should include
    (I) mode of onset and
    description of first
    episode. (ii) frequency and
    duration of each episode
    (iii) spontaneous or
    provoking causes (iv)
    associated auditory causes
    (v) EAR disease or any
    surgery on ear in the past.

       

    (1) Benign Paroxysmal
    Positional Vertigo (BPPV)

    It is brief episodes of
    vertigo precipitated by head
    movement in certain places.
    The most common cause, in
    elderly patients though no
    identifiable cause is known,
    commonly follows head trauma
    sequalea of vestibular
    neuritis, otologic surgery,
    infection or prolonged bed
    rest.

        

    BPPV characteristic clinical
    feature is that patient
    experiences giddiness
    following head movements
    like getting into or out of
    bed, rolling over or looking
    up and is associated with
    the nystagmus with
    distinctive characteristics-

        

    a) Latency period following
    provocative position 

    b) Intensifies gradually and
    has crescendo-decrescendo
    manner.

    c) Only 20-30 seconds
    duration even if position
    remains same.

    d) The nystagmus is
    torsionally beating towards
    undermost of the (offending
    ear) i.e. fast phase towards
    down ear. It is accompanied
    by a vertical up or down
    beating component because of
    post canal wall and anterior
    canal wall component
    respectively.

    e) Usually recurs and
    changes direction when
    patient moves back to
    sitting position.

    f) The response is
    fatiguable.

       

    PATHOGENESIS of BPPV

    Though there are two
    theories of mechanisms as to
    how vertigo occurs, the
    basic mechanism is
    accumulation of otoconial
    debris with higher specific
    gravity than endolymph
    within semicircular canal.
    It responds to linear
    acceleration including
    gravitation force.

        

    1) Schuknecht’s cupulithisis
    theory-

    The debris gravitates to
    adhere to the cupola of
    semicircular canal and
    changes in head position
    stimulates to cause
    giddiness. The theory,
    however, cannot explain all
    classical features of BPPV.

        

    2) Canalithiasis theory by
    Hall et al and supported by
    many authors.

    This theory postulates clot
    formation of floating
    otoconial debris near
    cupola. A clot moving in
    ampullofugal direction acts
    as a plunger on the
    endolymph, producing
    pressure or suction in the
    canal producing deflection
    of cupola and attack BPPV.

        

    VARIANTS OF BPPV

    Any of three semicircular
    canals may be involved. The
    direction of nystagmus will
    depend upon involvement of
    canal. 91% cases of
    posterior canal is involved.
    3% anterior and 6% of
    lateral semicircular canals
    are involved.

        

    – Both vertical canals (i.e.
    anterior and posterior)
    produce torsional nystagmus.
    Vertical component will
    identify the canal.
    Upbeating nystagmus will be
    in a posterior canal,
    whereas, down beating
    nystagmus will point towards
    anterior canal. Provocative
    movement for vertical canal
    will be moving from a
    sitting position to a head
    hanging position.

       

    – Horizontal canal variant
    was proposed first by
    McClure procedures pure
    horizontal nystagmus and is
    caused by lateral head turn
    in supine position. The
    nystagmus changes direction
    as the head is turned from
    one side to the other
    lateral side. It may be
    geotropic (fast phase
    towards dependent ear) or
    ageotropic (fast phase away
    from the dependent ear)

       

    – In canalithiasis it is
    geotropic whereas in
    cupulothiasis it is
    ageotropic.

       

    TESTS FOR BPPV

    – Hallpike-Dix Test -
    for vertical canal BPPV

       

    – Side-Lying test – for
    vertical canal. It is more
    comfortable and is used in
    elderly patients.

       

    – Roll-test -f or horizontal
    canal BPPV.

       

    Treatment 

    Medical therapy of
    vestibular suppressants is
    not effective. In fact, it
    may affect central
    habituation process when
    relieves symptoms.

       

    (a) Single treatment
    Approach

    Aim is to maneuver the
    debris from canal into
    vestibule.

    The two most commonly used
    methods are those described
    by Epley or Semont et al.

       

    (b) Habituation Exercises
    Approach

    In 1980, Brandt and Daroff
    proposed the exercises which
    are sequence of lateral
    head/trunk tilts, repeated
    many times a day for 2-3
    weeks to promote lossening
    and ultimately, dispersion
    of the debris towards the
    utricular cavity. These
    relieves patients vertigo
    but difficult to perform by
    patients because of
    experience of vertigo during
    these exercises. This is in
    sharp contrast to single
    manuvers of Epley or Semonts
    procedure.

       

    Surgical Approaches

    a) Gacek’s singular
    neurectomy.

    b) Postcanal plugging
    -procedure of choice by most
    otologists for BPPV.

        

    (2) Vestibular Neuritis

       


    This is the 3rd most common
    cause after BPPV and
    Menier’s.

       

    Clinical features:

    i) Sudden onset of vertigo
    with nausea and vomiting of
    a few days/

    ii) Absent audiologic
    findings and symptoms or
    signs.

    iii) Absent neurologic
    symptoms or signs.

    iv) Associated mostly with
    recent or concurrent URI
    (upper respiratory
    infection)

    v) Reduced or absent caloric
    response in one ear.

    vi) URIs – therefore can be
    seen in epidemics.

    vii) Autopsy reports axonal
    degeneration of one or more
    vestibular trunk points
    towards virus.

        

    Acute vertigo and
    spontaneous nystagmus which
    lasts a few days improves
    gradually though during
    recovery period any moment
    may provoke dizziness.
    Improvement is seen because
    (a) recovery of labyrinthine
    function (b) central
    compensation by adaptation
    though vestibular weakness
    can be demonstrated on one
    side. In elderly, it lasts
    longer.

    – BPPV has been reported
    following some vestibular
    neuritis patients.

    – Vestibular neuritis is
    single episode but some
    patient’s recurrent episodes
    may occur. Sequential
    vestibular neuritis in both
    ears may lead to
    differential diagnosis of
    bilateral vestibular
    neuritis.

        

    During investigations -
    vestibular neuritis showed
    reduced partial vestibular
    response in 90% of patients
    upto one month and 80% after
    6 months. 42% patients
    showed recovery to normal
    caloric response in 10 year
    follow up study.

       

    – Peculiarly superior
    division of vestibular
    neuritis trunk is commonly
    affected. This supplies
    horizontal and anterior
    semicircular canals, maculae
    of the utricle and
    anterosuperior part of
    saculae. Inferior division
    supplying posterior
    semicircular canal is
    spared.

      

    This is corroborated by
    findings of temporal bone
    pathology and analysis of
    3-dimensional properties of
    vestibulo occular nystagmus,
    in patients with vestibular
    neuritis.

       

    Differential Diagnosis:-

       

    – Cerebellar infarction

    – Wallenberg’s syndrome

    – Meniere’s disease

    – Acoustic neuromas

    – Migraine equivalent
    vertigo, 

    – Paraneoplastic syndrome, 

    – Metastatic carcinoma

    – Multiple sclerosis.

       

    Treatment : Symptomatic and
    supportive. Acute phase
    treated by labyrinthine
    sedatives and antiemetics.
    Possibly good effects of
    corticosteroids.

        

    Antiviral – No response

    Most of them have complete
    recovery. Those with
    persistent unsteadiness,
    have to undergo customised
    vestibular rehabilitation
    programme.

       

    (3) Bilateral Idiopathic
    Vestibulopathy

    Bilateral loss of vestibular
    function is induced most
    commonly by vestibuloxic
    effects of aminoglycosides
    gentamycin. This often has
    hearing loss in higher
    frequencies. Majority have
    no hearing loss but
    bilateral vestibular
    weakness. 20% with bilateral
    vestibulo hypofunction have
    no identifiable cause.

        

    Patterns of symptoms – 2
    patterns are seen

    (i) present with initial
    vertigo

    (ii) present with insidius
    progressive unsteadiness
    without vertigo.

       

    Patients complain
    dysequilibrium which is
    worse at night and also
    accompanied by oscillopsia.
    This is caused by loss of
    bilateral vestibulo-ocular
    reflex {VOR}. Clinically
    this is tested by making
    patient to read a Snellen’s
    chart with steady head and
    then during horizontal head
    oscillations at a frequency
    of about 2Hz. Normal
    vestibular response show a
    one-line deterioration in
    visual acuity and with
    bilateral vestibular
    involvement. Five line
    deterioration is seen.

       

    Testing is by bilateral
    thermal caloric responses
    and rotational chair
    testing.

      

    Management of patients with
    bilateral vestibular loss is
    difficult. 50% show some
    improvement with adaptable
    exercise. Emphasis is placed
    on maximizing and optimizing
    visual and proprioceptive
    sensory inputs to substitute
    for the lost vestibular
    inputs. Risk of drowning is
    seen.

      

    FAMILIAL VESTIBULOPATHY – 

    Described by Baloh et al
    in 1994 and is presumed to
    have autosomal dominant mode
    of inheritance. It is
    characterised by brief
    episodes of vertigo for
    several years. Subsequently,
    it results in chronic
    dysequilibrium and
    oscillopsia. Bilateral
    vestibular weakness and
    response on caloric testing,
    electronystagmography
    vestibulo ocular reflex
    reduced. Gain on rotation
    chair testing.

       

    All tests were normal,
    audiologic, imaging and
    neurological findings.
    Migraine headaches were an
    important feature of this
    syndrome. All members and
    their parents suffer from
    migraine.

       

    Treatment : All patients
    responded well to treatment
    with acetazolamide with
    resolution of attack of
    vertigo. The location of
    site of lesion is unknonwn.

      

    Another familial syndrome
    with episodes of little
    longer lasting vertigo and
    essential treatment migraine
    has been identified. No
    progressive bilateral
    vestibular weakness
    develops. Acetazolamide was
    helpful in reducing vertigo
    and migraine.

       

    RECURRENT VESTIBULOPATHY

    This clinical entity was
    described by LeLiever and
    Barber in 1981. Recurrent
    spontaneous episodes of
    vertigo similar to that of
    Meniere’s disease. However,
    no audiologic, neurologic
    symptoms and signs noted.
    The natural history is
    different from that of
    Menieres. 73 patients
    followed up for 8.5 yrs, 72%
    retained original diagnosis,
    however the diagnosis was
    changed to Meniere’s disease
    in 14% and 8% in BPPV.

       

    There is no known cause.
    Viral cause has been
    suggested. Periodic blockade
    of afferent activity of one
    vestibular nerve by
    reactivation of dominant
    virus is postulated as a
    mechanism. 22% patients
    showed reduced unilateral
    caloric response.

       

    Treatment: Symptomatic and
    assurance. The prognosis for
    spontaneous resolution is
    good.

          

  • David
    Solomon

    Distinguishing and
    Treating Causes of Central
    Vertigo

    Otolaryn Cl.of North
    Americal, vol.33(3), June
    2000, pg. 579- 

       


    When evaluating a case of
    acute vertigo, it is
    important to make sure to
    distinguish between
    peripheral and central
    cause. Central causes
    require urgent intervention
    or may require intensive
    care unit (ICU) monitoring.

      

    How history, examination and
    laboratory testing can help
    to confirm a central
    etiology is considered.

      

    History – patient feel
    “woozy”,
    “about to black
    out,”
    “disoriented” or
    “lightheadedness”.
    Worse while standing. These
    are connected with blood
    flow circulation to brain,
    therefore central.

       

    Causes : 1) Hyperventilation

    2) Orthostatic hypotension

    3) Vasovagal attacks

    4) Cause of decreased
    cardiac output

    5) Psychophysiologic

    6) Hypoglycemic

    7) Drug toxicities – like
    alcohol, barbiturates,
    benzodiazepine and 

    anticonvulsants.

    8) Postconcussion syndrome

    9) Infarction of labyrinth,
    brainstem or cerebellum

    10) Migraine headache.

       

    Examination and testing

    a) complete neurologic
    examination

    b) study of nystagmus and
    its induction test.

       

    Absence of a positive head
    impulse test in acute
    vertigo attack makes a
    central cause. 

       

    Bedside examination
    findings suggestive of
    nonperipheral etiology.

       


    Position Provoked Vertigo


    Brainstem and cerebellar
    lesion can cause persistent
    vertigo with vertical
    nystagmus or torsional
    nystagmus.

       

    1. Direction changing or
    purely vertical nystagmus

    2. Sustained or nonfatiguing
    positional nystagmus

    3. Dissociated
    (disconjugate) nystagmus

    4. Abnormal posture when
    seated, inability to stand

    5. Focal motor deficit

    6. Dysarthria, dysphagia,
    diplopia, dysmetrial (limb
    ataxia)

    7. Horner’s syndrome
    (sympathetic paresis of the
    pupil, with unilateral
    failure to dilate in
    darkness and ptosis)

    8. Loss of pin prick or
    temperature sensation on one
    side of the face, or on the
    other side of the body.

    9. Intractable hiccups.

       

    Ocular Motor Signs of
    Central Disease

    Persistent vertical
    nystagmus is certainly of
    central origin. It indicates
    brainstem involvement as
    well as diffuse cerebellar
    region.

       

    Diagnoses in Patients
    with Downbeat Nystagmus

       


    Infarction 25%

    Cerebellar (spinocerebellar)
    degeneration 24%

    Multiple sclerosis 13%

    Developmental anomaly (e.g.
    Chiari, basilar
    invagination) 12%

    Drug toxicity (phenytoin,
    carbamazepine) 4%

    Trauma 3%

    Neoplasm 3%

    Alcoholic cerebellar
    degeneration 2%

    Arteriovenous malformation
    2%

    AIDS, familial periodic
    ataxia, viral encephalitis,
    radiation 1% (each)

    No cause 5%.

       

    – Disconjugate recordings
    are indicative of lesions of
    the medical longitudinal
    fasciculus.

    – Perverted nystagmus is
    related to lesion of
    vestibular nuclei

    – Sea-saw nystagmus – cuased
    by midline compressive
    lesions in suprasellar area
    in which it is generally
    pendular.

    – Unilateral lesions in the
    rostral midbrain cause a
    jerk waveform see-saw
    nystagmus.

    – Vertical diplopia – sign
    of supranuclear or
    infranuclear pathology.

    – Periodic alternating
    nystagmus occur with lesion
    of posterior cerebellar
    vermis.

       

    Characteristics of
    Central Nystagmus:

    Central spontaneous
    nystagmus is direction
    changing pure vertical, or
    torsion, is not suppressed
    by vision and is associated
    with normal head impulse
    test and ataxia even for
    sitting patients cannot
    stand.

       

    Cerebellar signs:

    Whatever may be the
    aetiology, signs are as
    follows:

      

    1. Gaze-evoked,
    direction-changing
    horizontal nystagmus

    2. Rebound nystagmus

    3. Vertical, typically
    downbeat nystagmus, often
    worse in lateral gaze.

    4. Alternating skew
    deviation

    5. Saccadic dysmetria and
    major saccadic oscillations
    (flutte,r macrosquare-wave
    jerks)

    6. Position-provoked vertigo
    (not fitting benign
    paroxysmal positional
    vertigo)

    7. Oscillopsia at rest
    (caused by nystagmus) and
    head movement.

    8. Wide-based gait ataxia
    with poor tandem gait,
    inability to maintain
    Romberg position even with
    eyes open

    9. Poor horizontal and
    vertical smooth pursuit
    (absent VOR cancellation)

    10. Tremor, dysarthria, limb
    ataxia.

       

    Spinocerebellar atrophy

    Migraine

    Multiple sclerosis

    Internuclear ophthalmoplegia

    Vascular disease

    Lateral Medullary Syndrome

    Positive syndrome

    Cerebellar infarction.

       

    Vascular malformtion and
    headache

    Neoplastic disease

    Other conditions – Palatal
    tremor

    – Wernicke’s encephalopathy

    – Epilepsy

      

    All the above conditions are
    central cause of nystagmus.

         

  • NH
    Blevins, BL Carter (Tufts-New England Med Ctr,
    Boston)

    Clinical Forum: Routine Preoperative Imaging in
    Chronic Ear Surgery,

    Am J Otol 19: 527-538, 1998.

      

    Imaging studies, especially CT, can demonstrate the
    nature and extent of chronic otitis media, which may
    not be apparent on clinical findings per se. Such
    findings can affect operative treatment, especially
    in difficult and/or revision procedures. However,
    there is a view that routine radiography of the
    mastoid may suffice in being very helpful in most
    cases.

       

  • TS
    Karhuketo, HJ Puhakka (Tampere Univ, Findland)

    Middle Ear Imaging Via the Eustachian Tube With a Superfine Fiberoptic Videomicroendoscope.

    ORL J Otorhinolaryngol Relat Spec. 60: 30-34, 1998.

       

    With a fibreoptic videomicroendoscope inserted through the Eustachian tube, 56% of predetermined anatomical objects in the middle ear were visualized. 

      

    However, one may find obstructive sites or mucosal folds that may prevent a complete view of all the contents of the middle ear cleft.

        

  • Michael
    J Ruckenstein, (Univ of Pennsylvania)

    Vertigo & Dysequilibrium with Associated
    Hearing Loss

    Otolaryng. Cl.of N.America, June 2000.
    Vol.33(3), pg.535-562

      


    CONGENITAL

    Congenital malformations of the membranous or
    osseomembranous components of the inner ear results
    from defects in inner ear development during the
    fourth to eighth week of fetal gestation.

       

    The overall incidence of congenital is 1 in 1000
    live births. It is either syndromic or nonsyndromic
    presentation.

      

    Clinical presentation is with hearing loss which is
    either congenital or within two decades of life.
    Only 20% complained of vertigo or imbalance.

       

    CT Scan on MRI of high resolution reveal the
    abnormalities. Abnormal vestibular findings are
    recorded on vestibular testing.

       

    CLASSIFICATION OF CONGENITAL LABYRINTHINE
    ANOMALIES

    Malformations of the membranous labyrinth

    Complete membranous dysplasia

    Partial membranous dysplasia

    Cochleosaccular (Scheibe)

    Cochlea – basal turn (Alexander)

       

    Malformations of the osseous and membranous
    labyrinth

    Complete labyrinthine aplasia (Michel)

    Cochlear

    Aplasia

    Hypoplasia

    Incomplete partition (Mondini)

    Common cavity

    Labyrinthine

    Dysplasia of the semicircular canals

    Aplasia of the semicircular canals.

       

    Malformations of the vestibular aqueduct

    Narrow or wide internal auditory canal.

       

    Treatment:

    Hearing amplification with hearing aids or cochlear
    implants are the mainstay of treatment. Vestibular
    suppressant medication are indicated for bouts of
    vertigo if any.

       

    ACQUIRED

    Trauma – Temporal Bone

      


    Blunt trauma or penetrating trauma. Auto accidents
    or bullet or knife injuries to inner ear damage
    results into sensorineural hearing loss. Facial
    nerve may be damaged.

       

    Clinical presentation:

    Vertigo and hearing loss or facial nerve
    paralysis, bleeding from ear or watery fluid
    (Cerebrospinal fluid – CSF) from the ear. CT Scan
    may reveal fracture line in temporal bone.

       

    Treatment will depend upon the presentation and
    investigative findings. Exploration of ear and
    mastoid of facial nerve or CSF leak is present or
    conductive hearing loss is present.

        

    Barotrauma

    Rapid changes in ambient pressure may result in
    pressure transmitted to inner ear, thus causing
    temporary or permanent inner ear dysfunction.

       

    Aetiological factors are seen in drivers, airplane
    flight or forceful sneezing or airblast injuries.
    Treatment will depend upon the aetiological factors.

        

    Perilymph Fistula

       


    Three possible mechanisms:

    (a) Congenital dehiscences in labyrinth

    (b) Disruption of oval or round windows by secondary
    to trauma which may be iatrogenic, (poststapedectomy)
    or penetrating or severe implosive pressure trauma.
    Even barotrauma may cause the fistula.

    (c) Spontaneous – controversial

       

    Clinically – present with sudden sensorinueral loss
    associated with tinnitus and vertigo. Fluctuating
    hearing loss.

        

    Investigations: No valid or accurate diagnostic
    tests. Audioventricular testing is done. 

    Present – Exploration of middle ear and locating the
    leak and sealing it

       

    Otosclerosis

    Usually conductive hearing loss and the
    diagnosis is easy by audiological testing.
    Clinically young adults with tinnitus and conductive
    hearing loss. Family history may suggest
    otosclerosis.

       

    Usually no vestibular complaints. If at all any,
    then they complain of vertigo. Three possible
    patterns are noted. Positional vertigo or Meniere’s
    like syndrome or small number manifest as recurrent
    episodes of vertigo.

       

    Treatment : 

    It is by stapedectomy. Small number with
    sensorineural loss or mixed loss are treated with
    fluoride.

      

    Neoplasm:

    Cerebellopontine angle tumours, vestibular
    schwannoma, meningioma or petrous apex
    cholesteatomas.

       

    Clinically present with vertigo, hearing loss,
    tinnitus or facial nerve paryngitis. Very large
    tumours may demonstrte 5th, 9th, 10th or 11th with
    cerebellar signs.

        

    Diagnosis : By CT scan or MRI

    Treatment : It is operative treatment.

       

    Infectious:

    Labyrinthins: Either by bacteria or virus,
    depending upon otitis media or general viral
    infection. Herpes infection.

        

    Clinical presentation is by sudden severe hearing
    sensorineural hearing loss, with vertigo lasting for
    days. Hearing may be irreversibly damaged.

       

    Treatment will be by antibiotics and corticosteroid.
    Operative treatment for those with cholesteatoma or
    chronic mastiditis.

       

    Syphilis: 

    Is rare nowadays. It is diagnosed by VDRL. FTA -
    ABS or MHA – TP tests are done to confirm. Treatment
    is by antibiotics and steroids.

       

    Ototoxicity

    Most agents are toxic to cochlea. Aminoglycoside
    antibiotics are major vestibulotoxic drugs used
    today. Individual succeptibility, in addition to
    renal failure, hepatic failure or old age,
    concurrent use of other ototoxic drugs, familial
    history are other aetiological factors.

       

    The most common are Gentamycin and streptomycin and
    tobramycin. Outer hair cells of the vestibule is
    affected mainly. The basal regions of cochlea, the
    apices of the cristae, and the striolar regions of
    the maculae are affected most.

       

    Clinically – acute onset of hearing loss or
    imablance with oscillopsia is seen. These occurs
    while patient is on treatment or up to several weeks
    after treatment. Usually bilaterally affected.
    Vestibular damage is permanent. Bilateral vestibular
    reduced response is seen on caloric testing or ENG.

      

    Treatment is mainly by monitoring the effects of
    drug to prevent. Once it occurs then only
    symptomatic treatment is given.

      

    Immunologic:

    Autoimmune Inner Ear Disease

    Patients own immune system becomes reactive to
    self-antigens resulting into autoimmune disease.
    Multisystemic autoimmune disease like systemic lupus
    erythematosus may be associated. 

      

    It  is rare cause. Degeneration of organ of
    Corti, vestibular sensory organs, stria vascularis
    and dark cell layers, as well as fibrosis and
    osteoneogenesis is seen.

       

    Clinical Presentation :

    Rapidly progressive bilateral asymmetric
    sensorineural hearing loss is seen. Hearing levels
    fluctuates and 25-50% patients complain of vertigo.

       

    Cogan’s syndrome :

    Patients present with interstitial keratitis
    with vertigo, hearing loss and tinnitus. Ocular and
    labyrinthine pathology occur together or within 6
    months of each other.

      

    Other Multisystemic Autoimmune Diseases:

    Wegner’s granulomatosis, polyartertitis nodosa,
    rheumatoid arthritis, systemic lupus erythematosus,
    sarcoidosis and ulcerative colitis may involve the
    inner ear.

      

    Investigations are mainly various antigen antibody
    tests but are not very helpful. Only probable
    diagnosis is proved by positive response to
    imunosuppressant drugs like corticosteroids. 

      

    Dose is 1 to 2mg/kg/day for 1 month. Other drugs are
    methotrexate or cyclophosphamide. The maintenance of
    the dosages are required.

      

    IDIOPATHIC

    Meniere’s disease

    Symptom complex of vertigo,hearing loss, tinnitus
    and aural fullness. Pathology is endolymphatic
    hydrops.

       

    Clinically it presents as episodic vertigo
    associated with fluctuating and progressive hearing
    loss, chronic tinnitus and fullness of ears.

        

    Investigations – audiometric test

    ECOG

    FTA-AB – serological test

       

    Treatment – Medical – vestibular suppressants

    – diuretics

    – vasodilatation

      

    Surgical – Endolymphatic sac surgery procedure

    Gentamycin perfusion

    Vestibular nerve section

    Labyrinthectomy.

       

  • Craig
    S, Derkay, MD, and David H. Darrow, MD

    Voice Disorders and Phonosurgery II

    From the Department of Otolaryngology – Head and
    Neck Surgery, Eastern Virginia Medical School,
    Norfolk, Virginia

    The Otolaryngologic Clinics of North America
    Volume 33, Number 5, Ocober 2000, Pg. 1127


       

    Recurrent respiratory papillomatosis [RRP] is a
    disease of viral origin, caused by human
    papillomavirus.

      

    Although it is a benign disease, RRP has potentially
    morbidconsequences because of its involvement of the
    airway and the risk of malignant conversion.

       

    Recurrent respiratory papillomatosis is the most
    common benign neoplasm of the larynx among children
    and is the second most frequent cause of childhood
    hoarseness. 

      

    Although is usually involves the larynx, RRP may
    involve the entire aerodigestive tract.

      

    Because the most common symptoms of RRP are related
    to airway obstruction, it is not uncommon for
    children to be misdiagnosed initially as having
    asthma, croup, or chronic bronchitis.

       

    The hallmark of RRP in children is the triad of
    relentlessly progressive hoarseness, stridor, and
    respiratory distress.

      

    ORIGIN

      

    Human Papillomavirus

      

    Until the 1990s, HPV had been suspected but not
    confirmed as the causative agent in RRP.

      

    This uncertainty developed from an inability to
    culture the virus in vitro, and from the failure to
    demonstrate viral particles consistently in
    papilloma lesions using electron microscopy of HPV
    antibodies.

      

    With the use of viral probes, HPV DNA has been
    identified in almost every papilloma lesion studied. 

      

    The most common types identified in the airway are
    HPV 6 and HPV 11, the same types responsible for
    genital warts.

       

    An association between cervical HPV infection in the
    mother and the incidence of RRP has been well
    established.

        

    Adult-onset respiratory papillomas could reflect
    either activation of virus present since birth or an
    infection acquired in adolescence or adult life.

      

    Recurrent Respiratory Papillomatosis

    The most common sits for RRP are the limen vestibuli,
    the nasopharyngeal surface of the soft palate, the
    midline of the laryngeal surface of the epiglottis,
    the upper and lower margins of the ventricle, the
    undersurface of the vocal folds, the carina, and at
    bronchial spurs.

      

    Surgical Management

    No single modality has consistently been shown to be
    effective in eradicating RRP.

       

    The CO2 laser has been favored over cold instruments
    in the treatment of RRP involving the larynx,
    pharynx, upper trachea, and nasal and oral cavities.

      

    Although the CO laser allows surgical precision and
    excellent hemostasis, multiple procedures are often
    necessary.

        

    Because currently no therapeutic regimen reliably
    eradicates the HPV, when there is a question about
    whether papilloma in an area needs to be removed, it
    is prudent to accept some residual papilloma rather
    than risk damage to normal tissue and producing
    excessive scarring.

      

    Even with the removal of all clinically evident
    papilloma, latent virus may remain in adjacent
    tissue; this remaining latent virus may explain the
    recurrent nature of RRP.

       

    Adjuvant Treatment Modalities

    The most commonly recommended adjuvant therapy is
    alpha-interferon. The exact mechanism by which
    alpha-interferon elicits its response is unknown.

          

    Common interferon side effects fall into two
    categories: acute reactions [fever and generalized
    flu-like symptoms, chills, headache, myalgias, and
    nausea that seem to decrease with prolonged therapy]
    and chronic reactions [decrease in the growth rate
    of the child, elevation of liver transaminase
    levels, leukopenia spastic diplegia, and febrile
    seizures.

       

    Acetaminophen has been found to relive the fevers
    effectively, and interferon injections are best
    tolerated at bedtime. 

       

    Photodynamic therapy [PDT] in the treatment of RRP
    has been studied extensively:-

        

    Photodynamic therapy is based on the transfer of
    energy to a photosensitive drug. The drug originally
    used was dihematoporphyrin ether [DHE], which has a
    tendency to concentrate within papillomas more than
    in surrounding normal tissue.

        

    Ribavirin is an antiviral drug, used to treat
    respiratory syncytial virus pneumonia in infants,
    that has also shown some promise in the treatment of
    aggressive laryngeal papillomatosis. 

         

    Another antiviral drug that has been advocated in
    the treatment of RRP is acyclovir.

       

    It has been postulated that acyclovir may be most
    effective when there are comorbidities, such as a
    simultaneous infection with herpes simples virus.

       

    Two recent reports have stimulated interest in the
    intralesional injection of cidofovir [Vistide ]
    [HPMPC], a drug currently FDA-approved for use for
    HIV patients with CMV retinitis.

         

  • P. Chang, Los Angeles, USA.

    Controversies in Vestibular Schwannoma Treatment: Surgery versus Irradiation.


    ENT News, 9(5), Nov./Dec.2000, p.14-15

         


    Cropping of these controversies has been because of irradiation as an alternative to surgery. Microsurgery is the present day choice for vestibular schwannoma.

         


    The following questions arise in the critical minds of patients:

    a) What is the expected morbidity of surgery?

    b) Is hearing preservation possible?

    c) Can benign tumour be irradiated without any long-term side effects?

    d) How effective radiation is?

    e) Are the results competitive to that of surgery. Will all be judged in justifying the alternative treatment of Vestibular Schwannoma?

          



    Tumour: 


    Vestibular schwannoma tumours arise from neural sheaths and are benign. Their situation in internal auditory canal and cerebellopontine angle, make them dangerous by position. The tumour consists of nothing but proliferating Schwann cells, which is very slow viz. 1 to 2 mm per year. Majority grows producing progressive hearing loss. This growth however, exceptionally can be unpredictable. That is why in fit patient, intervention is required. Technological advances in early precise diagnosis by imaging techniques and advances in management have proved the surgical outcomes much favourable.

        


    However, technological advances in radiotherapy have also offered an alternative treatment.

          



    Surgical Background:


    It has come a long way from removal of tumour by finger, by Balance in London in 1894 to perfection of precise removal by translabyrinthine, retrosigmoid and middle fossa approaches derived by Dr. William House in 1964, almost without mortality and minimal of morbidity. Today there is likelihood of complete removal with zero mortality rate, near normal facial nerve function in 95% and less than 0.3% recurrence rate and 70% rate of preservation of hearing in selected patient makes the treatment by surgical excision treatment of choice.

         


    The negative points are that it is intracranial procedure with its attendant risks of C.S.F leak, meningitis and intracranial bleed. It incurs cost and 4-5 days of hospitalization.

        


    Today the treatment by radiation may be opted to (a) Medically unfit patients (b) Recurrent tumours (c) Elderly patients (d) Who refuse surgery. The use of radiotherapy as primary mode of treatment of vestibular schwannoma has also been promoted.

         



    Background of Radiotherapy


    Lars Leksell (1971) at Sweden (Karolinska Institute in Stockholm) first reported gamma radiation ports administered stereotactically during a single sitting to arrest the tumour growth.

         


    The principle is to target the lesion, minimising, the radiation dose to surrounding neural tissues. The term “stereotactic radiosurgery” was coined and particular technique used was called the ‘gamma knife’.

         


    The treatment evolved in last decades. The radiation dosage of 25Gy has been reduced optimally to 13Gy delivered by Linear accelerator and is now fractionate. This has resulted into improvement in tumour control and preservation of normal neural tissue.

         



    The Controversy


    – Because of close relations of tumour capsule to 7th and 8th nerve, it is impossible to avoid radiation to these nerves.

       


    – The effects of radiation are cell deaths and delayed vasculitis. Vasculitis is not observed because of sparse blood supply as against seen in
    glomus.

          


    – Subsequent surgical intervention, if required in these irradiated tumour, lead to hazzardous dissection resulting in poor hearing and facial nerve function.

          


    So the alternative treatment is reserved for those patients who are unfit or unwilling to undergo microsurgical removal of
    tumour.

          

  • John Diaz Day, (Neurological and Skull Base Surgeon, House Ear Clinic, Los Angeles, USA)

    Radiotherapy or microsurgery – which treatment and why?


    ENT News, vol.9(5),Nov/Dec.2000, p.16-17

          


    The microsurgical excisions are currently exceeded and continue to improve.

    If the results are compared with those centres with inexperienced teams doing small number of cases, the stereotactic radiotherapy gains momentum.

          


    Patients with tumours 3cm or larger most agree are candidates for surgery. Relief of mass effect and hydrocephalus is well achieved. Facial nerve function and hearing preservation in anyway par with large tumours. The extent of 60% in facial nerve function preservation is good.

        


    Main debate over patients with small or medium tumours, intracanalicular tumours tilt in favour of surgery for number of reasons.

        


    At this institution in 372 patients over the last 5 yrs had 95% of facial nerve function preservation and about 70% hearing preservation was seen. These results of function preservation are durable. This is not so in stereotactic radiosurgery where hearing may further deteriorate with time.

        


    Recurrent rate in surgery is 0.5% as against radiation which is 6-10%, where the tumor recurs or grows further.

        


    He also points out that if radiation fails subsequent microdissection results in poor function of facial nerve preservation and hearing preservation.

        


    Radiosurgical series still must stand the test of time when utilizing ‘control’ as a means of establishing efficacy. They must do better than the natural history of vestibular schwannomas left untreated. When roughly two-thirds of tumours will not change their appearance on serial imaging with no treatment, how do we can say that my treatment is effective at ‘controlling’ tumour growth over a similar follow-up period with a similar number of tumours not demonstrating
    growth ?

         


  • Andras A Kemeny, Royal Hallamshire Hospital, Sheffield, England


    What is the role of radiosurgery in Vestibular Schwannoma treatment?


    ENT News, Nov/Dec.2000, vol.9(5), p.19

        


    It is a surgical technique, the concentrated radiation is achieved by crossfiring 201 fine gamma ray beams focused into a single point. Initially with poor imaging and slow computers, this was difficult to achieve. But with the introduction of high resolution, volume acquisition MR imaging and powerful 3D computational software the true potential of this technique could be realised. 

         


    Since 1985, 540 accoustic neuromas were treated with mean age 51, 48% males, 21% (116) were bilateral tumours. The median diameter was 6-57mm. 36% had at atleast one previous resectional surgery. A large proportional had neurological deficit particularly with those who had surgical intervention. Even since 1995, only 20% have normal facial nerve function and 13% had none. Seventy-two cases of previously operated cases had complete deafness.

        


    In 1980, when 25Gy dose was given, facial weakness in 85% and hearing preservation was poor. With reduction of dose to 13-15Gy, radiological tumour control remained around 88% with minimum follow-up of 5 years. Useful hearing was preserved in 76% and facial weakness only in 5.2%. These results compare well with larger surgical series.

         


    Radiosurgical failures are not declared for at least 3 yrs and no surgery should be undertaken on this basis.

         


    The risks and difficulty of surgery after radiosurgery is exaggerated.

         


    A warning by nonpractising radiosurgeons is given to patietns of possibility of malignant change in later years. Very rarely seen. To date about 15000 acoustic neuromas are treated and by telephone survey, only 5 cases of sarcomatous change were confirmed after radiosurgery. Nevertheless, the alertness is necessary.

         


    Which cases should be referred to radiosurgery? Probably the answer is which should not be?

        


    Lesions beyond 3.5cm that produce larger mass effect may need surgical decompression. Tumours incidentally found may be monitored radiologically and audiometrically.

        


    Those above 65 years of age, the medically infirm and those who can’t afford even a low risk of surgical mortality will be more and more considered for radiosurgery.

        


    There is a demand for noninvasive methods of treatment with less disruption to their life. Those who are well informed by internet and those who are in medicolegal climate should be informed of availability of radiosurgery of these tumours.

         

  • Dr. Paul A Fagan, St. Vincent’s Hospital, Sydney, Australia

    How does the outcome of radiotherapy compare with microsurgery for vestibular schwannomas?


    ENT News, Nov./Dec.2000. vol.9(5), p.20

        


    The article discusses pros and cons of both treatment but tilts more in tumour of surgery.

       


    In summary, the author states surgery for acoustic neuroma is a proven, safe and effective treatment with reproducible results. In particular, the long-term safety of this treatment is well documented. Radiotherapy, on the other hand, does not achieve a cure, the early results are little different to the natural history of the disease and serious long-term complications can occur.

         

  • L Dade Lunsford, Ajay Niranjan, (Pittsburg, Philadelphia)

    What are the results and rationale of stereotactic radiotherapy in the management of vestibular schwannomas?


    ENT News, Vol.9(5), Nov./Dec.2000. P.23

         



    For acoustic neuromas, the surgical alternatives are microsurgery and gamma knife.

         


    Today, good imaging technique achievers have very early diagnosis with minimal symptoms. The goals of management have shifted from tumour removal to preservation of neurological function viz. facial nerve function and hearing preservation.

         


    The goals of radiosurgery are to inactivate the tumour, as against physical removal by microsurgery. The gradual tumour reduction in size is noted over the next two to seven years period. The aim is to prevent further growth, while preserving 7th and 8th nerve function and other neurological and employment status. 

        


    At the University of Pittsburgh, 622 patients have undergone gamma knife radiosurgery over a period of 13 years.

         


    Currently, 13Gy to the tumour margin in a single session is utilized. Usually within 6-18 hours patient is discharged. All patients are followed up with MRI and audiometric studies at 6-months, 1,2,4 and 8 years.

         


    Analysis of 5-10 year outcome of 162 unilateral tumours treated with radiosurgery between 1987 and 1992, a 98% tumour control rate has been achieved. Only 2% of patients required tumour resection. No additional difficulties were encountered in resection procedure.

         


    No patient with an intracanalicular tumour developed new facial or trigeminal neuropathies, 21 of 487 patients (4.3%) had improvement in hearing.

         


    With all patients, the concept of tumour growth control versus tumour removal should be discussed. All options should be put forward. According to him by 2001, many patients with newly diagnosed acoustic tumours should undergo gamma knife radiosurgery as the management option of choice.

              

  • Som PM, Curtin HD, Mancuso AA

    Imaging of the Neck 


    ORL 2000; 62: 186-198

         


    This article relates to the use of C-T scanning in staging of neck in details. A full written classification is given in the text together with diagnosis explaining each of the levels. It is very clear and consistent set of guidelines to help stage the neck on radiological grounds -
    CJW.

         

  • Kau R J, Alexiou C, Stimmer H, Arnold W.

    Investigations for neck nodes


    ORL, 2000; 62: 199-203

       


    This well-written article from Germany provides an overview of the current methods used in status of neck nodes in head and neck malignancies. It compares CT, MRI, ultrasound (US), US guided FNAC, colour doppler US and PET with clinical staging.

        


    The least accurate method of detecting lymph node, though the cheapest method of palpation gives 69.7% accuracy. Ultrasound with its limitation of 72.7%, and US guided FNAC 89%.¸CT has 84.9%, MRI 85%. PET scanning most accurate at 90.5% but is not easily available. Colour doppler studies -show reactive nodes have increased hilar blood flow, while metastatic nodes have peripheral blood flow.

       


    The advantage of US guided FNAC is that it gives histological diagnosis and staging. However, its invasive procedure is to be kept in mind.

        

  • Fertilo A, Som PM, Rinaldo A, Mondin V

    Classification of neck dissection


    ORL -2000; 62: 212-216

        


    Many terms are used in various neck dissection procedures but to describe accurately what procedure has been done is still confusing.

        


    The most commonly accepted classifications designed by Fertilo in 1998. This divides into (1) comprehensive neck dissection (2) selective neck dissection and (3) extended neck dissection.

        


    1. Comprehensive neck dissection – (including radical or modified radical) involves dissection of I-V level.

    2. Selective neck dissection 

    In this one or more lymph node levels are left in situ.

    3. Extended neck dissection – it implies removal of all I-V level nodes and additional lymph nodes or structures, which are not removed in radical neck. Additional structures include accessory nerve, jugular vein, or sternocleidomastoid muscle.

         


    The authors suggest the staging of the neck by P M Som to be methodology and then described the surgical procedures in the above manner i.e. level of lymph nodes and additional structures removed or preserved. This is simple method to record and compare.

          

  • Fertilo A, Silver CE, Rinaldo A, Smith RV 

    Surgical options for the neck


    ORL 2000: 62: 217-225.

       


    This article summarises the surgical options for both NO and node positive necks. It also discusses the adjuvant treatment of radiotherapy or chemotherapy.

         


    (A) In clinical and radiological negative neck – selective lateral neck dissection with levels II to IV or VI as necessary with or without preservation of 11th, Jugular vein or sternocleidomastoid.

         


    (B) In the necks – treatment varies on N stage.

         (a) High N stage neck – Radical neck dissection including VI and VII where necessary.

         (b) However, N stage neck – more selective neck dissections after levels I to V including VI or VII.

        


    Postoperative adjuvant therapy are best reserved for extracapsular spread. Authors prefer primary surgery as it allows accurate p-staging with obvious prognostic implications.
    CJW.

         

  • Ferjaoui M, Kooli H, Najeh D, Hajri H

    The nose in Crohn’s disease


    Revue De Laryngologie Otologie Rhinologie, 1999: 5: 341-342

         


    This is a case report of very aggressive type of primary atrophic rhinitis. With marked crustastions, destruction of the turbinates and septum with saddling of nose and involvement of maxillary sinus.

        


    The second biopsy done during (intestinal exacerbation) showed typical features of Crohn’s disease.

         


    The systemic therapy of intestinal disease improved all nasal pathology.

        


    The issue is to ask, patients of Primary Atrophic Rhinitis, about gastrointestinal symptoms and other lesions suggestive of Crohn’s disease.

        

  • Krouse JH 

    Staging of Inverted Papilloma


    Laryngoscope 2000: 110: 965-968

        


    Formerly medical maxillectomy through an external incision was treatment of choice as against that today endoscopy is the treatment followed by most of them. This is controversial because of an association of inverted papilloma with malignancy.

        


    This study utilized a literature review to develop a simple and easily applied staging system – based on endoscopic examination of the nasal cavity and CT scanning.

        


    The staging system is as follows:-

    Stage I – Disease is limited to nasal cavity.

    Stage II – It is limited to the ethmoid sinuses and medial and superior portion of the 

    maxillary sinuses.

    Stage III – Involves the lateral or inferior aspects of maxillary sinuses or extension 

    into the frontal or sphenoid sinuses.

    Stage IV – Involves tumour spread outside the confines of the nose.

        

  • Moreau PR 

    Laser Laryngeal Surgery


    Laryngoscope 2000; 110: 1000 – 1006


        


    This study is a retrospective analysis of 160 patients treated for laryngeal cancer with CO2 laser endoscopic microsurgery.

        


    Glottic tumours were treated with progressively more extensive cordectomies, extended if necessary to the contralateral cord. Supraglottic tumours had an excision limited to the vestibule, a trans-preepiglottic resection or a radical subglottic dissection. The results are as follows:-

        


    Five year survival was 97% for 98 tumours (infiltrative glottic tumours) and 100% for the 18 infiltrative supraglottic tumour and 27 in situ carcinoma. No local recurrences were noted in either group of 118 tumours (in whom two precancerous lesions were treated with a further excision) as in 27 in situ. Local control was thus 100%.

       

  • Rogers RR

    Oral applicances for OSA


    Sleep and Breathing, 2000: 4: 2: 79-83


        


    Currently used intra-oral devices are discussed. Oral Appliances Therapy (OAT) is used as an alternative to palatal surgery and/or continuous positive airway pressure (CPAP).

        


    The devices are – Mandibular Repositioning Devices (MRD), Tongue Retaining Devices (TRD). These devices are well tolerated, non-invasive and associated with low morbidity. They bring about objective changes in polysomnographic parameters and should always be considered as therapeutic options.

        

  • Coppit III G L, Perkins JA, Manning SC

    Hairy polyps ?


    International Journal of Pediatric Otorhinolaryngology 2000: 52: 3: 219-227.

        


    The authors report four cases of nasopharyngeal dermoids and teratomas along with review of literature which include 40 cases. These lesions colloquially are called hairy polyps. Clinically two distinction described by Arnold’s classification, which basically divides the lesions into dermoids, teratoids, true teratomas and epignathi. Dermoids comprise lesions containing two germinal layers (ectoderm and mesoderm). The other has 3 germinal layers with progressive degrees of differentiation.

         


    The major problem is that the teratomas are much more likely to be associated with polyhydramios and other congenital anomalies and possibly require intensive airway management – DS.

          

  • RD deShazo, M O’Brien, K Chapin, et al (Univ of South Alabama, Mobile)

    A New Classification and Diagnostic Criteria for Invasive Fungal
    Sinusitis


    Arch Otolaryngol Head Neck Surg 123:1181-1188, 1997.

        

    There is no consensus regarding the classification of fungal sinusitis, and there are no clinical criteria for diagnosis. The authors suggest a new classification system and diagnostic criteria for invasive fungal sinusitis. They are based on a series of patients undergoing surgery for chronic bacterial sinusitis and a review of the pertinent literature.

        

    There are 3 forms of invasive fungal sinusitis which the authors recommend to be termed granulomatous, acute fulminant and chronic invasive. The 2 patients in this series had the chronic invasive form. Two diagnostic criteria have been proposed by the authors: (1) sinusitis confirmed by radiologic imaging and (2) histopathologic evidence of hyphal forms within sinus mucosa, submucosa, blood vessels, or bone. 

       

    Diagnosis is made primarily by surgical findings as well as CT scan, and reasonable treatment can be obtained in terms of classification of sinusitis. Chronic invasive fungal sinusitis is thought to be seen primarily in immunocompromised and in diabetics, and the treatment should involve both antifungal treatment and surgery.

          

  • S Elwany, M Bassiouny, (Alexandria Univ, Egypt)

    Topical Levocabastine for the Treatment of Perennial Allergic Rhinitis

    J Laryngol Otol 111: 935-940, 1997.

         

    Oral H1-receptor antagonists which have found the primary treatment for chronic allergic rhinitis are associated with severe systemic side effects. Topical therapy should theoretically avoid these events, while producing a higher concentration at the site. A study reported shows the use of a nasal spray containing levocabastine which is a potent and highly selective H1-receptor antagonist, on the nasal mucosa in patients with chronic allergic rhinitis.

       

    The study has some remarkable findings in that there has been a reappearance of normal cilia and microvilli and more acinar cells in the post-treatment specimens collected in the biopsy. The number and activity of goblet cells and serous glands decreased as was the evidence of vascular congestion. These changes reduced the formation of edema fluid, and the reduction in the number of pinocytotic vesicles reduced the transmission of fluid across epithelial cells. Degranulated mast cells and eosinophils however, were still present at the end of the short study. 

        

    Although perhaps not as impressive as topical corticosteroids induced changes, the reported findings certainly suggest moderate anti-inflammatory properties of this topical antihistamine. Hence one should look beyond just the antihistaminic actions of these agents by probably combining with leukotriene and lipoxygenase inhibition studies.

  • Bergenius J, Perols O (Karolinska Hosp, Stockholm; Norrtalje Hosp, Sweden)

    Vestibular Neuritis : A Follow-up Study

    Acta Otolaryngol (Stockh) 119:895-899, 1999



    Vestibular neuritis usually involves one attack. 19 patients were followed up long term to determine, their auditory or vestibular symptoms.



    At 7 to 8 years after an initial attack of vestibular neuritis, half of 19 patients had a recurrence or episodic vestibular symptoms. These symptoms were related to the vestibular tests at onset and the patient’s age. Elevated stapedius reflex threshold at onset and a slower normalisation of canal response was correlated.



    Vestibular neuritis is a ablative problem of peripheral vestibular system and can be compared with Bell’s Palsy, which results into degeneration of axons followed by regeneration similarly vestibular neuritis, some mechanism causes recovery which can be demonstrated by ventribular functional recovery. However 1/3rd patients develop positional vertigo possibly because of retrograde degeneration of otoconia. It responds to treatment as well as idiopathic B.P.P.V. This is good article on long- term sequelae of vestibular neuritis.

         

 



 

Speciality Spotlight

 

    
  

  • Vasama J-P, Linthicum FH Jr. (House Ear Inst,Los Angeles)
    Meniere’s Disease and Endolymphatic Hydrops Without Meniere’s Symptoms:Temporal Bone Histopathology
    Acta Otolaryngol (Stock) 119:297-301,1999
     
    This is a good article from another authentic  study of T.Bare Sections studied in 21 yrs. Wherein E.Hydrops is noted  without any symptoms of Meniere’s .This study therefore is interesting in comparing histopathological finding in so-called  “normal” EARS with those of of patients with Meniere’s Disease. Nevertheless it is an established fact that E. Hydrops is the most important pathological finding correlating Meniere’s disease patients.
      

  • Yazawa Y,Suzuki M,Kitano H,et al (Shiga Univ,Otsu , Japan)
    Intraoperative Mitomycin C in Endolymphatic Sac Surgery for Meniere’s Disease : A pilot  Study.
    ORL J Otorhinolyngol Relat Spec 61:188-194,1999
      
    The use of mitomycin –C to prevent  postoperative fibrosis is the basis in this sac surgery done in 14 patients who in 6 months follow-up has shown no vertigo ,10db improvement in hearing in 5 patients and reduction of tinnitus.
      
    This may be of benefit in sac surgery provided long-term results are available .Long-term results of sac surgery  without mitomycin show definitely unsatisfactory results hence use of mitomycin in sac surgery may prove long term  results.
       

  • Yotsuyanagi T, Nihei Y, Yokoi K, et al (Hirosaki Univ, Japan)
    Functional Reconstruction Using a Depressor Anguli Oris Musculocutaneous Flap for Large Lower Lip Defects, Especially for Elderly Patients.
    Plast Reconstr Surg 103: 850-856, 1999
        

    The most common lesion of the malignant lesions of oral cavity is lower lip squamous carcinoma
         
    In planning the reconstruction of large excision defect the following factors should be kept in mind.
        
    – Maintenance of sphineteric action
    – Retention of sensation
    – A large enough opening for the mouth
    – Acceptable cosmetic appearance.
        
    In surgical technique described – Nerve supply and Blood supply is well preserved.
          

  • Raulin C, Schroeter CA, Weiss RA, et al (Laserklinik, Karlsruhe, Germany; Med Centre, Maastricht, The Netherlands; Johns Hopkins Univ, Baltimore, Md; et al)
    Treatment of Port-Wine Stains With a Noncoherent Pulsed Light Source: A Retrospective Study.
    Arch Dermatol 135: 679-683, 1999
       

    Thirty-seven patients with 40 port-wine stains between 1994 to 1997, aged 1 to 68 years were treated with intense pulsed light source (IPLS). Before and after treatment, photographs were taken. All side effects recorded. The treatment appears to be safe and effective.
        

  • Franceschi S, Levi F, La Vecchia C, et al (Centro di Riferimento Oncologico, Aviano, Italy; Registre Vaudois de Tumeurs, Lausanne, Switzerland; Instituto di Ricerche Farmacologiche “M Negri”, Milano, Italy; et al )
    Comparison of the Effect of Smoking and Alcohol Drinking Between Oral and Pharyngeal Cancer
    Int J Cancer 83: 1-4, 1999
       
    The relationship of exposure to alcohol and tobacco is established. However, the separate and combined effects of alcohol and tobacco between oral and pharyngeal cancer were compared in case-control investigation.
        
    274 patients with oral cancer and 364 with pharyngeal cancer, 1254 controls matched were studied. 
        
    Observation-Conclusion – Alcohol has a stronger effect on oral cancer than on pharyngeal cancer. This may help explain why oral cancer mortaility is rising in men from many developing countries after many years of declining.
        

  • Pritikin JB, Caldarelli DD, et al (Rusb-Presbyterian-St Luke’s Med Ctr, Chicago)
    Endoscopic Ligation of the Internal Maxillary Artery for Treatment of Intractable Posterior Epistaxis
    Ann Otol Rhinol Laryngol 107: 85-91, 1998
          
    Ten patients treated with ligation of internal maxillary artery branches, along with ligation of sphenopalatine artery in sphenopalatine fossa had success rate of 100%.
        
    This is another approach and has minimal morbidity. Problem is only verified with small number of patients. Appears to be a promising method.
         

  • Cheng D, Iriarte GC (Kaiser Permanente, Downey, Calif)
    The Paper Clip Nasal Dilator
    Laryngoscope 108: 1247-1248, 1998.
        
    A narrow nasal valve results in serve nasal obstruction.
         
    Plastic coated nasal clip shaped and inserted in rounded end of nostril, kept for one month serves the purpose very well.
          

  • Shoseyov D, Bibi H, Shai P, et al (Hadassa Med School, Jerusalem, Israel; Brazilai Hosp, Ashkelon, Israel; SHIRAM Asaf Harofe Med Ctr, Zerifin, Israel; et al)
    Treatment with Hypertonic Saline versus Normal Saline Nasal Wash of Pediatric Chronic Sinusitis.
    J Allergy Clin Immunol 101: 602-605, 1998.
         
    Thirty patients were studied randomly with double-blind study. 
         
    Instilling 1 -mL hypertonic saline (HS) 3 times daily for 1 month improves the clinical and radiological conditions of children with chronic sinusitis. This treatment is tolerable and inexpensive.
         
    This is an interesting study supporting the use of HS. The exact mechanism is not known.
       

  • Waridel F, Monnier P, Agrifoglio A (Univ Hosp, Lausanne, Switzerland)
    Evaluation of the Bone Resistance of the Sphenoid and Ethmoid Sinuses.
    Laryngoscope 107: 1667-1670, 1997
       
    This cadaveric study included 21 specimens. Resistance to breakage of these bony structures was determined critically by dynamometric assessment. 
         
    This anatomical study identified highly fragile sites which correlate with location of surgical complication of functional endoscopic sinus surgery.
        
    R. A. Otto comments: This simple study attempts to quantify bony resistances. It differs from Stankiewicz and Kainz and Stammberger, have stated that the weakest area is the area around the anterior ethmoidal artery, in the region of anterior base skull.
        

  • Metson R, Gliklich RE (Haravard Med School)
    Clinical Outcome of Endoscopic Surgery for Frontal Sinusitis
    Arch Otolaryngol Head Neck Surg 124: 1090-1096, 1998.
       
    Clinical results of this procedure was evaluated in 87 patients over a period of 2 yrs.
       
    To avoid surgical failures, authors now use bilateral drillout technique in all patients with frontal sinusitis after a Lynch procedure.
        
    R..A Otto comments:Though the results appear promising, long term follow-up are needed to determine it as a procedure of choice.
       

  • Casiano RR, Livingston JA (Univ of Miami, Fla)
    Endoscopic Lothrop Procedure: The University of Miami Experience.
    Am J Rhinol 12: 335-339, 1998.
       
    This 2 year study included 21 patients with persistent or recurrent frontal sinusistis. Lothrop procedure seeks to create a common frontal sinus ostium. Ostium patency rate of 75% was reported. This prospective study sought to pick up patients who will benefit from Endoscopic Lothrop procedure.
       
    A 57% patency rate was noted in recurrent sinusitis patients in whom conventional endoscopic tecnhiques failed. The chances of ostium patency was improved by maintaining a common frontal ostium of greater than 8mm in the anterioposterior dimension and 16 mm in the lateral dimension by Lothrop technique.
       
    Authors provide some useful information correlating ostia size and patency rates. The study is limited and has short-term follow-up – R.A. Otto.
        

  • Lawson W, Reino AJ (Moutn Sinai Med Ctr, New York)
    Isolated Sphenoid Sinus Disease: An Analysis of 132 Cases.
    Laryngoscope 107: 1590-1595, 1997.
        
    Sphenoid sinus disease raises difficult diagnostic issues. To distinguish from primary to secondary sinusitis or even primary to malignant disease is difficult. The 22 year study retrospectively was reviewed and signs and symptoms and radiographic findings were analysed.
         
    Headache was most common and visual disturbances being the next symptom.
        
    The key to diagnosis of isolated sphenoid disease is CT, with adjunct MRI as indicated. Findings of bone expansion, thinning and remodelling indicated Mucoceles and benign tumours. Bone erosion is pointed to malignant disease. A signal void in the sinus cavity on MRI is a sign of fungal sinusitis.
        
    Authors presented a CT algorithm to facilitate diagnosis and treatment selection.
        

  • Dolbie RA [Univ of Texas, San Antonio]
    A review of Randomized Clinical Trials in Tinnitus
    Laryngoscope 109: 1202-1211, 1999

    Most patients with tinnitus have subjective cases associated with sensorineural hearing loss attributable to aging, noise exposure, head injury, and other causes. Many patients with tinnitus have no hearing loss at all.

    None of these treatments provided replicable long-term relief of tinnitus compared with placebo. Nonspecific support and counseling may help, as do trycyclic antidepressants in patients with severe cases.

    This author has done a very comprehensive study of the current state of the art in terms of randomized clinical trials regarding tinnitus. His study is quite appropriate and his conclusions quite relevant. As he mentions, non-specific supportive counseling helps, as do antidepressants in severe cases. I would add that behavioral listening seems to be the most important and useful method we have in dealing with these patients.

  • Veling MC, Windmill I, Bumpous JM [Univ of Louisville, Ky]
    Sudden Hearing Loss as a Presenting Manifestation of Leukemia
    Otolaryngol Head Neck Surg 120: 954-956, 1999

    Sudden hearing loss is a rare initial manifestation of hematologic disorders. This report described a case in which sudden hearing loss was one of the presenting manifestations of leukemia.

    Woman, 65, was seen with acute-onset back pain. She reported a 6-day history of tinnitus and a 1-day history of sudden-onset bilateral hearing loss. Physical examination revealed bilateral serous middle ear effusions with intact tympanic membranes and clear external auditory canals. Laboratory tests revealed a white blood cell count of 33,200. Results of a bone marrow aspirate were consistent with acute lymphocytic leukemia. Audiologic examination revealed bilateral 
    profound sensorineural hearing loss. The patient received induction chemotherapy, with leukocytosis resolution. Audiologic examination results demonstrated significant improvement. The patient was discharged and has remained in remission. 

    This case was unusual in that deafness was one of the presenting symptoms of leukemia. 

    Typically, leukemia will cause deafness during its terminal stages. Leukemia can be seen as a presenting symptom of sudden deafness. The pathology of such patients, as seen from studies in temporal bones, suggests an immediate infiltration of pathologic leukemic cells throughout the labyrinthine spaces, followed by secondary degeneration of the sensory end organs and their cellular components.


  • Heiland KE, Goode RL, Asai M, el al [ Stanford Univ, Calif; Ehime-Univ, Ehime 
    City, Japan; Universitasspital Zurich, Switzerland]
    A Human Temporal Bone Study of Stapes Footplate Movement
    Am J Otol 20 : 81-86, 1999

    Below the level 0f 2.0 kHz, stapes vibration was primarily pistonlike. Above 2.0 kHz, Anterior-posterior rocking motion rose logarithmically with frequency. Near the 4.0 kHz level, rocking and pistonlike motion were almost equal.

    Stapes footplate vibration was mostly pistonlike upto 2.0 kHz. The motion became more complex at higher frequencies because of a rise in anterior-posterior rocking motion. Hingelike motions were not seen. This information may be of use in the design of ossicular replacement prostheses that mimic or improve upon normal stapes vibration.

    It is interesting that they identify similar findings in that there is pistonlike action, but with higher frequencies, a more complex rocking motion takes place. Such studies are of interest not only from a physiologic point of view but also for those who do surgery in this area to repair pathologic structures

  • Chauvin K Bratton C, Parkins C [Louisiana State Univ, New Orleans]
    Healing large Tympanic Membrane Perforations Using hyaluronic Acid, 
    Basic Fibroblas Growth Factor, and Epidermal Growth Factor
    Otolaryngol Head Neck Surg 121: 43-47, 1999

    Although 88% of tympanic membrane perforations heal spontaneously, the remainder require expensive
    tympanoplasty to avoid chronic problems. Use of epidermal growth factor [EGF] has improved nonsurgical closure rates
    dramatically in guinea pigs.

    Complete closure of the perforation occurred in all ears treated with HA and EGF There was no evidence of 
    cholesteatoma in any middle ear

    It could be nice to see such a study done in higher types of animals such as cats or monkeys. Perforations in animals such as
    guinea pigs have a remarkable propensity for self-healing.

  • Shea PF, Ge X, Shea JJ Jr [Univ of Tennessee, Memphis]
    Stapedectomy for Far-advanced Otosclerosis
    Am J Otol 20: 425-429, 1999, Pg.54
    Stapedectomy is indicated for those patients with far-advanced otosclerosis even in the absence of air conduction [AC]. 

    The negative Rinne test distinguished far-advanced otosclerosis from other types of hearing loss. Most patients with far-advanced otosclerosis benefited from stapedectomy. 

    These patients seem to be the most grateful because they are essentially deaf to begin with, but then achieve useful hearing. 

  • Bajaj Y, Bais AS, Mukherjee B [Lady Hardinge Med College, Delhi, India; SSK Hosp, Delhi , India: Kalawati Saran Children’s Hosp, Delhi, India]
    Tympanoplasty in Children : A Prospective Study
    J Laryngol Otol 112 : 1147-1149, 1998, Pg.89

    All children had a central perforation without cholesteatoma. Ears had to be dry for at least 6 weeks before surgery. Patients underwent type-I tympanoplasty with autograft temporalis fascia.

    Surgery is least successful in children with large or bilateral perforations. 

  • Golz A, Netzer A, Joachims HZ, et al [ Technion-Isreal Inst of Technology, Haifa; Westerman Research Associates Inc, Shrewsbury, NJ]
    Ventilation Tubes and Persisting Tympanic Membrane Perforations
    Otolaryngol Head Neck Surg 120: 524-527, 1999, Pg.90
    Myringotomy with ventilation tube insertion is the most common pediatric otologic operation. 

    A perforation was considered permanent if it persisted for more than 1 year after spontaneous extrusion or removal of tubes.

    Persistent perforations were also significantly more common among children under 5 years of age.

  • Eisenman DJ, Parisier SC [Lenox Hill Hosp, New York]
    Meatoplasty : The cartilage of the Floor of the Ear Canal 
    Laryngoscope 109: 840-842, 1999

    An adequate meatal opening is important in postoperative ear care.

    The success of otologic procedures frequently depends on a adequate meatal opening, Excision of the cartilage of the 
    floor of the ear canal is an important part of successful meatoplasty.

    It is important to have good meatus in order to allow self-cleansing of the enlarged canal or mastoid cavity.

  • Soultan Z, Wadowski S, Rao M, et al [State Univ of New York, Brooklyn]
    Effect of Treating obstructive Sleep Apnea by Tonsillectomy and/or Adenoidectomy on Obesity in Children
    Arch Pediatr Adolesc Med 153: 33-37, 1999, Pg. 195

    Obese children with enlarged tonsils or adenoids can have obstructive sleep apnea, which may cause poor growth and a failure to thrive. Effects of obstructive sleep apnea in children are disturbed sleep and sleep deprivation with subsequent daytime hypersomnolence and decreased activities, Obesity may be caused by this decreased energy expenditure.

    Increased gain in height, weight, and body mass index is associated with treating obstructive sleep apnea by tonsillectomy or adenoidectomy in most children, including the obese.

  • Fitzpatrick RE [Univ of California, San Diego]
    Treatment of Inflamed Hypertrophic Scars Using Intralesional 6-FU
    Dermatol Surg 25: 224 - 232, 1999, Pg 165.
      
    Intralesional injections of 5-FU in a concentration of 50 mg/ml were administered in doses ranging from 2 to 50 mg.
      
    Mixing 0.1 ml of Kenalog [Westwood Squib, Buffalo, NY] and 0.9 ml of 5-FU in the same syringe caused less pain and had greater efficacy.
       
    It was rare for a scar to not respond favorably. Scars with the greatest response were typically red, the most inflamed, the most symptomatic, and most firmly  indurated. The first signs of response were typically reduced pain and itching, followed by softening of the scar, then flattering and decreased redness. Hypertrophic scars were more responsive than keloids.
       
    The use of intralesional injections alone or in combination with Kenalog with pulsed dye laser is safe and effective in the treatment and prevention of hypertrophic scars and some small, isolated keloids.

  • Feder HM, Jr. Gerber MA, Randolph MF, et al [ Univ of connecticut, Farmington; Univ of connecticut, Hartford; Danbury, conn; et al]
    Once-daily therapy for Streptococcal Pharyngitis With Amoxicillin
    Pediatrics 103: 47-51, 1999, Pg. 199

    Patients with group A b-hemolytic streptococcal [GABHS] pharyngitis may be better able to comply with once-daily oral amoxicillin therapy than with treatment taken several times a day.

    Once-daily amoxicillin treatment is as effective as penicillin V therapy given 3 times daily in the treatment of GABHS pharyngitis.

  • Henriksson G, Westrin KM, et al (Huddinge Univ Hosp, Sweden; Karolinska Hosp, Stockholm)
    Recurrent Primary Pleomorphic Adenomas of Salivary Gland Origin: Intrasurgical Rupture, Histopathologic Features, and Pseudopodia.
    Cancer 82: 617-620, 1998.
        
    Retrospective study of 230 patients operated for benign salivary gland pleomorphic adenoma between 1974 to 1993 was done.
       
    Occurrence of pseudopodia (fingerlike extensions) appears to be important risk factor for local recurrences. This explains the lower recurrence rate in patients undergoing radical surgery, than those patients with enucleation and limited excisional surgeries with so called normal parotid tissue surrounding the tumour mass. If pseudopodia are present then long-term follow-up (to detect and treat recurrence) is required.
         
    The Authors reinforce the importance of appropriate surgical procedure because surgeon is not aware of presence of extensive pseudopodia at the time of surgery.
        

  • Goode RK, Auclair PL, et al (Armed Forces Inst of Pathology, Washington, DC: Natl Naval Dental Ctr, Washington, DC)
    Mucoepidermoid Carcinoma of the Major Salivary Glands: Clinical and Histopathologic Analysis of 234 Cases with Evaluation of Grading Criteria.
    Cancer 82: 1217-1224, 1998.
        
    High, intermediate and low grades have been reported. One study denotes the presence of cystic component of less than 10% is considered as high grade.
        
    In this study, 337 patients were analysed which included follow-up data. 84% were in parotid. 13% in submandibular gland and 3% in the sublingual gland. Four groups were formed Group I, survival free of disease. Group II, survival with local recurrence, Group III, survival with local metastases and Group IV, death of disease.
        
    This study identifies prognostic factors. Outcome varied significantly according to site and grade of the tumour. Metastases from submandibular glands were more frequent. The treatment should be based on clinical stage of the disease and histopathologic guide. Even low grade tumours in submandibular gland needs aggressive treatment and close follow-up.
        

  • Laskawi R, Rodel R, et al (Univ of Gottingen, Germany)
    Retrospective Analysis of 35 Patients with Acinic Cell Carcinoma of the Parotid Gland.
    J OralMaxillofac Surg 56: 440-443, 1998.
       
    This is a rare tumour, occurs in late middle age commonly in females. Retrospectively studied because of its rarity. The study included 35 patients treated between 1945 and 1994. Surgery is the therapy of choice. The response to radiation is not favourable either to prevent recurrences or increase in survival period. The latter part is of particular interest in management.
         

  • Yang CY, Andersen PE, et al (Oregon Health Sciences Univ, Portland)
    Nodal Disease in Purely Glottic Carcinoma: Is Elective Neck Treatment Worthwhile?
    Laryngoscope 108: 1006-1008, 1998.
       
    All patients were included with glottic cancer between 1984 to 1994. Ninety-two patients were identified who had at least 2 yrs of follow-up for T stage, cord mobility, CT scan, nodal disease, lesion extension, treatment modality and tumour pathology. Recurrences were reviewed.
        
    Occult nodal disease with NO glottic carcinoma was low with 0% incidence in T1 and T2 stage disease and 19% in T3 and T4 stage disease. Only paratracheal level II and III nodes were at high risk. Therefore, elective neck dissection should be performed for advanced disease in case with low morbidity. CT scanning was not useful for staging in these patients.
        

  • Asakage T, Yokose T, Mukai K, et al (Natl Cancer Ctr Hosp East, Chiba, Japan; Tohoku Univ, Miyagi, Japan)
    Tumor Thickness Predicts Cervical Metastasis in Patients with State I/II Carcinoma of the Tongue.
    Cancer 82: 1443-1448, 1998
           
    The retrospective study included 44 patients with previously untreated stage I/II carcinoma of tongue involving the anterior two thirds of the tongues. They were treated by partial glossectomy only. Twenty-one patients had cervical metastasis and 23 were without. Tumour thickness and other variables were compared.
           
    Tumour thickness more than 4mm thickness are at higher risk of cervical metastases and were regarded as having latent metastasis. Conservative supramyohyoid neck dissection, as performed for T1N1 or T2N1 carcinoma of the tongue may be suitable.
            
    This article confirms depth of invasion in more predictive of cervical metastasis than T classification. Spiro et al suggested this even for 2mm thickness and more.
        

  • Cruz IB, Snijders PJF, Meijer CJ, et al (Univ Hosp Vrije Universiteit, Amsterdam; Academic Centre for Dentistry, Amsterdam)
    p53 Expression above the Basal Cell layer in Oral Mucosa is an Early Event of Malignant Transformation and Has Predictive Value for Developing Oral Squamous Cell Carcinoma.
    J Pathol 184: 360-368, 1998.
        
    Majority of oral squamous cell carcinoma have mutations in the oncogene p53.
        
    To determine the relationship, immunohistochemical staining was performed on 11 premalignant lesions in which carcinoma developed. Therefore, p53 expression appears on early event in the carcinogenesis of premalignant lesions. 
       
    This combined with histologic criteria of dysplasia is danger sign. If more continued studies demonstrate this, it will be of great value in the management of patients with dysplastic biopsy specimens.
         

  • Int J Radiat Zakotnik B, Smid L, Budihna M, et al (Inst of Oncology, Ljubljana, Slovenia: Univ Dept. of Otorhinolaryngology and Cervicofacial Surgery, Ljubljana, Slovenia)
    Concomitant Radiotherapy with Mitomycin C and Bleomycin Compared with Radiotherapy Alone in Inoperable Head and Neck Cancer: Final Report.
    Oncol Biol Phys 41: 1121-1127, 1998.
        
    Sixty-four patients were randomly treated in 2 groups. One group received radiotherapy alone and other group received radiotherapy with concomitant above mentioned chemotherapy.
        
    Other group receiving radiotherapy with concomitant chemotherapy had significantly higher complete remission, disease free survival and better survival rates.

  • C. Gaelyn Garrett, MD, and Robert H, Ossoff, DMD, MD From the Department of Otolaryngology, Vanderbilt Voice The Otolaryngologic Clinics of North America
    Phonomicrosurgery II: Surgical Techniques
    Volume 33, Number 5, October 2000, Pg. 1063-1070
      
    Vocal fold stripping almost always results in the removal of normal epithelium and a significant portion of the superficial layer of the lamina propria [SLLP]. Frequently, the vocal fold heals with significant scarring within the lamina propria tethering the mucosal cover to the underlying vocal ligament.  Vocal fold vibration is hampered.
      
    In the treatment of benign nonneoplastic lesions, vocal fold stripping techniques should therefore be abandoned in favor of treatments that spare epithelial and mucosal tissue.
      
    Newer microlaryngeal techniques attempt adequate excision of the lesion without removing surrounding normal tissue.
      
    The CO2 laser causes tissue ablation to a depth of approximately 200
    mm at optimal laser settings.
      
    It has hemostatic properties for the microcirculation [vessels < 50
    mm], making it ideal for lesions such as palilloma that are highly vascular and involve the epithelium.
     
    Unfortunately, laser energy causes thermal damage to surroundings normal tissue, including the epithelial layer and deeper portions of the lamina propria, unnecessarily increasing the risk for postoperative scarring.
     
    Therefore, do not routinely use the laser for excision of benign nonneoplastic vocal fold lesions when sparing of the mucosal cover is indicated.
       
    Surgical Approach
       
    Phonomicrosurgical techniques have been developed to preserve as much as possible the cover-body vibration of the true vocal fold. These techniques have been described as microflap or mini-microflap approaches.
       
    They take advantage of a natural surgical plane within the mostly avascular Superficial  Layer of the Lamina Propria SLLP.
     
    Clinical reviews have reported excellent results with the microflap technique. The goal of the dissection is to excise the lesion within the SLLP without injuring the overlying epithelium and underlying vocal ligament.
     
    Postoperative Care
      
    Patients are placed on strict voice rest for 1 to 2 weeks gradual resumption of voice use under the guidance of the surgeon and a speech and language pathologist.  Most complaint patients can expect to achieve 90% or more of their premorbid voice by 3 months following surgery.

        

  • Forrest LA, Schuller DE, Karanfilov B, et al (Ohio State Univ, Columbus)
    Update on Intraoperative Analysis of Mandibular Margins
    Am J Otolaryngol 18: 396-399, 1997
       
    In 61 patients with involvement of alvelous, the study of serial frozen section biopsy of the cancellous bone at the mandibular stump demonstrated 100% corelation, and thus the extent of resection of the mandibule could be decided accordingly.
        
    This article provides some evidence of the effectiveness of this technique in assessing resection.
        

  • De Stefani E, Boffetta P, Oreggia F, et al (Registro Nacional de Cancer, Montevideo Uruguay; Inernatl Agency for Research on Cancer, Lyon, France; Academia Nacional de Medicina, Montevideo, Uruguay, et al).
    Smoking Patterns and Cancer of the Oral Cavity and Pharynx: A Case-Control Study in Uruguay.
    Oral Oncol, Eur J Cancer 34: 340-346, 1998.
        
    Four hundred and twenty-five men with confirmed lesions and 427 hospitalized controls were studied.
       
    Smoking black tobacco cigarettes seems significant in oral and pharyngeal carcinogenesis. Risk was decreased with filter use and cessation of smoking. Black tobacco contained high tobacco-specific nitrosamines. A high tar content was noted in hand-rolled cigarettes thus combination has more risk of oral cancer.
        
    This interesting article can help physicians counseling their patients – particularly impact of tobacco type and use of filtered cigarettes.
        

  • Colletier PJ, Garden AS, Morrison WH, et al (Univ of Texas, Houston)
    Postoperative Radiation for Squamous Cell Carcinoma Metastatic to Cervical Lymph Nodes from an Unknown Primary Site: Outcomes and Patterns of Failure.
    Head Neck 20: 674-681, 1998.
       
    Out of 136 patients with cervical metastasis from unknown primary sites, 39 patients underwent excisional biopsy and rest of them various types of neck dissection. All received radiotherapy subsequently. 58 months follow-up was done.
       
    Excisional biopsy and radiotherapy offers excellent disease control and survival rates. Those with ECE (extracapsular extension) and multiple nodal involvement the results are not as good. Radiation should start within 3 to 4 weeks and should be of full required dose.
       
    Excisional biopsy did not have any reduction in disease control or survival rates. However, it should not be an argument in all cases. Detrimental effects of ECE and multiple nodal involvement is confirmed by this study further. R.A. Otto.
        

  • Simon D, Koehrle J, Reiners C, et al (Heinrich-Heine-Univ, Dusseldorf, Germany; Unvi of Wurzburg, Germany; Univ of Essen, Germany)
    Redifferentiation Therapy with Retinoids: Therapeutic Option for Advanced Follicular and Papillary Thyroid Carcinoma.
    World J Surg 22: 569-574, 1998.
       
    About 33% of differentiated thyroid carcinoma (DTC) show loss of differentiation during progression of disease and then become refractory to standard treatment.
       
    Retinoid treatment (13-cis-retinoic acid) reduces tumour growth and reinduces iodide uptake suggesting that redifferentiation in cancerous growth in (DTC). This is not so in on anaplastic cancer.
       
    A 65% response rate was shown among patients of advance DTC. Thyroglobulin levels always do not accompany this response. Therapy is well tolerated with few side effects. No conclusions as the survival rates have been drawn.
       
    This study has offered a ray of hope in the management of advanced DTC patients and further studies may offer better hopes. R.A. Otto.
      

  • Gimm O, Ukkat J, Dralle H (Martin-Luther-Univ Halle-Wittenberg, Germany)
    Determinative Factors of Biochemical Cure After Primary and Reoperative Surgery for Sporadic Medullary Thyroid Carcinoma.
    World J Surg 22: 562-568, 1998.
      
    Twenty-seven patients underwent total thyroidectomy and compartment based microdissection of nodes. Thirty-seven patients with continuously elevated serum calcitonin levels underwent 4-compartment lymphodectomy at reoperation.
       
    The report of 100% normalizaiton in serum of calcitonin levels in node negative and pT1 patients is notable. Postoperative calcitonic level is powerful prognostic factor. However, it is not clear whether the patients who are biochemically cured have better outcome. By correlating tumour size with the presence and location of lymph node metastasis, this study provides useful guidelines for the extent of nodal dissection necessary at the time of primary operation of Medullary Thyroid Carcinoma. R.A. Otto.
        

  • Dralle H, Gimm O, Simon D, et al (Martin-Luther-Universitat Halle-Wittenberg, Germany; Heinrich-Heine Universitat, Dusseldorf, Germany; Gemeinschaftspraxis Innere Medizin-Endokrinologie, Heildelberg, Germany; et al)
    Prophylactic Thyroidectomy in 75 Children and Adolescents with Hereditary Medullary Thyroid Carcinoma: German and Austrian Experience.
    World J Surg 22: 744-751, 1998.
        
    In 1993, the RET proto-oncogene was identified as responsible for hereditary medullary thyroid carcinoma (MTC), since then patients with MTC based genetic screening have achieved biochemical cure by undergoing prophylactic thyroidectomy which prevents MTC and lymph node metastasis from developing.
         
      A major breakthrough in the diagnosis and treatment with identification of this genetic defect in thyroid tumours. Biochemical estimation of serum calcitonin to screen in no longer required. 
        
    These authors provide a sensible algorithm for management of these patients. The achievement in 96% patients of a biochemical cure is remarkable. Time will tell if biochemically curing these patients is superior. R.A. Otto.
       

  • Nilsson O, Lindeberg J, Zedenius J, et al (Karolinska Hosp, Stockholm; Lund Univ Hosp, Sweden; Uppsala Univ Hosp, Sweden)
    Anaplastic Giant Cell Carcinoma of the Thyroid Gland: Treatment and Survival Over a 25-Year Period.
    World J Surg 22: 725-730, 1998.
        

    Between 1930 and 1970, 50% of patients with ATC died within 3 months mainly by suffocation from the local tumour growth. Now only one similar death has occurred since 1989. Local tumour control has been achieved with debulking and pre and post operative doxorubicin and hyperfractionated accelerated radiotherapy.
        

  • Patel PC, Pellitteri PK, Patel NM, et al (Penn State Geisinger Health System, Danville,Pa)
    Use of a Rapid Intraoperative Parathyroid Hormone Assay in the Surgical Management of Parathyroid Disease.
    Arch Otolaryngol Head Neck Surg 124: 559-562, 1998.
        

    During parathyroid surgery patients underwent neck exploration and the parathyroid hormone assay is done by preremoval of parathyroids and postoperative, during operative procedure, thus guiding whether enough functioning of parathyroid tissue is received. If adenoma is suspected then preoperative 99mTc-sestamibi scanning was used to localize.
       
    Thus combination of preoperative scanning and intraoperative parathyroid hormone assay can guide unilateral exploration of neck.
       

  • Dhingra JK, Zhang X, McMillan K, et al (Tufts Univ, Boston; Lahey Clinic Med Ctr, Burlington, Mass; Massachusetts Inst of Technology, Cambridge)
    Diagnosis of Head and Neck Precancerous Lesions in an Animal Model Using Fluorescence Spectroscopy.
    Laryngoscope 108: 471-475, 1998.
         

    This animal experiment using laser induced fluorescence spectroscopy demonstrated the utility in the diagnosis of premalignant lesions like leukoplakia or erythroplakia and histologically as metaplasia and dysplasia. 
       
    If this technique could be used to enhance over clinical skills (60%-80% reliability) such a tool could be very useful. G.R. Holt.
        

  • Shaari CM, Farber D, Brandwein MS, et al (Mount Sinai School of Medicine, New York; City Univ of New York)
    Characterizing the Antigenic Profile of the Human Trachea: Implications for Tracheal Transplantation
    Head Neck 20: 522-527, 1998.
         
    This study of 10 human tracheal wall detects Class I (Human leukocyte Antigens A,B and C) and Class II (human leukocyte antigen DR) histocompatibility antigens.
       
    Different areas of the trachea have greatly different antigenicity. Minor salivary glands in the wall are highly antigenic. Antigenicity of the perichondrium varies. Mucopolysaccharide matrix is nonantigenic but the chondrocytes have antigenic properties. These differences in antigenicity indicate that some tracheal grafts would be more immunogenic than others and therefore more prone to rejection.
       
    This article forms an important foundation upon which tracheal transplantation is an exciting possibility, if all the hurdles are overcome. R.A. Otto.
       

  • London SD, Park SS, Gampper TJ, et al (Univ of Virginia, Charlottesville)
    Hyperbaric Oxygen for the Management of Radionecrosis of Bone and Cartilage.
    Laryngoscope 108: 1291-1296, 1998.
       
    Sixteen patients included in this study suggests good results with HBO therapy for the management of radionecrosis of the head and neck. Subjective and objective outcomes improved greatly.
       
    HBO therapy has become an important portion of the equation in the prevention and treatment of osteoradionecrosis and chondroradionecrosis.
        

  • Davison SP, Sherris DA, Meland NB (Mayo Clinic, Rochester, Minn; Mayo Clinic, Scottsdale, Ariz)
    An Algorithm for Maxillectomy Defect Reconstruction.
    Laryngoscope 108: 215-219, 1998
       
    One hundred and eight patients over a period of 5 yrs underwent reconstruction of maxillary defects.
       
    The majority can be best reconstructed with a prosthesis, obturator. The guidelines are :-
        
    – First choose a technique that retains greatest residual hard palate without comprising growth excision. 
    – Second, position the resection in the socket of an extracted tooth, to preserve tooth adjacent to the defect. 
    – Third, consider a split thickness skin graft. 
    – Fourth, to avoid the influence with the obturator bulb, remove the inferior turbinate. 
    – Fifth, if possible, use a feasible preserve palatal disease free mucosa for tissue coverage.
       
    Finally consider the removal of residual adynamic soft palate if 50% or more has to be resected. Preoperative planning of the surgical approach is crucial, and the authors offer an algorithm to assist in this process.
       

  • KJ Doyle, Y Sininger, A Starr (Univ of California, Irvine; House Ear Inst, Los Angeles)
    Auditory Neuropathy in Childhood.
    Laryngoscope 108: 1374-1377, 1998
        
    Auditory neuropathy has the following clinical features: Hearing loss for pure tones, impaired word discrimination, abnormal auditory brain stem responses, and NORMAL outer hair cell function. The results of audiologic testing in 8 children with hearing deficits most likely caused by neuropathy of the eighth nerve were reported.
       
    The assessments suggested that, though cochlear outer hair cell function was normal, the lesion was located at the eighth nerve.
      

  • JK Thiringer, MA Arriaga (Lackland Air Force Base, Texas; Pittsburgh Ear Associates, Pa)
    Stapedectomy in Military Aircrew
    Otolaryngol Head Neck Surg 118:9-14, 1998.
       
    Stapedial surgery may pose a considerable risk for those in certain occupations e.g. military aircrews who challenge the function of the cochleovestibular system with each mission. Aircrew members who have had stapedectomies have been rejected for all flying duties by the Surgeon General of the Air Force. As additional clinical experience was gained, waivers for flight duty were granted on an individual basis. The aeromedical outcome for aircrew members who returned to flight duty after stapedectomy was reviewed.
       
    Before aircrew members returned to flight duty, patients were subjected to centrifuge and altitude -chamber testing, electronystagmography, rotational chairs, and actual test flights. In the entire group studied, no episodes of sudden hearing loss or vestibulopathic conditions occurred.
        

  • JP Leonetti, T Origitano, et al (Loyola Univ, Maywood, III)
    Intracranial Complications of Temporal Bone Osteoradionecrosis
    Am J Otol 18:223-229, 1997
      
    Osteoradionecrosis of the temporal bone may follow radiation to the brain, parotid gland, nasopharynx, or superior cervical area. Life-threatening intracranial complications may follow.
      
    In 4 patients studied, complications observed were multiple brain abscesses, aneurysm of the internal carotid artery; a cholesteatoma of the external auditory canal with extensive destruction of the mastoid bone leading to thrombosis and meningitis of the sigmoid sinus; meningitis with a small epidural abscess over the middle fossa dura; and prolonged infection of the ear canal, middle ear, and mastoid resulting in fatal otitic meningitis. The 3 patients who underwent surgery (mastoid) survived requiring careful and regular follow-up.
      

  • PA Fagan, JP Sheehy, et al (St. Vincent’s Hosp, Sydney, Australia)
    The Cerebellopontine Angle: Does the Translabyrinthine Approach Give Adequate Access?
    Laryngoscope 108: 679-682, 1998

    It was previously believed that the translabyrinthine approach provided inadequate access to the cerebellopontine angle. The authors after analyzing 33 patients undergoing translabyrinthine surgery and 13 undergoing the posterior fossa approach have concluded that the translabyrinthine approach enables superior visualization through a wider angle of surgical access with minimal cerebellar retraction.

  • HM Dunniway, DB Welling (Ohio State Univ, Columbus)
    Intracranial Tumors Mimicking Benign Paroxysmal Positional Vertigo.
    Otolaryngol Head Neck Surg, 118:429-436, 1998.

    Benign positional vertigo may not always be benign, as indicated in this study where intracranial tumors were identified in five patients who presented as “benign paroxysmal vertigo.”

    When patients of “benign paroxysmal vertigo” do not improve after particle repositioning manoeuver, further assessment is needed to rule out intracranial new growths.
       

  • RC O’Reilly, SB Kapadia, D.B. Kamerer (Univ of Pittsburgh, Pa)
    Primary Extracranial Meningioma of the Temporal Bone.
    Otolaryngol Head Neck Surg 118:690-694, 1998.

    Though meningiomas typically occur intracranially, they may rarely arise de novo in the temporal bone. Because of the invasive nature of this tumor, surgical resection is difficult, and postoperative surveillance is necessary.

  • AE-M Moussa, KA Abou-Elhmd (South Valley Univ, Sohag, Egypt)
    Wegener’s Granulomatosis Presenting as Mastoiditis
    Ann Otol Rhinol Laryngol 107:560-563, 1998.

    Wegener’s granulomatosis is an uncommon auto-immune disorder, which has a peak incidence in the fifth decade of life with a slight male predominance. Typically, nasal problems are the initial manifestation. Otologic symptoms are rare.

    The authors report 2 cases of Wegener’s granulomatosis manifesting as mastoiditis (a fourteen-year-old girl and a 20-year-old woman).
       

  • Harti DM, P Aidan, O Brugiere, et al (Universite Paris VII)
    Wegener’s Granulomatosis Presenting as a Recurrence of Chronic Otitis Media.
    Am J Otolaryngol 19: 54-60, 1998.


    This is a case report of Wegener’s Granulomatosis manifesting otitis media with facial palsy. Plasma antineutrophil cytoplasm antibodies were detected by means of immunofluorescence. After three weeks of immunosuppressive therapy, facial palsy disappeared, the ESR had normalized and the size of pulmonary nodules had decreased.

    This case report highlights the need to bear in mind non-infectious causes of chronic otitis media with otorrhea.

  • R Indudharan, T Arni, KK Myint, et al (Universiti Sains Malaysia, Kelantan; Hosp Tengku Ampuan Afzan, Kuantan, Malaysia)
    Lymphoblastic Lymphoma/Leukemia Presenting as Perichondritis of the Pinna.
    J Laryngol Otol 112: 592-594, 1998


    A patient treated for perichondritis of the pinna was eventually determined to have B-lineage lymphoblastic lymphoma evolving to a leukemic phase. There was no pre-existing immunodeficiency.

    Though lymphoma is the second most common malignancy of the head and neck region, the pinna as the extranodal site of lymphoma, has been previously reported only once. Hence the need to broaden one’s diagnostic horizon when inflammatory lesions do not heal within a reasonable period.
      

  • G Venkatraman, DE Mattox (Univ of Maryland Baltimore)
    External Auditory Canal Wall Cholesteatoma: A Complication of Ear Surgery.
    Acta Otolaryngol (Stockh) 117 :293-297, 1997.


    Large primary cholesteatomas of the external auditory canal are rare. Cases arising from previous surgery are even less common.

    This article presents five cases of cholesteatomas arising from the floor of the external auditory canal after ear surgery. In all these patients, the cholesteatomas were extensive enough to require surgery. The authors postulate that a careful surgical technique would help prevent canal wall cholesteatoma.
       

  • E Gur, A Yeung, M Al-Azzawi, et al (Univ of Toronto)
    The Excised Preauricular Sinus in 14 Years of Experience : Is There a Problem ?
    Plast Reconstr Surg 102: 1405-1408, 1998.


    A few of the patients having a congenital pre-auricular sinus suffer from recurrent infections. In such cases surgical excision of the sinus tracts is required. Recurrence is very likely if the tract is not excised completely.

    The authors have reviewed 165 primary preauricular excision procedures in 146 patients over a period of 14 years.

    The recurrence rate was higher (15.79%) in patients who had active infection during surgery than in patients who did not have active infection (8.22%). The recurrence rate was higher (16.7%) in patients who had surgical drainage of an abscess before the procedure, and 8.16% in those who did not.

    Recurrence rates can be reduced by excising a piece of cartilage at the base of the tract and by demonstrating the sinus with dye injection and/or probing at the time of surgery.
        

  • Steven M Zeitels, MD
    Phonomicrosurgery I : Principles and Equipment
    The Origin and Development of Endoscopic Laryngeal Surgery

    From the Department of Otology and Laryngology, Harvard Medical School; and the Division of Laryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
    The Otolaryngologic Clinics of North America Volume 33, Number 5, October 2000, Pg. 1047-1062
        
    PHONOMICROSURGERY-
      
    Phonomicrosurgery is a means of maximally preserving the layered microstructure of the vocal fold, that is, the epithelium and lamina propria.
       
    Tissue Dissection : Laser Versus Cold Instruments.
    Unlike the laser, cold instruments provide tactile proprioception during delicate microdissection.
      
    Infusion into the superficial lamina propria is often helpful, whether a laser or cold instruments are used.
      
    Precise tangential dissection within the superficial lamina propria [i.e., subepithelial cyst dissection] is better accomplished with cold instruments.
      
    Cold instruments facilitate maximal preservation of the layered microstructure [lamina propria and epithelium] of the vocal folds.
       
    The CO2 laser is typically used for vocal fold surgery and enhances cold fd   instruments when the pathologic condition is vascular or is too large.
       
    The Rationales of Phonomicrosurgery.
    Phonomicrosurgical procedures are designed to improve aerodynamic efficiency and vocal quality by creating a smooth vocal fold edge that is not excavated with overlying flexible epithelium.
        
    There is a little difficulty in the growth and regeneration of normal epithelium, as occurs after a cordectomy that is left to heal secondarily.
         
    The subepithelial infusion of saline ad epinephrine into the superficial lamina propria has further enhanced the precision of microlaryngoscopic vocal fold surgery with the use of both laser and cold instruments.
       
    The author has used cold-instrument epithelial incision as a standard approach for the management of such pathologic conditions as cysts, epithelial atypia, and cancer.
       
    During the last 4 years, this approach has been extended to the management of nodules, polyps, ectasias, and varices, so a subepithelial resection of these traumatic lesions has become standard.
        
    Phonomicrosurgery has emerged as a physiologically based approach for benign and malignant disease.
          

  • T Hoshino, Y Ueda, H Mukohdaka, et al (Hamamatsu Univ, Japan)
    Acute Granulomatous Myringitis
    J Laryngol Otol 112: 150-153, 1998
       
    Acute and chronic myringitis seem to be caused by two different entities. 
        
    Acute myringitis manifests the following – otalgia, a granulomatous bulge along the malleus, and no middle ear infection.
        
    Chronic myringitis is characterized by erosion or thin granulation of the tympanic membrane – it can recur after debridement and cautery.
        
    Granulomatous changes of the tympanic membrane are rare. This article describes five causes of acute granulomatous myringitis.

  • NH Blevins, BL Carter (Tufts-New England Med Ctr, Boston)
    Clinical Forum: Routine Preoperative Imaging in Chronic Ear Surgery,
    Am J Otol 19: 527-538, 1998.
        
    Imaging studies, especially CT, can demonstrate the nature and extent of chronic otitis media, which may not be apparent on clinical findings per se. Such findings can affect operative treatment, especially in difficult and/or revision procedures. However, there is a view that routine radiography of the mastoid may suffice in being very helpful in most cases.
       

  • TS Karhuketo, HJ Puhakka (Tampere Univ, Findland)
    Middle Ear Imaging Via the Eustachian Tube With a Superfine Fiberoptic Videomicroendoscope.
    ORL J Otorhinolaryngol Relat Spec. 60: 30-34, 1998.
       
    With a fibreoptic videomicroendoscope inserted through the Eustachian tube, 56% of predetermined anatomical objects in the middle ear were visualized. 
       
    However, one may find obstructive sites or mucosal folds that may prevent a complete view of all the contents of the middle ear cleft.
        

  • RL Hebert II, GE King, JP Bent III (Med College of Georgia, Augusta)
    Tympanostomy Tubes and Water Exposure: A Practical Model.
    Arch Otolaryngol Head Neck Surg 124: 1118-1121, 1998.
       
    Myringotomy with tympanostomy tube placement is one of the very common otolaryngologic procedures done nowadays.
       
    Contrary to previous thinking, the authors have shown that entry of water into the middle ear is not promoted by showering, hair rinsing, or submersion of the head in clean tap water. The chances of water contamination increase by submersion in SOAPY water or swimming at a depth of more than 60 cms.
       
    Many of the previously advised water precautions are unnecessary in patients with tympanostomy tubes.
        

  • Rath T, Millesi W, Lang S, et al (Univ of Vienna)
    Mucosal Prelamination of a Radial Forearm Flap for Intraoral Reconstruction.
    Eur J Plast Surg 21: 166-170, 1998.
       
    In 5 patients the use of a distal radial forearm flap to which buccal mucosal grafts were meshed in reconstructing oral defects after radical resection of squamous cell carcinoma is described. It was safe, easy to use and successful. Although the time is needed between creation of the flap and its insertion, this time can be used to deliver preoperative radiation and chemotherapy.
      

  • Yotsuyanagi T, Yokoi K, et al (Hirosaki Univ, Japan)
    A Supportive Technique Using a Splint to Obtain Definite Contour and Desirable Protrusion After Reconstruction of Microtia
    Plast Reconstr Surg 101: 1051-1055, 1998
        
    The use of thermoplastic splint is used in 17 patients directly to the newly constructed ear, to prevent deformity resulting from odema and scarring. Patients were monitored for 3 yrs. The splints were used after the first and second stage of costal cartilage grafting.
        
    This technique is worth consideration. G.R. Holt.
          

  • Personelle J, de Souza Pinto EB, Ruiz RO (Sao Paulo, Brazil)
    Injection of Vitamin A Acid, Vitamin E, and Vitamin C for Treatment of Tissue Necrosis.
    Aesthetic Plast Surg 22: 58-64, 1998.
       
    Experimental animals used were rats. Injection of ACE pool, composed of all-transretinoic acid, vitamin A, and vitamin E is useful for the treatment of necrosis after routine plastic surgery.
       
    The antioxidants and their general health effects were used orally in selected patients to better prepare their tissue for surgery by G.R. Holt and found this regimen to be useful. 
       
    Well controlled clinical trial is needed – G.R. Holt.
      

  • Abou Chebel N, Beziat J-L, Torossian J-M (CHU Lyon-Nord, Cedex, France)
    Le Lambeau Myo-Muqueux de Buccinateur Pedicule sur les Vaisseaux Faciaux: Interet Dans la Reconstruction du Plancher de la Cavite Buccale: A Propos de 10 Cas.
    Ann Chir Plast Esthet 43: 252-257, 1998
       
    Ten patients were given the flap. The musculomucous buccinator flap described provided excellent- functional and esthetic results in the repair of the floor of the mouth. Its flexibility ensures good tongue mobility. However, it requires extraction of the mandibular molars and also must have intact facial artery that can be raised with the flap. The Doppler could also be used to identify the course of the facial artery intraorally. The flap must be placed anterior to the parotid duct and opening. The patient must now chew if the flap crosses alveolar ridge. G.R. Holt.
        

  • Kuhn J, Toohill RJ, Ulualp SO, et al (Med College of Wisconsin, Milwaukee)
    Pharyngeal Acid Reflux Events in Patients with Vocal Cord Nodules.
    Laryngoscope 108: 1146-1149, 1998.
        
    This study with controls demonstrated patients with vocal nodules were significantly more likely to experience pharyngeal acid reflux and pharyngeal episodes were more frequent. These finding suggests a contributory role for GEPR in pathogenesis of vocal cord nodules. Given this association, the vocal cord nodules in some patients should follow antireflux precautionary steps like elevating the head while sleeping and avoiding food 3 to 4 hrs before bedtime.
        
    Barium swallow is a poor indicator of reflux. It should also use empirical therapy of reflux in patients without any cause for development of vocal nodules. G.R Holt.
        

  • Rosenbower TJ, Morris JA Jr, Eddy VA, et al (Vanderbilt Univ, NashvilleTenn)
    The Long-term Complications of Percutaneous Dilatational Tracheostomy.
    Am Surg 64: 82-87, 1998.
       
    Out of 237 patients admitted in trauma centre, 95 patients underwent percutaneous tracheostomy. Fifty-five patients were available for final follow-up.
        
    The long-term complication rate of PDT is comparable to that of open tracheostomy. It is rapid, safe, easy, cost effective and is useful in patients requiring prolonged ventilatory support.
         

  • Ebraheim NA, Lu J, Skie M, et al (Med College of Ohio, Toledo)
    Vulnerability of the Recurrent Laryngeal Nerve in the Anterior Approach to the Lower Cervical Spine.
    Spine 22: 2664-2667, 1997.
        
    This is cadaveric study. Anatomy demonstrated suggest danger of injury to recurrent laryngeal nerve more on right side because the nerve courses outside esophagotracheal groove and runs in oblique direction relative to the sagittal plane. Inferior thyroid vessel should be ligated as laterally as possible and the retractor should be blunt tipped to retract the longus colli muscle to provide intermittent retraction of the midline structures.
        
    This article highlights the rationale of using left sided approach to the spine when possible. If right sided approach is used then above precautions are necessary to prevent injury to recurrent laryngeal nerve.
        

  • Postma GN, Shockley WW (Naval Med Ctr, Portsmouth, Va; Univ of North Carolina, Chapel Hill)
    Transient Vocal Fold Immobility
    Ann Otol Rhinol Laryngol 107: 236-240, 1998
        
    Common causes of adult vocal fold immobility (VFI) include, thyroid surgery, nonlaryngeal malignancy and viral insult. The 3 patients had acute VFI, an unusual condition.
        
    This VFI lasts for 4 weeks or less. Anything lasting more than 12 months is called permanent. A variety of causes of transient and temporary VFI, have been identified: metabolic, traumatic, infectious or inflammatory, autoimmune, CNS, mechanical and neoplastic. Some cases are idiopathic.
       
    This is nice article about the temporal differences between transient, temporary and permanent vocal fold immobility. These are to be identified before any therapy is undertaken.
       

  • Filler RM, Forte V, Chait P (Univ of Toronto; Hosp for Sick Children, Toronto)
    Tracheobronchial Stenting for the Treatment of Airway Obstruction
    J Pediatr Surg 33: 304-311, 1998
       
    A balloon expandable stent, the Palmaz stent, was inserted into 16 children with a variety of major airway obstructions. Thirty stents were inserted in 24 separate procedures during the 5 yrs.
       
    Results showed they are extremely useful in the treatment of neonates and infants with localized tracheomalacia and bronchomalacia in those with airway obstruction caused by surgery for congenital tracheal stenosis, in patients with incurable congenital heart disease. The stents can be inserted easily and can be left for long periods if necessary.
        
    More clinical studies need to be performed using improved stent designs, to optimize the results – G.R. Holt.
       

  • Yumoto E, Sanuki T, Hyodo M, et al (Ehime Univ, Japan)
    Three-Dimensional Endoscopic Mode for Observation of Laryngeal Structures by Helical Computed Tomography.
    Laryngoscope 107: 1530-1537, 1997.
       
    Helical scanning CT was used to produce high quality 3D endoscopic images of larynx. The method has been described. The method used was in 12 patients with normal and affected larynx, either by cancer, nerve palsy and atrophy. This method provided useful diagnositc and therapeutic information in patients with RLN palsy. In cancer patients axial images allowed better assessment of characteristic lesions than CT endoscopic images alone.
       
    This new technology can take 3D data and through obstruction technique, produce an image than appears as the “New” of the larynx through an endoscope. G.R.Holt.
        

  • Riley RW, Powell NB, Guilleminault C, et al (Stanford Univ, Calif)
    Obstructive Sleep Apnea Surgery: Risk Management and Complicaitons
    Otolaryngol Head Neck Surg 117: 648-652, 1997.
        
    Patients who undergo surgery for obstructive sleep apnea syndrome (OSAS) are at increased risk for postoperative airway obstruction, hypoxemia, hypertension and death.
        
    In 182 patients with 210 surgeries for OSAS, the risk factors were identified and were overcome.
        
    The use of fibre optic intubation can reduce intraoperative complications with OSAS who have large neck circumference and facial skeletal deficiency. Hypertension is a significant risk factor, and requires aggressive treatment. Nasal continuous positive airway pressure (CPAP) prevents hypoxemia.
        
    This article provides useful tips for the perioperative management of OSAS patients. R.A. Otto.
        

  • Osterlund A, Engstrand L (Univ Hosp, Uppsala, Sweden)
    An Intracellular Sanctuary for Streptococcus Pyogenes in Human Tonsillar Epithelium: Studies of Asymptomatic Carriers and In Vitro Cultured Biopsies.
    Acta Otolaryngol (Stockh) 117: 883-888, 1997.
        
    Streptococcus pyogenes was found in epithelial cells for both symptomatic and asymptomatic patients. This intracellular reservoirs could serve as the source for reinfection. Perhaps antibiotics with good intracellular penetration should be used.
        
    This study provided the novel hypothesis that the inner harbor for S.pyogenes in the tonsils may be intracellular and therefore requires the antibiotics capable of penetrating and destroying this intracellular bacteria, thereby, completely eradicating the bacteria and the chances of reinfection or passing on the infection to others. G.R. Holt.
        

  • Ament PW, Paterson A (Latrobe Area Hosp, Penn)
    Drug Interactions with the Nonsedating Antihistamines
    Am Fam Physician 56: 223-230, 1997.
        
    The nonsedating antihistamines – which include astemizole, fexofenadine, loratadine and terfenadine – are very commonly prescribed drugs.
       
    Terfenadine and astemizole cause serious adverse effects in interaction with macrolide antibiotics or the antifungal agents, quinine Such interaction appears to be less likely with fexofenadine and Loratadine.
        
    To avoid an adverse effect (drug-drug interactions) one must avoid prescribing any medication that may influence cytochrome P450 system.
        

  • Iro H, Zenk J, Waldfahrer F, et al (Saarland Univ, Homburg, Germany; Univ of Erlangen-Nuremberg, Germany; Dr. Horst-Schmidt-Klinikum, Wiesbaden (EII) Germany) 
    Extracorporeal Shock Wave Lithotripsy of Parotid Stones: Results of a Prospective Clinical Trial.
    Ann Otol Rhinol Laryngol 197: 860-864, 1998.
        
    A total of 76 patients ranging form 2 to 80 yrs were treated. These patients were treated with routine treatment of sialogogues, bougienage, gland massage etc. with no resolution.
       
    This effective treatment gives reliable long-term results. With this treatment, parotidectomy and its accompanying complications can be avoided.
        

  • Marvez-Vals EG, Ernst AA, Gray J, et a (Louisiana State Univ, New Orleans; Vanderbilt Univ Med Ctr, Nashville, Tenn)
    The role of Betamethasone in the Treatment of Acute Exudative Pharyngitis.
    Acad Emerg Med 5: 567-572, 1998.
        
    The double-blind clinical trial was performed over 3 months. Forty-six patients were randomized to placebo and 46 to Betamethasone.
         
    Betamethasone, used as an adjunct to antibiotic therapy reduces the time to pain relief. Most effective in patients with streptococal positive.
          

  • Naumann M. Zellner M, Tokya KV, et al (Bayerische Julius -Maximilians Universitat, Wurzburg, Germany)
    Treatment of Gustatory Sweating with Botulinum Toxin.
    Ann Neurol 42: 973-975, 1997.
        
    Gustatory sweating (Frey’s syndrome) has been treated with scopolamine or aluminum hydrochloride and tympanic nerve destruction.
        
    Intracutaneous injections of botulinum toxin (BTX) type A are more effective. Forty-five patients were treated. 50% patients reported complete relief and 50% showed substantial improvement.
       
    This is safe and effective method. Long-term follow up is needed. G.R. Holt.
        

  • Adair-Bischoff CE, Sauve RS (Univ of Calgary, Alberta, Canada)
    Environment Tobacco Smoke and Middle Ear Disease in Preschool-Age Children.
    Arch Pediatr Adolesc Med 152: 127-133, 1998
        
    Six hundred and twenty-five eligible children for this study were reviewed.
        
    Conclusions: Exposure to environmental tobacco smoke (ETS) during the first 3yrs of life significantly increased the risk of middle ear diseases (MED) in these first-grade children. Greater exposure to (ETS) had greater risk for MED.
        
    Avoding ETS during the first 3 years of life could have significant impact on MED and its associated morbidities.
         

  • Berrylin J Ferguson (Divn. Of Sino-nasal Disorders and Allergy, Dept. of Otolaryngology, Univ. of Pittsburgh School of Medicine, Pennsylvania)
    Mucormycosis of the Nose and Paranasal Sinuses
    Otolaryngo Clinics of North America, Vol.33(2), April 2000; 349-365
          
    It is uncommon and rarely affects healthy host. But for the afflicted patient, the speed with which it progresses and leads to the death, warrants immediate diagnosis and emergency treatment. It can be seen in diabetics and other immunocompromised patients. It starts in sinonasal region but rapidly progresses to rhinocerebral region and orbit producing proptosis and ophthalmoplegia.
         
    Aetiopathology
    It is a term used to refer to fungal infections of the order Mucorales which belongs to the class zygomycetes. These are termed as zygomycosis. This would also incorporate the other order of the class Entomophthorales. This latter is a tropical granulomatous infection of the subcutaneous tissues and paranasal sinuses by Basidiobolus and Delacroixia, which responds to local care in contrast to the order of mucorales.
        
    Most pathogenic species are members of the family. Mucoraceae, Rhizopus, Oryzae is the predominant pathogen and accounts for 60% of all forms of mucormycosis and 90% of rhinocerebral cases of mucormycosis. Apohysomyces elegans is the most recently recognised agent and caused mucormycosis in an immunocompetent individuals.
        
    Diabetics in ketoacidosis are disproportionately affected. Out of 26 patients with rhinocerebral mucormycosis, 70% were diabetic.
        
    Other risk factors include neutropenia, systemic steroids, protein calorie nutrition, solid organ and bone marrow transplant, immunodeficiency, leukaemia, intravenous drug abusers who may inject spores of mucorales with their drugs and then present with space-occupying lesions of the central nervous system. The relative infrequency of mucormycosis in patients with AIDS probably reflects the ability of neutrophils to prevent growth of the fungus.
        
    Signs and symptoms reported in patients within 72 hours of onset of Rhino-Orbital-Cerebral Mucormycosis.
        
    ¨ Fever
    ¨ Nasal ulceration or necrosis
    ¨ Periorbital or facial swelling
    ¨ Decreased vision
    ¨ Ophthalmoplegia
    ¨ Sinusitis
    ¨ Headache
    ¨ Facial pain
    ¨ Decrease in mental status
    ¨ Nasal discharge or stuffiness
    ¨ Corneal cellulitis
    ¨ Orbital cellulitis
    ¨ Proptosis
    ¨ Palatal or gingival necrosis
    ¨ Afferent pupillary defect
    ¨ CN VII palsy
    ¨ Periorbital pain
    ¨ Chemosis (without orbital cellulitis)
    ¨ Epistaxis
    ¨ Facial numbness
    ¨ Diplopia
    ¨ Facial necrosis
    ¨ Hemiplegia/stroke
    ¨ Malaise
    ¨ Ptosis (without ophthalmoplegia)
    ¨ Decreased hearing
    ¨ Toothache
    ¨ Earache.
       
       
    Treatment
          
        1) Reversal of cause of immunocompromisation
          
        2) Systemic Antifungal Amphotericin B
            Systemic amphotericin can be administered 1 to 1.5mg/kg per day intravenously by monitoring patients
         
        3) Repeated and extensive surgical debridement
            External techniques like external ethmoidecormy or Caldwell-Luc procedure, preferred to endoscopic
            management
            Orbital exenteration was advocated but is now controversial.
             
        4) Topical application of amphotericin is 50mg vial and intravenous amphotericin B and 10mL of sterile
             water. This can be nebulized with a Rhinoflow device into the nose. The dosage is 4 mL in each
             nostril 2 to 6 times a day.
            
        5) Hyperbaric oxygen can be used. It helps reverse the ischaemic acidotic conditions that perpetuates
            fungal growth. Usually given at two atmospheres for 1 hr on a daily basis upto 30 treatments. It then
            limits deformity by decreasing tissue of debridement.
                 

  • Kenneth M Grundfast, Nicole Siparsky and Diana Chuong 
    Genetics and Molecular Biology of Deafness- Update
    The Otolaryngologic Cl. Of North America, Vol.33(6), Dec. 2000,p.1367-1394
         
    Incidence of acquired types of hearing impairment diminished, but a growing proportion of all childhood hearing impairment is seen.
        
    Until recently only genes for HHI (Hereditary Hearing Impairment) were identified as syndromic causes. However in last 5 yrs many non-syndromic HHI were identified contributing to the HHI. Fifty-three loci have been identified for nonsyndromic HHI. Otolaryngologists, therefore, should have basic knowledge of HHI in order to diagnose, treat and prevent sensorineural hearing losses.
       
    Currently 25% of hearing impairment are congenital. 50% of these are hereditary. 2/3rd of these hereditary are nonsyndromic and 1/3rd are syndromic. 
        
    Apart from monitoring of infants at risk by OAE (otoacoustic emissions) and auditory brainstem response (ABR), newborn screening should include genetic testing (GJB2) as well, but is prohibitively expensive.
       
    Almost 50% of inherited deafness is caused by mutations in GJB2, which encodes connexin -26, a gap junction component on chromosome 13.
       
    In such early detection, early interventional programmes give larger benefit to these infants and children.
       
    Definition of Hearing loss vs Hearing Impairment
    Hearing loss means hearing was lost at birth
    Hearing Impairment means child was born with hearing impairment.
       
    Deafness versus hearing Impairment
    Deaf patient uses sign language primarily while hearing impaired patient uses speech as communication method.
        
    Congenital Hearing Impairment (CHI) versus Hereditary Hearing Impairment (HHI)
    CHI means deafness present at birth. It may be because of genetic mutation or pathologic process which occurs either during pregnancy or labour.
       
    HHI is the result of genetic mutation. It can manifest at birth or develop later in life.
        
    HHI present at birth is congenital hereditary hearing impairment, while HHI develops later is delayed onset hereditary hearing impairment. One of the most common types of HHI is autosomal dominant nonsyndromic delayed-onset of progressive hearing loss. Depending on the severity in the family, hearing loss will progress with the age. Several other family members affected helps it to differentiate this hereditary disorder from autoimmune inner ear disorder.
        
    Syndromic versus Hereditary Hearing Impairment
    The cause of a syndrome is either genetic or exogenous factors.
       
    Genetic examples are Usher’s, Pendred’s, Waardenburg’s, branchio-oto-renal syndromes. Exogenous examples are gene mutation caused cytomegalovirus, rubella or Goldenhar’s syndromes.
        
    It is important to remember that gene mutation can occur spontaneously so that a child affected may not have other relatives who are also affected.
        
    Syndromic versus Genetic Disorder
     It is important to note that syndromes which include hearing loss, may not manifest with it but can have other features. For example, Waardenburg’s syndrome only 17% have hearing loss. This is because of variability of gene expression.
       
       
    SYNDROMES AND NONSYNDROMIC HEARING LOSS
        

    There are 200 different syndromes with hearing impairment. Nearly, two-third is termed nonsyndromic which are associated with no other anomalies. Various modes of inheritance is seen in both viz autosomal recessive, autosomal dominant and X-linked transmission. Identification and location of many genes will further enhance understanding of this disorder.
       
    Inheritance Patterns
    Hereditary implies genetic basis of disorder. Three classical types being autosomal recessive, autosomal dominant or X-linked recessive. Though inheritance pattern varies in classical Mendelian patterns, the HHI is secondary to the interaction of several genes or the result of an interplay between genetic and environmental factors.
       
    (a) Autosomal Recessive
    Autosomal recessive comprises of 80% of hereditary deafness and the most common pattern. In the recessive transmission, the parents have normal or near normal hearing, inspite of possessing recessive gene. Typically there is a 25% chance that offspring might suffer. This is characterized by horizontal pattern. For offspring to exhibit, both parents must be carriers of the genetic disorder.
        
    (b) Autosomal Dominant
    Approximately 18% of cases. A vertical pattern of transmission. When one parent is a carrier, 50% of the offsprings suffer. If new mutation occurs in gene, it is inherited in dominant fashion. – thus offspring may be the first affected in the family.
       
    (c) X-Linked Recessive
    1% to 3% suffer. Genes located on X-chromosomes are involved. Affects males. This pattern of inheritance is similar to that of haemophilia, where mothers being the carriers but their male offspring are affected individuals.
        
    Abnormalities in Mitochondrial DNA
    This is another mode of inheritance of HHI. Maternal oocyte is the sole contributor of mitochondria. So any mitochondrial DNA mutation responsible for HHI in the mother will be transmitted to all of that mother’s offsprings. In some families, hearing loss may be the only mitochondrial disease.
        
    Mitochondrial DNA encodes mitochondrial proteins, tRNA and rRNA. Mutation in tRNA and rRNA are associated with nonsyndromic hearing loss. Another suspect in mitochondrial HHI is a mitochondrial import protein deafness/dystonia peptide (DDP).
       
    The expression of mitochondrial HHI varies greatly. Several other mitochondrial genes associated with nonsyndromic hearing loss and syndromic is already listed. Mutation in mitochondrial DNA encoding tRNA have been linked to HHI whereas mutation of Rrna is associated with susceptibility to aminoglycoside ototoxicity. DNA mutation mt3243 is associated with two syndromes (1) maternally inherited diabetes and deafness (MIDD) and (2) myopathy-encephalopathy-lactic acidosis stroke (MELAS).
          
          
    PENETRANCE, EXPRESSIVITY, AND GENETIC HETEROGENEITY
    The diagnosis of HHI inherited by autosomal recessive and autosomal dominant is not easy in some cases because of lack of manifestation of the features.
          
    The penetrance is the terminology used to indicate manifest expression of a gene. It is all-or-none phenomenon. So there are penetrant and non-penetrant genes. The expressivity is used to indicate the degree to which a penetrant gene will cause expression of abnormal function.
          
    Expression may be varied, even though the two individuals may possess the same gene. Recent research suggests that the sex of the parent from whom a gene mutation is inherited will influence the expression. This is termed as Genomic Imprinting.
        
    Genetic heterogenicity implies that different mutations involving different genes can result in an identical or similar phenotype. Not to be confused with a polygenic disorder, which is a phenotype that results from the interaction of multiple genes.
        
    Classification of Hereditary Hearing Impairment
         
    a) Syndromic Hereditary Hearing Impairment
    Syndromic are upto 30% of children with hereditary hearing impairment. There are many causative genes for these syndromes which have been identified. These are clinical syndrome. Hearing loss is conductive or mixed.
        
    b) Nonsyndromic Hereditary Hearing Impairment
    Almost 2/3rd in numbers. It is almost exclusively caused by mutations of single gene and these hearing impairments are not associated with any other abnormalities.
        
    There are several modes of inheritance of nonsyndromic HHI genes. Several genes have been isolated and cloned. The long list of genes, their loci and location on the chromosomes of autosomal recessive nonsyndromic HHI has been given and will be increasing as the research continues (Ref: Data from Van Camp G, Smith RJH: Hereditary Hearing Loss Homepage.)
        
    The list of syndromes out of few hundred, with inherited, gene, loci and location on chromosomes is prepared (Ref: Data from Van Camp G, Smith RJH: Hereditary Hearing Loss Homepage.)
        
    Hearing Loss Genes and Their Gene Products:
        
    Almost all genes implicated in HHI are identified in last 10 years. These genes encode related proteins which are studied in detail and include:
       
    a) Connexin genes
    b) Myosin genes
    c) POU genes
    d) Ion channel genes
        
    In addition number of genes have been identified (Ref: Data from Van Camp G, Smith RJH: Hereditary Hearing Loss Homepage.)
         
    (a) Connexin genes:
    This family is comprised of a group of genes that encode plasma membrane channel proteins of the alpha (A) and beta (B) types.
         
    (b) Myosin genes
    This family is related to the super family of myosin genes expressed throughout the body.
       
    (c) The POU genes
    Members of POU gene family encode transcription factors, some of which are expressed in the inner and middle ear.
       
    (d) The potassium channel gene super family includes genes that are expressed in the inner ear.
        
    One day genetic testing may be a useful diagnostic tool in the evaluation of Hearing Impairment.
        
    With growing understanding of genetic mutations and their effect on auditory function, scientists hope to develop treatments for many genetic disorders. Researchers explore the possibility of gene therapy for HHI and novel therapies to treat the deficiencies that arise due to genetic mutations. In the future, individuals carrying a genetic mutations responsible for progressive hearing loss may be able to receive a sufficient amount of normal gene product in order to prevent auditory dysfunction.
         
         
    CLINICAL APPROACH
    a) Family History - should be taken in details and should include all under age 30 with hearing problems.
        Certain hereditary traits should be inquired into.
        
    b) Physical Examination – to look at the patient as whole, to detect other abnormalities pointing to
        syndromes.
          
    c) Audiologic Testing - Cochlear and vestibular testing.
        
    d) Laboratory Testing 
       
    d) Radiologic Testing – CT and MR imaging
       
    e) Genetic Testing
        
        

  • Christopher J Hartnick, Robin T Cotton
    Congenital Laryngeal Anomalies
    Otolaryngologic Cl.of North Am. Vol.33(6), Dec.2000, pg.1293-1309
        
    Otolaryngologists face congenital laryngeal anomalies, which may be minor to severe. Such problems present at birth may require immediate attention. He should therefore have firm understanding of these aberrations in embryologic development. This article deals with pertinent embryology, relating to congenital laryngeal anomalies, reviews, the diagnosis and management in details.
       
    Embryology
    In 1885, His described the appearance of the respiratory primordium (RP) from an outpouching of the cephalic portion of the pharynx by the third week of gestation.
       
    The following description of the development occurs at different stages of development.
       
    According to Carnegie staging system for human embryologic development, there are two periods of development.
       
    The first period or the embryonic period is 8 weeks and comprises 23 stages.
    The second period is Foetal period spans the remaining 32 weeks of gestation.
       
    The larynx begins to develop during stage II (at 25 to 28 days) when RP appears as epithelial thickening on ventral aspect of the foregut.
       
    As the RP develops, outpouch of foregut lumen, the respiratory diverticulum (RD) grows into RP. As the RD develops from primitive pharyngeal floor at the level of adult glottis. The pharyngeal floor is separated from the primitive pharyngeal floor by primitive laryngopharynx which later becomes adult supraglottic region.
       
    Anomalies at this point can result into a number of larynotracheal anomalies.
    RD develops and extends inferiorly at stage 13 and 14 and get separated from developing heart and hepatic primordium by the septum transversum (ST).
       
    The esophagus get separated from RD by tracheoesophageal septum. Anomalies of septum transversum leads to bronchobiliary fistula. Arrest of cranial (upward) development of tracheoesophageal septum leads to tracheoesophageal or laryngeal c lefting and tracheoesophageal fistula. Anomalies of the RD itself can cause tracheal agenesis, tracheal stenosis, or complete tracheal rings.
       
    During stage 15 the ventral lumen of primitive laryngopharyngeal region becomes obliterated and gives rise to epithelial lamina (EL). In stage 19 to 23, EL recanalizes, reestablishing the connection between the ventral laryngeal portion and dorsal pharyngoglottic duct.
        
    Failure of recanalization of EL causes spectrum of disorder from laryngeal webs to laryngeal stenosis. With working knowledge, various anomalies can be adhered individually, starting from supraglottis to glottis, subglottis and upper trachea.
        
        
    LARYNGEAL WEBS
    Seventy-five percent webs occur at the level of the glottis. Severity of symptoms will depend on severity of webbing which are classified by Cohen as follows:-
       
    Type I – Anterior web involving 35% of glottis. 
               – The true vocal cords are visible. 
               – There is little or no subglottic extension, voice abnormal, slightly hoarseness.
       
    Type II – 35% to 50% glottic involvement. 
                – Thick anterior webbing with subglottic involvement. Cricoid abnormalities. 
                – Airway symptoms are uncommon, only during infection or intubation trauma. 
                – The voice is husky and weak.
       
    Type III – 50% to 70% glottic involved.
                 – Web thick anteriorly
                 – True vocal cords invisible
                 – Cricoid abnormalities
                 – Marked vocal dysfunction
                 – Airway symptoms severe and require artificial airway.
        
    Type IV – 75% to 90% glottis involved
                 – Uniformly thick anterior and posterior
                 – True cords, not visible
                – Subglottis narrowed
                – Aphonic
                – Airway – immediate help.
      
    Diagnosis is either by flexible laryngoscopy, or by good quality lateral radiograph. It will also demonstrate cricoid abnormality.
        
    Management :
    – Type I membranous web observed until the child is 3 to 4 years old and then web divided by a CO2 laser.
    – Type II cutting web on each side of the interval of 2 weeks and dilation. Keel placement by endoscopy. Tracheostomy is necessary.
    – Type III & IV. Also delayed till 3 to 4 yrs with tracheostomy and later by various reconstructive procedures.
      
    Congenital supraglottic webs are unknown. They could be in anterior part or more rarely in posterior part.
        
    Laryngeal Stenosis and Atresia
    It is the most severe form of anomalies. Glottic or supraglottic atresia requires immediate trachneostomy in the labour room and has high mortality ratio. These are also many times associated with host of other anomalies like tracheoesophageal fistula, esophageal atresia, urinary tract abnormalities and limb defects.
         
    Congenital subglottic stenosis is associated with abnormally shaped cricoid cartilage first described by Hollinger in 1954. It is to be differentiated from acquired stenosis, by history only i.e. absence of infection and instrumentation.
       
    When lumen of cricoid is less than 4mm in newborn or less than 3mm in premature, it is congenital subglottic stenosis.
        
    Symptoms will depend on severity of stenosis. Myer-cotton Grading system uses endotracheal tubes to grade. 
        
    It is graded in 4 grades –
    Grades I – 0-50% obstruction,
    Grade II – 51% to 70% obstruction,
    Grade III -71% to 99% obstruction
    Grade IV – Total obstruction.
      
    Congenital S.G.S. also improves as the larynx grows. Less than 50% require tracheostomy. Dilation has little to offer in cartilaginous stenosis.
       
    In some patients, anterior cricoid split may be necessary to avoid tracheostomy. There are indications worked out by paediatric otolaryngologists:
       
    1. Extubation failure on at least two occasions because of subglottic malformation.
    2. Weight greater than 1500g
    3. No ventilator support for at least 10 days before procedure
    4. Supplemental oxygen requirement less than 30%
    5. No congestive heart failure for at least 1 month before the procedure
    6. No acute respiratory tract infection
    7. No antihypertension medication for at least 10 days before the procedure.
        
    Grade I and Grade II lesion – Role of endoscopic laser treatment and short term stenting exists.
        
    Grade III and Grade IV - Open operative procedure of reconstruction are required.
        
    Laryngeal Clefts
       
    Posterior laryngeal clefts (PLCs) and laryngotracheal esophageal clefts (LTECs) derive from a common embryonic anomaly. 30% of these are associated with polyhydramnios. They are also associated with different syndromes with anomalies of other organs.
       
    Two classifications exists:
    A) Evan’s system. – LTEC, type I – supraglottic interaytenoid that extend, above the level of glottis. Cricoid is
         uninvolved. Type II - Cricoid and cervical trachea is involved. Type III - Extends to thoracic trachea.
        
    B) Benjamin’s Classification is modified Evans.
        Type I - cleft above vocal cord
        Type II - partial cricoid cleft and extends to vocal cords
        Type III – Total cricoid cleft with or without cervical tracheal cleft.
        Type IV - A cleft extending to thoracic trachea with or without involvement of bronchi.
         
    Symptom of Posterior Laryngeal Clefts (PLCs) - copious secretions, aspiration, cyanosis during feeding and recurrent pulmonary infecitons.
        
    Diagnosis : Flexible laryngoscopy
    Contrast esophagrams.
         
    Management : Repair of PLCs and LTECs requires control of the airway. Special instrument if any to be done endoscopically or by external operation procedure like laryngofissure or lateral pharyngotomy.
        

  • Hussam K, EL-Kashlan and Steven A Telian (Univ. of Michigan)
    Diagnosis and initiating treatment for peripheral system disorders: Imbalance and Dizziness with Normal hearing
    Otolaryng Clinics of N. America, vol.33(3), June 2000
       

    Peripheral vestibular system consists of :
    (a) Vestibular labyrinth harbouring neuroepithelium responsible for identifying position and movements of head.
       
    (b) Vestibular nerve (part of cochlear vestibular nerve) carrying nerve fibres from labyrinth to CNS
       
    Disorder of Peripheral systems definitely affects hearing loss along with balance affected. However, certain following conditions cause dizziness without hearing loss.
      
    (1) Benign paroxysmal positional vertigo (BPPV)
    (2) Vestibular neuritis
    (3) Recurrent vestibulopathy
    (4) Familial vestibulopathy 
    (5) Bilateral idiopathic vestibulopathy.
       
    Detailed clinical interrogation should include (I) mode of onset and description of first episode. (ii) frequency and duration of each episode (iii) spontaneous or provoking causes (iv) associated auditory causes (v) EAR disease or any surgery on ear in the past.
       
    (1) Benign Paroxysmal Positional Vertigo (BPPV)
    It is brief episodes of vertigo precipitated by head movement in certain places. The most common cause, in elderly patients though no identifiable cause is known, commonly follows head trauma sequalea of vestibular neuritis, otologic surgery, infection or prolonged bed rest.
        
    BPPV characteristic clinical feature is that patient experiences giddiness following head movements like getting into or out of bed, rolling over or looking up and is associated with the nystagmus with distinctive characteristics-
        
    a) Latency period following provocative position 
    b) Intensifies gradually and has crescendo-decrescendo manner.
    c) Only 20-30 seconds duration even if position remains same.
    d) The nystagmus is torsionally beating towards undermost of the (offending ear) i.e. fast phase towards down ear. It is accompanied by a vertical up or down beating component because of post canal wall and anterior canal wall component respectively.
    e) Usually recurs and changes direction when patient moves back to sitting position.
    f) The response is fatiguable.
       
    PATHOGENESIS of BPPV
    Though there are two theories of mechanisms as to how vertigo occurs, the basic mechanism is accumulation of otoconial debris with higher specific gravity than endolymph within semicircular canal. It responds to linear acceleration including gravitation force.
        
    1) Schuknecht’s cupulithisis theory-
    The debris gravitates to adhere to the cupola of semicircular canal and changes in head position stimulates to cause giddiness. The theory, however, cannot explain all classical features of BPPV.
        
    2) Canalithiasis theory by Hall et al and supported by many authors.
    This theory postulates clot formation of floating otoconial debris near cupola. A clot moving in ampullofugal direction acts as a plunger on the endolymph, producing pressure or suction in the canal producing deflection of cupola and attack BPPV.
        
    VARIANTS OF BPPV
    Any of three semicircular canals may be involved. The direction of nystagmus will depend upon involvement of canal. 91% cases of posterior canal is involved. 3% anterior and 6% of lateral semicircular canals are involved.
        
    – Both vertical canals (i.e. anterior and posterior) produce torsional nystagmus. Vertical component will identify the canal. Upbeating nystagmus will be in a posterior canal, whereas, down beating nystagmus will point towards anterior canal. Provocative movement for vertical canal will be moving from a sitting position to a head hanging position.
       
    – Horizontal canal variant was proposed first by McClure procedures pure horizontal nystagmus and is caused by lateral head turn in supine position. The nystagmus changes direction as the head is turned from one side to the other lateral side. It may be geotropic (fast phase towards dependent ear) or ageotropic (fast phase away from the dependent ear)
       
    – In canalithiasis it is geotropic whereas in cupulothiasis it is ageotropic.
       
    TESTS FOR BPPV
    – Hallpike-Dix Test - for vertical canal BPPV
       
    – Side-Lying test – for vertical canal. It is more comfortable and is used in elderly patients.
       
    – Roll-test -f or horizontal canal BPPV.
       
    Treatment 
    Medical therapy of vestibular suppressants is not effective. In fact, it may affect central habituation process when relieves symptoms.
       
    (a) Single treatment Approach
    Aim is to maneuver the debris from canal into vestibule.
    The two most commonly used methods are those described by Epley or Semont et al.
       
    (b) Habituation Exercises Approach
    In 1980, Brandt and Daroff proposed the exercises which are sequence of lateral head/trunk tilts, repeated many times a day for 2-3 weeks to promote lossening and ultimately, dispersion of the debris towards the utricular cavity. These relieves patients vertigo but difficult to perform by patients because of experience of vertigo during these exercises. This is in sharp contrast to single manuvers of Epley or Semonts procedure.
       
    Surgical Approaches
    a) Gacek’s singular neurectomy.
    b) Postcanal plugging -procedure of choice by most otologists for BPPV.
        
    (2) Vestibular Neuritis
       

    This is the 3rd most common cause after BPPV and Menier’s.
       
    Clinical features:
    i) Sudden onset of vertigo with nausea and vomiting of a few days/
    ii) Absent audiologic findings and symptoms or signs.
    iii) Absent neurologic symptoms or signs.
    iv) Associated mostly with recent or concurrent URI (upper respiratory infection)
    v) Reduced or absent caloric response in one ear.
    vi) URIs – therefore can be seen in epidemics.
    vii) Autopsy reports axonal degeneration of one or more vestibular trunk points towards virus.
        
    Acute vertigo and spontaneous nystagmus which lasts a few days improves gradually though during recovery period any moment may provoke dizziness. Improvement is seen because (a) recovery of labyrinthine function (b) central compensation by adaptation though vestibular weakness can be demonstrated on one side. In elderly, it lasts longer.
    – BPPV has been reported following some vestibular neuritis patients.
    – Vestibular neuritis is single episode but some patient’s recurrent episodes may occur. Sequential vestibular neuritis in both ears may lead to differential diagnosis of bilateral vestibular neuritis.
        
    During investigations - vestibular neuritis showed reduced partial vestibular response in 90% of patients upto one month and 80% after 6 months. 42% patients showed recovery to normal caloric response in 10 year follow up study.
       
    – Peculiarly superior division of vestibular neuritis trunk is commonly affected. This supplies horizontal and anterior semicircular canals, maculae of the utricle and anterosuperior part of saculae. Inferior division supplying posterior semicircular canal is spared.
      
    This is corroborated by findings of temporal bone pathology and analysis of 3-dimensional properties of vestibulo occular nystagmus, in patients with vestibular neuritis.
       
    Differential Diagnosis:-
       
    – Cerebellar infarction
    – Wallenberg’s syndrome
    – Meniere’s disease
    – Acoustic neuromas
    – Migraine equivalent vertigo, 
    – Paraneoplastic syndrome, 
    – Metastatic carcinoma
    – Multiple sclerosis.
       
    Treatment : Symptomatic and supportive. Acute phase treated by labyrinthine sedatives and antiemetics. Possibly good effects of corticosteroids.
        
    Antiviral – No response
    Most of them have complete recovery. Those with persistent unsteadiness, have to undergo customised vestibular rehabilitation programme.
       
    (3) Bilateral Idiopathic Vestibulopathy
    Bilateral loss of vestibular function is induced most commonly by vestibuloxic effects of aminoglycosides gentamycin. This often has hearing loss in higher frequencies. Majority have no hearing loss but bilateral vestibular weakness. 20% with bilateral vestibulo hypofunction have no identifiable cause.
        
    Patterns of symptoms – 2 patterns are seen
    (i) present with initial vertigo
    (ii) present with insidius progressive unsteadiness without vertigo.
       
    Patients complain dysequilibrium which is worse at night and also accompanied by oscillopsia. This is caused by loss of bilateral vestibulo-ocular reflex {VOR}. Clinically this is tested by making patient to read a Snellen’s chart with steady head and then during horizontal head oscillations at a frequency of about 2Hz. Normal vestibular response show a one-line deterioration in visual acuity and with bilateral vestibular involvement. Five line deterioration is seen.
       
    Testing is by bilateral thermal caloric responses and rotational chair testing.
      
    Management of patients with bilateral vestibular loss is difficult. 50% show some improvement with adaptable exercise. Emphasis is placed on maximizing and optimizing visual and proprioceptive sensory inputs to substitute for the lost vestibular inputs. Risk of drowning is seen.
      
    FAMILIAL VESTIBULOPATHY – 
    Described by Baloh et al in 1994 and is presumed to have autosomal dominant mode of inheritance. It is characterised by brief episodes of vertigo for several years. Subsequently, it results in chronic dysequilibrium and oscillopsia. Bilateral vestibular weakness and response on caloric testing, electronystagmography vestibulo ocular reflex reduced. Gain on rotation chair testing.
       
    All tests were normal, audiologic, imaging and neurological findings. Migraine headaches were an important feature of this syndrome. All members and their parents suffer from migraine.
       
    Treatment : All patients responded well to treatment with acetazolamide with resolution of attack of vertigo. The location of site of lesion is unknonwn.
      
    Another familial syndrome with episodes of little longer lasting vertigo and essential treatment migraine has been identified. No progressive bilateral vestibular weakness develops. Acetazolamide was helpful in reducing vertigo and migraine.
       
    RECURRENT VESTIBULOPATHY
    This clinical entity was described by LeLiever and Barber in 1981. Recurrent spontaneous episodes of vertigo similar to that of Meniere’s disease. However, no audiologic, neurologic symptoms and signs noted. The natural history is different from that of Menieres. 73 patients followed up for 8.5 yrs, 72% retained original diagnosis, however the diagnosis was changed to Meniere’s disease in 14% and 8% in BPPV.
       
    There is no known cause. Viral cause has been suggested. Periodic blockade of afferent activity of one vestibular nerve by reactivation of dominant virus is postulated as a mechanism. 22% patients showed reduced unilateral caloric response.
       
    Treatment: Symptomatic and assurance. The prognosis for spontaneous resolution is good.
          

  • David Solomon
    Distinguishing and Treating Causes of Central Vertigo
    Otolaryn Cl.of North Americal, vol.33(3), June 2000, pg. 579- 
       

    When evaluating a case of acute vertigo, it is important to make sure to distinguish between peripheral and central cause. Central causes require urgent intervention or may require intensive care unit (ICU) monitoring.
      
    How history, examination and laboratory testing can help to confirm a central etiology is considered.
      
    History – patient feel “woozy”, “about to black out,” “disoriented” or “lightheadedness”. Worse while standing. These are connected with blood flow circulation to brain, therefore central.
       
    Causes : 1) Hyperventilation
    2) Orthostatic hypotension
    3) Vasovagal attacks
    4) Cause of decreased cardiac output
    5) Psychophysiologic
    6) Hypoglycemic
    7) Drug toxicities – like alcohol, barbiturates, benzodiazepine and 
    anticonvulsants.
    8) Postconcussion syndrome
    9) Infarction of labyrinth, brainstem or cerebellum
    10) Migraine headache.
       
    Examination and testing
    a) complete neurologic examination
    b) study of nystagmus and its induction test.
       
    Absence of a positive head impulse test in acute vertigo attack makes a central cause. 
       
    Bedside examination findings suggestive of nonperipheral etiology.
       

    Position Provoked Vertigo
    Brainstem and cerebellar lesion can cause persistent vertigo with vertical nystagmus or torsional nystagmus.
       
    1. Direction changing or purely vertical nystagmus
    2. Sustained or nonfatiguing positional nystagmus
    3. Dissociated (disconjugate) nystagmus
    4. Abnormal posture when seated, inability to stand
    5. Focal motor deficit
    6. Dysarthria, dysphagia, diplopia, dysmetrial (limb ataxia)
    7. Horner’s syndrome (sympathetic paresis of the pupil, with unilateral failure to dilate in darkness and ptosis)
    8. Loss of pin prick or temperature sensation on one side of the face, or on the other side of the body.
    9. Intractable hiccups.
       
    Ocular Motor Signs of Central Disease
    Persistent vertical nystagmus is certainly of central origin. It indicates brainstem involvement as well as diffuse cerebellar region.
       
    Diagnoses in Patients with Downbeat Nystagmus
       

    Infarction 25%
    Cerebellar (spinocerebellar) degeneration 24%
    Multiple sclerosis 13%
    Developmental anomaly (e.g. Chiari, basilar invagination) 12%
    Drug toxicity (phenytoin, carbamazepine) 4%
    Trauma 3%
    Neoplasm 3%
    Alcoholic cerebellar degeneration 2%
    Arteriovenous malformation 2%
    AIDS, familial periodic ataxia, viral encephalitis, radiation 1% (each)
    No cause 5%.
       
    – Disconjugate recordings are indicative of lesions of the medical longitudinal fasciculus.
    – Perverted nystagmus is related to lesion of vestibular nuclei
    – Sea-saw nystagmus – cuased by midline compressive lesions in suprasellar area in which it is generally pendular.
    – Unilateral lesions in the rostral midbrain cause a jerk waveform see-saw nystagmus.
    – Vertical diplopia – sign of supranuclear or infranuclear pathology.
    – Periodic alternating nystagmus occur with lesion of posterior cerebellar vermis.
       
    Characteristics of Central Nystagmus:
    Central spontaneous nystagmus is direction changing pure vertical, or torsion, is not suppressed by vision and is associated with normal head impulse test and ataxia even for sitting patients cannot stand.
       
    Cerebellar signs:
    Whatever may be the aetiology, signs are as follows:
      
    1. Gaze-evoked, direction-changing horizontal nystagmus
    2. Rebound nystagmus
    3. Vertical, typically downbeat nystagmus, often worse in lateral gaze.
    4. Alternating skew deviation
    5. Saccadic dysmetria and major saccadic oscillations (flutte,r macrosquare-wave jerks)
    6. Position-provoked vertigo (not fitting benign paroxysmal positional vertigo)
    7. Oscillopsia at rest (caused by nystagmus) and head movement.
    8. Wide-based gait ataxia with poor tandem gait, inability to maintain Romberg position even with eyes open
    9. Poor horizontal and vertical smooth pursuit (absent VOR cancellation)
    10. Tremor, dysarthria, limb ataxia.
       
    Spinocerebellar atrophy
    Migraine
    Multiple sclerosis
    Internuclear ophthalmoplegia
    Vascular disease
    Lateral Medullary Syndrome
    Positive syndrome
    Cerebellar infarction.
       
    Vascular malformtion and headache
    Neoplastic disease
    Other conditions – Palatal tremor
    – Wernicke’s encephalopathy
    – Epilepsy
      
    All the above conditions are central cause of nystagmus.
         

  • NH Blevins, BL Carter (Tufts-New England Med Ctr, Boston)
    Clinical Forum: Routine Preoperative Imaging in Chronic Ear Surgery,
    Am J Otol 19: 527-538, 1998.
      
    Imaging studies, especially CT, can demonstrate the nature and extent of chronic otitis media, which may not be apparent on clinical findings per se. Such findings can affect operative treatment, especially in difficult and/or revision procedures. However, there is a view that routine radiography of the mastoid may suffice in being very helpful in most cases.
       

  • TS Karhuketo, HJ Puhakka (Tampere Univ, Findland)
    Middle Ear Imaging Via the Eustachian Tube With a Superfine Fiberoptic Videomicroendoscope.
    ORL J Otorhinolaryngol Relat Spec. 60: 30-34, 1998.
       
    With a fibreoptic videomicroendoscope inserted through the Eustachian tube, 56% of predetermined anatomical objects in the middle ear were visualized. 
      
    However, one may find obstructive sites or mucosal folds that may prevent a complete view of all the contents of the middle ear cleft.
        

  • Michael J Ruckenstein, (Univ of Pennsylvania)
    Vertigo & Dysequilibrium with Associated Hearing Loss
    Otolaryng. Cl.of N.America, June 2000. Vol.33(3), pg.535-562
      

    CONGENITAL
    Congenital malformations of the membranous or osseomembranous components of the inner ear results from defects in inner ear development during the fourth to eighth week of fetal gestation.
       
    The overall incidence of congenital is 1 in 1000 live births. It is either syndromic or nonsyndromic presentation.
      
    Clinical presentation is with hearing loss which is either congenital or within two decades of life. Only 20% complained of vertigo or imbalance.
       
    CT Scan on MRI of high resolution reveal the abnormalities. Abnormal vestibular findings are recorded on vestibular testing.
       
    CLASSIFICATION OF CONGENITAL LABYRINTHINE ANOMALIES
    Malformations of the membranous labyrinth
    Complete membranous dysplasia
    Partial membranous dysplasia
    Cochleosaccular (Scheibe)
    Cochlea – basal turn (Alexander)
       
    Malformations of the osseous and membranous labyrinth
    Complete labyrinthine aplasia (Michel)
    Cochlear
    Aplasia
    Hypoplasia
    Incomplete partition (Mondini)
    Common cavity
    Labyrinthine
    Dysplasia of the semicircular canals
    Aplasia of the semicircular canals.
       
    Malformations of the vestibular aqueduct
    Narrow or wide internal auditory canal.
       
    Treatment:
    Hearing amplification with hearing aids or cochlear implants are the mainstay of treatment. Vestibular suppressant medication are indicated for bouts of vertigo if any.
       
    ACQUIRED
    Trauma – Temporal Bone
      

    Blunt trauma or penetrating trauma. Auto accidents or bullet or knife injuries to inner ear damage results into sensorineural hearing loss. Facial nerve may be damaged.
       
    Clinical presentation:
    Vertigo and hearing loss or facial nerve paralysis, bleeding from ear or watery fluid (Cerebrospinal fluid – CSF) from the ear. CT Scan may reveal fracture line in temporal bone.
       
    Treatment will depend upon the presentation and investigative findings. Exploration of ear and mastoid of facial nerve or CSF leak is present or conductive hearing loss is present.
        
    Barotrauma
    Rapid changes in ambient pressure may result in pressure transmitted to inner ear, thus causing temporary or permanent inner ear dysfunction.
       
    Aetiological factors are seen in drivers, airplane flight or forceful sneezing or airblast injuries. Treatment will depend upon the aetiological factors.
        
    Perilymph Fistula
       

    Three possible mechanisms:
    (a) Congenital dehiscences in labyrinth
    (b) Disruption of oval or round windows by secondary to trauma which may be iatrogenic, (poststapedectomy) or penetrating or severe implosive pressure trauma. Even barotrauma may cause the fistula.
    (c) Spontaneous – controversial
       
    Clinically – present with sudden sensorinueral loss associated with tinnitus and vertigo. Fluctuating hearing loss.
        
    Investigations: No valid or accurate diagnostic tests. Audioventricular testing is done. 
    Present – Exploration of middle ear and locating the leak and sealing it
       
    Otosclerosis
    Usually conductive hearing loss and the diagnosis is easy by audiological testing. Clinically young adults with tinnitus and conductive hearing loss. Family history may suggest otosclerosis.
       
    Usually no vestibular complaints. If at all any, then they complain of vertigo. Three possible patterns are noted. Positional vertigo or Meniere’s like syndrome or small number manifest as recurrent episodes of vertigo.
       
    Treatment : 
    It is by stapedectomy. Small number with sensorineural loss or mixed loss are treated with fluoride.
      
    Neoplasm:
    Cerebellopontine angle tumours, vestibular schwannoma, meningioma or petrous apex cholesteatomas.
       
    Clinically present with vertigo, hearing loss, tinnitus or facial nerve paryngitis. Very large tumours may demonstrte 5th, 9th, 10th or 11th with cerebellar signs.
        
    Diagnosis : By CT scan or MRI
    Treatment : It is operative treatment.
       
    Infectious:
    Labyrinthins: Either by bacteria or virus, depending upon otitis media or general viral infection. Herpes infection.
        
    Clinical presentation is by sudden severe hearing sensorineural hearing loss, with vertigo lasting for days. Hearing may be irreversibly damaged.
       
    Treatment will be by antibiotics and corticosteroid. Operative treatment for those with cholesteatoma or chronic mastiditis.
       
    Syphilis: 
    Is rare nowadays. It is diagnosed by VDRL. FTA - ABS or MHA – TP tests are done to confirm. Treatment is by antibiotics and steroids.
       
    Ototoxicity
    Most agents are toxic to cochlea. Aminoglycoside antibiotics are major vestibulotoxic drugs used today. Individual succeptibility, in addition to renal failure, hepatic failure or old age, concurrent use of other ototoxic drugs, familial history are other aetiological factors.
       
    The most common are Gentamycin and streptomycin and tobramycin. Outer hair cells of the vestibule is affected mainly. The basal regions of cochlea, the apices of the cristae, and the striolar regions of the maculae are affected most.
       
    Clinically – acute onset of hearing loss or imablance with oscillopsia is seen. These occurs while patient is on treatment or up to several weeks after treatment. Usually bilaterally affected. Vestibular damage is permanent. Bilateral vestibular reduced response is seen on caloric testing or ENG.
      
    Treatment is mainly by monitoring the effects of drug to prevent. Once it occurs then only symptomatic treatment is given.
      
    Immunologic:
    Autoimmune Inner Ear Disease
    Patients own immune system becomes reactive to self-antigens resulting into autoimmune disease. Multisystemic autoimmune disease like systemic lupus erythematosus may be associated. 
      
    It  is rare cause. Degeneration of organ of Corti, vestibular sensory organs, stria vascularis and dark cell layers, as well as fibrosis and osteoneogenesis is seen.
       
    Clinical Presentation :
    Rapidly progressive bilateral asymmetric sensorineural hearing loss is seen. Hearing levels fluctuates and 25-50% patients complain of vertigo.
       
    Cogan’s syndrome :
    Patients present with interstitial keratitis with vertigo, hearing loss and tinnitus. Ocular and labyrinthine pathology occur together or within 6 months of each other.
      
    Other Multisystemic Autoimmune Diseases:
    Wegner’s granulomatosis, polyartertitis nodosa, rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis and ulcerative colitis may involve the inner ear.
      
    Investigations are mainly various antigen antibody tests but are not very helpful. Only probable diagnosis is proved by positive response to imunosuppressant drugs like corticosteroids. 
      
    Dose is 1 to 2mg/kg/day for 1 month. Other drugs are methotrexate or cyclophosphamide. The maintenance of the dosages are required.
      
    IDIOPATHIC
    Meniere’s disease
    Symptom complex of vertigo,hearing loss, tinnitus and aural fullness. Pathology is endolymphatic hydrops.
       
    Clinically it presents as episodic vertigo associated with fluctuating and progressive hearing loss, chronic tinnitus and fullness of ears.
        
    Investigations – audiometric test
    ECOG
    FTA-AB – serological test
       
    Treatment – Medical – vestibular suppressants
    – diuretics
    – vasodilatation
      
    Surgical – Endolymphatic sac surgery procedure
    Gentamycin perfusion
    Vestibular nerve section
    Labyrinthectomy.
       

  • Craig S, Derkay, MD, and David H. Darrow, MD
    Voice Disorders and Phonosurgery II
    From the Department of Otolaryngology – Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, Virginia
    The Otolaryngologic Clinics of North America Volume 33, Number 5, Ocober 2000, Pg. 1127
       
    Recurrent respiratory papillomatosis [RRP] is a disease of viral origin, caused by human papillomavirus.
      
    Although it is a benign disease, RRP has potentially morbidconsequences because of its involvement of the airway and the risk of malignant conversion.
       
    Recurrent respiratory papillomatosis is the most common benign neoplasm of the larynx among children and is the second most frequent cause of childhood hoarseness. 
      
    Although is usually involves the larynx, RRP may involve the entire aerodigestive tract.
      
    Because the most common symptoms of RRP are related to airway obstruction, it is not uncommon for children to be misdiagnosed initially as having asthma, croup, or chronic bronchitis.
       
    The hallmark of RRP in children is the triad of relentlessly progressive hoarseness, stridor, and respiratory distress.
      
    ORIGIN
      
    Human Papillomavirus
      
    Until the 1990s, HPV had been suspected but not confirmed as the causative agent in RRP.
      
    This uncertainty developed from an inability to culture the virus in vitro, and from the failure to demonstrate viral particles consistently in papilloma lesions using electron microscopy of HPV antibodies.
      
    With the use of viral probes, HPV DNA has been identified in almost every papilloma lesion studied. 
      
    The most common types identified in the airway are HPV 6 and HPV 11, the same types responsible for genital warts.
       
    An association between cervical HPV infection in the mother and the incidence of RRP has been well established.
        
    Adult-onset respiratory papillomas could reflect either activation of virus present since birth or an infection acquired in adolescence or adult life.
      
    Recurrent Respiratory Papillomatosis
    The most common sits for RRP are the limen vestibuli, the nasopharyngeal surface of the soft palate, the midline of the laryngeal surface of the epiglottis, the upper and lower margins of the ventricle, the undersurface of the vocal folds, the carina, and at bronchial spurs.
      
    Surgical Management
    No single modality has consistently been shown to be effective in eradicating RRP.
       
    The CO2 laser has been favored over cold instruments in the treatment of RRP involving the larynx, pharynx, upper trachea, and nasal and oral cavities.
      
    Although the CO laser allows surgical precision and excellent hemostasis, multiple procedures are often necessary.
        
    Because currently no therapeutic regimen reliably eradicates the HPV, when there is a question about whether papilloma in an area needs to be removed, it is prudent to accept some residual papilloma rather than risk damage to normal tissue and producing excessive scarring.
      
    Even with the removal of all clinically evident papilloma, latent virus may remain in adjacent tissue; this remaining latent virus may explain the recurrent nature of RRP.
       
    Adjuvant Treatment Modalities
    The most commonly recommended adjuvant therapy is alpha-interferon. The exact mechanism by which alpha-interferon elicits its response is unknown.
          
    Common interferon side effects fall into two categories: acute reactions [fever and generalized flu-like symptoms, chills, headache, myalgias, and nausea that seem to decrease with prolonged therapy] and chronic reactions [decrease in the growth rate of the child, elevation of liver transaminase levels, leukopenia spastic diplegia, and febrile seizures.
       
    Acetaminophen has been found to relive the fevers effectively, and interferon injections are best tolerated at bedtime. 
       
    Photodynamic therapy [PDT] in the treatment of RRP has been studied extensively:-
        
    Photodynamic therapy is based on the transfer of energy to a photosensitive drug. The drug originally used was dihematoporphyrin ether [DHE], which has a tendency to concentrate within papillomas more than in surrounding normal tissue.
        
    Ribavirin is an antiviral drug, used to treat respiratory syncytial virus pneumonia in infants, that has also shown some promise in the treatment of aggressive laryngeal papillomatosis. 
         
    Another antiviral drug that has been advocated in the treatment of RRP is acyclovir.
       
    It has been postulated that acyclovir may be most effective when there are comorbidities, such as a simultaneous infection with herpes simples virus.
       
    Two recent reports have stimulated interest in the intralesional injection of cidofovir [Vistide ] [HPMPC], a drug currently FDA-approved for use for HIV patients with CMV retinitis.
         

  • P. Chang, Los Angeles, USA.
    Controversies in Vestibular Schwannoma Treatment: Surgery versus Irradiation.
    ENT News, 9(5), Nov./Dec.2000, p.14-15
         
    Cropping of these controversies has been because of irradiation as an alternative to surgery. Microsurgery is the present day choice for vestibular schwannoma.
         
    The following questions arise in the critical minds of patients:
    a) What is the expected morbidity of surgery?
    b) Is hearing preservation possible?
    c) Can benign tumour be irradiated without any long-term side effects?
    d) How effective radiation is?
    e) Are the results competitive to that of surgery. Will all be judged in justifying the alternative treatment of Vestibular Schwannoma?
          
    Tumour: 
    Vestibular schwannoma tumours arise from neural sheaths and are benign. Their situation in internal auditory canal and cerebellopontine angle, make them dangerous by position. The tumour consists of nothing but proliferating Schwann cells, which is very slow viz. 1 to 2 mm per year. Majority grows producing progressive hearing loss. This growth however, exceptionally can be unpredictable. That is why in fit patient, intervention is required. Technological advances in early precise diagnosis by imaging techniques and advances in management have proved the surgical outcomes much favourable.
        
    However, technological advances in radiotherapy have also offered an alternative treatment.
          
    Surgical Background:
    It has come a long way from removal of tumour by finger, by Balance in London in 1894 to perfection of precise removal by translabyrinthine, retrosigmoid and middle fossa approaches derived by Dr. William House in 1964, almost without mortality and minimal of morbidity. Today there is likelihood of complete removal with zero mortality rate, near normal facial nerve function in 95% and less than 0.3% recurrence rate and 70% rate of preservation of hearing in selected patient makes the treatment by surgical excision treatment of choice.
         
    The negative points are that it is intracranial procedure with its attendant risks of C.S.F leak, meningitis and intracranial bleed. It incurs cost and 4-5 days of hospitalization.
        
    Today the treatment by radiation may be opted to (a) Medically unfit patients (b) Recurrent tumours (c) Elderly patients (d) Who refuse surgery. The use of radiotherapy as primary mode of treatment of vestibular schwannoma has also been promoted.
         
    Background of Radiotherapy
    Lars Leksell (1971) at Sweden (Karolinska Institute in Stockholm) first reported gamma radiation ports administered stereotactically during a single sitting to arrest the tumour growth.
         
    The principle is to target the lesion, minimising, the radiation dose to surrounding neural tissues. The term “stereotactic radiosurgery” was coined and particular technique used was called the ‘gamma knife’.
         
    The treatment evolved in last decades. The radiation dosage of 25Gy has been reduced optimally to 13Gy delivered by Linear accelerator and is now fractionate. This has resulted into improvement in tumour control and preservation of normal neural tissue.
         
    The Controversy
    – Because of close relations of tumour capsule to 7th and 8th nerve, it is impossible to avoid radiation to these nerves.
       
    – The effects of radiation are cell deaths and delayed vasculitis. Vasculitis is not observed because of sparse blood supply as against seen in glomus.
          
    – Subsequent surgical intervention, if required in these irradiated tumour, lead to hazzardous dissection resulting in poor hearing and facial nerve function.
          
    So the alternative treatment is reserved for those patients who are unfit or unwilling to undergo microsurgical removal of tumour.
          

  • John Diaz Day, (Neurological and Skull Base Surgeon, House Ear Clinic, Los Angeles, USA)
    Radiotherapy or microsurgery – which treatment and why?
    ENT News, vol.9(5),Nov/Dec.2000, p.16-17
          
    The microsurgical excisions are currently exceeded and continue to improve.
    If the results are compared with those centres with inexperienced teams doing small number of cases, the stereotactic radiotherapy gains momentum.
          
    Patients with tumours 3cm or larger most agree are candidates for surgery. Relief of mass effect and hydrocephalus is well achieved. Facial nerve function and hearing preservation in anyway par with large tumours. The extent of 60% in facial nerve function preservation is good.
        
    Main debate over patients with small or medium tumours, intracanalicular tumours tilt in favour of surgery for number of reasons.
        
    At this institution in 372 patients over the last 5 yrs had 95% of facial nerve function preservation and about 70% hearing preservation was seen. These results of function preservation are durable. This is not so in stereotactic radiosurgery where hearing may further deteriorate with time.
        
    Recurrent rate in surgery is 0.5% as against radiation which is 6-10%, where the tumor recurs or grows further.
        
    He also points out that if radiation fails subsequent microdissection results in poor function of facial nerve preservation and hearing preservation.
        
    Radiosurgical series still must stand the test of time when utilizing ‘control’ as a means of establishing efficacy. They must do better than the natural history of vestibular schwannomas left untreated. When roughly two-thirds of tumours will not change their appearance on serial imaging with no treatment, how do we can say that my treatment is effective at ‘controlling’ tumour growth over a similar follow-up period with a similar number of tumours not demonstrating growth ?
         

  • Andras A Kemeny, Royal Hallamshire Hospital, Sheffield, England
    What is the role of radiosurgery in Vestibular Schwannoma treatment?
    ENT News, Nov/Dec.2000, vol.9(5), p.19
        
    It is a surgical technique, the concentrated radiation is achieved by crossfiring 201 fine gamma ray beams focused into a single point. Initially with poor imaging and slow computers, this was difficult to achieve. But with the introduction of high resolution, volume acquisition MR imaging and powerful 3D computational software the true potential of this technique could be realised. 
         
    Since 1985, 540 accoustic neuromas were treated with mean age 51, 48% males, 21% (116) were bilateral tumours. The median diameter was 6-57mm. 36% had at atleast one previous resectional surgery. A large proportional had neurological deficit particularly with those who had surgical intervention. Even since 1995, only 20% have normal facial nerve function and 13% had none. Seventy-two cases of previously operated cases had complete deafness.
        
    In 1980, when 25Gy dose was given, facial weakness in 85% and hearing preservation was poor. With reduction of dose to 13-15Gy, radiological tumour control remained around 88% with minimum follow-up of 5 years. Useful hearing was preserved in 76% and facial weakness only in 5.2%. These results compare well with larger surgical series.
         
    Radiosurgical failures are not declared for at least 3 yrs and no surgery should be undertaken on this basis.
         
    The risks and difficulty of surgery after radiosurgery is exaggerated.
         
    A warning by nonpractising radiosurgeons is given to patietns of possibility of malignant change in later years. Very rarely seen. To date about 15000 acoustic neuromas are treated and by telephone survey, only 5 cases of sarcomatous change were confirmed after radiosurgery. Nevertheless, the alertness is necessary.
         
    Which cases should be referred to radiosurgery? Probably the answer is which should not be?
        
    Lesions beyond 3.5cm that produce larger mass effect may need surgical decompression. Tumours incidentally found may be monitored radiologically and audiometrically.
        
    Those above 65 years of age, the medically infirm and those who can’t afford even a low risk of surgical mortality will be more and more considered for radiosurgery.
        
    There is a demand for noninvasive methods of treatment with less disruption to their life. Those who are well informed by internet and those who are in medicolegal climate should be informed of availability of radiosurgery of these tumours.
         

  • Dr. Paul A Fagan, St. Vincent’s Hospital, Sydney, Australia
    How does the outcome of radiotherapy compare with microsurgery for vestibular schwannomas?
    ENT News, Nov./Dec.2000. vol.9(5), p.20
        
    The article discusses pros and cons of both treatment but tilts more in tumour of surgery.
       
    In summary, the author states surgery for acoustic neuroma is a proven, safe and effective treatment with reproducible results. In particular, the long-term safety of this treatment is well documented. Radiotherapy, on the other hand, does not achieve a cure, the early results are little different to the natural history of the disease and serious long-term complications can occur.
         

  • L Dade Lunsford, Ajay Niranjan, (Pittsburg, Philadelphia)
    What are the results and rationale of stereotactic radiotherapy in the management of vestibular schwannomas?
    ENT News, Vol.9(5), Nov./Dec.2000. P.23
         

    For acoustic neuromas, the surgical alternatives are microsurgery and gamma knife.
         
    Today, good imaging technique achievers have very early diagnosis with minimal symptoms. The goals of management have shifted from tumour removal to preservation of neurological function viz. facial nerve function and hearing preservation.
         
    The goals of radiosurgery are to inactivate the tumour, as against physical removal by microsurgery. The gradual tumour reduction in size is noted over the next two to seven years period. The aim is to prevent further growth, while preserving 7th and 8th nerve function and other neurological and employment status. 
        
    At the University of Pittsburgh, 622 patients have undergone gamma knife radiosurgery over a period of 13 years.
         
    Currently, 13Gy to the tumour margin in a single session is utilized. Usually within 6-18 hours patient is discharged. All patients are followed up with MRI and audiometric studies at 6-months, 1,2,4 and 8 years.
         
    Analysis of 5-10 year outcome of 162 unilateral tumours treated with radiosurgery between 1987 and 1992, a 98% tumour control rate has been achieved. Only 2% of patients required tumour resection. No additional difficulties were encountered in resection procedure.
         
    No patient with an intracanalicular tumour developed new facial or trigeminal neuropathies, 21 of 487 patients (4.3%) had improvement in hearing.
         
    With all patients, the concept of tumour growth control versus tumour removal should be discussed. All options should be put forward. According to him by 2001, many patients with newly diagnosed acoustic tumours should undergo gamma knife radiosurgery as the management option of choice.
              

  • Som PM, Curtin HD, Mancuso AA
    Imaging of the Neck 
    ORL 2000; 62: 186-198
         
    This article relates to the use of C-T scanning in staging of neck in details. A full written classification is given in the text together with diagnosis explaining each of the levels. It is very clear and consistent set of guidelines to help stage the neck on radiological grounds - CJW.
         

  • Kau R J, Alexiou C, Stimmer H, Arnold W.
    Investigations for neck nodes
    ORL, 2000; 62: 199-203
       
    This well-written article from Germany provides an overview of the current methods used in status of neck nodes in head and neck malignancies. It compares CT, MRI, ultrasound (US), US guided FNAC, colour doppler US and PET with clinical staging.
        
    The least accurate method of detecting lymph node, though the cheapest method of palpation gives 69.7% accuracy. Ultrasound with its limitation of 72.7%, and US guided FNAC 89%.¸CT has 84.9%, MRI 85%. PET scanning most accurate at 90.5% but is not easily available. Colour doppler studies -show reactive nodes have increased hilar blood flow, while metastatic nodes have peripheral blood flow.
       
    The advantage of US guided FNAC is that it gives histological diagnosis and staging. However, its invasive procedure is to be kept in mind.
        

  • Fertilo A, Som PM, Rinaldo A, Mondin V
    Classification of neck dissection
    ORL -2000; 62: 212-216
        
    Many terms are used in various neck dissection procedures but to describe accurately what procedure has been done is still confusing.
        
    The most commonly accepted classifications designed by Fertilo in 1998. This divides into (1) comprehensive neck dissection (2) selective neck dissection and (3) extended neck dissection.
        
    1. Comprehensive neck dissection – (including radical or modified radical) involves dissection of I-V level.
    2. Selective neck dissection 
    In this one or more lymph node levels are left in situ.
    3. Extended neck dissection – it implies removal of all I-V level nodes and additional lymph nodes or structures, which are not removed in radical neck. Additional structures include accessory nerve, jugular vein, or sternocleidomastoid muscle.
         
    The authors suggest the staging of the neck by P M Som to be methodology and then described the surgical procedures in the above manner i.e. level of lymph nodes and additional structures removed or preserved. This is simple method to record and compare.
          

  • Fertilo A, Silver CE, Rinaldo A, Smith RV 
    Surgical options for the neck
    ORL 2000: 62: 217-225.
       
    This article summarises the surgical options for both NO and node positive necks. It also discusses the adjuvant treatment of radiotherapy or chemotherapy.
         
    (A) In clinical and radiological negative neck – selective lateral neck dissection with levels II to IV or VI as necessary with or without preservation of 11th, Jugular vein or sternocleidomastoid.
         
    (B) In the necks – treatment varies on N stage.
         (a) High N stage neck – Radical neck dissection including VI and VII where necessary.
         (b) However, N stage neck – more selective neck dissections after levels I to V including VI or VII.
        
    Postoperative adjuvant therapy are best reserved for extracapsular spread. Authors prefer primary surgery as it allows accurate p-staging with obvious prognostic implications. CJW.
         

  • Ferjaoui M, Kooli H, Najeh D, Hajri H
    The nose in Crohn’s disease
    Revue De Laryngologie Otologie Rhinologie, 1999: 5: 341-342
         
    This is a case report of very aggressive type of primary atrophic rhinitis. With marked crustastions, destruction of the turbinates and septum with saddling of nose and involvement of maxillary sinus.
        
    The second biopsy done during (intestinal exacerbation) showed typical features of Crohn’s disease.
         
    The systemic therapy of intestinal disease improved all nasal pathology.
        
    The issue is to ask, patients of Primary Atrophic Rhinitis, about gastrointestinal symptoms and other lesions suggestive of Crohn’s disease.
        

  • Krouse JH 
    Staging of Inverted Papilloma
    Laryngoscope 2000: 110: 965-968
        
    Formerly medical maxillectomy through an external incision was treatment of choice as against that today endoscopy is the treatment followed by most of them. This is controversial because of an association of inverted papilloma with malignancy.
        
    This study utilized a literature review to develop a simple and easily applied staging system – based on endoscopic examination of the nasal cavity and CT scanning.
        
    The staging system is as follows:-
    Stage I – Disease is limited to nasal cavity.
    Stage II – It is limited to the ethmoid sinuses and medial and superior portion of the 
    maxillary sinuses.
    Stage III – Involves the lateral or inferior aspects of maxillary sinuses or extension 
    into the frontal or sphenoid sinuses.
    Stage IV – Involves tumour spread outside the confines of the nose.
        

  • Moreau PR 
    Laser Laryngeal Surgery