Arch Otolaryngol Research Articles

Tissue Expansion: King Khalid University Experience

Tissue expansion is a means of mechanically generating excess soft tissue adjacent to a defect. The advantage of this technique is that it enables replacement of missing tissue with similar tissue of matching color, texture and other inherent local characteristics. The mechanism of generating skin by this technique and the physiologic changes occurring in the skin during the process of expansion have been well studied in animal models. 1-3 However, meticulous attention to detail is required to reduce the incidence of complications associated with the technique and to achieve optimum results. We present here our experience with 128 tissue expanders in 97 patients in an Arab population. The treatment was carried out at King Khalid University Hospital from 1989-1996. The aim of the study is to evaluate the outcomes of tissue expansion, with a view to identifying the factors that could contribute to minimizing complications.

Sickle Cell Disease and Tonsillectomy

Background: Patients with sickle cell disease are recognized as having a relatively higher risk for postoperative complications, including fever, atelectasis, pneumonia, or sickle cell vaso-occlusion. Objective: To present a protocol for preoperative management of patients with sickle cell disease undergoing tonsillectomy, including the use of transfusions and intravenous hydration. Design: Retrospective chart review. Setting: Academic, tertiary care referral medical center. Patients: Seventy-five patients with sickle cell disease who underwent tonsillectomy with or without adenoidectomy were included for review. Preoperative management was documented, and risk factors were assessed. Intraoperative management was reviewed, and postoperative complications were identified and compared with preoperative data and management. Results: Preoperative management consisted of transfusions to a hemoglobin S ratio (hemoglobin S—total hemoglobin) less than 40% or a hemoglobin level greater than 100 g/L. Aggressive intravenous hydration of 1.5 times the maintenance fluid was given 24 hours before surgery. Increased complications were associated with a preoperative hemoglobin S ratio greater than 40% (P Conclusions: Children with sickle cell disease presenting for elective tonsillectomy should be given a transfusion to a hemoglobin S ratio less than 40% in an attempt to reduce postoperative complications. Additional factors, such as age and presence of obstructive sleep apnea, only increase the potential risks. Arch Otolaryngol Head Neck Surg. 1997;123:689-692

Efficient and persistent gene transfer of AAV-CFTR in maxillary sinus

Cystic fibrosis is a common, lethal, genetic disease caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR), and it is an attractive target for gene therapy. Adeno-associated virus (AAV) is a naturally replication-deficient single-stranded DNA parvovirus. Preclinical studies showed that CFTR transcripts and protein can be detected up to 6 months after transduction with an AAV-CFTR vector, 1 Flotte TR Afione SA Conrad C et al. Stable in vivo expression of the cystic fibrosis transmembrane conductance regulator with an adeno-associated virus vector. Proc Natl Acad Sci USA. 1993; 90: 10613-10617 Crossref PubMed Scopus (443) Google Scholar with no pathogenicity, 2 Conrad CK Allen SS Afione SA et al. Safety of single-dose administration of an adeno-associated virus (AAV)-CFTR vector in the primate lung. Gene Ther. 1996; 3: 658-668 PubMed Google Scholar suggesting that AAV performs well as a gene transfer vehicle for CFTR. The maxillary sinuses are attractive for evaluating new treatments of cystic fibrosis because they have ion-transport systems and microbiology similar to those of the lower respiratory tract. 3 Moss RB King VV Management of sinusitis in cystic fibrosis by endoscopic surgery and serial antimicrobial lavage: reduction in recurrence requiring surgery. Arch Otolaryngol Head Neck Surg. 1995; 121: 566-572 Crossref PubMed Scopus (121) Google Scholar , 4 Wine JJ King VV Lewiston NJ Method for rapid evaluation of topically applied agents to cystic fibrosis airways. Am J Physiol. 1991; 261: L218-L221 PubMed Google Scholar Recurrence of maxillary sinusitis may prove to be a surrogate for infectious exacerbations characteristic of cystic fibrosis lung disease.

Tubeless Spontaneous Respiration Technique for Pediatric Microlaryngeal Surgery

Background: Tubeless spontaneous respiration technique for pediatric microlaryngeal surgery may be accomplished using different anesthetic protocols. Two methods, inhalation of volatile anesthetic agents alone and in combination with intravenous propofol, are reviewed with regard to intraoperative airway stability, post-operative morbidity, recovery room course, and halothane concentration required during maintenance anesthesia. Design: Retrospective case series. Setting: Otolaryngology referral hospital. Patients and Methods: Twenty-nine microlaryngeal procedures were performed using tubeless spontaneous respiration technique in children ranging from 2 weeks to 11 years of age. The following 2 anesthetic protocols were used: inhaled volatile anesthetic agents alone in 18 procedures and in combination with intravenous propofol in 11. Anesthesia, surgery, and recovery room times were documented. Specific characteristics of anesthetic maintenance, including total anesthetic gas flow (liters per minute), variations of halothane concentration (percentage), and duration of halothane administration (minutes) were also recorded to calculate the mean concentration of halothane (percentage) delivered to each patient. Results: No statistical differences were observed between the 2 protocols in terms of anesthesia and surgical outcomes. Adjusting for differences in patient age, weight, maintenance duration, and total anesthetic gas flow, the introduction of propofol allowed a statistically significant reduction in the mean concentration of halothane required during maintenance anesthesia. Conclusions: Both tubeless spontaneous respiration technique protocols proved successful in this study. However, the addition of propofol allowed a significant reduction in the halothane requirement during anesthesia maintenance. This has the potential benefit of decreasing the exposure of operating room personnel to volatile anesthetics during tubeless spontaneous respiration technique. Arch Otolaryngol Head Neck Surg. 1997;123:209-214

Acoustic mechanisms: Canal wall-up versus canal wall-down mastoidectomy

The contribution of the middle ear air spaces to sound transmission through the middle ear in canal wall-up and canal wall-down mastoidectomy was studied in human temporal bones by measurements of middle ear input impedance and sound pressure difference across the tympanic membrane for the frequency range 50 Hz to 5 kHz. These measurements indicate that, relative to canal wall-up procedures, canal wall-down mastoidectomy results in a 1 to 5 dB decrease in middle ear sound transmission below 1 kHz, a 0 to 10 dB increase between 1 and 3 kHz, and no change above 3 kHz. These results are consistent with those reported by Gyo et al. (Arch Otolaryngol Head Neck Surg 1986;112:1262-8), in which umbo displacement was used as a measure of sound transmission. A model analysis suggests that the reduction in sound transmission below 1 kHz can be explained by the smaller middle ear air space volume associated with the canal wall-down procedure. We conclude that as long as the middle ear air space is aerated and has a volume greater than 0.7 ml, canal wall-down mastoidectomy should generally cause less than 10 dB changes in middle ear sound transmission relative to the canal wall-up procedure. (Otolaryngol Head Neck Surg 1998;118:751-61.)

Brief Bilateral Vocal Cord Paralysis After Insecticide Poisoning

We describe a new variant of life-threatening organophosphate toxicity syndrome that produces a brief bilateral vocal cord paralysis. There are 3 recognized types of toxicity syndrome: acute (instantaneous), intermediate (slightly delayed, ie, hours to days), and delayed (weeks to months). Ingestions of large doses of insecticides lead to a cholinergic crisis and possible death (acute-type syndrome). Exposures to lower doses may cause the intermediate- or delayed-type syndrome. The intermediate-type syndrome is characterized by slightly delayed polyneuropathy and generalized weakness. Transient vocal cord paralysis has also been reported in association with other neurologically profound findings. The delayed-type syndrome can produce muscle weakness for months. Our patient, a 2-year-old boy, was found eating a substance later found to be contaminated with insecticide. Within minutes, fever and somnolence developed, followed by progressive respiratory distress and stridor, without generalized weakness. The child's condition progressed to complete airway obstruction, and intubation was necessary. Emergency laryngoscopy and bronchoscopy were performed to rule out epiglottitis or a foreign body. Instead, a bilateral vocal cord paralysis was found. The paralysis lasted 2 days before completely resolving. Insecticide poisoning was suspected. We theorize that our patient manifested a combination of the acute-type syndrome, because of the immediacy of the onset of the symptoms (ie, fever and somnolence), and the intermediate-type syndrome, because of the transient vocal cord paralysis. Because of the potential dangers involved, we wish to familiarize physicians concerning organophosphate poisoning; to alert the medical community to this variant of toxicity syndrome, which involves transient bilateral vocal cord paralysis; and to demonstrate the benefit of early otolaryngological consultation for the prevention and treatment of airway obstruction in patients with suspected organophosphate poisoning, be it from insecticides or poison gas. Arch Otolaryngol Head Neck Surg. 1997;123:93-96

Mucosal Intact Laser Tonsillar Ablation

Background: A laser technique has been developed in the laboratory using a noncontact 810-nm diode laser. Results: Mucosal intact laser tonsillar ablation (MILTA) coagulates tonsillar lymphoid tissue while preserving the overlying mucosa. A canine model was used to evaluate this new method. The canine tonsils were exposed to laser energy for 5 to 6 minutes each at 8 to 10 W of power. This technique was compared with standard cold knife tonsillectomy. The dogs were observed carefully during the postoperative period. When comparing parameters such as onset of eating solid food, amount of food ingested per day, onset of normal activity, and degree of weight loss, MILTA showed significant benefit over the standard technique. The operative sites were evaluated and compared at 1.5 hours and at 7, 21, and 45 days after treatment. Conclusions: None of the tonsils treated by MILTA showed mucosal ulceration. At the end of 45 days, histopathological examination showed complete absence of tonsillar tissue with normal mucosa in both the MILTA and standard groups. Traditional tonsillectomy techniques are associated with moderate morbidity and the potential for serious hemorrhage. With the preservation of the overlying mucosa, the possible clinical advantages of this approach to tonsillectomy are the absence of bleeding, avoidance of general anesthesia in older patients, less operating time, and decreased postoperative morbidity. The potential for office treatment exists. Additional laboratory studies, as well as careful clinical trials, are indicated based on these encouraging results. Arch Otolaryngol Head Neck Surg. 1996;122:1355-1359

Outpatient Adenotonsillectomy

MITCHELL, RON B.; PEREIRA, KEVIN D.; FRIEDMAN, NORMAN R.; LAZAR, RANDE H. Author Information

Predictive Factors for Respiratory Complications After Tonsillectomy and Adenoidectomy in Children

Objective: To determine risk factors predictive of outcomes to aid in the cost-effective preoperative evaluation and postoperative management of patients who are undergoing tonsillectomy and adenoidectomy for obstructed breathing during sleep. Design: A historical cohort study with a nested case-control analysis that examined risk factors associated with postoperative respiratory complications. Setting: Children's Medical Center of Dallas, Dallas, Tex, which is a pediatric referral hospital for secondary and tertiary pediatric care with both private and university-appointed physicians. Patients: A convenience sample of 355 patients who were undergoing tonsillectomy and adenoidectomy for obstructed breathing during sleep throughout a 1-year period. Intervention: None. Main Outcome Measure: The occurrence of postoperative complications, including airway obstruction, apneas with oxygen desaturations, airway interventions (eg, endotracheal intubation), or administration of supplemental oxygen, as they related to associated medical conditions (eg, cerebral palsy or prematurity) and diagnostic tests (eg, chest x-ray film and electrocardiogram). Results: Five associated medical conditions (cerebral palsy; seizures; age, ≤3 years; congenital heart disease; and prematurity) were identified as important predictors of a complicated postoperative course using stepwise logistic regression analysis. Those children with an abnormal chest x-ray film or electrocardiogram were also identified as having an associated medical condition that was predictive of postoperative complications. Conclusions: Children with 1 or more of the associated risk factors identified should be considered candidates for postoperative inpatient observation. A preoperative chest x-ray film and electrocardiogram were found to be of little predictive value, and they are probably not cost-effective screening tests for postoperative respiratory complications. Arch Otolaryngol Head Neck Surg. 1997;123:517-521

Maturational Descent of the Epiglottis

Background: Otolaryngologists and anesthesiologists have described a maturational descent of the epiglottis that occurs in infancy and childhood. Objective: To investigate the changing level of the epiglottis to confirm and characterize this phenomenon more completely. Design: A survey of 500 images with 338 images selected for the study. Setting: A tertiary care facility. Patients: Asymptomatic children aged 1 day to 18 years. Main Outcome Measure: The position of the tip of the epiglottis was correlated with the cervical vertebral level. Results: Data indicate that maturational descent of the epiglottis starts in infancy and continues into adolescence. These results are statistically significant ( P Conclusion: Maturational descent of the epiglottis occurs in a predictable pattern. Understanding this phenomenon may facilitate laryngoscopic, as well as clinical and radiologic, evaluation of the airway in children. Arch Otolaryngol Head Neck Surg. 1997;123:627-628

Blunt Laryngotracheal Trauma in Children

GOLD, STEVEN M.; GERBER, MARK E.; SHOTT, SALLY R.; MYER, CHARLES M. III Author Information

Chronic Aspiration in Children

Objective: To assess the efficacy of bilateral submandibular gland excision and bilateral parotid duct ligation in treatment of chronic aspiration in neurologically impaired children. Design: Retrospective chart review and telephone follow-up interview. Setting: Tertiary care center. Patients: All patients from 1986 through 1994 who underwent bilateral submandibular gland excision and bilateral parotid duct ligation and had evidence of at least 1 episode of aspiration pneumonia in the year prior to undergoing surgery. Main Outcome Measure: Two main outcomes measures were (1) the change in number of hospitalizations for pneumonia and total number of lower respiratory tract infections between 1 year before and 1 year after surgical intervention and (2) telephone assessment of patient outcome with respect to parental satisfaction, effect on quality of life, care requirements, amount of suctioning, and use of voice. Results: Sixteen patients aged 16 months to 18 years were included. After surgical intervention, there was a significant decrease in the mean (±SD) number of pneumonias (2.3±1.44 before surgery, 0.9±1.2 after surgery; P Conclusion: Bilateral submandibular gland excision and bilateral parotid duct ligation reduce the incidence of aspiration pneumonias and hospitalization, and decrease overall care requirements in a select group of neurologically impaired children. Because they are voice sparing, are efficacious, and have a low morbidity, they should be considered before laryngotracheal separation or tracheoesophageal diversion. Arch Otolaryngol Head Neck Surg. 1996;122:1368-1371

Mandibular fracture and associated cervical spine fracture, a rare and predictable injury. Protocol for cervical spine evaluation and review of 1382 cases.

To assess the relationship and incidence of cervical spine injuries in patients with mandibular fractures and to recommend an organized approach to cervical spine evaluation in these patients. A retrospective review of medical records of all patients with mandibular fractures at a level I trauma hospital from 1984 through 1993. Patient demographics, injury, mechanism of injury, associated symptoms, physical presentation, and adjuvant radiographic evaluations were recorded. Level I, 1000-bed, urban trauma center in Atlanta, Ga. A total of 1382 patients with mandibular fractures were examined during the 10-year period of review. Cervical spine radiographs were obtained on 501 (36.3%) of these patients. From these radiographs, only 8 cervical spine fractures were found. All of the patients with cervical spine injuries (n = 8) had other associated maxillofacial injuries (n = 4), were involved in a motor vehicle accident (n = 7), or sustained gunshot wounds (n = 1). Judicious use of cervical spine radiographs in the appropriate setting of mandibular trauma is beneficial. However, clinical criteria should dictate rational use of radiographs, since the association between cervical spine injuries and mandibular trauma is rare and predictable.

Significance of epidermoid formations in the middle ear in fetuses and children.

To determine the incidence, size, and location of epidermoid formations (EFs), which have been suggested to be precursors of congenital cholesteatomas, in temporal bones from fetuses and children. We examined temporal bones from 226 fetuses and children up to the age of 10 years for the incidence, size, and location of EFs. Twenty-five EFs were identified in middle ears of 3 fetuses, 7 neonates, 9 infants, and 2 children aged 2 and 3 years. There was a male-female preponderance of 5:4. Generally, we saw EFs between the anterosuperior edge of the eardrum and the anterior limb of the tympanic ring, but 4 were below the level of the handle of the malleus. Their widths ranged from 25 to 300 microns. Keratinization was not observed in any EF. Contrary to previous reports, we found EFs not only in ears of fetuses, but also in ears of infants and children. Although EFs may persist in some ears, possibly developing into congenital cholesteatomas, our findings do not provide direct support for this concept.

Obstructive Sleep Apnea in Schwartz-Jampel Syndrome

Schwartz-Jampel syndrome (SJS) is a rare entity characterized by myotonia and skeletal abnormalities. Death and respiratory distress have previously been reported in newborns and young children with SJS. We describe a patient with SJS and snoring in whom polysomnography demonstrated obstructive sleep apnea and hypoxia. Although tonsillectomy with laser palatoplasty significantly widened the oropharyngeal introitus, obstructive sleep apnea persisted. Ultimate improvement occurred only after the institution of home therapy with bi-level positive airway pressure during the night. We also discuss the specific structural and neuromuscular features of SJS that may be responsible for upper airway obstruction.

Management of oropharyngeal trauma in children.

To determine the indications for admission, requisite imaging studies, and urgent medical or surgical intervention. We retrospectively reviewed the charts of 26 children (age range, 5 months to 14 years) who were seen by the otolaryngology service in the emergency department at the Children's National Medical Center, Washington, DC, from 1985 to 1993 and who were diagnosed as having oropharyngeal trauma. We specifically looked for common findings in the history and physical examination on initial presentation to predict the necessary steps in evaluation and management. Tertiary care pediatric referral center. Indications for admission were (1) concern about neurologic injury, (2) concern about vascular injury, (3) radiographic evidence of retropharyngeal free air or abscess, (4) pneumomediastinum, and (5) unreliable adult supervision at home. Six patients required surgery; 3 underwent retropharyngeal aspiration or incision and drainage procedures; 2 required neck explorations; and 1, who had an impaled foreign body in the parapharyngeal space, underwent surgical extraction. There were no vascular, neurologic, or other permanent injuries. Oropharyngeal trauma may result in palatal and posterior pharyngeal wall injury requiring closure of lacerations and management of retropharyngeal free air. Rarely does an injury lead to retropharyngeal abscess or significant pneumomediastinum. Lateral oropharyngeal injuries require increased concern about potential neurovascular impairment. However, neither the mechanism of injury nor the degree of injury correlates with the potential for neurovascular sequelae. Since neurovascular involvement may not become clinically apparent until days or weeks after the incident, admission for observation alone should be based on the distance from the patient's home to the hospital and on the level of reliable adult supervision. Indications for medical and surgical treatment of internal carotid artery thrombosis remain controversial.

Relationship between patient-based descriptions of sinusitis and paranasal sinus computed tomographic findings.

To evaluate the relationship of paranasal sinus symptoms with coronal computed tomographic (CT) findings. Prospective comparison of patient-based symptoms with imaging findings. Primary care and referral center office and hospital practices. Of 586 consecutive patients referred by otolaryngologists and primary care physicians for CT of the paranasal sinuses, 221 (151 women and 70 men; age range, 13-82 years; mean age, 44 years) participated by completing the Sino-Nasal Outcome Test-20 (SNOT-20) clinical questionnaire immediately before undergoing CT. Radiologists blinded to the patients' responses scored the degree of mucosal thickening at each of 12 sites on CT scans using a staged scale of severity (0-2 points). Bivariate analysis was performed to assess the relationship between patients' symptoms and CT findings. The SNOT-20 scores ranged from 0 (normal) to 78 (mean, 34). The most commonly reported symptom was fatigue. The CT scores ranged from 0 (normal) to 24 (mean, 4.07). Seventy-five patients (34%) had normal findings on the CT scan. The maxillary sinus was the most commonly involved site (96 patients, or 43%). The SNOT-20 and CT scores failed to significantly correlate (r = 0.11, P < or = .09). When the subset of patients with "positive" or "very positive" CT scans were considered, no significant correlation was observed (r = 0.12, P < or = .16). For the 132 patients reporting facial pain, the mean CT score was lower than for patients without facial pain (3.78 vs 4.78, P = .21). Patient-based reports of paranasal sinus symptoms failed to correlate with findings on CT scans; therefore, CT should be reserved for delineating the anatomy and pattern of inflammatory paranasal disease prior to surgical intervention.

Expression of p53 protein in advanced head and neck squamous cell carcinoma before and after chemotherapy.

The expression of p53 protein has been reported to be in the range of 35% to 67% in head and neck squamous cell carcinoma (HNSCC). Mutations of the gene for p53 protein have been associated with rapidly proliferating tumors, and p53 protein expression has been shown to be a significant predictor of worse survival in surgically resected HNSCC. To determine whether p53 protein expression in advanced (stages III and IV) HNSCC has any impact on tumor response to 2 to 3 courses of paclitaxel (Taxol) and carboplatin, we prospectively studied prechemotherapy specimens from patients with previously untreated, advanced-stage HNSCC. We also attempted to study residual tumors after chemotherapy to determine if the p53 status of the tumor changed. The expression of p53 protein was evaluated by immunohistochemical analysis (clone BP53-12-1; Bio-Genex, San Ramon, Calif). Tertiary university medical center. Two to 3 courses of chemotherapy with paclitaxel and carboplatin. Pathologic complete remission or residual tumor. The results of p53 immunostaining were positive in 24 (67%) of 36 HNSCC specimens before chemotherapy. After chemotherapy, 8 patients achieved pathologic complete remission. Before chemotherapy, the tumor was p53 negative in 2 patients and positive in 6 patients. No correlation of p53 protein expression with response to chemotherapy was noted. The expression of p53 protein converted from positive to negative in 5 (42%) of 12 specimens from patients with residual tumor after chemotherapy, with no impact on clinical outcome.

Supraglottic stenosis in infants and children. A preliminary report

Objectives: To describe a condition identified in the pediatric population that narrows the supraglottic larynx. This condition has been termedsupraglottic stenosis/collapse. To discuss common factors present in these children and to examine potential causes of this specific condition. Design: Retrospective review of patients with supraglottic stenosis/collapse from October 1985 to June 1993. Setting: Academic tertiary care children's hospital. Patients: Seventeen patients aged 7 months to 14 years underwent laryngoscopy and bronchoscopy for evaluation or follow-up of upper airway obstruction or respiratory failure and were found to have supraglottic stenosis/collapse. Main Outcome Measures: Each patient's records were reviewed for the average age at the time of diagnosis, history of prematurity, evidence of gastroesophageal reflux, history of long-term intubation, and any associated medical problems. In addition, patients were compared based on previous airway surgery (tracheostomy, laryngotracheal reconstruction, or anterior cricoid split). Results: Chronic upper airway obstruction was identified in 17 patients caused by supraglottic stenosis/collapse. All patients (100%) had undergone tracheostomy prior to the recognition of supraglottic stenosis/collapse. Fifty-nine percent of the patients had undergone laryngotracheal reconstruction, and 53% had a history of gastroesophageal reflux. Conclusion: Supraglottic stenosis/collapse is a distinct entity that may be related to prior laryngeal or tracheal surgery. This diagnosis should be considered when evaluating and treating patients with chronic upper airway obstruction following laryngeal and/or tracheal surgery. Arch Otolaryngol Head Neck Surg. 1997;123:337-341

Submucosal tumor extension in hypopharyngeal cancer.

To study the incidence and extent of submucosal tumor extension in hypopharyngeal cancer and to evaluate the impact on the tumor recurrence and overall survival rates. Fifty-seven resected specimens of hypopharyngeal cancer were studied in detail from January 1986 to December 1989 by use of the whole-organ, step-serial sectioning technique. Three types of submucosal tumor extension could be identified. Type I extension was characterized by a tumor with a smooth round contour that extended submucosally. The mucosa was thereby elevated and was detectable on gross inspection at operation. In type II extension, tongues and islands of tumor infiltrated within the submucosa, and these were not noticeable on gross examination. Skip metastasis in the submucosa where the submucosal tumor was completely separated from the main tumor bulk was classified as type III extension. Thirty-three patients (58%) had submucosal tumor extension. The frequencies (and extents of submucosal tumor extension) in the superior, medial, lateral, and inferior directions were 16% (3-10 mm), 37% (2-37 mm), 26% (2-37 mm), and 28% (3-35 mm), respectively. Two thirds of the submucosal extension was type I (22 of 33), and only 1 patient had a true skip lesion submucosally (type III extension). Type II submucosal extension was found in one third of the patients (11 of 33). This occurred significantly more often in the patients who had received radiotherapy before surgery (82% [9/11]; P < .001; 95% confidence interval, 1.28-4.44). The presence of submucosal tumor extension had no effect on the tumor recurrence and overall survival rates. The incidence of submucosal tumor extensions in hypopharyngeal cancer is high (58%), but most (67%) of them can be detected grossly at operation. The presence of submucosal tumor extension does not adversely affect the survival and tumor recurrence rates.