Chronic rhinosinusitis in congenital craniofacial malformations

OBJECTIVES: To review developmental abnormalities and iatrogenic alterations in sinus anatomy that may predispose patients with congenital craniofacial malformations to chronic rhinosinusitis. STUDY DESIGN: Retrospective study. METHODS: Seven patients with craniofacial malformations who were surgically treated by the senior author were included in the study. All were diagnosed with chronic rhinosinusitis refractory to medical management. Four patients had undergone previous corrective craniofacial surgery, and three of these patients developed iatrogenic sinus disease. Demographic data, diagnoses and anatomical abnormalities were included. RESULTS: Abnormal sinus anatomy was present in all patients, most commonly skull base abnormalities and dehiscent lamina papyracea. All patients underwent successful endoscopic surgical management (n = 7) for their chronic rhinosinusitis. Two patients had adjuvant external procedures. There were no complications and no recurrences after a mean follow up time of 15 months. CONCLUSIONS: Otolaryngologists should be aware of the possibility of chronic rhinosinusitis in patients with craniofacial malformations. Careful preoperative evaluation of radiographic studies should be performed as most of these patients will have abnormal sinus anatomy. In addition, patients who undergo surgery to correct their craniofacial malformations are susceptible to altered sinus anatomy that may predispose them to the development of iatrogenic chronic rhinosinusitis.     

The placement of middle ear ventilation tubes: Some indications and complications

Are they necessary? What are the indications? Does fluid necessitate tubes? A plea for conservatism? Complications? Answers to these questions are presented by an objective evaluation of patients.     

Nasal obstruction in children with craniofacial malformations

The etiology, patient evaluation and management of nasal obstruction in children with craniofacial malformations is broadly discussed. Specific reference is made to the experience by the senior author (WSC) with respect to nasal surgery in 29 of these patients during the 12 years from 1987 to January 1st, 1998.     

Stimulus, response, and state variables in the testing of neonates

This paper endeavors to answer three closely related questions: What motor behavior displayed by an infant may be considered to be a response to acoustic stimulation? What acoustic phenomena elicit such behavior? Does responsiveness vary with postconceptual age? Review of our work over the past decade reveals that we know the answers to the first two questions, but not the third. Briefly, arousal responses (eye and limb movements) are reliably elicited by wideband signals but not by narrowband signals. However, there is still confusion about whether preterm infants are more or less responsive than full term infants.     

Differential diagnosis and therapy of vertigo of vertebral origin

The following questions are discussed: Does vertigo of purely cervical functional origin really exist with clinical importance? How can it be determined by differential diagnosis? How can the ENT physician treat cervical vertigo?     

Does asbestos cause laryngeal cancer?1

Does asbestos cause laryngeal cancer? Asbestos is a known carcinogen. Its role in the aetiology of laryngeal cancer has been investigated and debated for the last three decades. Here, we consider much of the published evidence from post‐mortem studies, cross‐sectional, case–control and cohort studies. We feel that the weight of evidence does not support a causal association for asbestos with laryngeal cancer. The ‘positive studies’ raise important questions regarding an association; the opportunity may present itself to answer some of these as the incidence of asbestos‐related malignancy is increasing in the UK and Europe.     

The radiologic diagnosis of malignant tumors of the salivary glands.

Radiologic investigation of possible salivary gland malignancy may answer in part questions concerning the lesion under study. Is it an invasive tumor, as evidenced by tissue destruction? Is the tumor intrinsic or extrinsic in origin to the salivary gland? Does the tumor extend into the deep portion of the salivary gland or beyond it into surrounding soft tissues? Sialography plays the major diagnostic role in consideration of the radiologic diagnosis of malignant tumors of the salivary glands. However, certain advanced radiologic modalities such as salivary gland scanning with sodium pertechnetate or 67Gallium citrate, as well as cervical ultrasound and computed tomography, may prove useful. This paper attempts to provide some answers to these questions.     

The role of surgery in rhabdomyosarcoma of the head and neck in children

The role of surgery in the treatment of rhabdomyosarcoma of the head and neck has diminished during the past 25 years. Treatment of this tumor in the pediatric population has involved radical radiation therapy and chemotherapy with little or no role for surgery. However, the potential effect of irradiation on facial growth and the appearance of secondary irradiation-induced tumors has raised the question as to whether surgery may once again play a role in the treatment of these patients. Advances in skull base and reconstructive surgery and microsurgical techniques have permitted a reconsideration of initial ablative surgery. The head and neck surgical team must be prepared to respond in those patients in whom craniofacial development is at risk or recurrence has occurred after radical chemotherapy and/or radiation therapy.     

Airway management in Hallermann-Streiff syndrome

Hallermann-Streiff syndrome and other craniofacial anomalies predispose patients to airway emergencies. Anatomic abnormalities may render both intubation and tracheotomy unusually difficult. It is important for the otolaryngologist to be familiar with the special difficulties and hazards associated with these malformations in order to ensure optimal airway management.     

Indications for image-guided sinus surgery: the current evidence

BACKGROUND: Evidence-based medicine calls for a critical evaluation of the scientific evidence for treatments of disease. This report synthesizes the available evidence supporting the indications for image guidance in sinus surgery, examining two important questions: (1) Does image-guided sinus surgery (IGSS) reduce complication rates? (2) Does IGSS improve clinical outcomes? METHODS: Primary research articles evaluated for this report were identified using appropriate search terms and a PubMed search. Two authors independently reviewed each article. Articles were assigned an evidence level based on accepted guidelines: level 1 = randomized trials, level 2 = prospective cohort studies with comparison group, level 3 = case-control studies, level 4 = retrospective case series, and level 5 = expert opinion. RESULTS: We identified 105 articles for full review and highlight 5 articles in our report. Primarily, there is expert opinion (level 5) and case series (level 4) with and without comparison groups supporting the indications for IGSS. In addition, authors point out that sample size and design issues preclude definitive randomized trials using IGSS. CONCLUSION: Although randomized trials of IGSS are not practical, ethical, or feasible, clinical experience, expert opinion, and case series support the current indications for IGSS. Studies designed to draw conclusions about the role of IGSS in decreasing major complications of sinus surgery are not possible.     

Contribution of low-intensity pulsed ultrasounds to bone regeneration

A maxillo-facial surgeon manages patients with bone defects due to trauma, malformations or of iatrogenic origin. The surgical management has potentially deleterious effects and its cost for society is increasing. Hence, it is crucial to develop techniques stimulating bone growth, stimulating the regeneration of a fracture or filling bone deficit. Ultrasounds (US), vibrations of the same nature as sound but with frequencies above the highest audible frequency for men (above 20 kHz), are used in many fields, particularly in medicine, usually at frequencies of around 0.5 to 5 MHz (million cycles per second). Their biological effects are not fully understood yet, but it is well known that US have effects on organic tissues when their mechanical energy is converted into thermic energy. These effects induce vasodilation and modification of membrane permeability. Several publications present the benefit of US for the stimulation of bone regeneration after a fracture. We present an overview of current knowledge on the effect of pulsed ultrasound on craniofacial bone regeneration, with study results conducted within Inserm unit U1032 in Lyon, the current reference lab on this issue.     

Supraglottic contributions to pitch raising. Videoendoscopic study with spectroanalysis

Several questions pertaining to pitch raising recur frequently. Does the larynx rise with the production of higher frequencies? What happens to the pharyngeal walls between the soft palate and the larynx when the fundamental frequency is raised? How does the soft palate participate in pitch raising? To answer these questions, the present study was undertaken with the recently described simultaneous velolaryngeal endoscopy technique. Nine professional singers were asked to find the limits of their vocal range in any of six voice qualities: speech, falsetto, cry/sob, twang, belting, and opera. Simultaneous activities of the larynx, the pharyngeal walls, and the soft palate were submitted to videoendoscopy with synchronous voice recording and studied with spectroanalysis of discrete segments of the total phonation range. Our dual endoscopic study showed that 1) the larynx rose in all subjects with the production of higher frequencies, 2) with the highest fundamental frequency, the lateral pharyngeal walls significantly contracted toward the midline in an "upside-down V shape," creating a very narrow pharyngeal tube, and 3) the soft palate lifted and the velopharyngeal port narrowed considerably with higher frequencies.     

Who should be a stapes surgeon? An otologist or a generalist?

PURPOSE OF REVIEW: The overall experience with stapes surgery has declined, both within residency training programs, as well as in clinical practice. Does this change in the environment suggest that subspecialists rather than generalists manage patients with otosclerosis? RECENT FINDINGS: A decreasing availability of patients with clinical otosclerosis has encouraged trainees and practitioners to adopt strategies that will enable the maintenance of quality care to these patients. SUMMARY: Well trained generalists should be prepared to perform stapes surgery. Lack of experience or infrequent exposure to disease suggests that optimal care can be achieved by referring the patient to an experienced otologic surgeon.     

Advanced airway management strategies for severe OSAS and craniofacial anomalies

Pediatric OSAS and craniofacial malformations present challenges that require innovative approaches and comprehensive treatment strategies. Synchronous airway lesions, craniofacial malformations, obstructive anomalies of the tongue base, nasal vault and choanae are commonly addressed by subspecialists from various clinical and surgical academic traditions who practice variable levels of required communication. This is not a mere social requirement but an important requisite for intelligent and effective airway management. Membership of dedicated airway, aero digestive or craniofacial teams are desirable but not required. I expect this clinical brief to help many brilliant clinicians in their pursuit of perfection.     

Airway management in craniofacial surgery: experience in 542 patients

Five hundred and forty-two patients undergoing 579 craniofacial surgical procedures were admitted to the Intensive Care Unit of the Hospital for Sick Children, Toronto, during the 13-year period of 1972 to 1984. Ninety-eight of these patients underwent tracheotomies; 12 significant complications were documented. Two hundred and seventy-eight patients were managed with nasal endotracheal intubation for greater than 24 hours postoperatively; 42 related complications were documented. Good communication among the craniofacial surgeon, otolaryngologist, anesthetist and intensivist is crucial for the safe management of the various airway problems observed in patients with major craniofacial anomalies undergoing corrective surgery.     

Systematic qualitative histology of enossal implants with anodically oxidised surfaces]

Histological analysis of dental implants is often quantified by calculating the bone-implant contact rate (bone volume/total volume), whereas qualitative aspects like osteoconduction are underrepresented. The aim of this study was to focus on the micro-architectural properties of the bone-implant contact under physiologic loading using a systematic analysis of these characteristics.In 16 Beagle dogs we inserted 6 different types of dental implants in the hard bone of the mandible and the soft bone of the maxilla. After a healing period of two months the implants were loaded for three months and then histologically analysed. For the metric evaluation of qualitative histological aspects 12 examiners answered pivotal questions: 1. Is the implant functional sufficient? 2. Do you see close contact to bone, were bone is present? 3. Is the amount of bone at the implant at least similar to the peripheral bone? 4. Is the bone to implant contact homogenous? 5. Does the bone show a functional architecture? 6. Do you find osseoconductive bone apposition at the crestal and apical border? A superiority of anodic oxidized surfaces can be seen in questions 1, 2 and 3 mainly for the comparison of identical macrodesigns (MkIII). The potential for osseoconductivity (questions 4 and 5) shows a tendency for significant differences for the ZL Ticer implant. Homogenous bone to implant contact is rarely found, in contrast to rather positive implant function ratings. This suggests the existence of an optimum in the bone to implant contact rate.Bone to implant contact rate as an isolated quantitative parameter should in future be completed by a systematic, standardised and blinded analysis of qualitative properties.     

A comparison of standard radiographs and "scout-view" radiographs. The value for cephalometric analysis

Is the scout-view as reliable as the standard lateral view for cephalometric analysis? Cephalometric data (Delaire analysis) were obtained in ten patients with CT-scan and standard x-ray for comparison. Qualitative results showed imprecisions for craniofacial contours and soft tissue ptosis. Quantitative results were analyzed statistically and revealed a significantly higher level of error with scout-view tracings. The scout-view does not appear to be as reliable and takes longer to acquire than the standard lateral x-ray: for the pediatric population, it could be a disadvantage.     

Voice therapy for vocal fold paralysis

There is no doubt that vocal fold paralysis is a debilitating condition affecting an individual's general health and quality of life. Optimal management of a patient with vocal fold dysfunction by an otolaryngologist, speech scientist, and speech language pathologist results in detailed objective videostroboscopic evaluation of glottal configuration during phonation, acoustic and aerodynamic measures, laryngeal EMG (if appropriate), and the patient's self-rating of vocal disability. Profound glottal incompetence is typically managed surgically with a few voice therapy sessions after surgery to ensure optimal vocal function. Patients with more adequate glottal closure are often seen for voice therapy and lost to follow-up when their voices improve enough to satisfy their vocal needs. It is essential that a complete battery of assessments, including perceptual, aerodynamic, acoustic, and stroboscopic measures, be obtained at periodic intervals in surgical and nonsurgical patients so as to evaluate vocal function over time. One of the few rigorous studies of perceptual, acoustic, aerodynamic, and videofiberscopic findings in patients after medialization with fat and thyroplasty assessed patients before surgery and at short (1-3 months),middle (4-6 months), and long (7-12 months) intervals after surgery. Improvement in most parameters at short- and long-term intervals was noted but not in the middle interval. The best results were obtained in women. Continued difficulty in increasing and maintaining subglottal pressure for high-intensity phonation was observed in both male and female patients. This fine study raises a number of questions as follows. What objective phonatory measures should be assessed before and after intervention and at what time intervals? Why were the women's results better than the men's results when no correlation of age, pulmonary function, or severity of preoperative voice and aerodynamic impairment was observed? Should voice therapy be initiated at the 4- to 6-month interval when voice quality diminished or within 1 to 2 months after surgery so that the decrement in vocal function might not occur? Why did vocal function ultimately improve after 7 to 12 months? Heuer et al and Colton and Casper found similar outcome satisfaction in patients electing surgery compared with those that were seen for voice therapy; however, the patients with lesser glottal incompetence in both studies opted for therapy. Can we better define vocal parameters that help to predict which patients may need surgery rather than therapy? Should all patients with high airflow measures but near-normal subglottal pressures and MPT greater than 10 seconds undergo 6 weeks of voice therapy rather than medical intervention? If all surgical patients were seen for 6 weeks of postoperative therapy, would voice satisfaction ratings increase to greater than 70%? Can we perceptively or objectively differentiate patients whose postoperative voices will be excellent from those whose voices will be merely adequate? These questions can only be answered by the development and implementation of a rigorous protocol studying women and men of varying ages with unilateral vocal fold paralysis choosing medialization surgery and electing voice therapy. Standardized assessments must include perceptual,aerodynamic, acoustic, stroboscopic, and patient satisfaction measures during soft- and loud-intensity tasks before and at periodic intervals after the two interventions.     

Airway management in children with major craniofacial anomalies

Objectives: Delineation of clinical characteristics affecting the airway in a cohort of craniofacially deformed children. What factors differ between patients requiring and those not requiring surgical airway intervention? What factors predispose to the need for tracheotomy? When can decannulation be expected if tracheotomy is required? What interventions aid decannulation? Study Design: Five-year retrospective chart review at tertiary center. Methods: Two hundred fifty-one patients met the following entry criteria: enrollment in the New York University Institute of Reconstructive and Plastic Surgery's Craniofacial Clinic and admission to Tisch Hospital in Manhattan for surgery from 1990 to 1994. Hospital, clinic, and departmental office records were reviewed. All patients had major craniofacial bony anomalies and underwent administration of general anesthesia at least once. Results: Nearly 20% of all children required tracheotomy (47/251). Craniofacial synostosis patients (Crouzon, Pfeiffer, or Apert syndrome) had the highest rate of tracheotomy (48% [28/59]). Mandibulofacial dysostoses patients (Treacher Collins or Nager syndrome) had the next highest rate (41% [28/59]). Patients with oculo-auriculo-vertebral sequence were less likely to undergo tracheotomy (22% [9/41]). Children with craniosynostosis rarely required a surgical airway, unless there was marked associated facial dysmorphism (1% [1/72]). The duration of cannulation was related to the age at tracheotomy in a bimodal distribution. Generally, tracheotomies required before age 4 years remained for several years, whereas those placed after age 4 were removed after several weeks. The presence of a cleft palate correlated with reduced risk for tracheotomy, but the presence of a ventriculoperitoneal shunt correlated with an increased risk for tracheotomy. Procedures selectively used to improve the airway included midface advancement, mandibular expansion, tonsillectomy and adenoidectomy, uvulopalatopharyngoplasty, anterior tongue reduction, and endoscopic tracheal granuloma excision. Conclusions: The likelihood for surgical airway management is related to specific craniofacial diagnosis. The length of tracheal cannulation is greatest for infants and young children who manifest severe airway compromise, often because of nasal obstruction in combination with other anatomic factors. Early tracheotomy is advocated for these patients to promote optimal growth and development. Choanal atresia is often misdiagnosed in these infants; nasal obstruction is actually secondary to midface retrusion. Staged surgical interventions can allow eventual successful decannulation in nearly all cases of craniofacial syndromes.     

Modulation and control of synaptic transmission across the MNTB

The aim of this review is to consider the various forms and functions of transmission across the calyx of Held/MNTB synapse and how its modulation might contribute to auditory processing. The calyx of Held synapse is the largest synapse in the mammalian brain which uses the conventional excitatory synaptic transmitter, glutamate. It is sometimes portrayed as the 'ultimate' in synaptic signalling: it is a synaptic relay in which a single axon forms one synaptic terminal onto one specific target neuron. Questions that are often raised are: "Why does such a large and secure synapse need any form of modulation? Surely it is built simply to guarantee firing an action potential in the target neuron? If this synapse is so secure, why is a synapse needed at all?" Investigating these questions explains some general limitations of transmission at synapses and provides insight into the ionic basis of neuronal function by bringing together in vivo and in vitro approaches. We will start by defining the firing behaviour of MNTB neurons in vitro (in response to synaptic stimulation or current injection) and in vivo (in response to sound) and examining the reasons for different types of firing under the two conditions. Then we will consider some of the mechanisms by which transmission can be regulated. We will finish by discussing the following hypothesis: modulation and adaptation of presynaptic and postsynaptic conductances at the calyx of Held relay synapse are aimed at maximising the security of sound onset encoding while providing secondary information on frequency spectrum, harmonic envelope and duration of sound throughout the later part of the response.