Neurologic implications of glomus tumors in the head and neck.

Seventy-six patients with glomus tumors were evaluated. The incidenc- of cranial nerve paralysis in 37 percent and the incidence of intracranial extension is 14.6 percent. Jugular foramen syndrome is associated with 50 percent, and hypoglossal nerve involvement with 75 percent incidence of posterior fossa extension. Horner's syndrome is associated with 50 percent of middle cranial fossa invasion. The incidence of CNS tumor involvement with cranial nerve paralysis (not including VIIth nerve) is 52 percent.     

SIADH complicating deep neck abscess in infancy

Symptomatic hyponatremia due to syndrome of inappropriate secretion of anti-diuretic hormone (SIADH) in infancy is seen usually with pneumonia and meningitis and its association with deep neck abscess is not documented. Recognition and appropriate management of this complication is important to prevent mortality and long-term neurological morbidity. We report a 3-month-old infant with parapharyngeal abscess presenting with altered sensorium and recurrent seizures as a result of hyponatremia due to SIADH. The clinical course and outcome is described. Limitation of imaging modalities in an infant with airway compromise is discussed.     

Botulinum toxin injection into the cricopharyngeal muscle for dysphagia: report of 2 successful cases

Dysphagia is frequently observed in patients with sequelae after multiple cerebral infarctions and those with neuromyopathy. Dysphagia in these patients can be successfully treated by laryngeal suspension and cricopharyngeal myotomy. Surgery is not indicated in senile patients with serious complications, where conservative treatment is performed. We injected botulinum toxin into the right cricopharyngeal muscle with excellent results in two dysphagic patients with multiple cerebral infarction who refused surgery. There two cases developed dysphasia after multiple cerebral infarction, where surgical therapy was not indicated. Dysphagia is successfully treated by 5 units of botulinum toxin injected into the cricopharyngeal muscle. Botulinum toxin injection is considered useful for dysphagia in patients in whom surgery is not indicated. The effect of botulinum toxin lasts for 3 to 4 months. Injection of botulinum toxin is useful for patients with temporary dysphasia after cerebral infarction and soon improves swallowing with the assistance of rehabilitation.     

Extranodal malignant lymphomas of the head and neck

The management of primary extranodal lymphomas of the head and neck at The Princess Margaret Hospital is reviewed. This manner of presentation is uncommon and particularly rare in Hodgkin's disease. As with lymphomas at any other site, detailed investigation is necessary to determine the stage of the disease before definitive treatment is attempted. Surgery is normally restricted to biopsy. Radiation therapy and chemotherapy, alone or combined are the principal treatment modalities. Early disease (stages IA and IIA) may be treated by radiation alone with a cause specific survival of approximately 70% at five years and 60% at 10 years. Survival is better for histiocytic, nodular, and less bulky disease. Primary thyroid disease is uncommon but highly curable with local radiation. Similarly, orbital disease is usually locally curable with negligible sequelae. The addition of combination chemotherapy has significantly improved the prognosis with more advanced and bulky disease.     

Carcinoma of the subglottic area.

The subglottic area is defined as an anatomic region which is cylindrical in shape whose inferior margin is the inferior border of the cricoid cartilage and which is limited superiorly by an imaginary circle 5 mm below the free margin of the true vocal cords. Of 591 patients with glottic and subglottic cancers, only five (percent) had primary subglottic tumors and 132 (22 percent) had glottic tumors with subglottic extension. Sixty-five percent of the patients with glottic primary with subglottic extension were Stage 2 and 35 percent were Stage 3. Most patients were treated surgically. Hemilaryngectomy is a very satisfactory primary modality in the treatment of Stage 2 and some Stage 3 glottic lesions with subglottic extension. Stage 2 and 3 glottic cancers which involve greater than 10 mm of the subglottis carry a significantly decreased prognosis. Patients with T3 lesions with cord fixation with subglottic extension show a decreased survival.     

Bilateral internal laryngocele with open nasality--report of a case

Laryngocele is an abnormal saccule dilatation of the ventricle in direct communication with the laryngeal lumen. It is usually filled by air and mostly asymptomatic. This case is reported due to its rarity. A bilateral internal laryngocele with open nasality in 66-year-old man is described. Patient has been observed for 8 years with stable course of the disease and good general condition. Because the squamous cell carcinoma is known to occur in association with laryngocele necessity of control evaluation is very important. The etiology, classification, evaluation is discussed.     

Cochlear Implantation Without Mastoidectomy: The Pericanal Electrode Insertion Technique

Objective - A new minimally invasive cochlear implantation method with direct electrode insertion through the external auditory canal (EAC) is presented. Material and methods - Surgery begins with a retroauricular skin incision. The bony surface of the mastoid plane behind the ear is dissected free and the skin of the EAC is elevated together with the posterior part of the tympanic membrane. Cochleostomy is performed through the EAC with a microdrill anterior to the round window. A rim is drilled into the postero-superior region of the bony EAC immediately above the incus towards the outer border of the EAC and connected to the retroauricular surface by a short tunnel. The implant device is placed in the usual retroauricular area. The electrode is inserted through the tunnel and rim into the tympanic cavity and pushed into the cochleostomy hole. The electrode is immobilized in the rim using glass ionomer cement and covered with bone dust. After placement of the ground electrode, the retroauricular incision is closed. The tympano-meatal flap is replaced and a dressing is put into the EAC. Results - The new method has been applied thus far in 15 adults and pre-adolescent deaf patients (8 females, 7 males). A MED-EL Combi 40+ device was used in 14 patients and a Nucleus CI24M in 1. Pericanal electrode insertion was easy, with insertion depths into the cochlea of &;#83 30 mm with the MED-EL and of 20 mm with the Nucleus device. There were no surgical complications, infections or electrode extrusions during postoperative observation periods ranging from 6 months to >2 years. The functional results were comparable to those obtained with cochlear implantation via mastoidectomy. The pericanal electrode insertion technique has several advantages, the most important being that the danger of facial nerve damage is minimized and that the operating time is reduced by up to 50%. Conclusion - Cochlear implantation with pericanal electrode insertion is a simple, fast and particularly safe option which may replace the classical transmastoidal cochlear implantation method in adults and older children.     

Leukemoid reaction associated with pediatric nasopharyngeal carcinoma: An unusual presentation

Nasopharyngeal carcinoma is a tumor originating from the surface epithelial cells of nasopharynx. It is rare in children and adolescents. Most common physical finding is a neck mass. Most children with nasopharyngeal carcinoma present with advanced stage disease. The presentation with hematological abnormalities in patients without systemic metastasis is extremely rare. We reported a 14-year-old boy presenting with a mass at the right side of the pharynx and leukemoid reaction. To our knowledge, this is the first report of leukemoid reaction associated with pediatric nasopharyngeal carcinoma in English literature.     

Paediatric airway stenosis: laryngotracheal reconstruction or cricotracheal resection?

Modern surgical management of paediatric laryngotracheal stenosis includes a wide variety of surgical procedures. These can broadly be divided into two groups. First, laryngotracheal reconstruction (LTR) procedures in which the cricoid cartilage is split and the framework is expanded with various combinations of cartilage grafts and stents; and second, cricotracheal resection (CTR) where a segmental excision of the stenotic segment is done and an end-to-end anastomosis is performed. In this article we review the literature and our experience and discuss the relative indications for CTR and LTR in children. High decannulation rates have been reported for CTR; however, it remains a more extensive procedure than LTR involving extensive tracheal mobilization. If the tracheostomy site is included in the resection then a significant length of trachea is excised. Alternatively, LTR with cartilage grafting can precisely correct a specific stenosis with minimum morbidity and high decannulation rates for grade 2 and selected grade 3 stenosis. For the more severe stenosis treatment with LTR has been less successful. Retrospective data from this institution suggests that the children with grade 4 stenosis treated with LTR are more likely to require a subsequent open procedure to achieve decannulation than those treated with CTR. LTR is a less extensive procedure and is preferred for grade 2, selected grade 3 stenosis. CTR is the preferred option for grade 4 and severe grade 3 stenosis with a clear margin between the stenosis and the vocal cords.     

Cochlear implantation without mastoidectomy: the pericanal electrode insertion technique

OBJECTIVE: A new minimally invasive cochlear implantation method with direct electrode insertion through the external auditory canal (EAC) is presented. MATERIAL AND METHODS: Surgery begins with a retroauricular skin incision. The bony surface of the mastoid plane behind the ear is dissected free and the skin of the EAC is elevated together with the posterior part of the tympanic membrane. Cochleostomy is performed through the EAC with a microdrill anterior to the round window. A rim is drilled into the postero-superior region of the bony EAC immediately above the incus towards the outer border of the EAC and connected to the retroauricular surface by a short tunnel. The implant device is placed in the usual retroauricular area. The electrode is inserted through the tunnel and rim into the tympanic cavity and pushed into the cochleostomy hole. The electrode is immobilized in the rim using glass ionomer cement and covered with bone dust. After placement of the ground electrode, the retroauricular incision is closed. The tympano-meatal flap is replaced and a dressing is put into the EAC. RESULTS: The new method has been applied thus far in 15 adults and pre-adolescent deaf patients (8 females, 7 males). A MED-EL Combi 40 + device was used in 14 patients and a Nucleus CI24M in 1. Pericanal electrode insertion was easy, with insertion depths into the cochlea of > or = 30 mm with the MED-EL and of 20 mm with the Nucleus device. There were no surgical complications, infections or electrode extrusions during postoperative observation periods ranging from 6 months to > 2 years. The functional results were comparable to those obtained with cochlear implantation via mastoidectomy. The pericanal electrode insertion technique has several advantages, the most important being that the danger of facial nerve damage is minimized and that the operating time is reduced by up to 50%. CONCLUSION: Cochlear implantation with pericanal electrode insertion is a simple, fast and particularly safe option which may replace the classical transmastoidal cochlear implantation method in adults and older children.     

Fungal sinusitis

The incidence of fungal sinusitis is subjected to significant geographical variation. Basically, invasive and non-invasive fungal sinusitis is distinguished. Invasive fungal sinusitis is observed mainly in immunocompromised hosts. The diagnopsis is based on positive fungus detection combined with characteristic clinical features. The treatment of invasive fungal sinusitis is based on surgical debridement and systemic antifungal therapy. Non-invasive fungal sinusitis is either treated with surgery alone or surgery combined with systemic steroid therapy. The majority of studies showed no benefit of postoperative antimycotic medical treatment in patients with non-invasive fungal sinusitis.     

Nasopharyngeal carcinoma in children

Nasopharyngeal carcinoma (NPC) is rare in children. We report two cases from KK Women and Children's Hospital in Singapore, who presented with advanced locoregional disease. The various aspects of NPC in children are discussed. It is more common in males and black adolescents. The etiology is probably different from that in adult. Undifferentiated NPC or lymphoepithelioma is the commonest variety. Confusing symptoms like cervical lymphadenopathy and unilateral otitis media with effusion (OME) are among the commonest presentations. When children present with both conditions simultaneously, it is imperative to manage them like adult patients and perform nasendoscopy to rule out NPC. The disease stage at presentation is often more advanced compared with adults. These tumors are, however, associated with a higher cure rate as they are most radiosensitive. Radiotherapy with neo-adjuvant chemotherapy is currently the treatment of choice. Both cases achieved satisfactory control of the disease and are presently under close follow-up.     

Eustachian tube function in tympanoplasty

This paper describes central and peripheral eustachian tube function in relation to tympanoplasty. Central obstruction of the eustachian tube at the pharyngeal orifice is frequently correctable and is not a contraindication to tympanoplasty, whereas chronic cicatricial peripheral obstruction of the eustachian tube at the isthmus is a contraindication to tympanoplasty. These findings are based on tubal patency pressure studies measured with a mercurial manometer with the patient performing the Valsalva maneuver, with catheterization of the eustachian tube, and with politzerization. If the patient can autoinflate the middle ear and if the eustachian tube will open with politzerization, then the likelihood exists that there is no peripheral obstruction of the eustachian tube and you have a good candidate for tympanoplasty. When there is a perforation of the ear drum, the best test for eustachian tube function is microscopic examination of the middle ear mucosa. If the middle ear mucosa is perfectly normal, then you know that you have good eustachian tube function and can proceed with the tympanoplasty.     

鼾症与脑梗死的关系研究

目的 :探讨单纯型鼾症、憋气型鼾症和脑梗死的关系。方法 :脑梗死组 6 0例和正常对照组 6 0例 ,排除年龄、性别、肥胖等因素的影响 ,进行控制配比的析因研究。结果 :鼾症者较无鼾症者脑梗死的发生几率稍有增加 ,统计学分析差异无显著性意义。单纯型鼾症较无鼾症者 ,脑梗死的发生几率接近 ,差异无显著性意义。憋气型鼾症与单纯型鼾症比较 ,脑梗死的相对危险度明显增加 ,有统计学意义 (P <0 .0 5 )。憋气型鼾症与无鼾症者比较 ,脑梗死的相对危险度最高 ,差异有极显著性意义 (P <0 .0 1)。结论 :鼾症是脑梗死的可能原因之一 ,鼾症特别是有呼吸暂停的憋气型鼾症发生脑梗死的可能性大于无鼾症者。     

Flexible laryngoscopy in neonates and infants: insertion through a median opening in the face mask

The most common reasons for laryngoscopy in newborns and infants are inspiratory stridor and/or dyspnea. With the help of flexible endoscopes, especially with instruments of diminished diameter, laryngoscopy can be carried out even in premature newborns. We report on a technique of flexible laryngoscopy without the need for restraint and with improved safety. A modified face mask is used for endoscopy. An additional hole is made into the mask with a 4.5 mm drill. It is located in the midline just above the nostrils, about 2.5 cm above the ventilation opening. The flexible endoscope is passed into the nose and pharynx with ease. It does not interfere with the anesthetist's ventilation by the mask. In inhalation anesthesia with halothane, 100% oxygen is supplied. The larynx remains in its physiological position. The head is not retroflexed, and the tongue is not supported by an endoscope as in direct laryngoscopy. No muscle relaxation is used, and muscular activity of the larynx can be observed during spontaneous and assisted ventilation.     

Tachistophony, a measuring method for time threshold in hearing. A contribution to hearing theory

Tachistophony is presented as a method of measuring time-thresholds for understanding spoken signals and for recognising sound levels. The minimum total-time of periodically interrupted sound-events per second is assessed. The pause-total can reach a value between 4 and 9 times (in extreme cases up to 14 times) the sound flow period. The total of sound-pulses is measured only at 250 to 100 ms, with the recognition of values still operative. Due to the low information-content of numerical words their time-threshold is the lowest. The time-threshold lies considerably higher for one-syllable words and sentences with a higher information-content. The superiority of the left ear with dichotic stimulation is confirmed with monaural tachistophonic stimulation. These values are related to phase-frequencies of between 13 and 40 Hz. When the phase-frequency is lowered, comprehension below 8 Hz falls considerably. This is less apparent with phase-frequencies between 40 and 110 Hz.     

Multiple system atrophy manifested as dizziness and imbalance: a report of two cases

Multiple system atrophy (MSA) is a progressive neurodegenerative disease of undetermined origin that occasionally manifests as dizziness and imbalance. It is not often considered in clinical situations, especially not by neuro-otological consultants. Hence, we report our recent experience with two cases of MSA. One is that of a 62-year-old man with MSA with a predominant cerebellar feature, and the other is that of a 72-year-old man with MSA with a predominant parkinsonian feature. The results of the syncopic study correlated with orthostatic hypotension. The neuro-otological study in both patients revealed an abnormal eye tracking test, abnormal optokinetic nystagmus test and loss of visual suppression in the caloric nystagmus. These indicate that the central vestibular system, e.g., the cerebellum or brain stem, is affected by MSA, contributing to dizziness and imbalance. Therefore, diagnosis of MSA should be kept in mind by neuro-otological consultants when dealing with patients with dizziness and imbalance, especially when this is accompanied by orthostatic hypotension.     

UT-MUC-1, a new mucoepidermoid carcinoma cell line, and its radiosensitivity.

Mucoepidermoid carcinoma is a fairly common malignant disease of the salivary glands. It is usually composed of two cell types, mucus-producing mucous cells and cells that have squamous differentiation with or without keratinization. The treatment of choice is considered to be radical surgical removal of the tumor. Radiotherapy has been recommended for high-grade or advanced tumors. Information on the radiosensitivity of mucoepidermoid cancer is scant, but based on clinical experience, the cancer appears to be only moderately radiosensitive. UT-MUC-1 is a newly established cell line from a poorly differentiated mucoepidermoid carcinoma. The cell line is diploid, but with complex karyotype abnormalities, giving a similar DNA index when measured with flow cytometry as that from the original tumor, and produces a tumor with characteristics typical for mucoepidermoid cancer when heterotransplanted to nude mice. The cell line is radiation resistant, with an area under the curve of 2.30 + 0.21 Gy when measured with a 96-well plate clonogenic assay. This correlates with the clinical outcome of the patient and the clinical experience of the radiosensitivity of this tumor type.     

Flexible endoscopic evaluation of swallowing with sensory testing

PURPOSE OF REVIEW: Flexible endoscopic examination of swallowing with and without sensory testing is rapidly becoming a significant tool in the otolaryngologist's armamentarium for diagnosing dysphagia. Patients with swallowing disorders often present to the otolaryngologist, and an understanding of the utility of these techniques is critical. RECENT FINDINGS: Recent studies have confirmed that flexible endoscopic examination of swallowing with and without sensory testing is an exceptionally safe procedure with excellent portability. Flexible endoscopic examination of swallowing is accurate in diagnosing aspiration when compared with videofluoroscopy. Laryngopharyngeal sensory deficits as assessed by flexible endoscopic evaluation of swallowing with sensory testing are associated with cough, reflux disease, penetration, and aspiration. Both techniques have emerged as complementary to videofluoroscopic studies, rather than as replacements for the modified barium swallow. SUMMARY: Flexible endoscopic evaluation of swallowing with and without sensory testing is a safe technique that should be considered in the workup of patients with dysphagia presenting to the otolaryngologist.     

The formation of the middle ear cavity in primary tympanoplasty

Creation of the middle ear cavity in primary tympanoplasty in patients with chronic purulent epi- and epimesotympanitis is made in the end of the operation after the sanative measures. The destroyed chain of the auditory ossicles is repaired using tephlon daisy-shaped graft or its modifications. The graft is covered with a thin cartilaginous plate while the membraneous defect is filled with the temporal fascia. Lateral attic wall and posterior wall of the external acoustic meatus are made of cartilaginous plates, the cavity in the mastoid process is filled with fragments of the allogenic cartilage. The fragments and cartilaginous plates are employed in creation of the artificial antrum. The above tympanomastoidoplasty has been performed in 50 patients with a persistent antiinfection result in 90% of them. The number of patients with adequate hearing increased from 21 (42%) before the operation to 36 (72)% after it. Primary tympanomastoidoplasty is the operation of choice in patients with destructive otitis media purulenta chronica.