Clinical manifestations and audiologic diagnosis of acoustic neuromas.

If an AN is suspected, a detailed patient history and a thorough otologic and neurotologic physical examination should be carried out. The first echelon of diagnostic testing begins with a pure tone audiogram, speech reception threshold, speech discrimination testing, and acoustic reflex testing. If the clinician is even moderately suspicious of the presence of an AN, the patient should undergo a Gd-MRI scan. If suspicion is low, an ABR should be performed, and if negative, the patient should be reevaluated periodically.     

Goal planning in audiological rehabilitation

This paper describes the processes involved in goal planning, a means of structuring and evaluating a rehabilitation programme which is individually designed for a particular patient. The goal planning procedure involves a multi-disciplinary effort with the patient as an integral member of the team. Goals, which are identified from a strengths-needs list compiled by the team for a patient, are broken down into specific steps which should be easy to achieve by a given target date. The patient's strengths are used to help achieve the goals. Each step should be written in clear and objective terms and the use of vague goals such as 'the patient should make better use of a hearing aid', should be avoided. Goal planning does not dictate which therapy should be used but it does provide a framework for implementing any therapy that the team decide is appropriate. An example of a goal plan used in an audiological rehabilitation clinic is given.     

Association of facial paralysis with HIV positivity.

Facial paralysis, although a rare complication of AIDS related complex (ARC) or AIDS, may well be the presenting symptom of HIV positivity. A case report of facial paralysis followed closely by discovery of HIV positivity is described, along with a pertinent and extensive literature review. Seroconversion to HIV-positive status should be suspected in any high-risk patient presenting with idiopathic facial paralysis. HIV testing should be included in the evaluation of Bell's palsy and other idiopathic forms of facial paralysis in the at-risk patient.     

Carcinoma in situ of the glottic larynx

Carcinoma in situ (CIS) is part of the histopathologic spectrum of laryngeal disorders where invasive squamous cell carcinoma is the endpoint of cellular disarray. Few reports consider prognostic indicators that predict which lesions become invasive. Forty-one patients with CIS of the glottic larynx were analyzed for risk factors that would predict invasive cancer. Anterior commissure involvement by CIS resulted in 92% conversion to invasive squamous cell cancer compared to 17% of lesions limited to the mobile fold. Epidermal growth factor receptors were also analyzed and were found not to be helpful in predicting invasion. Lesions of the mobile fold should be removed endoscopically and the patient should be observed closely for recurrence. Anterior commissure involvement that is inaccessible to complete laser ablation should be radiated, and the patient should be observed carefully.     

Diagnosis and management of esthesioneuroblastoma

Esthesioneuroblastoma is an uncommon malignant neoplasm of the nasal vault that in the past was considered benign or low-grade malignant. Surgical approaches in the main were transnasal, with a high recurrence rate and ultimate patient death. With the modern imaging of CT and MRI, should the patient be willing and fit enough, esthesioneuroblastoma currently should be approached using a craniofacial resection. Large tumors should be considered for preoperative chemotherapy and postoperative radiotherapy. Local tumor recurrence is not uncommon and is generally related to the attention to local anatomic dissection. Neck metastases, when they present, should be excised using a modified neck dissection. Distant metastases may present at any time during the course of the disease, generally within 36 months, and may respond to local radiotherapy or systemic chemotherapy. Five-year survival currently appears to be optimized by surgery followed by postoperative radiotherapy and is approximately 65%.     

Informed consent of patients to medical intervention: role in recent medical practice

Legal relations between the patient and his/her doctor should be regulated by informed consent of the patient to medical intervention. This document must be signed by the patient or his/her legal agent after thinking over and be free will. It must be also signed by attending physician and head of the department or senior administration of the hospital.     

Localized laryngotracheobronchial amyloidosis: case report and review of the literature

Although localized laryngotracheobronchial amyloidosis is rare, the otolaryngologist--head and neck surgeon should be familiar with this condition. Its characteristic appearance can suggest its presence in a patient who has the typical initial symptoms. Biopsies during direct laryngoscopy and bronchoscopy can play both a diagnostic and therapeutic role. After an appropriate examination to rule out systemic involvement, the patient should be managed with conservative surgery, although the use of a CO2 laser might be more efficacious than conventional surgery. With appropriate diagnosis and treatment, patients should expect a favorable prognosis. In this article, we describe a new case of localized laryngotracheobronchial amyloidosis in a 67-year-old woman, and we review the literature on this subject.     

Functional evaluation of the patient with cholesteatoma

Aural cholesteatoma presents a challenging management problem. The literature abounds in excellent reports concerning surgical management, but emphasis should also be placed on the pre-operative evaluation of the patient in a systematic and complete manner. Relative to the patient's evaluation, the surgeon must decide whether or not surgery is necessary, the anticipated prognosis, and the effects of the management upon the patient in his socioeconomic environment. A series of seven questions are presented. Their answers should assist the otologist in systematically approaching the management of the patient with aural cholesteatoma.     

Esthetic anatomy of the nose

The sex, age, body build and general facial characteristics should influence the pre-operative considerations in designing an “ideal” nose for any patient requesting a corrective rhinoplasty. Certain acceptable points of difference between the desired “male” and “female” noses are described. The process of aging also affects the appearance of the nose; and such changes should be taken into consideration when planning a rhinoplasty on an older patient, so that there should be harmony of all the facial features. There are certain other characteristics of nasal physiognomy to be considered pre-operatively in respect to the patient's height as well as the general shape of the face and the outline of the profile; moreover, consideration should be given to possible desirable changes that may be brought about in altering an existing malocclusion or an imbalance between the jaws. The features of an “ideal” nose are described. It is suggested that, in comparing a given nose with the imaginary “ideal” for any specific patient, the deformities that require correction — providing they are considered amenable to correction — may be noted in a piecemeal fashion. This is recommended for the inexperienced surgeon who is not very esthetically minded, to enable him to evaluate the sum of deformities preoperatively, and to tackle them step-by-step at the operation.     

Inhalation of a Montgomery Safe T-tube plug.

The first case of an inhaled Montgomery Safe T-tube plug is reported. Both the surgeon and the patient should be aware of this possible complication and regular inspection of the plug is recommended. More than one plug should be provided with each T-tube.     

Gustatory sweating syndrome of the submandibular gland

Gustatory sweating syndrome involving the submandibular gland is rare. We present a case of a patient who experienced this syndrome 5 years after undergoing submandibular gland resection. Our patient was satisfied simply with an explanation of the disorder and reassurance. But in cases where further intervention is sought, medical and surgical options are available and should be individualized for the patient.     

Brown tumor of the facial bones: case report and literature review

Brown tumor, an uncommon focal giant-cell lesion, arises as a direct result of the effect of parathyroid hormone on bone tissue inpatients with hyperparathyroidism. The initial treatment involves the correction of hyperparathyroidism, which usually leads to tumor regression. We report a case of brown tumor of the right nasal fossa in a 71-year-old woman. The tumor had caused nasal obstruction and epistaxis. Laboratory evaluation revealed that the patient had primary hyperparathyroidism. Anatomicopathologic investigation revealed the presence of a giant-cell tumor We performed a partial parathyroidectomy, but the tumor in the right nasal fossa failed to regress. One year later we performed surgical resection of the lesion. The patient recovered uneventfully, and she remained asymptomatic and recurrence-free at the 1-year follow-up. Facial lesions with histologic features of a giant-cell tumor should be evaluated from a systemic standpoint. Hyperparathyroidism should always be investigated by laboratory tests because most affected patients are asymptomatic. Surgical resection of a brown tumor should be considered if the mass does not regress after correction of the inciting hyperparathyroidism or if the patient is highly symptomatic.     

Profound sensorineural hearing loss in polyarteritis nodosa. An atypical case of Cogan's syndrome

Parameters of importance for the development of thrombosis were investigated in a patient with polyarteritis nodosa (PAN) and profound sensorineural hearing loss. During the acute phase, platelet hyperaggregability, shortened platelet survival, and decreased fibrinolytic activity were found. The possibility is discussed that the etiology of the acoustico-vestibular symptoms in this patient could be an inner ear thromboembolic disorder. It is suggested that platelet functions and fibrinolytic activity should be investigated in patients with acoustico-vestibular symptoms and PAN or other systemic diseases. If abnormalities are found, specific platelet inhibitory and/or fibrinolysis-increasing treatment should be considered as an addition to the conventional medical treatment.     

Otolaryngologic manifestations of Down syndrome.

The DS patient has clear anatomic differences in the head and neck region when compared with the general population. These anomalies include a flat occiput, oblique palpebral fissures, epicanthal folds, speckled irides, a protruding tongue, prominent malformed ears, and a flat nasal bridge. Congenital otologic anomalies and acquired conditions such as otitis media are also more frequently observed in the DS population. The DS patient is predisposed to obstructive sleep apnea, and the diagnosis of sleep apnea in DS patients is more likely to be delayed. A child with DS who has a narrowed nasopharynx, large tongue, and a subglottis which is smaller than normal must be given special consideration at the time of intubation. Such a patient requires an endotracheal tube two sizes smaller than the standard size appropriate for the patient's age. The child should also be suspected of having and be evaluated for obstructive sleep apnea, to ensure that appropriate precautions are taken in the perioperative period. Finally, any DS patient undergoing preoperative evaluation for a general anesthetic should have a careful assessment of the cervical spine to avoid dislocation or spinal cord injury. Hearing loss may be suspected in any congenital syndrome. In DS, there is a clearly increased incidence of congenital temporal bone anomalies, external auditory canal stenosis, and otitis media. All DS patients should undergo hearing assessment in the neonatal period, with follow-up as appropriate. Aggressive treatment of conductive hearing loss and early amplification may be necessary to maximize speech and language development.     

Preoperative hearing and evaluations for cochlear implant patients. A preliminary report using a Minimal Auditory Capabilities battery

Two profoundly deaf patients were evaluated using the Minimal Auditory Capabilities (MAC) battery of speech discrimination tests. One patient was a multiple-channel cochlear implant patient (MC1) using a wearable speech-processor, the other a prospective cochlear implant patient using a hearing aid (HA). Results from the MAC battery showed that MC1 received significantly more auditory information via the speech-processor than was provided by the hearing aid to HA. These results indicated that the cochlear implant could be a suitable alternative for HA. However, the results indicated that HA gained some minimal benefit from the hearing aid and these results should be taken into consideration when deciding which ear should be implanted.     

Carcinoma of the Larynx: Predictors of Diagnostic Delay

Objectives In tumors of the upper aerodigestive tract a dose‐response relationship between tumor stage and its prognosis raises the chance of a reduction in the diagnostic delay. The interval between the first symptom and the start of tumor‐specific therapy and the influencing factors is not well known. The goals of this study were to investigate the diagnostic delay and the influencing factors and to predict the factors that prolong the diagnostic process. Study Design Prospective, nonrandomized study. Methods The intervals between first symptom and first consultation of a physician (patient delay) and between first consultation and first tumor‐specific therapy (doctor delay) were investigated. Predictors for increased patient or doctor delay were evaluated, and a multiple logistic regression model for increased doctor delay was developed. Results The total diagnostic delay (sum of patient and doctor delays) was 3 to 4 months. A multifactorial model for the ratio of odds revealed that for women and glottic cancers (1.73) the chance was twice as high for a doctor delay greater than 30 days, whereas subjects with an increased patient delay (>30 d) had reduced odds of being delayed by the physician. Conclusions The higher chance of extended doctor delay for glottic tumors compared with supraglottic tumors should be reflected in differential therapeutic strategies. Even unspecific lesions of the vocal folds should be followed up at the end of the therapy, at least. Therapies of glottic lesions without final control have the chance of resulting in delays in treatment. Women, especially, should be included in a follow‐up examination. On the other hand, patients with increased patient delay have lower odds of longer doctor delay, which may be the result of tumor growth and, consequently, easier diagnosis.     

异位颅咽管瘤的诊断与治疗

目的探讨异位颅咽管瘤（ectopic craniopharygioma）的临床诊断、手术疗效及预后，以期减少临床漏诊误诊。方法将收治的采用内镜经鼻入路手术治疗、病理确诊的3例异位颅咽管瘤患者的临床症状、影像学检查、手术方法以及预后情况进行总结。结果3例患者发病部位分别位于蝶窦、颞下窝1例，随访22个月，分别采用2次内镜经鼻入路手术，并行放疗后肿瘤组织恶变致全身多器官功能衰竭死亡；后鼻孔、软腭1例，术后随访18个月，未见复发；颞下窝1例，术后随访3年，未见复发。结论异位颅咽管瘤非常罕见，诊断主要依靠病理及免疫组化检测。手术切除目前仍然作为首选治疗方式，是否应行放射治疗有待商榷。     

Guiding patients through the choices for treating vestibular schwannomas: balancing options and ensuring informed consent

Counseling patients who are diagnosed with vestibular schwannomas, formerly known as acoustic neuromas, can be challenging. The health care provider has the responsibility to explain, in understandable language, to the patient or legal representative the proposed treatment options, risks and complications associated with each form of treatment, and alternatives to treatment, including no therapy. Patients should be encouraged to gather information before making a treatment decision. For the physicians managing these patients, information should be delivered in a balanced way to ensure patient understanding of their options leading to adequate informed consent.     

Infantile olfactory neuroblastoma. A clinicopathological study with review of the literature.

A case of olfactory neuroblastoma occurring in a 3-year-old girl is reported. The rarity of the lesion in early childhood is stressed and discussed with the clinico-pathological characteristics of the tumour, which are apparently more aggressive the younger the patient. Olfactory neuroblastoma should be considered as a possible diagnosis regardless of the age of the patient.     

Psychopathology in patients with presumed nasal deformities (author's transl)

If a patient with a "normal" nose desires rhinoplastic surgery, psychopathologic behavior should be recognized. In such patients, surgery is contra-indicated and the origin for the neurosis should be investigated. Two patients are presented in whom psychoanalysis was useful in correcting complex neurotic fixations on the nose with their attendant psychic dysharmonias. Therapy provided each patient with a more satisfying personal image. Each patient's desire for corrective nasal surgery was eliminated and patients were better able to accept their nasal features as well as gain positive social adjustments in their future lives.