Combining Free Flap Reconstruction and Craniofacial Prosthetic Technique for Orbit,Scalp, and Temporal Defects

Objectives: To identify factors leading to successful application of prosthetic techniques following free flap reconstruction of the orbit, scalp, and temporal region. Study Design: Retrospective review. Methods: Twenty-eight patients who underwent free flap reconstruction for defects of these regions between 1989 and 1996 were reviewed for clinical parameters, flap loss, patient survival, and implant loss rate. Prosthetic usage rates were compared before and after introduction of a site-specific reconstructive algorithm. Results: Free flap success rate was 93%, whereas osseointegrated implant loss rate was 11%. In addition to implants, a reconstructive strategy that provided thin, vascular tissue between bone and skin, a flat platform in the temporal region, and preservation of orbital cavity depth led to increased prosthetic usage. Conclusions: Craniofacial prosthetic techniques can significantly augment the results of free flap surgery for the orbit, scalp, and temporal region. Successful combination of these techniques requires a site-specific surgical approach.     

Validation assessment of the Chinese-version Chronic Ear Survey: a comparison between data from English and Chinese versions

The Chronic Ear Survey (CES) is a valid, disease-specific measure for the evaluation of health status and treatment effectiveness for adults with chronic suppurative otitis media (CSOM). This study compares the validation properties of the English and Chinese versions of the CES. The CES was translated into Mandarin Chinese by means of a parallel model. The Chinese version of the CES (CCES) was administered to 103 patients in a prospective manner, then was validated according to established criteria for reliability, validity, and longitudinal sensitivity. The CCES demonstrated good test-retest reliability and internal consistency (Cronbach's a = 0.81). The CCES significantly correlated with the Mandarin Chinese (Taiwan) version of the generic 36-Item Short-Form Health Survey (TSF-36). The standardized response mean for the CCES total score was 2.1, indicating excellent sensitivity to clinical change. This validation study demonstrated that the performance characteristics of the CCES were equivalent to those of the English-version CES. The CCES is a valid tool for evaluation of adults with CSOM among the Chinese-speaking population.     

Tissue eosinophilia in chronic sinusitis: quantification techniques

OBJECTIVE: To ascertain the reliability of a proposed method for quantifying tissue eosinophilia in sinus mucosa. DESIGN: Prospective cohort study. INTERVENTIONS AND OUTCOME MEASURES: Pathology slides from patients undergoing endoscopic sinus surgery for chronic rhinosinusitis were independently assessed by 2 reviewers. Using a proposed systematic counting method, the degree of tissue eosinophilia was quantified. Disease severity was assessed by computed tomographic (CT) staging. Intrarater, interrater, and intrapatient reliability was determined using correlational reliability analysis. The degree of correlation between tissue eosinophilia and CT stage was determined. RESULTS: One hundred thirty-two slides from 65 patients were reviewed. The mean (SD) eosinophil density was 23.4 (37.2) eosinophils per high-power field. Only 12 patients (18%) had no eosinophils on histopathologic analysis. Strong intrarater (r> or =0.91 for each rater, P<.001) and interrater reliability (r> or =0.82 between raters, P<.001) was noted for the quantification method. A moderate degree of correlation was found between CT scan stage and degree of tissue eosinophilia (Spearman rho = 0.62, P<.001). CONCLUSIONS: The proposed method for quantifying tissue eosinophilia in sinus mucosa is reliable and valid. A relatively strong correlation exists between CT scan stage and tissue eosinophilia in chronic rhinosinusitis.     

Validation of outcomes survey for adults with chronic suppurative otitis media

Currently, there is no valid, disease-specific outcomes measure to evaluate health impact and treatment effectiveness for patients with chronic suppurative otitis media (CSOM). The Chronic Ear Survey (CES) is a new, disease-specific outcomes measure for CSOM that was administered in a prospective manner to 91 patients with CSOM. It was then validated according to established criteria for reliability, validity, and sensitivity to clinical change by correlation with objective data and self-assessment questionnaires such as the Hearing Handicap Inventory for Adults (HHIA) and the generic 36-Item Short-Form Health Survey (SF-36). Significant correlations between subscale scores of the CES and audiometric data and between subscale scores of the HHIA and SF-36 were found. The standardized response mean for the CES total score was 0.42, indicating moderate sensitivity to clinical change. Overall, results demonstrated that the CES is a reliable and valid instrument for investigation of health status and health-related quality-of-life outcomes.     

Visual field change in low-tension glaucoma over a five-year follow-up

There is some evidence that the nature and progression of disease in low-tension glaucoma may be distinct from other open-angle glaucomas. The authors assessed visual field change by retrospective case review of all patients treated for low-tension glaucoma by the Glaucoma Service, Wills Eye Hospital, for at least 5 years. Sixty-two glaucomatous eyes of 36 patients were identified. All eyes were treated medically and 40 (65%) underwent at least one surgical procedure. Twenty-eight eyes (47%) had initial field loss confined to a single hemi-field and in the remainder both hemi-fields were involved. Thirty of 57 eyes (53%) showed progression at 3 years and 38 (62%) of 57 had progressed by 5 years. A dense scotoma extending from the nasal periphery toward fixation was the most common visual field defect. The rate of field change in this population is significantly greater than in a cohort of primary open-angle glaucoma patients also seen at Wills Eye Hospital, but who had elevated intraocular pressures. Patterns of field loss and rate of progression in this low-tension glaucoma population suggest that the natural history of low-tension glaucoma differs from high-tension open-angle glaucoma.     

The role of image-guidance systems for head and neck surgery.

BACKGROUND: Although image-guidance systems have gained widespread acceptance for neurosurgical procedures, their role for extracranial surgery of the head and neck is yet to be defined. OBJECTIVES: To describe the authors' experience with image-guidance systems and to measure the effects of image-guided technology on the performance of minimally invasive otolaryngological procedures. DESIGN: Prospective cohort study. METHODS: Optical- and electromagnetic-based image-guidance systems were used during the performance of endoscopic surgery on patients with disease of the paranasal sinuses, orbit, skull base, and temporal bone (n = 79). Results were compared with those in control patients who underwent similar surgery without image guidance during the same period (n = 42). RESULTS: Intraoperative anatomical localization was accurate to within 2 mm at the start of surgery in all cases. Accuracy degraded by 0.89 +/- 0.20 mm (mean +/- SE) during the operative procedure. The use of an image-guidance system increased operating room time by a mean of 17.4 minutes per case (image-guidance group, 137.3 +/- 6.0 minutes [mean +/- SE]; control group, 119.9 +/- 5.7 minutes; P=.006) and increased hospital charges by approximately $496 per case. Intraoperative blood loss (image-guidance group, 178.4 +/- 18.0 mL [mean +/- SE]; control group, 149.4 +/- 20.1 mL) and complication rates (image-guidance group, 2.7%; control group, 4.7%) did not differ significantly between groups. CONCLUSIONS: Image-guidance systems can provide the head and neck surgeon with accurate information regarding anatomical localization in cases with poor surgical landmarks caused by extensive disease or prior surgery; however, the use of such systems is associated with increased operative time and expense.     

A comparison of image guidance systems for sinus surgery

Objective: Intraoperative computed tomographic guidance systems are available which utilize either electromagnetic (radiofrequency) or optical (infrared) signals to localize instruments within the surgical field. The objective of this study was to compare the use of these two different image guidance technologies for sinus surgery. Study Design: Prospective cohort study. Methods: The electromagnetic-based InstaTrak system (n = 24) and the optical-based Stealth-Station (n = 49) were compared in a series of 73 consecutive sinus series which utilized image guidance technology. Results: Both the electromagnetic and optical systems provided anatomic localization to within 2 mm during surgery. Intraoperative reregistration was effective in correcting for any anatomic drift. There were no intraoperative complications. Mean operative times were 156.3 ± 8.9 minutes for the electromagnetic and 139.2 ± 17.7 minutes for the optical system (P < .05). The average intraoperative blood loss did not differ significantly between groups (electromagnetic, 190.6 ± 28.7 mL; optical, 172.4 ± 23.0 mL). Each system was noted to have limitations. The presence of metallic objects in the operative field interfered with functioning of the electromagnetic system, whereas the optical system required a clear line of sight to be maintained between the infrared camera and surgical handpiece. Both systems required specialized headsets to be worn by patients during surgery to monitor head position. The electromagnetic system also required these headsets to be worn during the preoperative computed tomography scan. Conclusion: Although these two image guidance systems both proved valuable for anatomic localization during sinus surgery, individual preferences can be based on distinct differences in their design and operation.     

Four-Contact Glove Probe Method for Rapid Recording of Cardiac Electrograms during Surgery

A technique is presented for recording four simultaneous electrograms from the heart during operation for cardiac arrhythmias. This technique permits intraoperative maps of cardiac electrical activity to be constructed more rapidly than is possible with single-point mapping, thereby decreasing the risks to the patient and yielding more information about cardiac events.