Scientific posters

Scientific Posters The scientific posters provide an opportunity for visual presentation of charts, drawings, and photographs, supplemented with 1 or 2 pages of text. Authors will post the times they will be available for questions.The posters will be available Sunday to Tuesday, September 22-24, from 7:00 AM to 8:00 PM in the Sails Pavillion of the San Diego Convention Center.

P001

Genioglossus Advancement and Hyoid Myotomy: Shortand Long-Term Results Chairat Neruntarat MD (presenter) Bangkok Thailand

Objectives: Successful results of genioglossus advancement and hyoid myotomy with suspension (GAHM) in the treatment of obstructive sleep apnea (OSA) have been reported. However, there were few studies of the long-term results. The purpose of this study was to compare the short-term versus long-term results in patients undergoing GAHM. Methods: Forty-six patients with hypopharyngeal obstruction underwent GAHM. Uvulopalatal flap was an adjunct surgical procedure for palatal obstruction. Patients had a mean age of 40.1 + 4.2 years and a mean body mass index of 28.9 + 2.1 kg/m a. The majority of the patients were male. Data on the patients were compared from preoperative to the short-term (6 months) and long-term (more than 3 years) postoperative assessment points. Statistical analysis was performed. Results: The mean follow-up was 39.4 + 5.7 months with a range of 37 to 46 months. The mean preoperative RDI, short-term RDI, and long-term RDI were 47.9 _+ 8.4, 14.2 _+ 3.9, and 18.6 + 4.1, respectively. The mean preoperative LSAT, short-term LSAT, and long-term LSAT were 81.2% _ 2.9%, 88.8% _+ 2.7%, and 87.2% -+ 3.1%, respectively. There were significant differences between short-term and long-term results (P < 0.05). The change in body mass index was significantly different in the patients with and without recurrence (2.1 + 0.3 kg/m 2 vs 0.4 _+0.2 kg/m 2, P < 0.05). Thirty (65.2%) patients had long-term clinical success, and 6 (16.7%) patients with short-term success did not have long-term success. Conclusion: GAHM appears to be an effective procedure and results in long-term success. However, patients with weight gain are at risk of recurrence. P002

Malar and Orbital Fractures Among Army Soldiers: 1980-2001 Jeffrey Shere MD; Jason R Boole MD (presenter); Paul Amoroso; Michael R Holtel MD CDR USN MC APO AE; TriplrArmy Mdcl HI,"Natick MA; TriplrArmy Mdcl HI

Objectives: We present the demographics, associated injury, and mechanisms of 3599 patients with malar fractures and 1141 patients with orbital floor fractures. Methods: Retrospective analysis of data extracted from Augu~ 2002

1980 to 2000 from the Total Army InjurY and Health Outcomes Database, a comprehensive database based on the ICD9 CM coding system. Results: The majority of patients were young males in both groups. 96% were male and most were 20 to 25 years old. Of 3599 malar fractures, 407 were associated with a mandible fracture, 314 with an orbital floor blowout, 291 with a nasal fracture, and 291 with miscellaneous facial fractures. Of 1141 orbital floor fractures, 314 were associated with malar fractures, 117 with nasal fractures, 58 with mandible fractures, and 92 with miscellaneous facial fractures. Of patients with orbital floor fractures, 213 had an associated eye injury including diplopia, conjunctival hemorrhage, iridocyclitis, vitreous hemorrhage, retinal hemorrhage, eyelid ptosis, traumatic optic neuritis, and miscellaneous eye injuries. The most common mechanisms of injury include fighting, sports, and motor vehicle accidents. Conclusion: We report the results from one of the largest series of malar and orbital floor fractures. Only 8.7% of malar fractures have an associated orbital floor fracture, and only 27.5% of orbital floor fractures were associated with a malar fracture. Eye injuries were seen in 20% of orbital floor fractures. Fighting is the predominant mechanism, and young males are the most frequent group involved in both types.

PO03

Palatal Injection Sclerotherapy for Snoring Chairat Neruntarat MD (presenter) Bangkok Thailand Objectives: Significant improvement has been reported in the measures of snoring following Injection Snoreplasty. Sotradecol is injected into the submucosal layer of the soft palate to induce fibrosis and reduce palatal flutter snoring. However, other sclerotherapy agents have been successfully used to treat various head and neck lesions. The purpose of this study was to assess the safety and efficacy of sclerotherapy with Aethoxyskerol for the treatment of primary snoring. Methods: Palatal injection sclerotherapy was performed in 38 snorers on an outpatient basis under local anesthesia. Aethoxyskerol (3% hydroxy polyethoxydodecan) was injected submucosally (0.5-1 cc) into the soft palate. Treatment sessions were performed at a minimum of 6 weeks apart. Patients had a mean age of 38 years and a mean body mass index of 27.9 kg/m 2. Most of the patients were male, with simple snoring determined by history and confirmed by p o l y s o m n o -

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graphic study. Data on patients were compared from pre- to posttreatment assessment points. Statistical analysis was performed by using Student's t test. Results: All patients tolerated the procedure well, and it was performed in an average of 10 minutes. The mean followup was 12 months (10-14 months) after the last session. Significant improvement was observed in the snoring (8.5 -+ 3.2 vs 2.7 +_ 1.4, P < 0.05) and Epworth Sleepiness Scale (11.1 + 3.4 vs 7.9 _+2.2, P < 0.05). Complications included mucosal breakdown in 18% and transient foreign body sensation in 21%. Posttreatment pain was rated as minimal (visual analog scale <4) for 7 days. Patients underwent a mean of 2.2 treatment sessions. The overall success rate was 82%. Conclusion: Snoring and daytime sleepiness decrease following palatal injection sclerotherapy. It appears to be a safe, inexpensive, and effective procedure, which can be performed in carefully selected patients. P004

Adenovirus-Mediated Gene Transduction of Murine Middle Ear Thomas Lee MD (presenter); Anne E Luebke PhD; Craig A Buchman MD

Miami FL; Miami FL; Chapel Hill NC

Objectives: The mouse has been a frequent subject of gene mutation and gene knockout studies and is an ideal animal model from which to study the molecular intricacies of otitis media. This study was performed to demonstrate the feasibility of gene transduction of the mouse middle ear mucosa by a simple tympanostomy. We also tested if second-generation viral vectors (replication defective) improved transduction durations when compared to first-generation vectors (replication defective). Methods: Twenty BALB/c mice received transtympanic injections of either first- or second-generation adenoviral vectors containing the lacZ gene. Mice were then sacrificed at 3, 7, 14, 21, 28 days. Their temporal bones were harvested and processed, and immunohistochemistry to detect the beta-gal protein was performed. Staining in the middle ear mucosa was then quantified. Results: All mice had healed tympanic membranes by day 7. For both viruses, nearly 100% of the middle ear mucosa was transduced when studied on day 3. After 28 days, 25% of the mucosa remained transduced for first-generation viral vectors while 75% of the mucosa remained transduced for second-generation viral vectors. Conclusion: Transtympanic injection is an easy, repeatable way to introduce genetic material into the mouse middle ear mucosa. The newer, less immunogenic viral vectors allow for longer transduction times and have shown no ototoxic qualities in other studies. Virus-mediated gene transfer may become a useful method in studying and treating otitis media at the molecular level.

PO05

Quantitative PCR Analysis of VZV DNA in Ramsay Hunt Syndrome Yasushi Furuta MD PhD (presenter); Fumio Ohtani MD; Satoshi Fukuda MD PhD

Sapporo Japan; Sapporo Japan; Sapporo Japan

Objectives: Varicella-zoster virus (VZV) reactivation causes facial palsy in Ramsay Hunt syndrome (RHS). Although antiviral agents have been used for the treatment of RHS in combination with steroids, their effects on facial palsy remain controversial. This study analyzed the VZV load to assess the efficacy of the therapy in patients with RHS. Methods: We used a TaqMan PCR assay to analyze the VZV DNA copy number in saliva samples from 18 RHS patients who received acyclovir-prednisolone therapy. Results: VZV DNA was detected in 11 of the 18 patients (61%) by TaqMan PCR. Within 2 days after initiation of the treatment, the VZV copy number showed a decrease in 10 of the 11 PCR-positive patients, whereas the viral load increased in the remaining one patient. The recovery of palsy was complete in 13 of the 18 patients (72%). The highest viral copy number in patients who showed incomplete recovery was significantly higher than that in patients who recovered completely. Conclusion: Acyclovir-prednisolone therapy may suppress the VZV load in patients with RHS. The results also suggest that a high VZV copy number in saliva samples is a poor prognostic marker for recovery from facial palsy in RHS patients. P006 Effect of Leukotriene Receptor Antagonist on Nasal Polyps A c e v e d o Eulalio Vivar MD; Rodriguez Carlos Carrasco MD (presenter); Sue Archbold

Mexico City Mexico; Distrito Federal Mexico; Nottingham United Kingdom

Objectives: (1) To investigate the response to montelukast, a leukotriene D 4 receptor antagonist, as an add-on therapy to topical and inhaled corticosteroids in patients with sinonasal polyps. (2) To investigate the count of eosinophils and other inflammatory cells on nasal lavage and histologic changes in a nasal biopsy specimen at the start and end of treatment. Methods: It was a prospective, placebo-controlled, doubleblind trial. Our regimen included a 3-month trial of montelukast, 10 mg daily, as an add-on therapy to intranasal and inhaled corticosteroids. Patients were assessed at the end of this study and were given a clinical score, based on patients' symptoms by direct interview and examination findings. Collection of nasal secretions was performed. We evaluated the characteristics of the cells of the nasal lavages, especially eosinophils, and we also took a nasal biopsy specimen to

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investigate the histologic changes at the start and end of treatment. Results: Clinical subjective improvement in nasal polyps occurredin 64% (P < 0.001). Objective improvement occurred only in 50% of the patients (P > 0.005), as determined by clinical examination and endoscopic evaluation. Nasal lavages show a reduction of eosinophil count in 60% (P < 0.001) of the patients with treatment and no significant changes without it. Histologic changes in the nasal biopsy specimen show a reduction of the edematous eosinophilia of the stroma in 50% (P > 0.005) and minimum reduction of mast cells in the patients with treatment and no significant changes in patients without treatment. Conclusion: We conclude that antileukotrienes play a significant role in controlling polyposis and symptoms secondary to sinonasal disease, and they might be a viable alternative to long-term steroid therapy and repeated surgical dtbridement. Antileukotrienes stop one of the stimuli of eosinophilia. By blocking the effect o f leukotrienes, we prevent increased transendothelial migration and eliminate one of the major survival factors for human eosinophils. There was a positive correlation between leukotrienes D 4 and C 4 and eosinophils. P007 The Use of a Lateral Nasal Wall Flap in Facial Translocation Approach to the Skull Base Sheng-Po Hao MD (presenter); Kai-Ping Chang MD Taipei Taiwan (Republic of China)," Taipei Taiwan (Republic of Chino)

Objectives: Facial bone graft necrosis is a common complication of facial translocation approach to the skull base. We will demonstrate the use of a newly designed lateral nasal wall flap to resurface the inner defect of the translocated facial bone graft, thereby preventing its necrosis. Methods: Lateral nasal wall flaps based on nasoalveolar vessels were developed before facial osteotomies in facial translocation to the skull base. The flaps were transposed to resurface the inner defects of the translocated facial bone grafts. From July 1999 to June 2001, 40 consecutive patients who underwent facial translocation approach to remove skull base tumors were enrolled in this study, including 32 patients who had either preoperative or postoperative radiation therapy. Results: The lateral nasal wall flap survived in every case. There were only two complications, including one translocated facial bone graft necrosis possibly resulting from flap detachment and one flap reflection. There was no bare bone observed under sinoscopy in 97% of the cases in 6 months after surgery. Conclusion: The use of a lateral nasal wall flap to resurface the translocated facial bone graft significantly improves the viability of the translocated facial bone graft. This modified facial translocation technique also aids in detecting early local recurrence.

Scientific Posters

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PO08

MCM2: A More Sensitive Proliferation Marker than Ki67 for Oropharynx Squamous Carcinoma Sam Wiseman MD (presenter); Peter T Lin; Wesley L Hicks Jr DDS MD; Thom R Loree MD; Nestor R Rigual MD; Helen Swede; Joel Huberman; Janet Winston Buffalo NY; Buffalo NY; Buffalo NY; Buffalo NY; Buffalo NY; Buffalo NY; Buffalo NY

Objectives: MCM2 is a member of the family of minichromosome maintenance (MCM) proteins that play an important role in the regulation of DNA replication. MCM2 has been shown to be a proliferation marker in several types of tissue. In this study we compared the sensitivities of the commonly used proliferation marker, Ki-67, with the new proliferation marker, MCM2, in 35 squamous cell carcinoma tumors of the oropharynx. Methods: Parallel sections of 35 oropharyngeal tumors were stained with antibodies against MCM2 and Ki-67. The tumor subsites were: base of tongue in 15 patients, tonsillar fossa in 13 patients, pharyngeal wall in 5 patients, and faucial arch in 2 patients. Antigen retrieval was carried out for Ki-67 but not for MCM2. The percentage of positively stained nuclei was scored for each antibody. Results: For all specimens the average frequency of staining by anti-MCM2 (65.2%) was significantly greater (paired t = -4.46, P < 0.001) than by anti-Ki-67 (44.8%). This finding did not substantially vary by tumor subsite or when analyzed with the Wilcoxon signed rank test. MCM2 expression was highly correlated with advanced tumor grade (Spearman's r -- 0.62, P < 0.001.). Neither MCM2 nor Ki-67 significantly correlated with tumor size or the presence of neck nodal metastases. Conclusion: Our data suggest that MCM2 may be a more sensitive marker of cellular proliferation than is Ki-67. Given these results, MCM2 may be a useful biomarker in predicting tumor response to adjuvant and neoadjuvant therapies. Additionally, this enhanced sensitivity may be of clinical value, given that staining with MCM2 is technically less demanding. P009 Clinical Manifestations of Mutations in Cx26 Doris Lin MD (presenter); Lawrence R Lustig MD; Anil K Laiwani MD San Francisco CA; Baltimore MD; San Francisco CA

Objectives: Mutations in Cx26 are the most common known cause of congenital severe-to-profound deafness. This study retrospectively reviews the clinical presentations of patients with Cx26 mutations to help aid in diagnosis, genetic counseling, and provision of prognostic information. Methods: There were 34 patients with Cx26 mutations presenting to two hearing loss referral centers whose charts were reviewed for clinical presentation.

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Results: There were 8, 21, and 4 patients with homozygous, heterozygous, and compound heterozygous mutations, respectively. Of the patients with homozygous mutations, 80% presented before age 7, 50% had a positive family history of hearing loss, and all had bilateral severe hearing loss. Among the patients with heterozygous mutations, 33% presented in childhood, 17% had a positive family history, and 67% had bilateral hearing loss. Except for one patient with normal hearing, all the adults in this category had an alternative diagnosis for hearing impairment including presbycusis, otosclerosis, and endolymphatic hydrops. Of the patients with compound heterozygous mutations, 67% presented in childhood, 50% had a positive family history, and all had bilateral hearing loss. Three of the 34 patients had abnormal CT scans involving the cochlea, IAC, and EAC. Conclusion: Mutations in Cx26 have been shown to be responsible for a majority of recessive nonsyndromic hereditary hearing impairment in children. However, mutations in Cx26 have shown a varied presentation, including adult-onset hearing impairment, underscoring its role as an important component of the human cochlea. PO10

Expression of Collectin in Human Nasal Mucosa Seul Ki Jung; Jin Ho Choi; Sang Hag Lee MD; Soon Jae Hwang; Heung-Man Lee MD PhD (presenter) Seoul South Korea; Seoul South Korea; Seoul South Korea; Seoul South Korea; Seoul South Korea

Objectives: Snrfactant protein A (SP-A) and surfactant protein D (SP-D) are calcium-dependent lectins and are important components of the antibody-independent pulmonary host defense system or innate immunity. It is not known about the presence of collectins in human nasal mucosa. The purpose of this study was to investigate the expression of collectin proteins in human nasal mucosa and to compare the expression of SP-A and D mRNA in normal nasal mucosa and in chronic inflammatory nasal mucosa. Methods: Ten chronic rhinitis patients were recruited. Ten subjects with normal nasal mueosa were used as controls. Reverse transcriptase-polymerase chain reaction was done to detect the SP-A (A1, A2) and SP-D mRNA. Immunohistochemical staining of SP-A and SP-D was done. Results: SP-A protein was expressed in the nasal epithelium and in the epithelial cells of the submucosal glands. SPD mRNA and protein were not expressed in the nasal mucosa. SP-A2/GAPDH mRNA ratio in chronic rhinitis mucosa is greater compared with that in normal nasal mucosa. Conclusion: These data provide the first evidence of the presence of collectins in human nasal mucosa, and increased expression of SP-A may play a protective role in chronic nasal inflammatory diseases

P011

Polymeric Membrane Dressings for Endonasal Sinus Surgery P Perry Phillips MD (presenter) Sheboygan WI Objectives: To evaluate polymeric membrane dressing as a sinus surgery dressing. Methods: A prospective trial of 35 consecutive patients undergoing endonasal sinus surgery. All patients had polymeric membrane dressings placed into their middle mental region after endonasal sinus surgery for 5 days. Variables evaluated were pain on removal, postop bleeding control, bleeding post removal, migration of packing material, synechia formation, odor upon removal, occurrence of toxic shock syndrome, and occurrence of hypersensitivity reactions. Pain was measured subjectively with a 0-4 pain scale with 0 = no pain, 1 = mild pain, 2 = moderate pain, 3 = moderately severe pain, and 4 = severe unbearable pain. Postremoval bleeding was rated 0 to 4 with 0 = no bleeding, 1 = mild bleeding, 2 = moderate bleeding, 3 = severe bleeding, and 4 = life-threatening bleeding/return to OR. Results: Pain on removal was minimal, rating 0.54 on the 0-4 scale. 46% of patients reported tickling or pressure but no pain on removal. No patients had moderate or severe Pain reported. Postpacking removal bleeding was minimal with a rating of 0.34 on the 0-4 scale. Postop bleeding control was excellent with no patients requiring repacking or return to the OR for bleeding. Synechia formation was minimal in two patients with no obstructing synechia or lateralization of the middle turbinate. Hypersensitivity, toxic shock, migration of dressings, and foul odor did not occur. Conclusion: Polymeric membrane wound care sheets make excellent intranasal sinus dressings with minimal pain on removal and excellent wound healing properties. They are cost-effective ($6.36 per sheet) and well tolerated. P012

Steroid and Antiviral Therapy in Idiopathic Sudden SNHL Mani Hossein Zadeh MD (presenter); Jan S Storper MD; Jaclyn B Spitzer PhD New York NY; New York NY; New York NY

Objectives: To analyze the efficacy of steroid and antiviral therapy in the management of idiopathic sudden sensorineural hearing loss (SSNHL). Methods: Charts of patients presenting to the otology service over the last 8 years were reviewed. Only patients presenting and starting treatment within 7 days of onset of SSNHL were selected. Fifty-one patients were evaluated. Thirty were male, and 21, female. The average age was 49 years at the time of treatment. Eleven patients (22%) presented with vertigo. SSNHL was defined as at least a 10-decibel SNHL, occurring in at least 3 frequencies. All patients were

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placed on a 3-week steroid taper. In addition, they simultaneously received a 1-week course of valcyclovir and a 3-week course of famotidine. Recovery of hearing, based on the preand posttreatment audiogram, was the main outcome measure. Patient age, time since onset, vertigo, and audiogram configuration were also analyzed. Results: Thirty-seven patients (73%) reported complete recovery of hearing at follow-up, and repeat audiograms confirmed the change. All patients with mid-frequency hearing loss and up-sloping hearing loss recovered with treatment. Conclusion: Our treatment protocol produced a recovery rate of 73%, which exceeds the spontaneous recovery rate. Antiviral therapy proves beneficial in the treatment of idiopathic sudden-onset SNHL. According to our results, age, onset of SSNHL, and vertigo do not play a role in prognosis under the current treatment. The configuration of hearing loss was a factor in recovery. We obtained a 100% recovery in midfrequency and up-sloping SSNHL. P013 Anthrax: ENT Manifestations and Current Concepts Ari I Wirtschafter MD (presenter); Sreekant Cherukuri MD; Michael S Benninger MD Detroit MI; Southfield MI; Detroit MI

Objectives: In light of recent events, anthrax has once again taken center stage in the world of science and the world in which we live. Since patients with anthrax may initially present to otolaryngology clinics, it is important for the otolaryngologist to know how to diagnose and treat this entity. Methods: An extensive literature review of MEDLINE, as well as Web-based information sites such as the Centers for Disease Control (CDC) and Up to Date, was performed. Results: Current information on epidemiology, microbiology, pathogenesis/clinical manifestations, diagnosis, and treatment is presented. In particular, emphasis is placed on ENT manifestations and oropharyngeal anthrax. Conclusion: Successful diagnosis and treatment is dependent upon a high level of suspicion. Specific guidelines for treatment are presented. This paper was accepted in Otolaryngology-Head and Neck Surgery and will be published January 2002. P014

The Role of Mitomycin-C in the Endoscopic Treatment of Subglottic Stenosis James Chan MD (presenter); Lee Michael Akst MD; Isaac Eliachar MD Cleveland Hts OH; Cleveland OH; Cleveland OH

Objectives: Restenosis is the primary reason for surgical failure in the management of subglottic stenosis (SGS). Mitomycin-C, an antiproliferative agent, has been reported to be effective in reducing scar formation in the upper airway.

We investigated the role of mitomycin-C in the endoscopic treatment of SGS. Methods: A retrospective review of patients who presented with SGS, surgically treated by a single otolaryngologist between January 1994 and January 2002, was conducted. The majority of patients were successfully managed endoscopically. Within this endoscopic group, patients who underwent topical application of mitomycin-C are compared to those who did not. Outcomes measured include number of patients requiring repeat procedures, mean increase in airway size, and mean time between procedures. Results: Of the 52 patients initially managed endoscopically, 12 ultimately required laryngotracheal reconstruction or a tracheostomy. Of the 40 remaining patients, 29 patients received mitomycin-C, and 11 did not (groups were similar). In those receiving mitomycin, 17 of 29 (59%) required repeat procedures, mean increase in airway was 33%, and mean time between procedures was 7.7 months. In the control group, 3 of 11 (27%) required repeat procedures, the mean increase in airway size was 43%, and the mean time between procedures was 11 months. Conclusion: The majority of patients with SGS can be successfully maiaaged endoscopically. In this retrospective study, the addition of mitomycin-C did not appear to significantly improve outcomes. The number of patients requiring repeat procedures, the time between procedures, and the postoperative airway size were not improved in the mitomycin group as compared to control. P015

Videostrobe, Mirror, and Fiberoptic Laryngoscopy: Objective Comparisons Danny T Kewson MD (presenter); Robert Meleca MD; James P Dworkin PhD; Ilene Garfield MA West Bloomfield MI," Detroit MI; Detroit MI; Detroit MI

Objectives: In the office, laryngeal examination can be accomplished by using multiple diagnostic modalities including mirror examination, flexible fiberoptic laryngoscopy, and rigid endoscopy, with or without stroboscopy. Gould (1983) reported that the mirror examination provided adequate visualization of the larynx in up to 70% of patients, although this percentage has not been validated by controlled studies. With the introduction of the flexible fiberoptic laryngoscope, and more recently rigid videostroboscopy, visualization of the larynx is generally believed to be substantially improved. However, ability to obtain satisfactory visualization of the larynx and accuracy of diagnosis, comparing mirror, flexible fiberoptic laryngoscopic, and rigid videostroboscopic techniques has not been studied comprehensively or objectively. Our study looked to quantify in what percentage of patients, when compared to more traditional diagnostic tools such as mirror examination and/or flexible fiberoptic laryngoscopy,

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videostroboscopy adds to or changes the diagnosis of laryngeal pathologies, thus changing treatment plans. Methods: A retrospective review of 200 charts was conducted evaluating the ease of visualization of the larynx, quality of image obtained, and accuracy of diagnosis for various laryngeal disorders using mirror examination and/or fiberoptic laryngoscopy in comparison to rigid videostroboscopy. Results: Rigid videostroboscopy added information or changed the diagnosis, therefore changing treatment plans in greater than 20% of patients diagnosed with various laryngeal pathologies using either mirror examination and/or flexible fiberoptic laryngoscopy. Conclusion: Rigid videostroboscopy is an important inoffice diagnostic tool that will change or alter the diagnosis of various laryngeal pathologies in over 20% of patients undergoing only mirror examination and/or fiberoptic laryngoscopy. P0I 7

OSAS in Children: Correlation Between Endoscopy and PSG Fabiana Cardoso Pereira Valera MD; Melissa Amelotti Gomes Avelino MD; Daniela Carlini MD; Shirley Piganatari PhD; Reginaldo Fujita PhD; Luc Louis Maurice Weckx MD PhD (presenter) Ribeirao Preto Brazil; Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil

Objectives: Hypertrophy of the tonsils and adenoids is considered the major predisposing factor for obstructive sleep apnea syndrome (OSAS) in children. Although the diagnosis of OSAS can be clinically suspected, it is preferably confirmed by polysomnographic examination. We correlate clinical findings and polysomnographic exams when studying OSAS in children. Methods: 132 children with clinical history of snoring and apnea were evaluated at the Division of Pediatric Otorhinolaryngology Federal University of Sao Paulo from 1999 to 2001. They all had Careful history, physical examination, and nasopharyngoscopic and polysomnographic examinations. Patients were divided by age in 2 categories: preschool children and school children. Each group was subdivided in 4 groups: group 1, with no hypertrophy of adenoids and tonsils; group 2, with isolated adenoid hypertrophy; group 3, with isolated tonsil hypertrophy; and group 4, with hypertrophy of both adenoids and tonsils. The results of the polysomnographic examinations were analyzed and compared within groups and age categories. Results: No statistically significant differences were observed for any of the group or age categories, either when polysomnographic results were correlated with symptoms or with the clinical and endoscopic findings. Overall, a greater tendency for apnea was observed in preschool children, although statistical significance was not achieved. Conclusion: Based on this study, we concluded that there

is no correlation between polysomnographic results and clinical or endoscopic findings in children with a history of snoring and apnea. Other factors such as neurologic development may play a role in the genesis of apnea. P0I 8

Predictors of Sleep Apnea Syndrome in Men and Women Johanna Dalhqvist MB (presenter); Karl Franklin; Diana ViviAnn Berggren MD PhD; Marie Marklund DDS PhD; Ake Dahlqvist MD PhD Umea Sweden; Umea Sweden; Umea Sweden; Umea Sweden; Umea Sweden

Objectives: To identify easily measured anatomical predictors of sleep apnea syndrome (SAS) by using routine examinations. Methods: All patients (801:596 men and 205 women), who between August 1997 and May 2000 were referred due to suspicion of SAS, were consecutively included in the study. A standardized ear, nose, and throat examination and an overnight sleep apnea recording were performed. The apnea/ hypopnea index (AHI) was defined as the number of apneas and hypopneas per hour of sleep, and SAS was defined as AHI > 5. Univariate ANOVA and logistic regression analyses were used. Results: AHI was significantly associated with age, body mass index (BMI), and the width of the uvula for both men and women. The height and retroposition of the tongue and the distance between the uvula and the dorsal pharyngeal wall were significantly associated with the AHI only for men. Strongest predictors of SAS in women were age (OR = 1.1; 95% CI, 1.06-1.14), BMI (OR = 1.1; 95% CI, 1.02-1.16), retroposition of tongue (OR = 1.8; 95% CI, 1.09-3.04), width of uvula (OR = 1.6; 95% CI, 1.00-2.60), and gag reflexes (OR = 0.35; 95% CI, 0.149-0.832). In men the predictors were slightly different: age (OR = 1.1; 95% CI, 1.04-1.08), BMI (OR = 1.1; 95% CI; 1.07-1.19), height of the tongue (OR = 1.2; 95% CI, 0.941-1.63), and gag reflexes (OR = 0.63; 95% CI, 0.385-1.02). Conclusion: Easy identifiable predictors for men with SAS are the position of the tongue, width of the uvula, and BMI. For women over 50 years, obesity and a wide uvula seem to be risk factors for SAS. P019

Endoscopic Management of Pediatric Subperiosteal Orbital Abscess Lynne Hsueh Yee Lim FRCS;Yaw Khian Chong MD (presenter); Dharambir S Sethi MD Cincinnati OH; Singapore Singapore; Singapore Singapore

Objectives: To characterize the presentation of and feasibility of endoscopic management of pediatric subperiosteal orbital abscesses (SPOA).

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Methods: Retrospective case series of 12 consecutive pediatric patients. All had endoscopic drainage within 24 hours of admission when a third-generation cephalosporin failed to halt disease progression. Every patient had a sinus CT scan and ophthalmologist's review preoperatively. Results: 12 consecutive pediatric patients had SPOA complicating sinusitis. All were treated with endoscopic drainage when third-generation cephalosporin failed. The mean age of the patients was 9.4 years, and the male/female ratio was 2:1. No racial predominance was observed; only 3 of 12 presented with sinorespiratory symptoms, 12 of 12 had eye swelling, 7 of 12 had fever, 5 of 12 had headache, 2 of 12 had nasal block or rhinorrhea. The mean duration of symptoms was 4.3 days. Nine of 12 had unilateral sinus involvement, 3 of 12 had bilateral sinus involvement, and 11 of 12 had ethmoidal involvement. Six of 12 had frontal involvement, and none had maxillary or sphenoidal involvement. Eleven of 12 had unilateral SPOA, 1 of 12 had bilateral SPOA, and 2 of 12 required additional external approach surgery. One of 12 had endoscopic drainage failure due to lateral sited SPOA. Streptococcus species and Staphylococcus aureus were the most common causes of infection. No anaerobes were found. There were no surgical complications, and no recurrent SPOA was observed. The average hospital stay was 3.5 days. Conclusion: Unlike SPOA in adults, pediatric SPOA presents more acutely and often without sinorespiratory symptoms. Endoscopic drainage of medial SPOA can be performed safely and is curative when antibiotics fail. However, lateral SPOA may require an additional external surgical approach. P020

Oral Intake and Gastrostomy Tube Dependence after Chemoradiotherapy Ankit Patel MD (presenter); Jason G Cundiff MD; Fred Rosen MD; Louis G Portugal MD

Chicago IL,"Chicago IL,"Chicago 112Chicago IL

Objectives: To evaluate the incidence of dysphagia, ability for oral intake, and incidence of gastrostomy tube dependence in patients who received aggressive, concomitant chemoradiotherapy for treatment of advanced squamous cell carcinoma of the head and neck. Methods: A retrospective chart review was performed for all patients receiving concomitant chemoradiotherapy from 1996 to 2000 for stage III and IV squamous cell carcinoma of the head and neck. Charts were reviewed for incidence of (1) dysphagia, (2) patients dependent on gastrostomy tube for nutrition, and (3) patients who were unable to take any food or liquids by mouth. End points were determined at presentation, and then at 6, 12, and 18 months post treatment. Results: At 6 months, 95% of patients had dysphagia, 85% were dependent on gastrostomy tube, and 48% of patients were unable to take food or liquid by mouth. At 12 months, 79% had dysphagia, 74% were dependent on gastrostomy

tube, and 58% were unable to take food or liquid by mouth. At 18 months, 88% had dysphagia, 81% were dependent on gastrostomy tube for nutrition, and 56% were unable to take food or liquid by mouth. The two most common reasons for gastrostomy tube dependence were dysphagia and aspiration. Conclusion: Prolonged dysphagia is a significant problem after concomitant chemoradiotherapy, with a high percentage of patients dependent on gastrostomy feedings after treatment. A subset of patients was found with late onset of dysphagia noted 18 months after treatment. These findings warrant further study but merit consideration when counseling patients regarding treatment options. P021

Acoustic Rhinometry of Nasal Obstruction Treated with Nasal Steroids Kwai Onn Chan MBBS FRCS (presenter); De-yun Wang MD Singapore Singapore; Singapore Singapore

Objectives: Intranasal corticosteroids are the mainstay in the pharmacological treatment of perennial rhinitis. Nasal obstruction is one of the cardinal symptoms and is usually assessed subjectively. This is a prospective study in which acoustic rhinometry (AR) is used to objectively measure the effectiveness of intranasal corticosteroids in improving nasal obstruction. Methods: Forty-five consecutive patients with nasal obstruction from perennial rhinitis were treated with fluticasone propionate. Pre- and posttreatment nasal obstruction was assessed subjectively with a visual analogue score (VAS) and objectively with AR. The changes in nasal airway patency and the correlation between VAS and AR measurements were statistically analyzed. Results: VAS improved significantly from 6.3 (pre) to 3.9 (post). Nasal cavity volume increased significantly from 10.4 cm 3 to 11.4cm 3. Minimum cross-sectional area (MCA) also significantly improved from 1.31 cm 2 to 1.46 cm 2. There was a poor correlation between VAS and AR measurements. There was a good correlation between the MCA and nasal cavity volume measurements with AR. Conclusion: Intranasal corticosteroids subjectively and objectively improve nasal obstruction. AR is reliable in the objective evaluation of nasal obstruction as reflected by the good correlation between MCA and nasal cavity volume. However, there is poor correlation between symptoms (VAS) and AR measurements. P022

Minimal Incision Technique for Cochlear Implantation Adrien A Eshraghi MD (presenter); Thomas J Balkany MD; Fred F Telischi MD; Fazil Necdet Ardic MD; Simon I Angeli MD

Miami FL; Miami FL; Miami FL' Izmir Turkey; Miami FL

Objectives: Extended postauricular incisions have been used for many years in cochlear implantation surgery. Based

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on reports by Robertson and O'Donoghne, we have standardized a surgical technique with a small (3 to 4 cm) incision. This prospective study evaluates the surgical technique and patient acceptance of minimal incision technique for cochlear implantation in adults and children. Methods: 50 patients underwent cochlear implantation with a minimal postauricular incision less than 4 cm. The difficulties and techniques related to the size of the incision, age of the patient, and the type of implant are presented and discussed with the use of color photographs. A questionnaire was used to evaluate the value of this technique among patients and parents. Results: All of the 3 currently FDA-approved devices can be implanted with this technique. We use minimal hair removal. Patients report less discomfort and numbness following surgery. In addition, edema is reduced, allowing initial stimulation at 2 to 3 weeks. The incision is especially well received by parents of young children. However, surgical time is extended by an average of 15 minutes. Conclusion: Minimal postauricular incision technique has proved to be an effective and practical approach for cochlear implantation in adults and children. Patients, and particularly parents of the youngest children who undergo this new surgical technique, report greater satisfaction regarding the size of the incision and the postoperative care. There are no additional complications compared with previous techniques. P023

Micronucleus Assay As Radiosensitivity Indicator in Head and Neck Tumor Patients Eduardo Busto MD PhD (presenter); Mabel Sardi MD; Marina Di Giorgio

Capital Federal Argentina," Buenos Aires Argentina; Buenos AiresArgentina Objectives: The aim of radiation oncologists is uncomplicated locoregional control of cancer by radiation therapy. The maximum dose used is limited by occurrence of severe late normal tissue reactions (NTR) within treatment volume. Cellular and molecular mechanisms of these reactions are not yet understood. There is evidence that the extent of late NTR may depend on the individual cellular radiosensitivity. The objective is to assess the individual cytogenetic response to radiotherapy by applying the cytokinesis blocked micronucleus (MN) assay to peripheral blood lymphocytes in H&N cancer patients undergoing radiation therapy as part of their treatment, in comparison with the clinical response observed. Methods: We have retrospectively analyzed 19 patients with H&N tumors, who had radiation therapy as part of treatment, with or without late effects. We used MN assay on peripheral blood lymphocytes. Estimated frequency of MN was done in peripheral blood culture of lymphocytes stimulated to mitotic proliferation during 72 hours' culture, adding cytochalasin B after 44 hours culture. We evaluated (a) spontaneous MN fre-

quency, taking into account the previous treatment and (b) frequency of MN after in vitro irradiation with 2 Gy, compared with the expected value (calibration curve of healthy donors). Results: In reference to the individual cytogenetic response, both spontaneous MN frequency and radiation induced in vitro after 2 Gy show significant increase compared to the expected values from the mentioned calibration curve in patients with late effects in their outcomes. Conclusion: The method applies well to the objective. It is easy and rapid to perform in a routine clinical laboratory. Preliminary cytogenetic data suggest a correlation with clinical outcome. The correlation obtained encourages us to begin a prospective study in order to predict late effects of radiation therapy in patients with H&N malignant tumors. P024

Multiple Primary Malignancies in the Head and Neck Tatsutoshi Suzuki MD (presenter); Makito Okamoto MD; Kazuo Yao MD; Katsuhide Inagi MD; Meijin Nakayama MD; Hiromi Nagai MD

Sagamihara Japan; Kanagawa-Ken Japan; Sagamihara Japan; TokyoJapan; Kanagawa Japan; Kanagawa Japan Objectives: Recent advancements in medical management along with the increased life span have contributed to the increased opportunity of detecting multiple primary malignancies (MPM). The goal of this review was to evaluate the accuracy of diagnosis of MPM in the head and neck region. Methods: A total of 1989 malignancies were registered in the head and neck data file at Kitasato University Hospital between July 1972 and December 1998. Among them, 121 patients (6.1%) were diagnosed as having MPM according to the criterion reported by Warren and Gates. The patients were divided into 108 double, 11 triple, and 2 quadruple primary malignancies. Patients were divided into the following 4 subgroups: (1) synchronous double primary malignancies (SDPM), (2) metachronous double primary malignancies in which index tumor was identified as first tumor (MDPM-F), (3) metachronous double primary malignancies in which index tumor was identified as second tumor (MDPM-S), and (4) triple and quadruple primary malignancies (TQPM). Clinical review was performed by using medical records. Results: Most index tumors were classified as squamous cell carcinoma (91 cases). Among the 53 MDPM-F and 29 MDPM-S patients, second malignancy was found within 5 years in 36 patients and 12 patients, respectively. The prognosis of patients with SDPM was very poor as evidenced by the longest survival of only 34 months. The prognosis of MDPMF was substantially better than that of SDPM. The prognosis of MDPM-S was lower than that of MDPM-E Conclusion: It is beneficial to follow patients as long as possible to facilitate diagnosis of tumor recurrence, metastasis, or MPM.

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P025

Timing Error of Postural Control and Voluntary Eye Movements in Meniere's Disease Elina Isotalo MD (presenter); Ilmari Pyykko MD Helsinki Finland; Stockholm Sweden

Objectives: Patients with severe Meniere's disease have problems of balance even during attack-free periods, and many of them also have problems of visual targeting on objects. The aim of the present study was to evaluate whether these problems correlate with each other and whether the oculomotor pathology is significant in patients with severe Meniere's disease. Methods: Twenty-six patients with severe Meniere's disease treated with intratympanically applied gentamicin of the affected ear were examined. Pseudo-random (with reference to timing, size, and side of the step) saccades and pseudo-random pursuit eye movements (PEMs; target trajectory made of a combination of two sinusoidal waves of different frequencies) and posturographic tests were done at the same time, before or after the gentamicin treatment. For normative data of voluntary eye movements, 45 control subjects were tested. Posturography was tested in 29 normal subjects. The severity of symptoms in patients with Meniere's disease was assessed according to the total handicap score of AAO-HNSF (1985). The results of patients with Meniere's disease were compared to those of control subjects. In patients with Meniere's disease, the correlation of oculomotor and balance performances and the correlation of oculomotor performance and severity of symptoms were evaluated. Results: Saccadic eye movements and balance were severely deteriorated in patients with Meniere's disease, and these disorders correlated strongly with each other. But PEMs were not so strongly affected in these patients as balance and saccadic eye movements were, even though most Of the parameters of PEMS were significantly poorer in patients with Meniere's disease than in control subjects. The oculomotor disorders were mainly prolongation of latency in the saccades or poorer gains in PEMs. The latter disorders were due to the "saccadization" of PEMs. The phase lag of PEMs was not affected, since the saccades compensated the total eye tracking. The severity of symptoms in patients with Meniere's disease correlated with the prolongation of latency in saccades and with poorer gains in PEMs. Conclusion: The oculomotor dysfunction found in this study can be best interpreted as a timing error of saccades and PEMSs in patients with severe Meniere's disease. Since the oculomotor activities may vary due to the stage and activity of Meniere's disease, patients with advanced disease were chosen to participate in this study. Results of this work (ie, deficits of voluntary eye movements, correlation of oculomotor pathology and balance disorders, correlation of clinical symptoms and oculomotor pathology) reflect the findings typical of patients with severe Meniere's disease. The misleading information

derived from the affected vestibular System was able to cause a prolongation of the premotor processing of voluntary eye movements, resulting in increased latency of saccades and the saccadization of PEMs. In severe Meniere's disease, the programming of oculomotor and postural responses shows the same pattern of disturbance, an error of timing. According to this work, a pure vestibular lesion (with advanced severity) can cause disorders of voluntary eye movements. P026

Volume-Rendering CT in the Preoperative Assessment and Localization of Subglottic Stenosis David Goldenberg MD (presenter); Reuven Shreiber MD; Aviram Netzer MD; Avishay Golz MD; Henry Z Joachims MD Baltimore MD; Haifa Israel; Haifa Israel; Haifa Israel; Haifa Israel

Objectives." Preoperative evaluation is essential prior to surgical treatment of subglottic stenosis. Ordinarily, this evaluation includes two-dimensional imaging (CT) and an invasive endoscopic procedure. This study investigates the feasibility and clinical value of high-resolution volume-rendering CT as an additional tool for the preoperative diagnosis and localization of subglottic stenosis, as well as postoperative follow-up. Methods: As part of the normal workup of suspected subglottic stenosis, the standard CT examination was modified to enable volume rendering post processing on 10 patients in our department. A spiral multislice (4) MX 8000 CT scanner (Phillips Medical Systems) was used. The parameters used were: slice width, 3.2 mm; pitch, 0.875 quad; 0.5-second rotation time; reconstruction intervals of 1.6 ram; and 120 kVA. Processing software by Philips, 4D angiography package (volume rendering), was tailored to demonstrate the upper airway. Results." Volume rendering of the upper airway provided the surgeons with an accurate 3D representation of the upper airway and gave enhanced details of the stenotic segment, especially in the longitudinal axis. In addition, the animation of the rendered images allowed for multidirectional viewing of the stenotic lesion. Precise preoperative diagnosis was attained in all 10 cases. Conclusion." Our results were very promising. VR is capable of demonstrating the exact level and severity of the stenotic segment. In addition VR gives the surgeon a 3D preview of the lesion prior to surgery. This noninvasivetechnique appears to be useful both preoperatively and postoperatively in the follow-up of patients with subglottic stenosis. P027

Traeheostomy in High-Risk Preterm Infants: Current Trends Kevin D Pereira MD (presenter); Allison Rae MacGregor MD; Chad M McDuffie MD; Ron B Mitchell MD Houston TX; Houston TX; Houston TX; Albuquerque NM

Objectives: To study the factors influencing the need for tracheostomy in a population of preterm infants. Methods: Premature infants that required tracheostomies

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from February 16, 1997, to February 15, 2001, were identified; and information on weight, gestational age, intubations, comorbid conditions, and outcomes was collected. Infants were divided into two groups by birth weight and gestational age. Group 1 included 23 infants born <30 weeks and <1500 g. Group 2 included 10 infants born _>30weeks and >_1500 g. Comorbid conditions were scored and a total score was calculated for each patient. Results: Group 1 had a higher incidence of patent ducms arteriosus, bronchopulmonary dysplasia, interventricular hemorrhage, necrotizing colitis, and retinopathy of prematurity. Group 1 had a higher average number of failed extubations (4.9 vs 3.29), a greater oxygen requirement (52.38% vs 36.4%), and lower average weight at tracheostomy (3.58 kg vs 4.17 kg) when compared to group 2. Group 2 had more congenital anomalies than group 1. Subglottic stenosis (39.1% vs 20%) and laryngomalacia or tracheomalacia (30.4% vs 20%) were more common in group 1. The average total score for group 1 was 6.7, and for group 2, 3.9. Conclusion: Severity of pulmonary disease was the most significant factor associated with the need for tracheostomy in extreme prematurity. In older preterm neonates the need for tracheostomy was associated with an increased incidence of congenital anomalies. A cumulative score of 3 and above was associated with a higher need for tracheostomy. P028

Relationship of DPOAE and TEOAE in Patients with Acoustic Neuroma Fazil Necdet Ardic MD (presenter); Fred F Telischi MD; Adrien A Eshraghi MD

Izmir Turkey; Miami FL; Miami FL

Objectives: The aim of this study was to study the relationship of transient evoked otoacoustic emissions (TEOAE) and distortion product otoacoustic emission (DPOAE) pattern in patients with acoustic neuroma. Methods: A retrospective review of data gathered from patients treated between 1992 and 1997. A total of 97 patients were studied, and of these, 28 patients had both DPOAE and TEOAE patterns available for analysis. DPOAE were divided into cochlear and noncochlear patterns. TEOAE were determined to be present (normal), reduced, and absent. Tumor size, PTA (pure tone average), and discrimination score were also measured and compared. Results: There were 15 females and 13 males identified. The average tumor size was 1.97 cm and average PTA was 54 dB. Of the 28 patients with DPOAE and TEOAE results, 26 patients had either absent or reduced TEOAE and 2 had normal TEOAE. Of the 26 patients with reduced or absent TEOAE, 20 had cochlear-pattern DPOAE and 6 had noncochlear-pattern DPOAE. The 2 normal TEOAE patients had noncochlear-DPOAE pattern. Conclusion: The findings in this study suggest that

DPOAE measurement is more specific in distinguishing between cochlear and noncochlear contribution of hearing loss in patients with acoustic neuroma. This is the first study, to our knowledge, comparing both TEOAE and DPOAE in patients with acoustic neuroma. P029 Morphologic Changes Following UPPP and Palatal Advancement B Tucker Woodson MD (presenter); Laura T Brusky MD Milwaukee Wt; Milwaukee WI

Objectives: Uvulopalatopharyngoplasty (UPPP) success rates are higher when minimal cross-sectional airway area increases. Few studies have compared morphologic changes following UPPP to other surgical techniques. We speculate that traditional UPPP may not affect the retropalatal airway above the level of excision. The goal of this pilot study is to assess morphologic changes in the retropalatal airway between two different palatal surgical procedures used for treatment of OSA. Methods: Preoperative and postoperative sitting and supine awake videonasopharyngoscopy was performed as part of routine office airway examination in 12 patients who had undergone palatopharyngoplasty without tonsillectomy. Assessments were performed at least 6 weeks following the surgical procedure. Comparable images preoperatively and postoperatively were digitized and analyzed for surgical changes. Results: Seven patients had prior UPPP and 5 had undergone palatal advancement pharyngoplasty. Upper airway endoscopy allowed only measurement of qualitative and relative airway changes. Following UPPP, no consistent change at the level of palatal resection was observed (change, 5.1% + 16.2%; P = NS). When the distal palate below the level of obstruction was the minimal cross-sectional area, significant change was observed (58.4% +_ 16.1%, P < 0.05). Following palatal advancement, increases in minimal cross-sectional area were observed (42.8% _+ 16.9%, P < 0.05). These changes were in both anterior-posterior and lateral wall dimensions. Conclusion: These preliminary results support the hypothesis that the morphologic effects of UPPP on airway size are limited to the distal palate. Surgical techniques, such as palatal advancement to address obstruction when the minimal crosssectional area is more rostral, may increase airway size. P030

Kikuchi's Disease in Children Hsin-Ching Lin MD (presenter); Chih-Ying Su MD

Feng Shan City Taiwan (Repubfic of China); Kaohsiung Taiwan (Republic of China)

Objectives: Kikuchi's disease (KD), histiocytic necrotizing lymphadenitis, is a rare self-limiting disorder typically

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affecting the cervical lymph nodes. It has occasionally been misdiagnosed as malignant lymphoma or other serious diseases. The disorder has received little attention in children; hence, we have reviewed our pediatric patients with KD over the past 16 years. Methods: From January 1986 to June 2001, a series of 23 patients (under 16 years of age) who underwent cervical lymph node biopsies and proved to have KD were enrolled in this study. Clinical features of this disease, specific characteristics of our patients, and long-term follow-up results were completed. The follow-up period averaged 6.5 years (range, 0.5 to 15.3 years). Results: There were 8 girls and 15 boys (1:1.88) with a mean age of 12.8. All of the affected cervical lymph nodes were located in the posterior cervical triangle. Unilateral and bilateral cervical lymph nodes were affected in 19 and 4 patients, respectively. The dimensions of affected lymph nodes were commonly in the range of 0.5 to 4 cm (91.3%). In two patients, the size of enlarged lymph nodes reached up to more than 6 cm. Leukopenia was observed in 5 patients (21.8%), and fever, in 7 patients (30.4%). One patient developed systemic lupus erythematosus (SLE) 5 years later. The cervical lymphadenopathy usually resolved itself without any medical treatment within 6 months after a definite diagnosis was made. No recurrence has since been noted. Conclusion: The results of this study demonstrate that KD in children has a completely different gender predominance compared with the adult population and shows a preference for boys. We suggested that pediatric cervical lymphadenopathy, especially located in the posterior triangle, should be considered for the possibility of KD. The children with KD require a systemic survey and regular follow-up for several years to rule out the development of SLE. P031

Adenovirus-Mediated Dominant-Negative Induced Apoptosis in Laryngeal Cancer

c-myb-

Ki Hwan Hong MD (presenter); He Keun Yi PhD; Pyung Han Hwang MD

Chonju South Korea; Chonju Chonbuk South Korea; Chonju Chonbuk Soutt~ Korea

Objectives: Although the role of c-myb in head and neck cancer has not been well studied, the aberrant expression of cmyb in laryngeal cancer suggests that c-myb may play an important role in carcinogenesis. Consequently, disrupting cmyb function might provide a strategy for controlling laryngeal cancer cell growth. The purpose of this study is to investigate the apoptosis of dominant-negative c-myb-expressing laryngeal cancer cells and the possibility for treatment with adenovirus-mediated dominant-negative c-myb gene therapy. Methods: All tumor cell and normal tissues were obtained from patients undergoing therapeutic operation for laryngeal cancer and were assayed for the expression of c-myb and bcl-

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2 in tumor and normal tissue by RT-PCR. The cell proliferation by 3H-thymidine assay was examined after AdDN-myb infection and apoptosis by DNA fragmentation, FACScan, and Western immunoblot analysis for bcl-2 expression after treatment with etoposide. Western immunoblot for AktfPKB phosphorylation and quantitative PCR for IGF-II, VEGF mRNA expression were assessed. Results: The expression of c-myb and bcl-2 in laryngeal cancer tissues was significantly higher than that of normal tissue, indicating that these genes may play an important role in carcinogenesis of laryngeal cancer. AdDN-myb-infected cells caused a significant reduction of cell proliferation and remarkably increased their apoptosis through the downregulation of bcl-2 expression and the inhibition of Akt/PKB pathway activation. Specifically, AdDN-myb-infected ceils were significantly inhibited the bcl-2 protein expression cotreated with chemotherapeutic drug. AdDN-myb also inhibited the expression of IGF-lI and VEGF in SNU-1076 cells. Conclusion: These results support that c-myb may play an important role in laryngeal carcinogenesis; dominant-negative c-myb may be an effective way to induce apoptosis of laryngeal cancer cells. The adenovirus-mediated dominant-negative cmyb gene therapy may be potentially useful for the treatment of laryngeal cancer. P032

Surgical Management Experience

of Sialorrhea: A 15-Year

Nell Hockstein MD (presenter); Daniel Sharya Samadi MD; Steven D Handler MD

Philadelphia PA; Philadelphia PA; Philadelphia PA

Objectives: Chronic sialorrhea affects between 10% and 35% of patients with cerebral palsy. These patients experience significant medical and psychosocial complications. Treatment options include behavioral, medical, and surgical therapy. When conservative therapy fails, surgical intervention can definitively treat this disorder. Surgical treatment may involve duct ligation, duct repositioning, excision of the major salivary glands, or any combination of these procedures. We report our 15-year experience with surgical management of sialorrhea, including treatment outcomes and complications. Methods: A retrospective chart review of 31 patients with sialorrhea who underwent bilateral parotid duct ligation and submandibular gland excision. Results: 31 patients underwent bilateral parotid duct ligation and submandibular gland excision. There were 15 (48%) males and 16 (52%) females. The average age at excision was 9.5 years. Complications included transient weakness of the marginal mandibular nerve and a temporary parotid sialocele. Patients and caregivers report a high level of satisfaction postoperatively. Presence of an external scar was of limited concern to parents. Conclusion: Bilateral parotid duct ligation and submandi-

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bular gland excision is an excellent option in the surgical management of sialorrhea. P033

Relation Between Labyrinthine Portion of Facial Canal and Cochlea Seishi Hasebe MD (presenter); Isamu Sando MD DMedSc; Yorihisa Orita MD Pittsburgh PA; Pittsburgh PA; Pittsburgh PA

Objectives: Facial nerve stimulation after cochlear implantation occasionally occurs. One of its main factors considered is that facial nerve in the labyrinthine portion of the facial canal (LPFC) is close to the electrode inserted in the upper half of the basal turn of the cochlea. To investigate this anatomical fact further, a computer-aided reconstruction was performed to measure the thinnest part of the bony wall between the canal and the cochlea. Methods: The materials used were 15 human temporal bone specimens obtained from 14 individuals without any known congenital anomaly or evidence of ear disease, whose ages were 11 to 108 years at death. The specimens were processed histologically and prepared for light microscopic study. The images of the LPFC and cochlea in series of histology sections were identified under the microscope, entered into the computer through the CCD camera, and reconstructed three-dimensionally for measurement. Results: The thickness of the bony wall between LPFC and the cochlea ranged from 0.0 to 0.5 mm (average, 0.25 ± 0.14 mm). (In one case, bony wall dehiscence was observed; the facial nerve was attached to the spiral ligament of the basal

turn.) Conclusion: From our study, the bony wall between LPFC and cochlea was found to be extremely thin or, in one case, defective. It suggests that this portion is fragile to electrode insertion susceptible to formation of bony defects due to osteodegeneration and that, in those cases, the facial nerve may be easily stimulated by electrode. P034

Postoperative Radiation Therapy for Adenoid Cystic Carcinoma of the Head and Neck Damon A Silverman MD (presenter); Tom Carlson MD; Deepak Khuntia MD; Richard Bergstrom MD; Jerrold Saxton MD; Ramon M Esclamado MD Shaker Heights OH; Cleveland OH; Cleveland OH; Shaker Heights OH; Cleveland OH; Cleveland OH

Objectives: The puIpose of this study is to clarify the role for postoperative radiation therapy for adenoid cystic carcinOma (ACC) of the head and neck as it relates to tumor site, T stage, and margin status at the time of surgical resection. Methods: A retrospective chart review of 129 ACC patients was performed, with 75 previously untreated patients eligible for further study. Patients were grouped according to whether

or not they received postoperative radiation, and statistical analysis was performed by using Kaplan-Meier plots and Cox proportional hazard models controlling for tumor site, T stage, and surgical margin status. Outcome measures included overall survival, locoregional recurrence, and distant metastases. The mean follow-up period was 88.7 months. Results: Out of a total of 75 patients, 25 were treated with surgery alone and 50 were treated with surgery and postoperative radiation. Comparison of Kaplan-Meier 10-year estimates of overall survival, locoregional recurrence, and distant metastases for the surgery alone and surgery with radiation groups failed to demonstrate a significant difference when correlated with tumor site (P > 0.05). However, postoperative radiation conferred a significant benefit in overall survival for advanced T stage (T4) lesions (P = 0.02). A significant benefit was also seen in terms of locoregional recurrence for patients with microscopic residual disease at the time of surgery (P = 0.018). Conclusion: The findings of this study suggest that advanced T stage and positive microscopic margins at the time of surgery are important factors in determining the necessity for postoperative radiation therapy in the treatment of adenoid cystic carcinoma of the head and neck.

P035 Tuberculosis in the Upper Aerodigestive Tract Somchai Srirompotong MD (presenter); Dr Kwanchanok Yimtae; Supaporn Srirompotong MD Khon Kaen Thailand; Khon Kaen Thailand; Khon Kaen Thailand

Objectives: To describe the clinical manifestations of tuberculosis in the upper aerodigestive tract. Methods: A review of medical records of patients diagnosed with mycobacterium tuberculosis of the upper aerodigestive tract between January 1991 and December 2000. Results: 45 patients presented with upper aerodigestive tract tuberculosis. The nasopharynx was involved in 23 patients, the larynx in 16, the tonsils in 6, and the soft palate in one. One patient had tuberculous infections in both the nasopharynx and tonsils. The mean duration of symptoms before diagnosis was 2.1 months. The pathological findings included caseous granuloma and/or positive acid-fast bacilli (AFB) in 39 cases and chronic granulomatous inflammation with negative AFB in 6. Pulmonary tuberculosis was found in 19 of the 36 patients x-rayed. A positive serologic test for HIV infection was found in 4 of 26 patients. These 26 patients who received a full course of treatment responded well. Conclusion: The most common site of tuberculosis in the head and neck involves cervical lymph nodes and nasopharynx. Upper aerodigestive tract tuberculosis is difficult to differentiate from carcinoma; thus, tissue biopsy is necessary for a definite diagnosis. A chest x-ray and screening for HIV infection are recommended for all patients with upper aerodigestive tract tuberculosis.

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Evaluation of Medical Accuracy When Using Telemedicine in a Multidisciplinary Tumor Meeting Joacim Stalfors MD (presenter); Thomas Westin MD PhD; Ms Jan-Ove Persson

Gothenburg Sweden; Gothenburg Sweden; Horby Sweden

Objectives: Head and neck cancer patients in the western part of Sweden are regularly presented at a Multidisciplinary Tumor (MDT) meeting held once a week at the regional hospital in Gothenburg. These MDT meetings are attended by all physicians involved in the patients' care, as well as patients and relatives. To minimize travel for patients and physicians, telemedicine has been introduced as a means of participating in the meetings. The aim of this study is to determine if TNM classification based on presentation by means of telemedicine is as accurate as face-to-face (FTF) presentation. Methods: All patients presented at the MDT meeting from 1998 to 1999 were included in the study. The majority, 199 patients, were presented FTF in Gothenburg, while 49 were presented by means of telemedicine. Patients' charts were studied retrospectively. Data registered were TNM classification, diagnosis, and treatment. Results: The decision from the MDT meeting was sometimes changed once the patient met the specialist at the regional hospital after the MDT meeting. Four patients got another TNM classification after the visit at the specialist's office. Two of these were presented with telemedicine, and the other was a control patient. A statistical significance could not be found (P = 0.173). Conclusion: Medical decisions concerning diagnosis and TNM classification can be reached by means of telemedicine without compromising demands on accuracy. P037

Ear, Nose, and Throat Manifestations in HIV-Exposed Children Claudia R Figueiredo MD (presenter); Luc Louis Maurice Weckx MD PhD; Regina Celia Succi MD; Beatrice Maria Neves

Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil

Objectives: This study was conducted with the objective to evaluate the prevalence of otolaryngologic diseases in children born to mothers infected with human immunodeficiency virus (HIV) and to assess the correlation between AIDS and the incidence of otitis media, sinusitis, parotid hypertrophy, and adenotonsillar hypertrophy. Methods: This was a prospective study from November 1997 to February 2001. One hundred sixteen children (80 with AIDS and 36 seroreverters) were submitted to careful anamnesis and ENT examination. Clinical findings were correlated in both groups, and immunological status was determined in children with HIV infection. Results: ENT manifestations were present in 92% of the

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children with AIDS and in 80% of the seroreverters. Prevalence of acute otitis media, secretory otitis media, and adenoidal hypertrophy was similar in both groups; but prevalence of acute sinusitis, chronic otitis media, and parotid hypertrophy was significantly greater in children with AIDS. Conclusion: The prevalence of acute sinusitis, chronic otitis media, and parotid hypertrophy was significantly greater in children with HIV infection. The other manifestations were similar in both groups. P038

BPPV: 1500 Epley and Semont Maneuvers Carlos Garcia MD (presenter); Alfredo H Luis; Diogo Oliveira E Carmo MD; Joao Paco MD PhD

Lisbon Portugal; Caldas da Rainha Portugal; Lisbon Portugal; Lisbon Portugal

Objectives: BPPV is the most common form of vertigo. In this presentation we describe the path to the diagnosis of the different types of BPPV, the different treatments, and the results and complications. Methods: Patients are evaluated for their dizziness and/or vertigo with videonystagmography and posturography (SOT). The recording on videonystagmography enables us to read the nystagmus during the exam and to recall it afterwards to confirm the diagnosis. The maneuver is always done under videonystagmography, and all the different phases of the treatment are recorded. Results: We have performed 1500 maneuvers during the last 5 years, and we present the results according to the different diagnosis (geotropic, ageotropic, lateral canal, bilateral), its complications, and failures. The overall rate of success is approximately 75% for a single maneuver and approximately 90% for two or more maneuvers. Conclusion: BPPV is the most frequent cause of vertigo and the most simple one to treat. The use of videonystagmography in the diagnosis and in the treatment of this condition enables us to refine the diagnosis and study, review, and discuss the treatment. It is a simple cost-effective treatment with a high rate of success. P040

Histological Analysis of Inferior Turbinate Hypertrophy Kwai Onn Chan MBBS FRCS (presenter); Luke Kim-Sian Tan MD FRCS

Singapore Singapore; Singapore Singapore

Objectives: Nasal obstruction is often caused by inferior turbinate (IT) hypertrophy. Although the immunological mechanisms causing IT hypertrophy have been intensely studied, the histological characteristics of IT hypertrophy have not been thoroughly evaluated. This is a retrospective study of the clinical presentations and histological features of patients with inferior turbinate hypertrophy. Methods: Nineteen patients with nasal obstruction from IT

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hypertrophy, not responding to intranasal steroid sprays, underwent a partial or subtotal inferior turbinectomy. In 15 patients, a septoplasty was also done. RAST was done to determine if the patients had allergic rhinitis (AR) or nonallergic rhinitis. The IT specimens were fixed in formalin and stained with H & E. The specimens were examined under low power (xl0) to measure the bone thickness, the bone-basement membrane thickness, and the density of glands and blood vessels in the submucosa and stroma. High power (x40) was used to determine the type of epithelium and count the mean number of neutrophils, eosinophils, lymphocytes, plasma cells, and mast cells per high-power field. Results: The mean bone thickness was 1.59 mm, and there was no difference between AR and non-AR. The mean bonebasement membrane thickness was 2.05 ram, and this was significantly thicker in patients with AR. The density of glands was greater than that of blood vessels in the submucosa but in the stroma, this pattern was reversed. There was no difference in gland and blood vessel density between AR and non-AR. Lymphocytes were the most common cell population, followed by mast cells and plasma cells. 84% had predominantly respiratory epithelium, 63 % had areas of nonciliated epithelium, and 5% had areas of squamous metaplasia. Conclusion: The histological characteristics of the IT in AR and non-AR are remarkably similar. The only significant difference was that the stroma was much thicker in AR.

for a distance of 3 cm, and used to reline the resulting hypopharyngeal raw surface. Insetting of the colon was started, reconstructing the contralateral piriform sinus; the surgeon proceeded by suturing the cut edges of the colon to the posterior wall, the postcricoid wail (considered a critical technical point, postcricoid mucosa conservation maximized), and the hypopharyngeal mucosa, closing the pharyngotomy. The infrahyoid muscles were anchored to the hyoid bone for reinforcement of the suture. Factors evaluated included functional outcome with regard to the deglutition, speech capacity, and removal of the gastrostomy/tracheostomy tube. Results: The two-staged hypopharyngeal colon repair resulted in decannulation and deglutition without evidence of aspiration in 8 (67%) of the 12 patients; 4 (33%) patients developed a stricture at a pharyngocolic anastomosis and had additional procedures: one received intermittent antegrade dilatation for a long time, and 3 patients had creation of a large pharyngostoma, closed 3 to 4 weeks later. Two of these 4 patients had restored deglutition and 2 have a gastrostomy in place for feeding. These 4 patients were not decannulated; however, they speak when the tracheostomy tube is occluded. Conclusion: Functionalreconstruction of the circumferential hypopharyngeal caustic stenosis resection can be achieved through a two-staged colon interposition, with swallowing without aspiration and decannulation at a rate approaching 70%. P042

P041

Medication Profile of a Group of Elderly Fallers

Repair of the Hypopharynx after Caustic Stenosis Resection

Priya D Krishna MD (presenter); Marian Girardi MA; Horst R Konrad MD

Robert Thome MD PhD (presenter); Daniela Curti Thome MD Sao Paulo Brazil,"Sao Paulo Brazil

Springfield IL; Springfield IL; Springfield IL

Objectives: Background: Repair of extensive circumferential caustic hypopharyngeal stenosis continues to be a chal, lenge for the surgeon because a functioning larynx must be spared. Objective: To evaluate the use of a two-staged colon interposition for reconstruction of the hypopharyngeal defect that results from resection of circumferential caustic stenosis. Methods: Twelve patients, 9 adults and 3 children, aged 7 to 48 years (average age, 25.4), with severe caustic stenosis of the hypopharynx had colon interposition repair, performed in two surgical stages. All patients had tracheostomy and gastrostomy. In the first stage, the colon segment, transposed to the neck through the retrosternal route, was sutured high up on the retropharyngeal space after its end was closed by inverting sutures. In the second stage (3 weeks later), the hypopharyngeaisupraglottic scar was resected through ample anterolateral pharyngotomy approach immediately below the hyoid bone; a superior portion of the thyroid lamina was removed, exposing the hypopharyngeal area to direct vision. In 5 patients with the stenosis involving supraglottic structures, a conventional supraglottic laryngectomy was performed before the hypopharynx was resected. The colon was elevated from the retropharyngeal space bed, opened in the midline along a tenia

Objectives: To examine types of medications used and comorbidities in order to more effectively predict falls risk for elderly patients. Methods: Retrospective review of patients in balance disorders/falls prevention clinic in a tertiary referral center. 36 patients over age 65 who had fallen once or more in the year prior to their visit to the clinic. Average age was 78.4 years, mean number of falls was 3.4, and based on previous study, average number of prescription medications was 5.8. Main outcome measures were number of antihypertensive, antiarrhythmic, and antidepressant medications and frequency of comorbid factors. Results: The mean number of antihypertensive medications taken by patients was two. In a previous study, 58.3% of this patient population had hypertension and 100% of these patients were on antihypertensive medications at the time of initial evaluation. Antiarrhythmics were used in 11.1% of patients, with a mean number of 1.5 medications. Vestibular suppressants were used by 33.3% of the patients and antidepressants were used by 19.4% of these patients. Depression was a comorbid factor in 41.7%, more than twice the frequency of patients on antidepressants. Of the 15 patients with visual complaints, 33.3% had glaucoma and 33.3% had more gen-

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Volume 127 Number 2

eralized symptoms (blurry vision). Sixty percent of glaucoma patients were on appropriate medications. Conclusion: As many of these medications (antihypertensives, antidepressants) have vestibular or balance symptoms and side effects, identification of elderly persons at risk of falling is of great significance in order to aid these persons more effectively in preventative and rehabilitative interventions. P043

Minimizing Complications in the Use of Titanium Condylar Head Reconstruction Prostheses Courtney Catherine Artman MD (presenter); J Dale Browne MD Winston-Salem NC; Winston-Salem NC

Objectives: In head and neck oncologic surgery, mandibulectomy to include the condylar head is often required for elimination of disease. While vascularized grafts are a stable and proven choice of technique, there is increased patient morbidity with increased operative time and donor site complaints. As an alternative, titanium condylar head reconstruction prostheses are a viable choice for reconstruction, although there has been concern over erosion of the glenoid fossa. Methods: Six patients are reported with a follow-up spanning 3 years. Each patient underwent mandibulectomy involving the condyle for tumor, with subsequent primary reconstruction with a titanium condylar reconstruction prosthesis. Charts were reviewed for operative technique, pathology, adjunctive radiation therapy, and complications. Results: Of the 6 patients, 4 are alive without disease. Pathologies were squamous cell carcinoma in 3 patients, as well as giant cell tumor of bone, Ewing's sarcoma, and rhabdomyosarcoma. There have been no prosthesis extrusions outside of the confines of the glenoid fossa. Complications included mild trismus and the development of a mild crossbite in all patients. In spite of their mild crossbite, those patients with dentition were able to bring their bite into occlusion. In all cases, the condylar head was wrapped in preserved joint capsule or adjacent temporalis muscle/fascia and secured with permanent purse-string sutures. Care was taken to duplicate the length and angulation of the native mandible from angle to superior extent of the condylar head. Conclusion: Titanium condylar prostheses are a viable choice in the setting of tumor resection and reconstruction. P044

Cochlear Implants in Congenital Inner Ear Anomaly Chong-Sun Kim MD PhD (presenter); Sun O Chang MD PhD; Seung Ha Oh MD PhD; Soon Hyun Ahn MD; Hyo Jeong Lee MD; Hong-Ju Park MD Seoul South Korea; Seoul South Korea; Seoul South Korea; Chongno-Gu South Korea; Seoul South Korea; Seoul South Korea

Objectives: A deaf ear with a congenital inner ear anomaly

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was regarded as contraindication to cochlear implantation due to low population of spiral ganglion neuronal cells and difficulty of operation. But recently there were some reports that adequate hearing threshold could be obtained by cochlear implantation in deaf patients with mild inner ear anomaly. We analyzed the postoperative performance score of our cases with inner ear anomaly. Methods: Retrospective chart review of 14 deaf patients with congenital inner ear anomaly who received cochlear implant operation from November 1988 to August 2001. Radiologic findings, classification of inner ear anomaly, problems during operation, number of electrodes inserted, and postoperative performance score were analyzed. Results: Eleven patients had cochlear anomaly including 10 cases of Mondini dysplasia and one case of common cavity dysplasia. The other 3 cases included 2 cases of enlarged vestibular aqueduct syndrome and one semicircular canal anomaly. In 12 cases, all of the active electrodes could be successfully inserted without problems, and a hearing threshold of about 40 dB could be obtained in most cases. Conclusion: There was no difficulty in insertion of electrodes into the malformed cochlea, and the postoperative perforrnance score showed no significant differences from normal cochlear implantation group except in cases with narrow internal auditory canal. P045

The Radiographic Features of Vocal Cord Paralysis Jivianne Lee MD (presenter); Joel A Sercarz MD; Robert B Lufkin MD Los Angeles CA; Los Angeles CA; Los Angeles CA

Objectives: The purpose of this study was to define, illustrate, and discuss the radiographic features of vocal cord paralysis. Methods: The medical charts, computed tomography (CT), and/or magnetic resonance (MR) scans of 25 patients with clinically documented vocal cord paralysis were retrospectively reviewed. The medical history, physical findings, and imaging characteristics of each patient were determined. Radiographically, vocal cord positioning, piriform sinus symmetry, arytenoid cartilage orientation, and laryngeal muscle morphology were all evaluated. Results: All patients (25/25 = 100%) demonstrated asymmetric enlargement of the ipsilateral piriform sinus and paramedian positioning of the paralyzed vocal cord on CT and/or MR scans. Anteromedial deviation of the arytenoids, atrophy of the thyroarytenoid and posterior cricoarytenoid muscles, and laryngeal ventricle enlargement were also evident in some of the imaging studies. Conclusion: Vocal cord paralysis demonstrates distinctive imaging features on CT and MRI. Recognition of this constellation of radiographic findings can assist in the diagnosis of vocal cord paralysis and lead to more timely detection and treatment.

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Endoscopic Management of Frontal Mucoceles Dharambir S Sethi MD (presenter) Singapore Singapore Objectives: To review the efficacy of endoscopic management of frontal mucoceles and to analyze the factors determining the surgical success. Methods: Between January 1995 and December 2001, 30 patients with isolated frontal mucoceles were treated by the author; 26 were managed by endoscopic techniques. Mucoceles extending to and also involving the ethmoid bones have been excluded from this review. In one subject, the mucocele occurred in a type III frontal cell; in 2, the mucocele was located in the lateral part of the frontal sinus; and in another, there was a defect in the posterior table with cerebrospinal fluid leakage noted intraoperatively. Endoscopic procedure varied from a frontal sinusotomy with ethmoid bulla intact, anterior ethmoidectomy, and frontal sinusotomy to type II and type III drainage. Results: The frontal opening was regularly monitored in all patients and remained patent in all but one patient, who subsequently required obliteration of the frontal sinus. All patients remain symptom-free. Factors relating to the surgical success were analyzed and will be presented. The mean duration of follow-up is 38.6 months with range of 4 to 72 months. Conclusion: The author concludes that endoscopic drainage of frontal mucocele is safe, minimally invasive, and costeffective for most cases. Selection of cases is important for surgical success. P048

Effects of VEGF-Treated Gelfoam Implants Post-Tumor Excision James C Banich MD (presenter); M Rita I Young PhD; Kristin Kolesiak; Gregory J Matz MD

Westchester IL; Hines IL; Maywood IL; Maywood IL

Objectives: This study examined the local immune response generated by a Gelfoam implant impregnated with vascular endothelial derived growth factor (VEGF) at the site of tumor excision in mice injected with Lewis lung carcinoma (LLC). The Gelfoam implants were later extracted and analyzed for the presence of CD34 ~: cells (progenitor cells), DEC205 + (dendritic) cells, CD1 lb + cells (macrophages), and CD31 + cells (endothelial cells). The objective was to examine the effects on local tumor immunology post excision in a live mouse model. Methods: C57BL/6 mice were implanted with dorsal subcutaneous implants of LLC. Tumors were grown for 2 weeks, then excised. Following tumor excision, a Gelfoam implant was placed into the excision site. Mice in the experimental group received VEGF injected directly into the Gelfoam. Control implants received buffered saline. Implants were harvested at days 4, 7, 14, and 21. The Gelfoam was denatured and ceils were analyzed by flow cytometry.

August 2002

Results: The control groups demonstrated a significantly higher percentage of CD34+ cells within Gelfoam at day 4. The control group showed a significantlyhigher percentage of DEC205 ÷ ceils at days 4 and 14. On day 7, the reverse was seen. The percentage of CD31 ÷ cells was significantly increased in the control group at day 4 and at day 14. This reversed at day 7. The VEGF group showed a higher percentage of CD1 lb ÷ cells at days 4 and 14. Conclusion: A Gelfoam implant impregnated with VEGF has significant impact on the local immune milieu and potential application in modulating local immune responses after tumor excision. P049

Fat Augmentation for Nonparalytic Glottic Insufficiency Hsiung Ming-Wang MD (presenter); Chen Yen-Yu MD Taipei Taiwan (Republic of China); Taipei Taiwan (Republic of China) Objectives: While autogenous fat augmentation for glottic insufficiency has been used before, relatively little information is currently available on the effectiveness of fat injection in patients with nonparalytic glottic insufficiency resulting from problems such as various defects of vocal atrophy or sulcus vocalis. Methods: This paper compares retrospectively the efficiency of fat injection after surgery in patients with vocal atrophy (n = 16) and sulcus vocalis (n = 8).The perceptual acoustic and phonatory functions and videolaryngostroboscopic data were evaluated before and after fat augmentation in 24 patients. Results: Mean follow-up time was 10.0 months. Fifteen patients displayed excellent results; one showed some improvement; 6 experienced postprocedure failure; and 2 were not available for follow-up analysis. Perceptual rating showed significant improvement in grade, roughness, and breathiness (P < 0.05). The videolaryngostroboscopic rating showed significant improvements in vocal fold edge linearity, vocal fold vibration amplitude, and mucosal wave excursion (P < 0.05). More improvement in vocal atrophy was observed compared with sulcus vocalis following fat injection procedures. Our research showed improved middle defects compared to those in the anterior and posterior. Conclusion: Fat injection is an effective autogenous implant and may be considered as an option in the treatment of patients with vocal atrophy or sulcus vocalis. Although fat reabsorption was a problem, repeating the procedure could be considered. P050

Epineurial Pseudocysts of the Intratemporal Facial Nerve Sarah L Pertzborn MD (presenter); Patrick J Antonelli MD Gainesville FL; Gainesville FL Objectives: Pseudocysts of the facial nerve are infrequent-

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ly encountered during temporal bone surgery or during neurootologic evaluation. Very little has yet been reported on these lesions. The purpose of this report is to describe the senior author's experience with epineurial pseudocysts (EPs) of the intratemporal facial nerve. Methods: A retrospective case review was performed on all patients with intratemporal EPs seen in a tertiary referral center over the past 3 years. Results: EPs were identified on computed tomography in the mastoid segment in 6 patients. MR revealed relative brightness on T 2 weighted images and mild contrast enhancement. In 3 of 6 patients, all children, bilateral, symmetrical EPs were found during evaluation for profound sensorineural hearing loss. In 2 adults and 1 child, EPs were identified during evaluation for recurrent facial palsy (n = 1) and spasticity (n = 2). EPs were excised in the 3 symptomatic cases and 2 patients at the time of cochlear implant placement. In all cases, EPs appeared as a 5- to 10-ram balloon-like swelling of normal facial nerve epineurium. EPs were consistently responsive to facial nerve electrical stimulation, but minimal facial nerve activation occurred during dissection parallel to the trunk of the facial nerve. No facial palsy developed after EP excision. In one patient, bilateral facial spasticity was observed after excision. Histopathologic examination revealed fibroadipose tissue without nerve tissue. Conclusion: Facial nerve EPs are uncommon lesions that are typically found in the mastoid segment. Surgical excision may be safely performed for control of facial motor symptoms or for cochlear implant placement. P051

An Evaluation of Bilateral Bone-Anchored Hearing Aids Claudia Michaela Priwin MD (presenter); Stefan Stenfelt PhD; Ann Edensvard; Gosta Granstrom MD PhD DDS; Anders R M Tjellstrom MD PhD; Bo Hakansson PhD

Stockholm Sweden; Gothenburg Sweden; Gothenburg Sweden; Gothenburg Sweden; Goteborg Sweden; Gothenburg Sweden Objectives: Since the technique to anchor bone-anchored hearing aids (BAHAs) with the use of osseointegrated implants was developed in 1977, more than 10,000 patients have been fitted worldwide. The majority of the patients are fitted unilaterally but have bilateral hearing losses. The main objective of this study was to reveal benefits/drawbacks with bilateral fitting of BAHAs in patients with symmetric sensorineural hearing losses and an additional conductive component. The possible effects have been divided in 3 categories: spatial hearing thresholds, directional hearing, and binaural hearing. Methods: Twelve patients with bilaterally fitted BAHAs were included. Baseline audiometry was done to obtain patient status. Skull size and position of the fixtures were recorded. Tone thresholds in free field, speech reception thresholds, directional hearing, and binaural masking level difference were measured with both unilateral and bilateral BAHAs. Also, 2 questionnaires regarding the patients' opin-

ions and the use of bilateral versus unilateral BAHAs were distributed. Results: Eleven of the 12 patients preferred the use of bilateral BAHAs and wore them all their awake time. The hearing tests done were conducted monaurally on both ears and bilaterally. In the tests conducted monaurally, the results were best on the first fitted side, which usually is the best ear, although the results were better all over with bilaterally fitted BAHAs. There was also a tendency that patients with congenital ear malformations were doing better than patients with chronic otitis media when fitted bilaterally. Conclusion: It seems like binaural hearing is possible to obtain by fitting the patients with bilateral BAHAs. The tendency of better test results in patients with congenital ear malformations may even suggest that this patient category should be fitted with bilateral BAHAs early in life. P052 Deglutition Syncope Sreekant Cherukuri MD (presenter); Glendon M Gardner MD

Southfield MI; Detroit MI Objectives: Deglutition (or swallow) syncope is an uncommon, vagally mediated etiology for syncope that may be seen in children and adults. The mechanism of syncope involves afferent impulses from the upper gastrointestinal tract and efferent impulses to the heart that can produce a variety of potentially life-threatening bradyarrhythmias such as atrioventricular block or asystole. Despite the commonness of dysphagia as a presenting complaint to the otolaryngologist, this entity has never been reported in the ENT literature. The objective of this paper is to familiarize the otolaryngologist with the diagnosis and management of deglutition syncope. Methods: Two cases of deglutition syncope are reported, along with a comprehensive review of the literature. In evaluating patients with syncope, a thorough history is the most important factor in making this diagnosis; a temporal relationship between the syncopal episode and eating or drinking should be sought. Holter monitoring can confirm the diagnosis, and an esophageal evaluation complete with imaging should be performed on all patients. Results: The first patient underwent 24-hour Holter monitoring, which revealed a 6-second episode of asystole that correlated with swallowing. The second patient had a negative 24-hour Holter monitor and has been managed by diet modification. Conclusion: While changes in eating habits may be effective in some cases, treatment of any underlying esophageal abnormality may abolish the episodes. In the absence of esophageal pathology, permanent pacemaker placement is often indicated and curative. Otolaryngologists should be aware of deglutition syncope as a clinical entity, since many patients present with a chief complaint of dysphagia. Familiarity with its symptoms, diagnostic criteria, and management can provide appropriate and timely treatment to patients with this uncommon condition.

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OtolaryngologyHead and Neck Surgery August 2002

Scientific Posters

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Modern Management of Tracheal Involvement by Thyroid Disease Nimesh N Patel MB ChB FRCS (presenter); Roy Farrell FRCS Pinner United Kingdom; Shatton Bamford United Kingdom

Objectives: Thyroid disease infrequently involves the trachea; however, when it does, the management of these patients represents a surgical challenge. We wished to review our series of patients that had suffered from tracheal involvement from thyroid disease and examine them within the context of recent developments in airway management and modem understanding of the pathophysiology of thyroid malignancy. Methods: A retrospective chart review of all patients presenting to our unit with malignant and benign thyroid disease with airway involvement was conducted. Results: Patients from 1999 to 2002 were included in the study. There were 10 patients with massive multinodular goiter causing airway compression and 6 patients with papillary thyroid carcinoma with airway involvement. Airway involvement was managed with (1) no intervention, (2) airway stenting, (3) tracheal excision and end-to-end anastomosis, (4) the authors' tracheal excision, castellation and twist technique, and (5) laryngectomy. In our series only one patient required a permanent tracheotomy and one needed a laryngectomy. Conclusion: No single technique is appropriate for the management of these patients. Modern approaches enable the majority of patients to avoid permanent tracheotomy. The surgeon undertaking surgery for thyroid malignancy needs to be equipped with the expertise to deal with tracheal involvement. P054

Vocal Fold Vibratory Pattern Postcricothyroid Approximation Saramira Cardoso Bohadana MD (presenter); Luis U Sennes MD PhD; Domingos H Tsuji MD PhD Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil

Objectives: The purpose of this study was to evaluate effects of cricothyroid approximation on the vocal folds vibration in both genders. Cricothyroid approximation simulates cricothyroid muscle contraction by approximating cricoid and thyroid cartilage's, increasing fundamental frequency of the voice. The main indications for this procedure are voice hoarseness due to superior laryngeal nerve paralysis and rheumatoid and endocrinological diseases in women. Methods: Thirty fresh cadavers' larynges were used for experiment. Arytenoids cartilages were approximated by suturing both together, closing the glottis. Humidified compressed air was injected inside tracheal tube, causing vocal folds vibration. Cricothyroid approximation was performed by sutures placed in cricoid and thyroid cartilage. Calipers were used to measure the length of the membranous portion of vocal folds, pre and post cricothyroid approximation. Vocal folds vibration was recorded by a camera of videokymogra-

phy. Fundamental voice frequency, vocal folds vibratory amplitude, and vibratory cycle phases (opened, closed, opening and closing phases) were measured pre- and postoperatively. Open quotient, closed quotient, and speed quotient were then calculated and analyzed. Results: There was a statistically significant lengthening of the vocal folds after cricothyroid approximation, more noticeable in female laryngeal specimens. Fundamental voice frequency was increased, but no relation with the increased length of the vocal folds could be observed. Vibratory amplitude was significantly reduced, as was vibratory cycle duration. Conclusion: Although female laryngeal specimens had shown longer length when compared with the male, there was no statistically significant difference in the cricothyroid approximation effect on the vocal frequency according to gender. P055

p27 Gene Suppresses Growth of Human Laryngeal Carcinoma Hep-2 Cells Yongzhu Sun (presenter); Peng-Cheng Cui MD; Guizhe Li; Wenxian Chen Xi'an China; Xian China," Xi'an China; Xi'an China

Objectives: To explore the effect of p27 gene on the growth inhibition of laryngeal carcinoma cell line Hep-2. Methods." The p27 cDNA was transfected into human laryngeal carcinoma cell line Hep-2 cells with lipofectamine. The growth rate, cell cycles, and colony formation rate of transfected cells were observed by means of MTT and FCM assay. Results: Expression of p27 in Hep-2 was identified by dot blot and Western blot analyses. The growth rate of Hep-2 transfected with p27 gene was markedly suppressed. Colony formation in soft agar was also decreased significantly. Cell cycle analysis by flow cytometry showed that the number of cells in G0-G1 phase of Hep-2 cells was significantly increased while the number of cells in S and G2+M phase was decreased compared to that of the control Hep-2 cells. Conclusion: Transduction of p27 gene into lower expression cancer cells can restore its suppressive effect on cell growth by arrest of cell cycle at G1 phase. P056 Regional Recurrence after Neck Dissection for Head and Neck Cancer Ali Amar; Abrao Rapoport MD; Sergio A Franzi MD (presenter); Marcos B Carvalho Sao Paulo Brazil," Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil

Objectives: Neck recurrences rarely can be treated with curative intention. This study evaluates the location of neck recurrences and the outcome of salvage therapy. Methods: In a retrospective study of 943 patients submitted to neck dissection, 95 developed neck recurrences as a first

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sign of relapse of disease. The neck side and neck recurrence level were determined in patients with and without postoperative radiotherapy. The disease control rates were calculated. Results: Ipsilateral recurrences were diagnosed in 49 patients, contralateral neck (nondissected) in 36, bilateral in 5, and indeterminate in 5 patients; 61% of ipsilateral and 48% of contralateral neck recurrences were in level II (upper jugular nodes). Among 52 treated patients, the disease control after 12 months was 30% (25% for ipsilateral and 36% for contralateral recurrences). After neck recurrence treatment, 9 patients had recurrences at the primary site, and distant metastasis was diagnosed in 4 other patients. Conclusion: The majority of neck recurrences occurred in level II. Neck recurrence is the worst prognostic sign. Good results cannot be expected with conventional treatment. P057

Northern England FESS Study: Analysis of the Outcomes Perumkuiam S Arunachalam (presenter); Andrew Robson FRCS MBBS; Ralph Messersmith; Sean Carrie

Gosforth United Kingdom; Carlisle United Kingdom; Carlisle United Kingdom; New Castle United Kingdom

Objectives: A prospective analysis of functional endoscopic sinus surgery was started in 1996. This was regionally funded and coordinated by the clinical audit department at Cumberland Infirmary, Carlisle. The aim was to assess both the shortand long-term efficacy of FESS, by using subjective and objective patient outcome measures. Methods: 131 patients who were operated on between January 1996 and June 2000 were included in this series. There were 71 females and 60 males, aged between 14 and 78 years (mean age = 45 years). The patients were assessed by using a modified Lund and Mackay staging system, which includes visual analogue symptom score, surgical score, radiological grading, and endoscopic appearance. Results: Fifty-five percent of the patients attended followup. In 97% of reviewed patients, there was symptomatic improvement at 3 months, which dropped to 91% at 6 months. Maximum improvement was noted for nasal obstruction, and least, for headache/facial pain. As expected, the most revealing findings on endoscopy were improvement in polyp bulk and a postoperative increase in nasal adhesions. Conclusion: Analysis of the available data shows significant symptomatic improvement especially in nasal obstruction and nasal discharge. There was corresponding improvement in nasal endoscopic findings. Further steps, such as telephone reminders, are underway to improve the follow-up rates. P058

Interesting Presentations of Ohiori Type I Malformation Rhoda Wynn MD (presenter); Ari Judah Goldsmith MD

Brooklyn NY; Brooklyn NY Objectives: Chiari type I malformation is characterized

by cerebellar tonsil herniation through the foramen magnum, resulting in lower cranial nerve neuropathies. It typically presents in adolescence or early adulthood. Manifestations may include new-onset upper airway obstruction due to upper airway hypotonicity from lower cranial neuropathies and vocal cord paralysis. We describe and discuss two such cases. Methods: The first case is an 18-year-old male referred for new-onset snoring, gasping, and daytime somnolence. Examination revealed mildly enlarged tonsils, moderately enlarged adenoids, and a normal larynx. He deteriorated to severe stridor over the next 5 days. The second case is an 18-year-old male seen in the ER for severe stridor. He was diagnosed with bilateral vocal cord paresis 3 years before, but MRI and neurologic consultation revealed no etiology. The first patient was intubated; the second had emergent tracheotomy. Both had flexible laryngoscopy prior to intervention and subsequent MRI of the head and neck. Results: In both patients, flexible laryngoscopy showed bilateral vocal cord paralysis, and MRI of the head and neck revealed Chiari type I malformation. They were both treated with neurosurgical decompression. Conclusion: In the absence of obstructive disease, a neurologic abnormality such as Chiari malformation should be suspected in new-onset upper airway obstruction and/or bilateral vocal cord paralysis in the adolescent, though the development of cranial neuropathies or radiographic evidence may be delayed. Establishing a proper diagnosis is important, as Chiari malformation may be treated with neurosurgical decompression, with possible improvement in cranial nerve weakness. P059

Is Stepdown Monitoring Required Following Tx/UPPP? Eric M Gessler MD (presenter); Peter C Bondy MD

Portsmouth VA; Virginia Beach VA Objectives: To determine if risk of airway compromise following tonsillectomy with uvulopalatopharyngoplasty justifies the added cost and inconvenience of stepdown intensive care unit monitoring. Methods: Study Design and Setting: A retrospective chart review of 130 patients undergoing isolated tonsillectomy with uvulopalatopharyngoplasty was conducted in a tertiary medical center. Results: Eight patients out of 130 (6.2%) and 3 of 12 patients with comorbidities (25%) had postoperative desaturation below 90%. The average length of stepdown unit stay was 18 hours. No patient had an adverse respiratory event. Conclusion: Stepdown unit monitoring is not necessary. Caution should be exercised in patients with comorbidities, as they seem more prone to desaturation. Adverse respiratory events are rarer than previous studies describe. Significance: The added expense of stepdown unit monitoring can be spared.

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OtolaryngologyHead and Neck Surgery August 2002

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Spectrographic Methods of Voice Identification Maria Dolores Romero MD (presenter); Secundino Fernandez MD PhD; Francisco Vazquez MD; Laura Sarrasqueta RN; Rafael Garcia-Tapia MD

Pamplona Spain; Pamplona Spain; Pamplona Spain; Pamplona Spain; Pamplona Spain Objectives: Individual identification by means of a voice spectrographic analysis can be of great utility in forensic medicine, the study and treatment of speech and hearing disorders, and the field of security industry. There is controversy about the reliability of the results obtained with this method for individual identification because of intraspeaker variability. Our main goal is to determine acoustics parameters that will be able to get a significant percentage of correct answers in the voice identification when we are using samples obtained in different acoustic situations and with different methods of sample collection. Methods: We used a Power Mac 9600/233 computer with Soundscope software for voice analysis of samples from 20 subjects (10 woman and 10 men); the samples were obtained by direct recording in the laboratory, telephone line recording, and magnetic tape records. The recording protocol included the speech of isolated vowels, diphthongs, and running speech. We studied the following parameters: fundamental frequency, I-I/N ratio, the first 8 harmonics, and the main characteristic of the 3 first formants. Results: There are no significant differences among the different situations of sample recording. In relation with the sample collection method, there are no significant differences among the different recording methods (magnetic tape, digital recording, etc). We have found that telephonic line recording provides us less information than others. The acoustic parameters that give us more information are the fundamental frequency; the mean, maximum, and medium values; and the range of harmonics. Conclusion: Spectrography is a useful tool in the voice identification process if you get a wide and representative sample and a sufficient acoustic quality. P061

A Significance of Navigation System in Temporal Bone Surgery Satoshi Fukuda MD PhD (presenter); Eiji Chida MD PhD; Yuji Nakamaru MD PhD; Masahiko Saheki MD; Yasushi Furuta MD PhD

Sapporo Japan; Sapporo Japan; Sapporo Japan; Sapporo Japan; Sapporo Japan Objectives: Computer-aided image-guided surgery has allowed for advances in the safety and accuracy of nasal surgery. But the significance of this system, especially in accuracy for temporal bone lesions, is considered to be still controversial. Temporal bone surgical procedures require exacting accuracy, more so than other image-guided applica-

tions. So accuracy is key to this application. This study evaluated the accuracy and significance of this system for surgery in temporal bone lesions. Methods: Thirty-five patients, consisting of 22 cholesteatomas including reoperative cases, 6 cochlear implants including ossifying cochlea, 3 cases of chronic otitis media, 3 cases of facial nerve palsy, and 1 eosinophilic granuloma of petrous apex, were operated on with the use of an optical-track navigation system from July 1999 to December 2001. Results: The accuracy in our series was 0.37 mm on average. So it was significantly useful to recognize and observe the target points and aimed structures accurately during surgery, including petrous apex cholesteatoma, cochlear implant in a child for ossifying cochlea, and cholesteatoma involving the skull base. Conclusion: In conclusion, this navigation system ensures supplemental safe, accurate, and reliable operation and also is considered to be useful for academic explanation to medical students and academic training for residents. Disadvantages of this system for now are regarded as expensive cost and time for registration. A congenital anomaly, reoperative cases losing their anatomical landmarks, petrous apex lesion, and cochlear implant in ossified cochlea are regarded as good indications for using this system. P062

Evolution of Patients with Head and Neck Cancer Ali Amar; Abrao Rapoport MD; Carlos N Lehn; Sergio A Franzi MD (presenter) Sao Paulo Brazil; Sae Paulo Brazil;Sao Paulo Brazil; Sao Paulo Brazil Objectives: Recurrences of head and neck cancer are very common. This study evaluates the higher risk period for recurrences. It can help to define strategies for follow-up. Methods: In a retrospective study of 943 patients submitted to surgical treatment for head and neck cancer, 297 had recurrence of disease. The time between treatment and relapse of disease in different sites (primary site, neck, distant metastasis, or second primaries) was established for each primary site and for different stages. The results were expressed in medians and quartiles. Results: 74% of recurrences were diagnosed in the first 18 months after treatment. Recurrences at primary site, in the neck, or distant metastasis showed a median time of 270, 210, and 435 days, respectively. The incidence of second primaries ranged between 2% and 3.1% per year. Tumors of oral cavity, larynx, and pharynx developed local recurrences after a median time of 240, 480, and 300 days, respectively. Conclusion: The most recurrences occurred in the first 18 months after surgical treatment, and the follow-up should be monthly in this period. After 24 months, the risk of local or regional recurrences is the same as development of second tumors.

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Volume 127 Number 2

P063

The Effects of Tobacco Smoke in Otolaryngologic Patients Manuel Pais Clemente MD PhD (presenter); Laudelina R Carvalho Pais Clemente MD; Eduardo A Cardoso MD; Antonio Pires Castanheria

Porto Portugal," Porto Portugal; Vila Nova d Gaia Portugal," Potro Portugal

Objectives: Children exposed to passive smoking are believed to be more susceptible to development of serous otitis media (SOM). Some authors have noticed a higher incidence of inflammatory paranasal sinus diseases (IPSD) in tobacco smokers. The carcinogenic effect of tobacco smoke on the larynx is a dogma of the past century. Regarding these data, the authors review the charts of patients with SOM, IPSD, and laryngeal neoplasms, demonstrating a close relation between these clinical entities and tobacco smoking. Methods: The charts of the Department of Otolaryngology were reviewed for SOM, sinusitis, and laryngeal neoplasms. The review included 100 children with age between 2 and 10 years, 50 children of nonsmoking parents, and another 50 children of smoking parents. Patients with sinusitis were reviewed during a 10-year period. Laryngeal cancer affected 711 patients during 21 years. All clinical records were examined, including past and family history, clinical examination, objective tests, and surgical findings as follow-up data. Results: SOM was 3 times more frequent in children of smoking parents than in those of nonsmoking parents. Smoking individuals had 40% more incidence of sinusitis than nonsmokers. Of patients with laryngeal cancer, 94% were smokers, demonstrating a strong correlation with tobacco smoking. Conclusion: SOM, inflammatory diseases of paranasal sinus, and laryngeal carcinomas are a serious problem of public health that needs aggressive prevention programs throughout the world. Once more is demonstrated the wide harmful effects of tobacco and the necessity to be aware. P064

Partial Inferior Turbinectomy Using the Microdebrider David B Wexler MD (presenter); Itzhak Braverman MD

Hadera Israel; Hadera Israel Objectives: Inferior turbinate reduction is a common operation for treatment of nasal obstruction. Common turbinectomy techniques are prone to excessive or poorly controlled resection with disruption of the turbinate form. We report on use of a microdebrider for partial inferior turbinectomy, selected for its controlled and rapid removal of nasal soft tissue while sparing general form of the turbinate. Methods: Eight women and 27 men underwent bilateral inferior turbinate reduction with the Xomed XPS Microdebrider alone (n = 1) or combined with septoplasty (n = 22) or sinus surgery (n = 12). One to two mm of nasal mucosa was

removed from the medial and inferior portions of the inferior turbinates. Postoperative packing was placed in most cases. Sinonasal symptom questionnaires were completed by the patients before and surgery. Detailed follow-up was accomplished at 4 to 5 months postop, including questionnaire, videoendoscopy, and sometimes mucosal biopsy. Results: Follow-up of 4+ months was available for 17 patients. Nasal endoscopy showed well-healed turbinate membranes and preservation of turbinate form, with widening of the medial nasal airway space. Nasal breathing improved after surgery (P < 0.01), and thick nasal drainage was reduced (P < 0.05) without associated crusting, irritation, sneezing, loss of smell, or dryness. Early postop bleeding occurred in 3 of 35 (7.9%) patients, indicating need for routine packing. Synechiae were seen in 2 of 35 (5.2%) patients, associated with residual septal deviation. Postop biopsies (n = 7) showed dense subepithelial fibrosis and regenerated epithelium, generally of respiratory pattern. Conclusion: Inferior turbinate reduction can be accomplished efficiently with the microdebrider device. The turbinate heals with conchal form preserved while the medial nasal airway is enlarged. In conjunction with standard septal/sinus procedures, nasal breathing improves. Long-term follow-up on a larger patient group is warranted. P065

Surgical Management of Amiodarone-lnduced Thyrotoxicosis Christine Blanche Franzese MD (presenter); Brendan C Stack Jr MD

Hershey PA; Hershey PA

Objectives: Amiodarone can cause the development of thyroid dysfunction in patients with or without thyroid disease. With increased usage from its placement in the ACLS guidelines and acceptance in cardiac transplant programs, the incidence of amiodarone-induced thyrotoxicosis (AIT) will likely increase. Medical management is complex, not standardized, and frequently fails. This study investigates the role of surgery in AIT and proposes indications for surgical management of AIT. Methods: Two AIT case reports at a tertiary care institution and 40 surgical AIT cases in the world literature are reviewed and analyzed. The two cases involved patients with cardiomyopathy and resistant arrhythmias. Despite medical therapy, both patients' conditions failed to improve. Forty cases of AIT in the world literature are evaluated with respect to symptoms and onset, medical therapy, AIT classification, pathology, perioperative management, and complications. Results: Both patients underwent total thyroidectomy without difficulty or complication, one as an outpatient and one as an inpatient with an intraaortic balloon pump. One patient received a successful cardiac transplant and the other remains a viable candidate. In the literature, the majority

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(85%) of surgical cases are AIT type II (less common type) with no underlying thyroid disease. Range and duration of symptoms varied, in addition to attempted type and duration of medical management. Almost all patients (95%) underwent total thyroidectomy, and all were successful with no mortality and minimal morbidity. Conclusion: Amiodarone-induced thyrotoxicosis can develop in any patient during or after amiodarone therapy. Medical managementSs extremely difficult due to the lack of a proven, consistent therapeutic armamentarium, and surgery offers a safe, viable option. Surgical management should play a larger role in treatment algorithms and should be strongly considered for those patients whose conditions necessitate the continuation of amiodarone or those with severe symptoms resistant to medical therapy. P066 Recalcitrant Otorrhea Due to Pseudomonas Biofilm Marcella R Bothwell MD (presenter,); Arnold L Smith MD; Thomas E Phillips MD Columbia MO; Columbia MO; Valdosta GA

Objectives: One or more episodes of otorrhea after tympanostomy tube insertion may affect 21% of patients with tubes. Chronic drainage may affect 3.6% of patients with tubes. Occasionally, otorrhea may be unresponsive to topical and oral systemic antibiotics appropriate to cultures obtained. The biofilm mode of growth confers on the associated organisms a measurable decrease in antimicrobial susceptibility. The effect on susceptibility may be intrinsic (ie, inherent in the biofilm mode of growth) or acquired (ie, caused by the acquisition of resistance plasmids). Methods: This is a case report of 4-year-old child with a greater than 1-year history of intermittent ear drainage. The child's drainage improved over the summer after removal and replacement of the left ear tube and adenoidectomy. Otorrhea resumed in November, and culture showed Staphylococcus aureus. Rifampin and quinolone drops failed to eradicate otorrhea. Repeat culture showed yeast, and again, culture-directed therapy with Diflucan failed. The child's otorrhea persisted, and final culture before systemic IV therapy was started and tube removal showed Pseudomonas. Consequently, only the tube was removed, and quinolone antibiotic drops were resumed. Results: Electron microscopy of tube identified a biofilm with Pseudomonas will be shown. On 1-week return for followupl otorrhea was completely resolved and tympanic membrane was healed. Conclusion: Culture-directed therapy for otorrhea generally leads to improvement. However, cultures may not reflect the underlying biofilm on the tympanostomy tube. The biofilm may render the organism resistant to conventional systemic and topical therapy. Tube removal in recalcitrant otorrhea should be considered.

August 2002

P067

Coblation-Assisted Tonsillotomy: The Henry Ford Experience Ari I Wirtschafter MD (presenter); Kathleen Yaremchuk MD Detroit MI; Dearborn MI

Objectives: To evaluate the intraoperative and postoperative course of patients who underwent coblation-assisted tonsillotomy. Methods: Retrospective chart review of 67 patients with an average age of 12 who underwent coblation-assisted tonsillotomy for one of the following reasons: tonsillar and adenoid hypertrophy, chronic tonsillitis, or both~ Subjects' charts, identified from ENT clinic patients who had undergone coblationassisted tonsillotomy, were reviewed. All patients had met traditional criteria for tonsillectomy as outlined by the academy guidelines. Surgical technique consisted of the use of the Evac 70 hand-piece. Standard coblation-assisted tonsillotomy techniques were used, whereby 90% to 95% of the tonsil was removed, taking care not to violate the capsule. Results: Interviews with patients and their families, anesthesia staff, and recovery room nurses suggest a significant decrease in postoperative, as well as intraoperative, pain when this technique is utilized. 3 patients developed postop bleeding, of which 2 required control within the operating room. Of those with a history of recurrent infection, one patient later developed a peritonsillar cellulitis and one developed a peritonsillar abscess. Conclusion: Preliminary results demonstrate excellent pain control and rapid recovery with a slightly higher incidence of postop bleeding consistent with the learning of a new technique. Patients with a history of recurrent infection may be subject to recurrent disease secondary to incomplete removal of tonsillar tissue. P068

Role of CT and MR Image for Treatment of Supraglottic Cancer Jung-II Cho (presenter); Young-Mo Kim; Seung-Joon Lee; Hyung-Jin Kim; Jee-Young Han Seoul South Korea; Inchon South Korea; Inchon South Korea; Inchon South Korea; Inchon South Korea

Objectives: For conservation surgery of supraglottic cancer, an accurate evaluation of extent of laryngeal involvement should be done. This study was designed to compare preoperative CT and MR findings with actual postoperative histopathological findings and thereby evaluate their reliability in determining extent of cancer. Methods: Twenty-three supraglottic cancer patients were selected. All patients had CT and MR. 9 of these patients underwent total laryngectomy; 8, supraericoid laryngectomy; and 6, supraglottic laryngectomy. Obtained larynges were sectioned at a plane corresponding to the CT or MR plane. Gross

OtolaryngologyHead and Neck Surgery Volume 127 Number 2

and .histopathological findings were compared with CT and MR images at supraglottic, glottic, subglottic levels. Results: Eight subsites (supraglottis: base of tongue, preepiglottic space, arytenoid, false cord; glottis: ipsilateral and contralateral vocal folds, anterior commissure, and subglottis) for determination of surgical planning were examined. At the supraglottic level, there were 8 (14%) false-positives and 7 (10%) false-negatives among 72 subsites. There was only one false-negative among 51 glottic subsites, but 7 (14%) false-positives were present. One false-positive was present among 9 subsites of the subglottis. Conclusion: Planning of conservation surgery for supraglottic cancer could be still limited due to overall inaccuracy (18%) of preoperative CT and MR images compared to postoperative histopathology. Adjunctive diagnostic methods such as direct endoscopy should be considered preoperatively. P069

Preoperative Staging of Inverted Papilloma by MRI Keita Oikawa MD (presenter); Yasushi Furuta MD PhD; Nobuhiko Ordate MD; Tatsumi Nagahashi MD; Akihiro Homma MD, PhD; Satoshi Fukuda MD PhD

Sapporo Japan; Sapporo Japan; Sapporo Japan; Sapporo Japan; Sapporo Japan; Sapporo Japan Objectives: Sinonasal inverted papilloma (IP) is a rare benign tumor, which is locally aggressive. IP has a tendency to recur after surgical resection and is occasionally associated with squamous cell carcinoma. Radical en bloc resection by lateral rhinotomy and medial maxillectomy has been recommended as the initial management; however, conservative endoscopic sinus surgery has also been shown to be effective in selected cases. To determine adequate surgical approaches, a staging system for IP based on extent and location of tumor has been advocated. The present study investigated whether preoperative assessment by magnetic resonance imaging (MRI) actually predicts the extent of IE Methods: MRI was retrospectively reviewed in 21 IP cases without knowledge of the surgical findings. Preoperative and postoperative stages were graded according to the staging system proposed by J. H. Krouse. Results: Preoperative staging by MRI was coincident with postoperative staging verified by surgical findings in 18 of the 21 cases (86%), which included 1 case of stage TI, 3 cases of T2, and 14 cases of T3. Two cases of stage T2 were judged as stage T3, and one T3 case was judged as stage T2 by MRI. Dissociation between preoperative and postoperative findings in the frontal sinus was observed in 3 of the 21 cases (14%). Conclusion: In most cases, MRI assessment of the preoperative extent of IP accurately predicts the extent of tumor involvement. However, careful evaluation of tumor extension into the frontal sinus is needed for planning the surgical approach.

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P070

Clinical Feature of Hearing Loss Caused by TECTA Mutation Satoshi Iwasaki MD (presenter); Tomoyuki Hoshino MD; Mituyoshi Nagura; Tamotsu Takeshita MD

Hamamatsu Japan; Hamamatsu Japan; Hamamatsu City Japan; Hamamatsu City Japan Objectives: The TECTA gene, which encodes c~-tectorin, has recently been cloned, c~-Tectorin is a major component of the noncollagenous matrix of the tectorial membrane. This study reports the clinical features in family with nonsyndromic hearing impairment and mutation in the TECTA gene. Methods: The present family displayed autosomal dominant hearing impairment through 3 generations. Audiograms were available for 4 members of the pedigree. Speech discrimination test, otoacoustic emissions, caloric test, and computed tomography were also performed. For one member, we can chart the hearing impairment via audiometric examinations over a long term. We sequenced exons (1-20) of the TECTA gene in 4 affected individuals. Mutation analysis was performed by genomic exon sequencing. Results: The five-frequency average in 4 affected individuals was 42.2 _+ 3.7 dB in the right ear and 42.3 + 4.5 dB in the left ear. Mean age at onset of hearing impairment was 5 years. All the affected members had normal vestibular function. Progression of hearing impairment was not confirmed for a 15-year period from the ages of 6 to 21 years in one affected member. These patients had a G>A missense mutation at nt 6063 in exon 20. A mutation in the TECTA gene, localized in the zona pellucida domain, was detected in all 4 affected individuals. Conclusion: A mutation localized in the zona pellucida domain resulted in the prelingual and stable hearing loss in midfrequency in an autosomal dominant family. Localization of the mutation in the different modules of protein may have caused different clinical features.

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P071

Septic Thrombosis of Intracranial Sinuses Ing Ruen Lim MBBS FRCS (presenter); Henry K K Tan MD Singapore Singapore; Singapore Singapore

Objectives: Advances in therapy have lowered the incidence of septic thrombosis of intracranial sinuses. Though rare, it is associated with significant morbidity and mortality. This article reviews the diagnosis and management of this potentially lethal condition. Methods: Case series of 4 consecutive patients with the diagnosis of septic intracranial thrombosis at a tertiary medical center. Literature review on the current management of this condition. Results: 3 patients had cavernous sinus thrombosis (one of

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whom is bilateral); 1 patient had sigmoid sinus thrombosis. All had antecedent history of infective sinusitis, with associated otomastoiditis in 2 of them. Only 2 of the patients were immunocompromised in contrast to the other 2 who had no underlying medical condition. Aside from systemic signs of sepsis, the presentation was dramatic, with proptosis, ophthalmoplegia, and chemosis in those with cavernous sinus thrombosis, but less so in the patient with lateral sinus thrombosis. The diagnosis was confirmed with imaging. Aggressive medical therapy coupled with appropriate surgical drainage allowed resolution of the condition with minimal neurological sequelae. The literature on current use of antibiotics, anticoagulants, and surgery is also reviewed. Conclusion: Thrombosis of intracranial sinuses is a rare but serious condition. Timely diagnosis and management are the keys to a better outcome. P072

Clinical and Surgical Aspects of Cholesteatoma in Children Dragoslava Djeric MD PhD (presenter); Snezana S Babac MD Belgrade Yugoslavia; Belgrade Yugoslavia

Objectives: Cholesteatoma in children is considered to be a more aggressive than in adults. Various surgical procedures have been used to eradicate cholesteatoma, but the ideal method for treatment of children cholesteatoma remains a controversial subject. The purpose of the study is to present our experience in the diagnosis and treatment of cholesteatoma in children. Methods: The study included 178 consecutive cholesteatomas, diagnosed and operated on in 166 children, aged 3 to 15 years. All children were operated on for the first time at our institute between 1990 and 2000. A retrospective chart review was performed on the examined patients with special attention to the clinical, surgical, and pathological data. Results: Our results showed that most of the children with cholesteatoma had been treated when cholesteatoma otitis was enlarged, affecting ossicular chain and the walls of the tympanic cavity. In the majority of children (71.8%), various types of ossicular lesions were found. In more than half of the children, the cholesteatoma was enlarged involving the tympanic cavity and mastoid spaces. Conclusion: The choice of surgical procedure depended on location of cholesteatoma, condition of mucosal layer, tubal function, and hearing loss. In our study one-stage tympanoplasty as canal wall down was done in about 30% of ears, and as canal wall up, in about 35%. Two-stage tympanoplasty was done in 10% of patients, and modified radical mastoidectomy, in about 28% of patients. Recurrence of cholesteatoma was found in 21% of operated ears, more often after wall-up (31%) than after wall-down procedures (9%).

P073

Free Flap Reconstruction Syndrome

for Trigeminal

Trophic

Eileen H Dauer MD (presenter); Scott E Strome MD; Jan L Kasperbauer MD; Eric J Moore MD Rochester MN; Rochester MN; Rochester MN," Rochester MN

Objectives: Trigeminal trophic syndrome (TTS) is an unusual but well-recognized complication arising from trigeminal nerve injury, most commonly from nerve ablation attempts in patients with medically refractory tfigeminal neuralgia. The classic triad includes anesthesia in the trigeminal distribution, facial paresthesias, and crescentic lateral nasal erosion and ulceration. Ulcerations in other facial locations have been described. The etiology of the tissue destruction is unconscious repetitive self-induced trauma in areas where the patient experiences postablativ e paresthesias. The wounds may become secondarily infected and are notoriously resistant to conventional wound care, possibly related to diminished vascular supply. The literature offers no definitive management recommendations, and attempts at reconstruction have had limited success. We present a case of TTS in a patient who underwent sensate free flap reconstruction with a favorable outcome. Methods: A chart review was undertaken to include our case patient along with 7 other patients previously diagnosed with TTS at the Mayo Clinic. Treatment options and outcomes are compared, and a literature review is included. Results: Previous reports of successful reconstruction in TTS have emphasized the importance of utilizing well-vascularized, sensate tissue. Accordingly, the area of ulceration in our case patient has completely resolved after reconstruction of her defect with a sensate lateral ann free flap, and she has been off intravenous antibiotics for the first time in 3 years. Conclusion: Free tissue transfer offers an attractive option for repair of tissue destruction in patients with TTS because it replaces insensate and devascularized tissue with sensate tissue carrying its own vascular supply. P074

Bilateral Cochlear Implantation with a Perimodiolar Array: Early Results Michael Nell Waltzman MD (presenter); Noel b Cohen MD; J Thomas Roland Jr MD; William H Shapiro MA; Susan B Waltzman PhD New York NY; New York NY," New York NY; New York NY; New York NY

Objectives: Studies in progress to determine the efficacy of bilateral implantation have used several types of electrode arrays and speech processing strategies. The purpose of this study is to prospectively evaluate the speech understanding in quiet and noise conditions in subjects with bilateral implants by using the most recent Nucleus CI24RCS (with the contour

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electrode array) and Advanced Combination Encoding (ACE) speech processing strategy. Methods: To date, 4 profoundly hearing-impaired adults received simultaneous bilateral Nucleus CI24RCS cochlear implants programmed with the ACE strategy. In order to minimize potential contamination, the surgical technique involved completing one side prior to implanting the second side. Phoneme, word, and sentence tests presented in quiet and noise, unilaterally and bilaterally, were used to assess speech perception preoperatively and at 3 months postoperatively. A questionnaire was administered to determine patient preference and satisfaction. Results: Subjects demonstrate a range of improvement in speech understanding post implantation in the majority of conditions. Although the best word and sentence scores were not always in the bilateral condition, patient preference and satisfaction revealed an affinity for bilateral stimulation. All subjects had full insertions of the electrode arrays with no surgical complications. Conclusion: Preliminary results indicate that bilateral implantation is effective in improving speech understanding under most conditions. Patients who have undergone this procedure have expressed a preference for the bilateral condition over the unilateral conditions, even in the absence of improved test scores in a few of the testing paradigms. Expanded studies of perception and localization with bilateral implants are proceeding. P075

Basaloid Squamous Cell Carcinoma: An Aggressive Squamous Cell Variant Pamela C Roehm MD PhD (presenter); Eugene N Myers MD Pittsburgh PA; Pittsburgh PA

Objectives: Basaloid squarnous cell carcinoma (BSCC) is a rare variant of squamous cell carcinoma (SCC). This histologic variant has a rapidly progressive course with frequent metastases. Using a large patient database, we sought to describe our institution's experience with this tumor. Methods." Charts of 44 patients with documented BSCC of the head and neck presenting between 1989 and 2000 were reviewed with respect to presentation, history, pathologic factors, treatment, and outcomes. Results: Of 44 patients studied, 12 were female and 32, male. Mean age at diagnosis was 59.7 years. Mean duration of symptoms was 8.4 months (median of 3 months). Symptoms included dysphagia (27%), pain (27%), hoarseness (20%), bleeding (11%), and weight loss (11%). Primary sites included oropharynx (34%), hypopharynx (23%), larynx (18%), and oral cavity (11%). 11% of patients presented at stages I or II; 18% of patients, at stage III; and 45%, at stage IV. 73% of patients had a history of smoking. Alcohol use was also common. 14% of patients had a history of a previous head and neck tumor, and 9% had received radiation therapy. 16% of

patients had a history of gastrointestinal reflux disease. Treatment modalities included surgical excision (73%) (64% with neck dissections), radiation therapy (50%), and chemotherapy (23%). For 31 patients with available records, mean follow-up was 20 months. 45% had recurrences, and 26% had documented distant metastases. Conclusion: BSCC remains an advanced tumor of the elderly tobacco/alcohol user. Outcomes were similar to those of conventional SCC. P076

Pediatric Cervical Abscess: Predictors of Therapeutic Outcome Shefali Shah MD (presenter); John Maddalo770 MD Chicago IL; Chicago IL

Objectives: A retrospective study was conducted to elucidate predictive factors of inflammatory adenopathy, not requiring surgical therapy, versus frank abscess. Methods: One hundred five children were admitted to Children's Memorial Hospital from January 1995 to January 2000. Their charts were surveyed for signs, symptoms, laboratory and radiological studies, and subsequent management. Results: Seventy-one (67.6%) required operative intervention, 10 (9.5%) required aspiration, and 24 (22.9%) resolved with intravenous antibiotics alone. Eighty patients (76.1%) underwent computed tomography. Conclusion: At the time of initial presentation, fluctuance was found to be the best physical predictor of procedure-oriented intervention (ie, either aspiration or surgery; positive predictive value = 98%). However, coalescence alone was seen both groups (total of 8 of 80 patients). These children resolved with antibiotics alone. All patients improved with either antibiotic therapy or procedure-oriented intervention. P077

Meningeal Carcinomatosis Presenting with Hearing Loss Ronald G Shashy MD (presenter); Colin L W Driscoll MD Rochester MN; Rochester MN

Objectives: Meningeal carcinomatosis is defined as diffuse infiltration of the leptomeninges by metastatic cancer. The authors describe two cases of meningeal carcinomatosis presenting as progressive sensorineural hearing loss and review the existing literature. Methods: A retrospective review of two cases of meningeal carcinomatosis presenting with hearing loss. Results: Case 1: A 59 year-old gentleman with history of melanotic skin lesions described a 1-year bilateral progressive hearing loss associated with tinnitus and vertigo. He was initially diagnosed with autoimmune ear disease and treated with steroids and methotrexate without improvement. He also complained of neck pain radiating to the vertex/occiput and a 20-

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lb weight loss. An enlarged fight axillary lymph node prompted a biopsy and this revealed metastatic melanoma. Head MRI was reported as negative but CSF examination revealed metastatic melanoma. Case 2: A 71-year-old female presented with an 18-month history of progressive hearing loss, vertigo, and tinnitus. Audiograms confirmed a progressive bilateral decline, and ENG showed a bilateral peripheral deficit. Head MRI revealed bilateral contrast enhancement of the eighth cranial nerves and internal auditory canals. CSF evaluation showed metastatic breast adenocarcinoma. Conclusion: Meningeal carcinomatosis is a rare disorder but must remain in the differential diagnosis for patients presenting with progressive sensorineural hearing loss, particularly in the setting of a patient with a history of cancer. The primary tumor is usually breast or lung adenocarcinoma or malignant melanoma of the skin. Patients most commonly present with headache, fatigue, dizziness, or cranial neuropathies. Gadolinium-enhanced MRI and CSF cytology are instrumental in determining the diagnosis. P078

Otolaryngologic Findings in Myotonic Dystrophy Type 1 Ryuichi Osanai MD (presenter); Masanobu Kinoshita MD; Kazuhiko Hirose MD

Chiba Japan; Kawagoe Saitama Japan; Fuchu Tokyo Japan

Objectives: Background: Otolaryngologic examinations that include eye movement and stapedial reflex (SR) tests can contribute to the quantitative evaluation of muscular involvement in myotonic dystrophy type 1 (DM1). Methods: We measured the thickness of lateral rectus muscles and areas of the pontine base and tegmentum on the magnetic resonance imaging (MRI) of 12 DM1 patients and 6 agematched controls and studied their correlation with saccadic velocity and CTG repeat [(CTG)n] length. We also performed a case-control study that compared the SR waveform (latency: L, contraction time: C50, and relaxation time: D50) measured by the acoustic impedance method in 13 patients with DM1 and in 14 control subjects matched for age and sex. The correlation between these findings and (CTG)n length in DM1 patients was also examined. Other otolaryngologic findings including swallowing disorders will also be mentioned briefly. Results: (1) Saccadic velocity and thickness of the lateral rectus muscles in DM1 were markedly lower than those in the controls. No significant difference was found in the areas of pontine base and tegmentum between the two groups. Saccadic velocity and thickness of the lateral rectus muscles showed a strong positive correlation. Patients with greater (CTG)n lengths had lower saccadic velocities. (2) C50 and D50 in DM1 patients were significantly prolonged, whereas L was not. Both C50 and D50 in DM1 patients were significantly correlated with (CTG)n lengths, whereas L was not. Conclusion: DM1 patients should be given otolaryngologic examinations for a quantitative evaluation of muscular involvement.

P079

Factors Influencing the Closed Reduction of Nasal Bone Fractures Nafee Poopat MD (presenter); Robert H Mathog MD

Berkley MI; Franklin MI

Objectives: Nasal bone fractures continue to be the most common fracture of the facial skeleton. There are many different philosophies regarding the importance of timing, technique, comorbid fractures, and postoperative care in the treatment of these patients. This study will identify the key factors influencing successful repair of nasal bone fractures. Methods: Data from 200 patients diagnosed with nasal bone fractures from 1999 to 2001 were reviewed for factors including position of fracture, age, sex, bleeding, obstruction, comorbid conditions, timing of repair, technique, postoperative compliance, and duration of splinting. Successful repair was measured by external appearance and patients' subjective reports comparing preoperative and postoperative satisfaction. Results: Of the patients diagnosed with nasal bone fractures from 1999 to 2001, 200 were available for the current study. Timing of reduction, completeness and adequacy of reduction, and postoperative compliance seemed to play major roles in the outcome of the repair. Conclusion: Many factors influence the successful repair of nasal bone fractures. Of these, timing, technique, and patient postoperative compliance play the most important roles. Other factors such as bleeding, age, and sex may play minor roles; however, no strong association has been found in this study. Prompt diagnosis, completeness of reduction, and preop patient counseling regarding the importance of follow-up and postoperative care are exceedingly important in the care of these injuries.

P080 The Reverse Flow Flap in the Vessel-Depleted Neck Samuel Shiley MD (presenter); Gary Nesbit MD; Daphne A Bascom MD; James I Cohen MD PhD; Judith Skoner MD; Mark K Wax MD

Portland OR; Portland OR; Pittsburgh PA; Portland OR," Charleston SC; Portland OR

Objectives: Fasciocutaneous free flaps have become the reconstructive option of choice following ablation for head and neck oncologic processes. The successful transfer of vascularized tissue requires a donor arterial and recipient venous supply to be available in the neck. Occasionally, one encounters a venous-depleted neck due to multiple previous procedures or oncologic resection. Rarely is arterial supply a problem. Methods: This poster presents the interesting case of a patient who required carotid resection yet maintained an intact internal jugular vein on the ipsilateral side. Consideration of going to the contralateral neck was undertaken. Flow through the distal stump of the external carotid was felt to be adequate to supply the donor free tissue. Results: Revascularization with this reverse flow flap was undertaken and successful. Approximately I to 2 months later,

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she suffered rupture of her common carotid graft with placement of a stent. Angiography demonstrated the vascularization of the fascial free flap from the contralateral carotid artery through the extracranial circulation. Conclusion: In those rare instances where arterial vascular supply is depleted in the recipient neck, reverse flow flaps may very well play a role. P08l

Variability in Cochlear Implant Thresholds Tina Chung-Ting Huang MD (presenter); Samuel C Levine MD; Sharon L Smith MS Edina MN; Minneapolis MN; Minneapolis MN

Objectives: Cochlear implants are used in an attempt to restore functional hearing in patients with profound sensorineural hearing loss, including those with otosclerosis and Meniere's disease. It is assumed that once implanted, these patients will have stable performance of their implants. However, we noted that patients with Meniere's disease appeared to have a greater amount of variability in their T thresholds than the remainder of our implant patients. We undertook a review to determine if such a difference existed, using patients with otosclerosis as a comparison group. Methods: Retrospective review of the cochlear implant T threshold measurements for 8 adult patients with Meniere's disease and 5 adult patients with otosclerosis implanted and followed at the University of Minnesota from 1988 to 2001. Testing was performed by a single examiner using the same equipment. Three channels were used for statistical analysis (basal, middle, and apical channels). The variability in T threshold values between consecutive visits was calculated and analyzed. Results: A statistically significant difference was found in the overall variability between the two groups with the otosclerosis patients having a higher level of between-visit variability than the Meniere's group. Conclusion: We found a significant difference in the variability of the T thresholds, with the otosclerosis patients having a larger amount of variability than the Meniere's patients. This finding was contrary to our initial observation and may be related to the natural history of the two diseases. P082

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Diagnosis and Management of Laryngeal Schwannomas Seth M Cohen MD MPH (presenter); John Sinaceri MD; Mark S Courey MD Nashville TN,"Nashville TN; Nashville TN

Objectives: Laryngeal schwannomas are rare submucosal lesions that may present with hoarseness, dysphagia, foreign body sensation, stridor, or asthma-like symptoms. An endoscopic biopsy of these lesions may be difficult and hinder subsequent treatment. We present two cases of laryngeal schwannomas and discuss their management. Methods: Two cases of laryngeal schwannomas are presented. Information was obtained from medical records

including clinical presentation and course, operative reports, radiologic studies, and pathologic evaluation. Results: Due to the submucosal location, an endoscopic view alone may underappreciate the laryngeal involvement by the schwannoma. Hence, appropriate radiologic evaluation is necessary to assess the true extent of the lesion. As evidenced by the two cases, the capsule may prevent the surgeon from obtaining a deep biopsy and an adequate tissue specimen. The second case demonstrates that scarring at the biopsy site may impair subsequent removal of the lesion. Conclusion: After the degree of airway involvement has been evaluated, an open approach is more appropriate for excision of laryngeal schwannomas. P083

Posttransplant Lymphoproliferative Disorders in the Head and Neck Jennifer Bailes MD (presenter); Frank R Miller MD; Howard S McGuff DDS; Aamir Ehsan San Antonio TX; San Antonio TX,"San Antonio TX; San Antonio TX

Objectives: Posttransplant lymphoproliferative disorders (PTLD) are EBV-driven lymphoid proliferations that affect up to 4% (2% to 10%) of allographic organ recipients. PTLD is related to therapeutic immunosuppression and can range from a polyclonal lymphoproliferation to malignant lymphoma. Primary sites of presentation in the head and neck include Waldeyer's ring, oral cavity, and salivary glands. In the head and neck region, it is critical to differentiate PTLD from other types of head and neck neoplasms. Methods: Case review of two patients with PTLD of the head and neck region (oral cavity and cervical lymph node). An analysis of the etiology, clinical presentation, diagnostic studies, and therapeutic modalities in PTLD will be presented. Results: This paper will review the diagnosis and management of PTLD in the head and neck region. This paper will focus on the essential role of modern pathologic techniques (including molecular diagnostics) to diagnose PTLD. Conclusion: It is critical to differentiate the benign lymphoproliferative disorders from malignant lymphoma, as well as other neoplastic processes. This report will describe the differential diagnosis with particular emphasis on the role of pathologic analysis including immunophenotyping, molecular diagnostics, EBV assays, and immunohistochemistry. An approach to the posttransplant patient with a head and neck mass will be described. P084

Mohs Surgery in the Management Sebaceous Carcinoma

of Extraocular

Seilesh Babu MD (presenter); Michael S Benninger MD; Sreekant Cherukuri MD Farmington Hills MI; Detroit MI; Southfield MI

Objectives: Sebaceous gland carcinoma is an uncommon

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but aggressive cutaneous tumor. It usually arises from the meibomian glands of the eyelid, but rarely it can be found elsewhere on the skin. Approximately 75% of extraocular occurrences involve the head and neck region, Controversy exists regarding the ideal management of these tumors. The mainstay of treatment heretofore involved wide local excision with frozen section monitoring with a possible role for radiation therapy. In this paper, we report our experience with extraocular sebaceous carcinoma treated with Mohs surgery to demonstrate its role in the management of this aggressive tumor. Methods: Between 1991 and 2001, 3 patients were treated in the Henry Ford Health System for extraocular head and neck sebaceous gland carcinoma with Mohs surgery alone. Results: The ages of the patients were 47, 71, and 79. All were evaluated by means of frozen hematoxylin and eosinstained histologic sections obtained by using standard Mohs fresh tissue technique. The mean follow-up period was 19 months (range, 1-42 months). Two patients remained diseasefree (14-42 months). The third patient had a lesion inside the nasal vestibule. Mohs surgery was attempted, but due to the difficult location of the lesion, negative margins could not be obtained. That patient went to the operating room for wide local excision with frozen-section margins. Conclusion: Mohs surgery is an effective treatment for sebaceous carcinoma of the head and neck when the primary lesion is in an accessible area of the skin. For lesions with difficult access, wide local excision with frozen-section margins is recommended. P085

Auditory Processing in Patients with Temporal Epilepsy Juliana Meneguello MSc; Fernando Danelon Leonhardt MD (presenter); Liliane D Pereira PhD Santo Andre Brazil; Sao Paulo Brazil," Cotia Brazil

Objectives: Temporal epilepsy, one of the most common presentations of this pathology, causes excessive electrical discharges in the regio n of the final station of the auditory pathway. The anatomical and functional integrity of the auditory pathway structures is essential 'for the correct processing of auditory stimuli. The aim of this research was to characterize auditory processing in patients with temporal epilepsy regarding the auditory mechanisms of discrimination from sequential sounds and tone patterns, discrimination of the sound source direction, and selective attention to verbal and nonverbal sounds. Methods: Of 35 individuals, recruited from the Epilepsy Ambulatory of Neurology Discipline from "Universidade Federal de Silo Paulo/Hospital S~o Paulo," 13 attended the assessment. Among these, 8 with temporal epilepsy were assessed, after excluding those with nonconfirmed diagnosis or with the focus of discharges not limited to this lobe. The evaluation was realized with the following special auditory

tests: Sound Localization Test, Duration Pattern Test, Digits Dichotic Test, and Non-Verbal Dichotic Test. Their performances were compared to the performances of individuals without neurological diseases. Results: Similar performances were observed between patients with temporal epilepsy and the control group regarding the auditory mechanism of discrimination of the sound source direction. When the auditory mechanism of discrimination from sequential sounds and tone patterns and selective attention to verbal and nonverbal sounds were compared, the patients with temporal epilepsy presented worse results. Conclusion: The results of this study allow us to conclude that patients with temporal epilepsy submitted to the central processing assessment present a worse response to the test when compared with normal individuals in a similar age group. P086

Octreotide in the Detection of Recurrent Paragangliomas Andres Bustillo MD (presenter); Fred F Telischi MD; Thomas J Balkany MD Coral Gables FL; Miami FL; Miami FL

Objectives: To evaluate the role of octreotide scintigraphy in detection of recurrent paragangliomas. Methods: A case repott based on the follow-up of a 35year-old WF who had previously undergone surgical resection of a left-sided glomus jugulare at our institution Results." Three years out from surgery on routine followup, the patient complained of mild otalgia and tinnitus. Physical examination at that time revealed a 4-ram area of friable tissue in the floor of the EAC, just lateral to the annulus. A follow-up audiogram at this time showed symmetric hearing, which was within normal limits. MRI and CT done at that time failed to detect recurrence, even when compared to previous postoperative scans. An octreotide scan also done at that time was positive for increased uptake, suggesting the possible recurrence of the glomus jugulare. Several days later, the patient was taken to the operating room, where under monitored anesthesia a biopsy was taken from a small left EAC lesion. Pathology confirmed the recurrence of the glomus jugulare. Conclusion: Conventional follow-up of surgically and radiotherapy-treated paragangliomas is usually carried out with physical examinations and either MRI and or CT scans. Up to now, octreotide has been reserved for primary diagnosis, for which it is a reliable imaging modality. However, the postsurgical and postradiation changes seen on conventional imaging make the diagnosis of small recurrent lesions difficult. The octreotide study was able to detect the small recurrence because it binds directly to receptors on the tumor and it is not affected by postsurgical or postradiotherapy changes. The intrinsic resolution of most commercially available

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gamma cameras is about 1 cm, making it quite sensitive and able to detect small tumors. Although this patient did not have metachronous lesions, octreotide scintigraphy can also aid in the detection of such lesions. P087

Prediction of Postoperative Voice in Vocal Polyp Patients Meo-Jin Baek MD (presenter); Bu-hyun Hwang MD; Jae-Wook Eom MD; Eui-Kyung Bang; Soo-Geun Wang MD PhD

Pusan South Korea; Pusan South Korea; Pusan South Korea; Pusan-gu Pusan South Korea; Pusan South Korea

Objectives: Though patients who have undergone surgery due to pathologic voice with benign laryngeal diseases are concerned about postoperative voice quality, there was no way to propose postoperative voice objectively. For this reason, the authors attempted to synthesize predictive postoperative voice based on preoperative voice. Methods: The authors evaluated 47 patients who experienced laryngeal microsurgery due to pathologic voice with benign laryngeal diseases. The voice was analyzed by Computerized Speech Lab 4300B. Linear Prediction and Pitch Synchronous Overlap and Add methods were used to synthesize the predictive voice, and we also made the programs using these methods. For assessment of synthetic voice, we compared the sound wave and spectrographic patterns between preoperative and synthetic voice. And we also did the acoustic evaluation to determine the similarity between the real postoperative voice and the synthetic voice. The degree of similarity was composed of 5 scales such as different, slight different, similar, almost same, and same. Results: Synthetic voice showed improvement of noise component in the high-frequency range that was seen in preoperative voice on spectrographic analysis. In a perceptual test, the degree of similarity in both the postoperative voice and the synthetic voice was similar and almost the same in 75% of test voices. Conclusion: The synthesized voice from this program was not completely identical to the real postoperative voice but most of the tested synthetic voices were satisfactory in perceptual tests. So we conclude that this study is a meaningful trial that showed the possibility of synthesis of a postoperative voice by using the preoperative voice. P088

Sinonasal Undifferentiated Experience

Carcinoma:

An Asian

Andrew Heng-Chian Loy MBBS FRCS (presenter); Kent Mancer MD; Christopher Goh MD

Singapore Singapore; Singapore Singapore; Singapore Singapore

Objectives: Sinonasal undifferentiated carcinoma (SNUC) is a rare and highly aggressive neoplasm. Previous reports

have demonstrated generally poor outcomes despite combination therapy. We describe our experience in Singapore of 6 patients with SNUC. Methods: A retrospective review of patients who had histologically proven SNUC between 1996 and 2001 was performed. All patients had Epstein-Barr virus (EBV) serology testing done at the time of diagnosis. Results: 6 patients were identified. There were 4 males and 2 females, and their ages ranged from 13 to 73 years (mean, 47.3 years). The most common presenting symptoms were nasal obstruction and epistaxis. All patients had advanced disease at the time of presentation. While all had nasal and ethmoidal complex involvement, 4 also had sphenoidal sinus involvement, 2 had extension to the orbit, and 3, to the cranial cavity (2 cavernous sinus and 1 cribriform plate). EBV serology was negative in 4, but 2 patients had strongly positive antibody titers. These 2 patients did not have significantly more extensive disease at presentation, nor did they have poorer outcomes. All patients except one (who refused chemotherapy) received combination radiotherapy and chemotherapy, and 2 patients had craniofacial resections. 2 have died of disease with a survival of 19 and 47 months, 2 are alive with disease 3 and 10 months after completion of therapy, and 2 are alive without evidence of disease. Conclusion: In a population at high risk for nasopharyngeal undifferentiated carcinoma, SNUC remains a rare entity, which is best treated with multimodality combination therapy. The role of EBV remains unclear in the development of this tumor. P089

Bone Conduction Implant (BCI): A Feasibility Study for an Implanted BCI Mans Eeg-Olofsson MD (presenter); Stefan Stenfelt PhD; Gosta Granstrom MD DDS PhD; Bo Hakansson PhD; Anders R M Tjellstrom MD PhD

Gothenburg Sweden; Gothenburg Sweden; Gothenburg Sweden; Gothenburg Sweden; Gotheborg Sweden

Objectives: Two factors are of major importance for an implanted BCI: (1) Will a transducer placed closer to the otic capsule improve sound transmission and quality? (2) What are the anatomical/surgical possibilities to get a titanium implant integrated close to the cochlea? Methods: Measuring devices were placed on the eminentia arcuata in an intact dry skull via the foramen magnum. Test signals via vibrators were introduced at different distances from the cochlea. In human cadaver heads, implants were screwed in place. A test vibrator was tried for size and shape. Results: When a stimulus was introduced directly on the otic capsule, the gain was 10 to 15 dB as compared to a stimulus on a conventional titanium implant in the mastoid cortex. The space available in the mastoid bowl was limited, and the present transducer had to be adjusted to fit in.

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Conclusion: A transducer placed close to the cochlea will increase the gain with 10 to 15 dB, and by adjusting the shape and size, it is possible to have the device inside the mastoid bowl. The basic prerequisites for an implanted BCI are there. P090

Smoking Cessation Practice Guillermo Til-Perez MD; Carlos Magri-Ruiz (presenter); Gabriel Jaume-Bauza MD; Manuel D Tomas-Barberan MD; Pedro Sarria Echegaray MD; Sebastian Mas-Merchant Palma de Maflerc Spain; Palma deMaflorca Spain; Islas Baleares Spain; Palma de Mallorc Spain; Baleares Spain; Palma deMallorca Spain

Objectives: Tobacco is the leading cause of death in the Western world, followed by AIDS and traffic accidents. In addition to causing lung and heart disease, tobacco directly involves the ENT area. We want to define the functioning of a smoking cessation unit. Methods: The smoking population in our working area (700,000 people) represents approximately 35 % of the overall population. As of January 2000, our ENT department has had a smoking cessation unit open to the whole population. Four hundred twenty five patients have been treated during this period. Available therapies are pharmacological (bupropion or nicotine replacement), psychological, or a combination of both. All patients are followed up for at least 1 year. Results: In this study we analyzed the results achieved during our first year of work and the rate of smoking abstinence, both momentary and long term. Results vary with each treatment used. Our cessation rate ranges from 22% to 38%. Conclusion: The fight against tobacco should include all physicians, meaning that the ENT specialist should be directly involved. Smoking cessation units represent a further working field that our specialty should be able to encompass and support. P091

Risk Factor for Obstructive Sleep Apnea: NARES Gerd Rasp MD (presenter); Rose Fintelmann; Matthias Kramer; Richard de la Chaux; Peter Ostertag MD Muenchen Germany; Muenchen Germany; Muenchen Germany; Munchen Germany; Muenchen Germany

Objectives: Nonallergic rhinitis with eosinophilia syndrome (NARES) is a frequently overlooked disease and constitutes a chronic eosinophilic nasal inflammation resulting in nasal obstruction. Obstructive sleep apnea syndrome (OSAS) constitutes a potentially life-threatening disease caused by the collapse of the upper airway (eg, due to nasal congestion). Our objective was to evaluate whether NARES constitutes a risk factor for OSAS. Methods: 44 patients presenting symptoms of sleep apnea were examined for nasal diseases. NARES (n = 10) was diagnosed by patient's history, negative in vivo (prick, intranasal

provocation) and in vitro allergy tests (SX1 screening test-similar to Phadiatop [Pharmacia Cap-FEIA, Freiburg, Germany]), and elevated local eosinophilic cationic protein. 34 patients without chronic nasal diseases (such as allergic rhinitis, chronic nasal or paranasal sinus infection, nasal polyposis, etc) served as controls. All patients underwent polysomnography. Results: Patients suffering from NARES (mean age, 57 years; 9 male: 1 female; mean body weight index, 29.6 kg/m2) revealed more pathologic sleeping parameters: mean apnea index (AI) = 26.2/h, hypopnea index (HI) = 18. l/h, respiratory disturbance index (RDI, apnea/hypopnea index) = 44.3/h, and minimal 02 saturation during sleep = 77.0% compared to controls (mean age, 60 years; 31 male:3 female; mean body weight index, 28.5 kg/m2): AI --- 15.6/h, HI = 8.9/h (P < 0.01), RDI = 24.5/h (P < 0.05), and minimal 02 saturation = 84.5% (P < 0.01)i Conclusion: Patients suffering from a chronic eosinophilic but nonallergic nasal inflammation, NARES, showed significantly impaired sleeping parameters. Our data point to NARES as one relevant risk factor for OSAS. P092

Hemangioma of the Middle Ear and External Auditory Canal Manoj T Abraham MD (presenter); Darius Kohan MD; Elena Opher MD; Mark J Levenson MD New York NY; New York NY; New York NY; New York NY

Objectives: Capillary and cavernous hemangiomas of the middle ear and external auditory canal are rare lesions, which are often difficult to differentiate from other pathologic vascular entities. We review our experience with middle ear and external auditory canal hemangiomas, in the context of a comprehensive literature review, to determine distinguishing clinical, radiological, and pathologic features. Pathology specimens were evaluated and compared to glomus tumors in order to elucidate the difficulty in obtaining hemostasis with the argon laser with these hemangiomas. Methods: Retrospective chart review of a series of 3 cases. Pathologic analysis with microscopic measurement of fixed, hematoxylin and eosin-stained surgical specimens. MEDLINE review of all relevant English literature. Results: Including our series, there are 22 cases of middle ear and external auditory canal hemangiomas reported in the literature. No age or sex predilection was evident. The most common presenting clinical symptom was progressive conductive hearing loss. Surgical extirpation with tympanoplasty was the treatment of choice and was highly effective with only two documented cases of recurrence. Microscopic evaluation of selected pathology specimens revealed a statistically significant difference in the vascular lumen diameter of capillary and cavernous hemangioma when compared to glomus tumors.

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Conclusion: Middle ear and external auditory c a n a l hemangiomas are rare vascular lesions, which are amenable to surgical cure. The surgeon must be aware that it is difficult to obtain hemostasis with the argon laser in these cases, most likely due to the large vascular lumen and minimal fibrous stroma found in these lesions. P093

Endoscopic Mucoceles

Approach

for Frontoethmoidal

Sinus

Rodrigo P Santos MD (presenter); Luiz Henrique F Barbosa MD; Marco Aurelio B G Belfort MD; Fernando Danelon Leonhardt MD; Ricardo G Ferri MD; Luis C Gregorio MD Sao Paulo Brazil," Sao Paulo Brazil," Sao Paulo Brazil," Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo-SP Brazil

Objectives: The mucocele is an expansive benign tumor due to the filling of a closed cavity with mucus. Frequently involving the frontoethmoidal sinus, it is a rare otolaryngological condition. The etiology is divided into inflammatory and obstructive causes. The aim of this study was to evaluate the endoscopic endonasal surgical approach for frontoethmoidal sinus mucoceles. Methods: ThiIteen patients were followed during the period from January 2000 to April 2001, regarding the clinical findings, evolution, and surgical results. Results: All patients presented proptosis as the major symptom. Seven patients had the inflammatory form, and two, the obstructive form. Two patients presented ophthalmological complications and underwent orbital decompression associated with the endoscopic endonasal technique. There were no recurrences in our study. Conclusion: The endoscopic endonasal approach for frontoethmoidal sinus mucoceles is an effective treatment for the disease, avoiding the complications of the early techniques. P094

Successful Late Treatment of Arytenoid Dislocation Robert C Wang MD (presenter); Philip T Ho MD Las Vegas NV; Nellis AFB NV

Objectives: Arytenoid dislocation is an uncommon problem usually occurring following intubation injury. Early intervention with reduction is generally advocated, although observation, speech therapy, and botulinum toxin injection have also been reported as treatments. A case is presented of arytenoid dislocation with severe hoarseness treated successfully 16 days after injury. Methods: Following a 6-hour facial cosmetic surgery under general anesthesia with endotracheal tube intubation, a 69-year-old woman experienced severe hoarseness without aspiration. After no improvement 16 days later, examination revealed an immobile, widely abducted right vocal cord. Intraoperative closed reduction was performed by microdirect laryngoscopy under general anesthesia.

Results: After 1 week, mild hoarseness remained with the right vocal cord medialized but with minimal motion. Two weeks postoperatively, full abduction and adduction of the right vocal cord was observed with return to a normal voice within 4 weeks after reduction. Fiberoptic exam photos will be shown. Conclusion: Successful reduction of a posterolaterally dislocated arytenoid cartilage after 16 days can be achieved with return of normal vocal cord motion and voice. After endotracheal intubation, persistent hoarseness may indicate arytenoid dislocation. Intact innervation may be confirmed by laryngeal EMG. Late diagnosis does not obviate a successful restoration of function by closed reduction. P095

Facial Paralysis and Occult Tumor Involvement of the Temporal Bone Fazil Necdet Ardic MD (presenter); Fred F Telischi MD; Eloy Villasuso III MD Izmir Turkey; Miami FL; Miami FL

Objectives." The otolaryngologist is frequently confronted with a patient with progressive facial paralysis. In some patients, radiologic workup may be negative and the patient may not present with other signs and symptoms. A history of malignancy should lead to a search for possible tumor involvement of the facial nerve. We present a case series of patients presenting with progressive facial nerve paralysis in whom exploration led to the finding of malignant involvement of the facial nerye. Methods: A case series and review of the pertinent literature. Results: We present 3 patients with history of malignancy of the parotid gland, skin, and the external auditory canal for which they had been previously treated. These patients had no other signs or symptoms, and imaging was equivocal. Exploration led to discovery of malignancy in the middle ear or mastoid causing the facial paralysis. Conclusion: A recommendation is made to explore the intratemporal course of the facial nerve, middle ear, and mastoid regions in patients who present with progressive facial nerve paralysis and normal imaging. This is especially important in patients with a history of head and neck neoplasm. P096

Strovideolaryngoscopy Rioja Spain

in the Teaching Staff of La

C Aranzazu Perez Fernandez MD (presenter); Julian Preciado MD, Jose Luis Lacosta MD PhD Logrono Spain; Logrono Spain; Logrono Spain

Objectives: Videostroboscopy is one of the most practical techniques for clinical examination of the larynx. It is a technique that provides useful information concerning the nature of vibration and immediate image of the presence or absence of pathology. We wanted to study the teachers' vocal folds.

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Methods: The subjects utilized in this research were 344 teachers of the Rioja region, divided in two groups (172 normal and 172 pathologic). In the stroboscopic analysis we have studied the configuration of glottic closure, the condition of the vocal fold edge, the amplitude of the vocal fold movement, the mucosal wave, and phase closure; andwe have classified the teachers as normal and pathologic. Results: We found the following vocal pathologies: 83 nodules of vocal folds, 29 cases of chronic laryngitis, 18 cases of hyperfunctional dysphonia, 11 vocal fold polyps, 10 cases of vocal fatigue, 7 cases of hypertrophy of the false fold, 4 submucosal suffusions, 4 cases of hypofunctional dysphonia, 3 cysts of vocal folds, and 1 sulcus vocalis. Conclusion: Videostroboscopic analysis is a procedure that allows an excellent evaluation of the vocal folds and of the vibratory margin of the vocal cord. This procedure is useful to diagnosis minimal vocal disorders, which could go unnoticed with routine endoscopy. P097

Mandibular Fracture Patterns Robert E King MD (presenter); Guy J Petruzzelli MD PhD Oak Park IL' Maywood IL

Objectives: Mandible fractures are among the most common injuries seen in trauma center settings. Recent shifts in mechanism of injury and age of patients sustaining these fractures are documented. This study attempts to define current, predictable patterns of fracture, based upon patient and injury mechanism profiles. Methods: Data collected on 133 patients with 229 mandible fractures treated by the Otolaryngology--Head and Neck Surgery and Oral Maxillofacial Surgery services were retrospectively analyzed. Patients were categorized based on age, mechanism of fracture, and anatomic location of fracture(s). Multivariate analysis of data was performed to determine significant relationships among groups. Results: Violent crimes accounted for the majority of fractures (52%) in this study, and parasymphyseal fracture represented the most common site (35%). There existed a statistically significant (P < 0.001) correlation between patient age and mechanism of injury, as well as injury mechanism and site of fracture. Correlation between patient age and fracture site did not achieve statistical significance. There existed greater than expected associations of gunshot wounds and motor vehicle accidents with parasymphyseal fractures, persons struck by automobiles and falls with condylar fractures, and assault with angle and body fractures. Children (age <16) demonstrated no dominant mechanism of injury, while young and middle-aged adults (age 17-50) were likely to be victims of assault or MVC. Older adults (>50) tended to be injured as a result of a fall or MVC. Conclusion: Updated data on associations of specific patie:!t and injury characteristics with mandibular fracture

patterns can guide physicians in the diagnostic workup of these patients. P098

Transphenoidal Approach to Petrous Apex Lesions Julie Thorp Kerr MD (presenter); James V Crawford MD Tacoma WA; Tacoma WA

Objectives: To date, there have been 3 reports of a transphenoidal approach to excise and drain petrous apex cholesterol granulomas. We will describe our experience with a transphenoidal approach for management of this lesion. Through a comprehensive review of the literature, we will address the clinical and diagnostic features and the therapeutic options for the petrous apex granuloma. Methods: A 35-year-old male with a history of headaches presented to the emergency department with sudden onset of right face and arm parasthesias. The patient also had a dull frontal headache. His head and neck and neurologic exam were significant for decreased sensation in his right arm and right V1, V2, V3 distribution. CT scan, MRI, and MRA demonstrated a left intraclival soft tissue lesion protruding beyond the posterior sphenoidal wall. The lesion's features were most suggestive of a cholesterol granuloma. The patient was taken to the operating room where the tumor was approached via a left sphenoidotomy. Results: The tumor was identified and fenestrated. Operative findings were consistent with a cholesterol granuloma. Postoperative MRI demonstrated no evidence of recurrent disease. The patient remains asymptomatic. Conclusion: Management of cholesterol granulomas of the petrous apex is complex. Treatment of this cyst requires creation of a cyst cavity and a drainage tract to prevent reaccumulation. Adequate treatment of this lesion has been met by a variety of surgical approaches, each with their own advantages and disadvantages. The approach depends on lesion location, audiologic function on the affected side, and position of prominent vascular structures. P099

Otolaryngology and the American Presidency Michael Patrick McDowell MD (presenter); George Murrell MD Portsmouth VA; Virginia Beach VA

Objectives: To present in an entertaining fashion the otolaryngologic maladies from which American presidents have suffered. An emphasis will be placed on the historical aspect of each disease state including the evolution of treatment regimens and expected outcomes. In addition, perspective will be given to how each disease affected each president's life, legacy, and political era. Methods: A review of medical and lay literature concerning the American presidents yields several examples for presentation. Results: Three examples will be presented: George

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Washington (fatal upper airway infection), Ulysses Grant (fatal tongue carcinoma), Grover Cleveland (successful surgery of palate malignancy). Conclusion: Among the 43 presidents of the United States, 3 have had significant otolaryngologic pathology. George Washington's upper airway infection, Ulysses S. Grant's squamous cell carcinoma, and Grover Cleveland's verrucous carcinoma present the opportunity to examine each president's political legacy, unfortunate pathology, and influence on the history of otolaryngology. P100 MRI Evaluation of Medical Treatment for Adenoid Hypertrophy and Sinusitis Christos Georgalas MD (presenter); Karen Thomas FRCR; Catherine Owens MD; Solomon Abramovich FRCS; Gideon Lack

London United Kingdom; London United Kingdom; London United Kingdom; London United Kingdom; London United Kingdom

Objectives: To assess the efficacy of a combined antimicrobial and antiinflammatory regimen for adenoid hypertrophy (AH) and/or sinusitis, by using clinical symptom scores and MRI changes. Methods: Thirteen children referred to a tertiary allergy clinic with symptoms of AH had their nasopharynx and sinuses evaluated by MRI scanning. All children were treated with a 6-week course of co-amoxiclav, 5 days of oral prednisolone (2 mg/kg) and 3 months of intranasal mometasone and oral loratadine. All MRI measurements were repeated after medical treatment. The main clinical symptoms were graded before and after treatment, by using a scale from 0 to 5 (maximum overall clinical score, 20). The size of adenoids, airway, and nasopharynx were measured from Tl-weighted midsagittal and axial images. A 0 to 3 grading scale was used for sinusitis signs and turbinate mucosal thickening. Results: Treatment resulted in a greater than 60% improvement in overall clinical symptom score and marked improvement in assessment on MRI findings. Pretreatment, MRI demonstrated enlarged adenoids in 10 out of 13 children and sinusitis in 12 out of 13 children (5 had severe sinusitis: score 2-3). Following treatment, there was a significant reduction in adenoidal size and sinus involvementassociated with a greater than 50% increase in airway diameter. Conclusion: (1) Children with AH have evidence of upper airway inflammation, sinusitis, and nasal mucosal thickening. (2) Prolonged treatment with antiinflammatory and antimicrobial medication results in marked clinical improvement. (3) Clinical response to treatment is accompanied by improvement in MRI findings: decrease in sinus involvement, reduction in adenoid size, and increase in airway diameter.

P101

Gender-Related Proportionality of the Larynx: What Are the Changes? Luis U Sennes MD PhD (presenter); Mr Felipe Fortes; Saramira Cardoso Bohadana MD; Domingos H Tsuji MD PhD

Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil

Objectives: The objective of this study is to evaluate absolute and relative dimensions of several laryngeal structures to identify those changes that occur during pubertal development that may determine gender variability, and consequently, different voice quality and incidence of functional diseases. Methods: Twenty-seven fresh adult human cadaver larynges were examined (12 females, 15 males). Many measures correlating thyroid and crycoid cartilage and vocal folds were taken and statistically analyzed for gender-related differences. Results: The gender variability was pronounced in thyroid angles and absolute sagittal dimensions, but it was not significant in the absolute transverse measures. The relative proportions of the structures in a same larynx were more constant and less related to gender. We observed that the vocal fold elongation and its angle reduction in males were not proportional to thyroid laminas enlargement and its angle reduction nor to the increase of crycoid diameters. Conclusion: The gender-related laryngeal variability was a consequence of the pronounced thyroid enlargement in relation to crycoid cartilage, but was also due to changes in the relation between them. P102

Learning Functional Neck Dissection in a Teaching Hospital Jose Maria Verdaguer MD; Carolina CA Alfonso Carrill MD (presenter); Juan Ignacio Jino De Diego MD; Maria PI Prim Espada MD PhD; Ricardo Millan Bernaldez MD

Madrid Spain; Madrid Spain; Madrid Spain; Madrid Spain; Madrid Spain

Objectives: To determine if the learning of functional neck dissection (FND) is safe at a tertiary academic referral center under adequate supervision. Methods: We have made a retrospective study comparing FND performed by staff surgeons and residents in laryngeal and hypopharyngeal cancer patients. With this purpose, we have selected 186 bilateral FND operated between 1988 and 1998 in clinically NO or N1 necks. The results were evaluated according to 4 major standpoints: length of the procedure, immediate complications (serohematoma, wound dehiscence, hemorrhage, and lymphorrhagia), long-term spinal impairment, and oncologic status of the neck (2 years after the operation). Results: One hundred forty seven cases (79.03%) were operated by two staff surgeons, and 39 (20.97%), by one res-

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ident under direct supervision of a staff member. No significant differences were found between staff and resident procedures with respect to serohematoma (5.3% vs 6.5%), wound dehiscence (3.2% vs 5.3%), hemorrhage (4.8% vs 4.3%), and lymphorrhagia (1.6% vs 2.2%); and there was no evidence of regional disease (88.5% vs 89.2%). However, differences exist in the length of the procedure (172.3 minutes vs 215.1 minutes) and long-term spinal impairment (1.1% vs 2.2%). Conclusion: On the basis of our experience, FND can be taught to residents, in a controlled environment, with an acceptable rate of complications and comparable oncological results. The time required for the training makes it necessary to select the most adequate cases to teach this technique P103

Anatomical Relation of the Hipoglossal Nerve Mr Felipe Fortes; Luis U Sennes MD PhD (presenter.]; Erasmo S Silva MD Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil

Objectives: Cranial nerve dysfunction is the most frequent complication following carotid artery surgery, and the hipoglossal is the most injured nerve. The aim of this study is to establish the anatomical relation between the carotid artery bifurcation and hypoglossal nerve. Methods: Carotid artery and hypoglossal nerve dissections were carried out in 38 fresh corpses. All the individuals were placed in standard position, and the dissections were performed with surgical technique. The relation between the hipoglossal nerve and the carotid bifurcation was studied, and measurements were made from the dissected carotid bifurcation to the XII nerve. Results: Twenty-six individuals were male, and 12, female. The majority were white (n = 30), and 8 were nonwhite. The distance between the hypoglossal nerve and the carotid artery bifurcation ranged from 0.5 cm to 4.3 cm, with a mean of 2.1 cm, median of 2.0 cm, and standard deviation of 0.63 cm. Neck length, age, gender, and race were related with the measurements and failed to show significant statistical correlation ((z > 0.05).

Conclusion: In this sample there was a great anatomic variation of the distance between the hypoglossal nerve and the carotid artery bifurcation, and there was no statistical difference concerning age, gender, race, and neck length. A better understanding of the anatomic course of this nerve and its variation in relation to carotid artery bifurcation is relevant to prevent hypoglossal nerve lesions in carotid artery surgery. P104

Sympathetic Chain Paraganglioma Mimicking Carotid Body Tumor Renald M Smith Jr MD (presenter); Phillip K Pellitteri DO Danville PA; Danville PA

Objectives: The cervical sympathetic chain (CSC) is an

unusual location for extraadrenal paragangliomas. This entity may be mistaken preoperatively for the more common carotid body tumor' or intravagal paraganglioma. Computed tomographic and angiographic findings may raise suspicion for CSC involvement rather than the more common locations in the head and neck. Methods: We present a patient initially suspected to have a carotid body tumor on the basis of clinical and radiographic findings, who was found at surgery to have a paraganglioma of the CSC. A literature review of CSC paragangliomas is also performed. Results: A patient presenting with an asymptomatic pulsatile neck mass on routine physical examination was given a preliminary diagnosis of carotid body tumor on the basis of characteristic computed tomographic findings and angiography Preoperative preparations were made, including urinary and serum catecholamine screening, vascular surgery consultation for possible carotid bypass, and planning for intraoperative EEG. Surgical findings demonstrated a tumor of the CSC, which was found to be consistent with paraganglioma on pathological examination. Following resection, the patient has done well despite the presence of the expected Homer's syndrome. An extensive literature review discloses relatively few cases of CSC paragangliomas. Conclusion: The CSC should be considered as a potential location in the differential diagnosis of suspected paragangliomas of the head and neck. Diagnostic imaging should be carefully evaluated for atypical findings that may raise suspicion for this entity. This will assist in directing preoperative preparation, patient counseling, and surgical planning. P105

Nonketotic Hyperglycinemia Unusual Cause of Aphonia

of the Neonate:

An

G P Hetter MD (presenter); Walter M Belenky MD Las Vegas NV; Detroit MI

Objectives: An infant's cry is the first clue to the wellbeing of the child. Its importance is so great that it is even incorporated into the first diagnostic evaluation of the newborn, the Apgar score. When the newborn has a noted voice change, it can be a signal to the clinician of a pathologic process. We will present an unusual cause of aphonia in the infant and also review the literature. Methods: This is a case report of a 6-day-old male who presented to our children's hospital otolaryngology service with complaints of a weak, almost silent cry. The patient was born to a 31-year-old gravida 2, para 1 woman. At 39 weeks' gestation, the baby was delivered by emergent cesarian section secondary to poor fetal heart tones, a nuchal cord, and possible macrosomia. The prenatal care was complicated by gestational diabetes mellitus. Birth weight was 3289 g, and Apgar scores were 8 at 1 minute and 9 at 5 minutes. On day 1 of life, the patient was noted to have a very weak to silent cry

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with normal muscle tone, oral intake, and physical examination. The patient was discharged home on hospital day 3 and referred to the children's otolaryngology service for evaluation of the voice change. Upon evaluation by the otolaryngology service, the patient was noted to have no cry, no stridor, no wheeze, a generalized hypotonia and weakness, and lethargy with poor respiratory effort. The patient was immediately intubated and transferred to the neonatal intensive care unit. Results: Further physical examination of the patient revealed a hypotonic child with brisk reflexes, myoclonic jerks, and frequent hiccups. Chest x-ray, cranial ultrasound, echocardiogram, direct laryngoscopy, and bronchoscopy were all normal. Sepsis workup and genetic workup were negative. Finally, a metabolic workup revealed a slightly elevated serum glycine level and a markedly elevated cerebral spinal fluid glycine level. The CSF/serum glycine ratio was noted to be 0.31 (normal, 0.08). The diagnosis was nonketotic hyperglycinemia. Nonketotic hyperglycinemia is a defect in glycine metabolism, which results in both an elevation in serum and cerebrospinal fluid levels of glycine. Inhibitory glycine receptors are found in the spinal cord and brain stem. Also, there are excitatory N-methyl-D-aspartate receptors located throughout the brain, which are allosterically activated by glycine. Conclusion: Aphonia and dysphonia of the newborn have been previously categorized into various causes: (1) neurologic, (2) congenital and genetic anomalies, (3) tumors, (4) infection and granulomatous disease, (5) trauma, (6) endocrine and metabolic, (7) physiologic, (8) psychogenic, and (9) iatrogenic. It is therefore important to evaluate these patients thoroughly to find a diagnosis and to expedite an effective treatment. This case is presented to emphasize an unusual but devastating cause of aphonia and to review the literature. P106

End-Stage TMJ Fixation Reconstructed Using Fascial Free Tissue Transfer Samuel Gubbels MD (presenter); Thomas W Albert MD DMD; James I Cohen MD PhD; Daphne A Bascom MD; Mark K Wax MD Portland OR; Portland OR,"Portland OR; Pittsburgh PA; Portland OR

Objectives: Two decades ago, Teflon prosthetic reconstruction of temporomandibular joints for dysfunction was popular. As time has gone on, these implants have proven to be fraught with complications. Many patients who had this form of reconstruction ultimately required the implant to be removed. Many ancillary procedures were subsequently required in an attempt to improve their TMJ function. Methods: We present a case of a young woman who, following Teflon reconstruction of her temporomandibular joints, developed significant bilateral osseous fixation of the joint t° the skull base and ramus of the mandible. Seventeen corrective procedures were performed over a 20-year period.

The patient presented with massive bony overgrowth and fixation with an interincisal opening of only 3 ram. Results: An excision was done of the descending ramus of the mandible with drill-out of the fixating bone to the skull base. A radial forearm fascial free flap was placed between the skull base and the remaining mandibular ramus. The interincisal opening was increased to 3 cm. Placement of this free vascularized tissue flap was performed to prevent reformation of the bony overgrowth. Conclusion: Functionalrehabilitation was greatly improved. The technique with short- and long-term results will be presented. P107

Treatment of Laryngeal Sarcoidosis with CO 2 Laser and Mitomycin.C C Blake Simpson MD; Joshua C James (presenter) San Antonio TX; San Antonio TX

Objectives: We present a case of laryngeal sarcoidosis with obstructive supraglottic stenosis that was successfully treated with CO 2 laser excision and topical mitomycin-C application. A discussion of the laryngeal manifestations of sarcoidosis, medical and surgical treatment options, and the potential role of mitomycin-C in granulomatous disease is covered. Methods: A 60-year-old female with a long-standing history of laryngeal sarcoidosis was referred to our clinic because of a history of progressive shortness of breath and stridor with exertion after treatment with intralesional corticosteroid injections and laryngeal dilation had failed at an outside facility. Fiberoptic laryngoscopy showed extensive scar and granuloma formation between the laryngeal surface of the epiglottis and the right arytenoid, with limited abduction of the right vocal fold, and airway narrowing due to scar contracture. The patient underwent microlaryngoscopy with CO 2 laser division of the stenotic region, followed by topical application of mitomycin-C (0.4 mg/1 cc saline) to the surgical bed for 3 minutes. Results: The patient's shortness of breath resolved following surgery, and fiberoptic laryngoscopy after the procedure showed complete resolution of the stenosis. The patient has not had any recurrence of her stenosis and remains symptomfree at 2 years postoperatively. Conclusion: Laryngeal sarcoidosis continues to be a challenging condition, particularly when it manifests as supraglottic stenosis. Topical mitomycin-C, in conjunction with laser division of the stenosis, appears to be a useful adjunct in the treatment of this condition. Mitomycin-C appears to work by inhibiting fibroblast proliferation and ultimately reducing collagen deposition and scar formation. Because fibroblasts play a key role in granuloma formation and stability, topical mitomycin-C may hold promise in the treatment of granulomatous diseases of the aerodigestive tract.

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Diagnostic Dilemmas of Metastatic Lesions to the Petrous Apex Sam Kim MD (presenter); Michelle Pontius MD; Douglas D Backous MD Dupont WA; Seattle WA; Seattle WA

Objectives: A case of poorly differentiated, metastatic neuroendocrine carcinoma of the temporal bone in a 70-year-old male with a previously irradiated prostate carcinoma is presented. The pitfalls and management challenges are discussed in order to arrive at a logical approach for diagnosing and appropriately treating patients with these uncommon neoplasms. Methods: Review of the preoperative studies, intraoperative findings, and surgical pathology results from this case are combined with an extensive literature review to elucidate clinical, radiographic, and treatment challenges in this cohort of patients. Results: Metastatic lesions involving the petrous bone are seen in up to 22% of patients with primary tumors from sites including the breast (21.3%), lung (12.8%), and prostate (10.6%). Symptoms include hearing loss (40.4%), vertigo (14.9%), facial paresis (14.9%), tinnitus (12.8%), and otalgia (8.5%). Up to 36.2% of patients remain asymptomatic until late in disease progression. Sites on the temporal bone involved by metastatic lesions include the petrous apex (32.6%), internal auditory canal (15.6%), mastoid (8.5%), external auditory canal (7.8%), and middle ear (3.5%). Conclusion: Metastatic lesions to the temporal bone are difficult to diagnose and treat. Initial findings on history, physical examination, and radiographic imaging are typically nonspecific and often mimic benign or infectious etiologies. Early diagnosis is imperative for optimal treatment and can be had with a prudent and judicious workup in patients with clinically suggestive features. P109 Final Part of the Natural History of Head and Neck Cancer Jose C Barauna MD; Marcos B Carvalho; Carlos N Lehn; Abrao Rapoport MD; Sergio A Franzi MD (presenter) Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil

Objectives: Relapse of disease is very common in head and neck cancer patients. This study reports an experience in palliative care of patients with incurable disease. Methods: 112 patients with incurable disease due to recurrence after multimodal therapy or inoperable disease were treated by a multidisciplinary team. The symptoms and survival were analyzed. Results: The main symptom was pain, which was present in 72% of patients, weight loss in 64%, dysphagia in 57%, and bleeding in 15% of patients. The mean weight loss was 1.45

kg/mo (1.0 to 4.0 kg), in spite of adequate food intake. The mean survival after inclusion in the group was 3 months (1 day to 16 months). All patients received morphine for pain control, and constipation was the most frequent side effect. Conclusion: Pain is the main symptom in head and neck cancer patients with incurable disease. The opioids are very effective for pain control. Weight loss remains a great problem in these patients. Pl10

Diagnosis of Vascular Anomalies by Using CT with Contrast and 3-D Reformation Thomas Peyton Nowlin IV MD (presenter); Lennhanh P Tran MD Triplr Army Mdcl HI; Triplr Army Mdcl HI

Objectives: We present our experience in evaluating two pediatric patients suspected to have vascular anomalies, using computed tomography with nonionic contrast and 3-dimension (3-D)reformation. Methods: The first child with U-shaped cleft palate, micrognathia, and glossoptosis presented with frequent emesis, dysphagia, and failure to thrive. Gastroesophageal reflux was suspected on flexible laryngoscopy and confirmed on esophagoduodenoscopy. Barium swallow study showed posterior esophageal compression suggestive of vascular anomaly. Computed tomography (CT) with contrast and 3-D reformation showed multiple vascular anomalies to include retroesophageal right subclavian artery and a common takeoff from the aorta, giving rise to both common carotids. The second child presented with recurrent croupy cough, reactive airway disease, and obstructive adenotonsillar hypertrophy. Anterior tracheal wall compression was observed on diagnostic laryngobronchoscopy. Postoperative CT with contrast and 3-D reformation showed a bovine arch and an innominate artery compressing the anterior tracheal wall. Results: The first patient underwent repair of the aberrant subclavian artery and recovered well without recurrent emesis. The second patient had adenotonsillectomy and did well with medical treatment. Conclusion: CT with contrast and 3-D reformation provided superb resolution to allow accurate diagnosis of vascular abnormalities. The test can be performed in less time and with the patient awake or sedated. Unlike magnetic resonance imaging, CT scanning does not require nonmagnetized ventilation equipment for general anesthesia. Overall, CT with contrast and 3-D reformation may be a better diagnostic modality in the evaluation of vascular abnormalities. P111 Recovery after Subtotal Tonsillectomy with Ionized Field Ablation Kelvin C Lee MD; Rita Rourer BS (presenter); Nadim Bikhazi MD; Joseph M Bernstein MD New York NY; New York NY; Ogden UT; New York NY

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Objectives: Traditional tonsillectomy in children has been well documented in the literature to cause significant pain and changes in diet after surgery. Subtotal tonsillectomy has been described as an alternative procedure with less morbidity for patients with obstructive tonsillar hypertrophy. This study is designed to prospectively assess the postoperative course of children undergoing subtotal supracapsular tonsillectomy with ionized field ablation. Methods: Children with tonsillar hypertrophy undergoing subtotal supracapsular tonsillectomy with ionized field ablation were prospectively studied for the time and ease of operation and their postoperative course. These patients with their parents completed a 14-day diary, which included daily assessments for pain, diet, and activity. Results: Nineteen children were entered in the study and completed the 14-day diary and follow-up visit. Surgery, on average, took less than 20 minutes and had minimal blood loss or no other significant complications. Postoperatively, the average level of pain after surgery peaked at less than 5 on a 10-point scale. By day 5, the average child reported no pain and had resumed a completely normal diet. Conclusion: Subtotal supracapsular tonsillectomy with ionized field ablation has a favorable intraoperative and postoperative course when compared to other studies of traditional subcapsular tonsillectomy. Prospective randomized studies are needed to definitively compare this procedure to more traditional approaches. Pl12

Spontaneous CSF Otorrhea and Encephalocele Marc D Rosenthal MD (presenter); Thomas © Willcox MD

Philadelphia PA Objectives: To review the documented cases of adult-onset spontaneous cerebrospinal fluid (CSF) otorrhea and encephalocele and its diagnosis and treatment and to report 10 new cases of this rare entity. Methods: Retrospective chart review and review of the current literature. Results: Conductive hearing loss, aural fullness, and active otorrhea are common findings at the time of presentation. 10 out of 10 patients were found to have an encephalocele at the time of surgery. Conclusion: To identify patients with spontaneous CSF otorrrhea requires a high index of suspicion. Important clues to diagnosis include profuse, clear otorrhea in patients with tympanic membrane perforation or following myringotomy tube placement and/or episodes of recurrent meningitis. Beta2 transferrin is a reliable means to aid in diagnosis. CT and MRI help localize the defect and identify encephaloceles preoperatively. Successful closure of the defect can be obtained via a transmastoid approach, combined with a middle fossa approach if necessary.

P113

Usher Syndrome: Importance of Otolaryngologic Examination Manuel Pais Clemente MD PhD; Laudelina R Carvalho Pais Clemente MD; Carla Pinto Moura MD; Antonio F Vales MD; Antonio Castanheira MD (presenter); F Domingues MD

Porto Portugal; Porto Portugal; Leca da Palmeira Portugal; Porto Portugal; Porto Portugal; Porto Portugal

Objectives: Usher Syndrome (US) is a congenital autosomal recessive disorder characterized by sensorineural hearing loss associated with a progressive pigmentary retinopathy. It presents clinical and genetic heterogenity. Three clinical subtypes are distinguished by hearing and vestibular different features. Progressive pigmentary retinopathy is present in all patients. Type I of US (US1) associates severe to profound hearing loss with absent vestibular response. US type II (US2) is characterized by moderate to severe hearing loss and normal vestibular function. The rare type III (US3) is considered when there is a later and progressive onset of hearing loss, which is moderate to profound with normal or almost normal vestibular function. Methods: Three cases of US were identified in the Department of Otolaryngology in a retrospective study. The ENT examination and ophthalmological and genetic records were reviewed. Results: There were two cases of US2, one female and one male. They presented a severe and profound sensorineural hearing loss with normal vestibular function. There was one US3 female with a history of severe and progressive hearing loss of late onset. She had discrete vestibular impairment. The 3 patients presented with retinitis pigmentosa and had normal karyotypes. Conclusion: Three types of US are usually recognized and are distinguished by differences in hearing and vestibular function and not by ophthalmological criteria. The role of the otolaryngologist is essential for differential diagnosis, which has a great impact on the follow-up, prognosis, and treatment of hearing impairment when indicated. Pl14

Management of Tracheocutaneous Fistula in the Pediatric Patient: Postoperative X-ray? G P Hetter MD (presenter); Michael S Haupert DO

Las Vegas NV; Clarkston MI

Objectives: The objective of this study is to evaluate the management of tracheocutaneous fistulas in the pediatric patient and to determine the necessity of the postoperative chest x-ray. Methods: A retrospective review was completed of 11 patients who underwent closure of tracheocutaneous fistula at the Children's Hospital of Michigan between 1997 and 2001. All procedures were completed by the pediatric otolaryngology service. All patients had been decannulated for a minimum of

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6 months without resolution of tracheocutaneous fistula. Preoperative first-generation cephalosporin antibiotics were given to every patient. A bronchoscopy to rule out airway obstruction was either done 1 month prior to or at the time of closure of the fistula. The patients' age at tracheostomy, sex, indication for tracheostomy, length of cannulation, period of decannulation, drain usage, chest x-ray usage and findings, and other medical conditions were recorded. Results: The average age at the time of tracheostomy was 48.6 months with a range of 0 months to 236 months. There were 7 males and 4 females. Airway obstruction was the primary indication for tracheostomy in 7 patients. Prolonged intubation secondary to pulmonary disorder was the indication in 3 patients, and emergent aiiway stabilization was the indication in the final patient. The average length of cannulation was 64.3 months with a range of 7 months to 106 months. The average length of time from decannulation to fistula closure was 15.9 months with a range of 9 months to 32 months. Penrose or rubber band drains were used in 7 patients. A chest x-ray was completed postoperatively in 4 patients. One patient was noted to have subcutaneous emphysema postoperatively, while no other complications were noted in the remaining patients. The patient with subcutaneous emphysema had nausea and vomiting and coughing and palpable crepitus immediately postoperatively. The subcutaneous emphysema was confirmed by chest x-ray and resolved spontaneously while being observed overnight. Conclusion: Although this study is limited by its low patient numbers and its retrospective nature, we find that complications of tracheocutaneous fistula closure are rare. The low number of complications in this series could be attributed to meticulous technique in closure of fistulas ending with drain placement. Also, the complications that can be detected by use of a routine chest x-ray--pneumomediastinum,pneumothorax, and subcutaneous emphysema--can be diagnosed by signs and symptoms alone. A chest x-ray could then be completed to confirm the diagnosis. In conclusion, postoperative chest x-rays are not routinely needed unless clinical suspicion of postoperative complications exists. This would avoid the added cost of chest x-rays and radiation exposure to the pediatric patient. P115

A Deceptive Cause of Airway Obstruction in a Child William T Lowrance (presenter); Lucinda A Halstead ME) Charleston SC; Charleston SC Objectives: To report an unusual presentation of airway obstruction secondary to nontuberculous mycobacterial mediastinal lymphadenopathy in a child. Methods: Interventional case report. A 23-month-old child with insulin-dependentdiabetes mellitus and hypothyroidism presented with a 1-week history of cough, fever, stridor, and wheezing. The patient was treated with steroids and [32-ago-

nists for suspected croup. Otolaryngology consultation was obtained when the patient's condition failed to improve. Results: Fiberoptic laryngoscopy showed pus in the subglottis and trachea, consistent with bacterial tracheitis. Despite IV antibiotics, steroids and antireflux medication, the patient's biphasic stridor worsened and symptoms of air trapping appeared, raising the possibility of foreign body aspiration. Chest X-ray showed only a left perihilar infiltrate. Bronchoscopy revealed granulation tissue obstructing both main-stem bronchi and severe external compression of both main-stem bronchi. A CT scan showed a mediastinal mass circumferentially compressing the carina. Endobronchial biopsy was positive for acid-fast bacilli. The patient's condition deteriorated while on antitubercular drugs. Debulking by posterolateral thoracotomy and bronchoscopy relieved the airway compression, and the patient has done well. Conclusion: Mediastinal lynphadenopathy can mimic the common causes of airway obstruction such as croup, bacterial tracheitis, and foreign body aspiration, as evidenced by this child's symptoms. This case illustrates the importance of reevaluating a patient when appropriate treatment measures fail. As her chest x-ray was nonrevealing, bronchoscopy with endobronchial biopsy was key in establishing an accurate diagnosis. Although uncommon, mediastinal lymphadenopathy caused by nontuberculous mycobacterium is an important cause of airway compression and can masquerade as many other diseases. P116

Epidemiology of Otitis Media with Effusion (OME) Among Saudi Children Siraj M Zakzouk MD (presenter) Riyadh Saudi Arabia

Objectives: To study the prevalence of otitis media with effusion (OME) and its effect on hearing impairment in children in Saudi Arabia. Methods: A random selection survey of 9540 Saudi children from the 4 main provinces of Saudi Arabia, covering all socioeconomic and demographic groups of people, was carried out. Screening were performed by otolaryngologist and audiologist using pneumatic otoscope and tympanometry and pure tone audiometry using interacansticand GSI 30. A questionnaire was filled including age, sex, parents' relationship, and family history of deafness. Results: 9540 children were screened, 4189 (44%) boys and 5351 (56%) girls. 2054 children were below the age of 4 years, 3615 were between 4 and 8 years, and 440 were between 8 and 12 years. Consanguinity of parents: 19% were first cousins, 28% were second cousins, and the rest had no family relationship. The overall prevalence of hearing impairment was 13% OME with type B tympanogram in 768 children, 712 (92.7%) of them with hearing impairment. The male children have 9,14% incidence, while female children have

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8%. The highest rate of OME was found in children aged up to 4 years. Conclusion: The role of OME in causing hearing impairment is demonstrated in this study. More males than females were affected. The prevalence of OME decreased with the increasing age of the children. P117

Targeted Chemoradiation and Surgery for Temporal Bone Cancer: Case Reports Srikanth I Naidu MD (presenter); Merry E Sebelik MD Memphis TN; Memphis TN

Objectives: Primary squamous cell carcinoma (SCCA) of the temporal bone is a rare entity with no standardized treatment. In advanced stages, other treatment regimens, such as surgical resection followed by radiation therapy or conventional chemoradiatiou followed by surgical resection, survival rates remain low. We present two cases of advanced stage primary SCCA of the temporal bone who remain disease-free after treatment with combined targeted intraarterial cisplatin and radiation therapy followed by surgical resection and reconstruction. Methods: Subject A, a 60-year-old man, underwent concurrent intraarterial cisplatin and radiation therapy followed by right radical mastoidectomy. Subject B, A 52-year-old female, also underwent the same chemoradiation regimen for 2 months with a right lateral temporal bone resection and reconstruction 3 months later. Results: Subject A remains disease-free 8 years post therapy. Subject B is free of disease 3 months post treatment. Conclusion: Neoadjuvant chemoradiation therapy with targeted intraarterial cisplatin followed by resection may provide improved local tumor control and survival over other treatment regimens for advanced stage primary SCCA of the temporal bone. P118

Bupropion and Tinnitus in Smoking Cessation Therapy Guillermo Til-Perez MD; Carlos Magri-Ruiz (presenter); Gabriel Jaume-Bauza MD; Manuel D Tomas-Barberan MD; Sebastian Mas-Merchant; Pedro Sarria Echegaray MD Palma de Maflorc Spain; Palma deMallorca Spain; Islas Baleares Spain; Palma de Mallorc Spain; Palma deMallorca Spain; Baleares Spain

Objectives: Relationship between bupropion therapy for smoking cessation and onset of tinnitus. The secondary effects of bupropion are well known by therapists that commonly use this drug: insomnia, GI disturbances, tremors, dry mouth, blood pressure disturbances, dizziness, etc. However, despite not being clearly included in the literature, we have seen an ear symptom in 2 patients treated with this drug in our smoking cessation unit: tinnitus. Methods: Study involving 2 female patients who devel-

oped constant bilateral tinnitus after bupropion therapy initiation at established doses. Results: Patients aged 45 and 48 with no interesting pathological history and no previous hearing disturbances. A few weeks after initiating bupropion therapy, they developed constant bilateral tinnitus. A 30-dB fall in high frequencies (8000 Hz) was seen in the audiometry in both patients. The first step was to reduce the dose by half (150 rag/day) in both cases. Even then, tinnitus persisted in both patients. Tinnitus resolved in one patient 4 months after complete treatment discontinuation, while in the other patient, tinnitus was still present 12 months later despite bupropion therapy discontinuation. Conclusion: The onset of tinnitus with the initiation of bupropion therapy and its resolution, at least in one patient, leads to the suspicion of a possible causal relationship between bupropion and tinnitus. P119

Melanotic Oncocytic Metaplasia of the Nasopharynx Takahiro Kamijo MD (presenter); Katsuhide Inagi MD; Tadashi Motoori; Keiko Hasumi RN Kitamoto Saitama Japan; Tokyo Japan," Kitameto Japan; Kitamoto Saitama Japan

Objectives: Melanotic oncocytic metaplasia (MOM) of the nasopharynx was first reported by Shek et al in 1995. Five cases of nasopharyngeal MOM have been reported. Although pathological characteristics were documented in these cases, no clinical appearances including a photograph of this lesion were described. It is well known that oncocytic change in the upper respiratory tract is an uncommon finding. Moreover, the melanotic variant of oncocytic metaplasia of the nasopharynx has been documented as extremely uncommon. Methods: Four cases of nasopharyngeal MOM were experienced during the period between March 2001 and January 2002. Both clinical appearances and pathological characteristics were examined. Literature reviews were performed. Results: Four male cases out of 150 Japanese patients who underwent nasopharyngeal endoscopic examination had MOM of the nasopharynx. Age distribution was between 55 and 72 years old. Clinical appearance of these lesions presented small black nodules located around the opening of the eustachian tube and at the upper wall of the nasopharynx. Pathological characteristics showed that nodules were composed of seromucinous glands with oncocytes. These oncocytes appeared abundant in eosinophilic granular cytoplasm with black-brown granules. Also, dendritic cells with melanotic pigmentations were observed in the overlying epithelium. Finally, we diagnosed the present cases as MOM of the nasopharynx. Conclusion: Although it has been reported that nasopharyngeal MOM is extremely uncommon, we identified 4 cases of nasopharyngeal MOM in less than a year by using a nasopharyngeal endoscope. Nasopharyngeal MOM might be

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peculiar to Asian people because all previous cases were reported from Asian areas. P120

Factors Affecting the Treatment Outcome of Acquired Laryngotracheal Stenosis at Srinagarin Dr Thumnu Art-Smart (presenter); Dr Kwanchanok Yimtae; Sompong Srisanpang MD; Pataravoot Vatanasapt MD; Teeraporn Ratana-Anekchai MD Khon Kaen Thailand; Khon Kaen Thailand," Khon Kaen Thailand; Khon Kaen Thailand; Khon Kaen Thailand

Objectives: To evaluate the factors affecting the decannulation rate of acquired laryngotracheal stenosis Methods: A cross-sectional analysis of 252 acquired laryngotracheal stenosis patients at Srinagarind hospital between 1995 and 2000 was studied. Site(s), severities (luminal diameter, segmental length, cord mobility), and therapeutic methods were analyzed. Results: Among these patients, impaired vocal cord mobility has a significantly worse outcome (odds ratio = 2.92, P = 0.0035). In cases of subglottic stenosis, the resection technique and combined open technique have a significantly more successful outcome than the expansion technique (P = 0.017) Conclusion: Normal vocal cord mobility, resection technique, and combined open technique are good prognostic factors. P121

Severe Sensorineural Hearing Loss in Kleinfelter's Syndrome Samuel J Daniel MD (presenter); Blake C Papsin MD; Julian M Nedzelski MD FRCS Toronto Canada; Toronto Canada; Toronto Canada

Objectives: Klinefelter's syndrome is the most common sex chromosome disorder affecting 1 in 500 men across all ethnic groups. In early childhood, the diagnosis is difficult to make because of the subtle clinical findings. Common presenting features include delayed speech development, learning difficulties at school, and unusually rapid growth in midchildhood. The objective of this poster presentation is to discuss two unusual cases of Klinefelter's syndrome associated with profound sensineural hearing loss. Methods: Two male patients with Klinefelter's syndrome, having the 47 XXY karyotype, were referred to our institution for cochlear implantation. The mode of presentation, diagnostic audiological and radiological tests, and treatment modality are detailed. Results: The first patient, a 15-month-old male, presented with bilateral profound hearing loss causing impaired language development. The second patient presented with a cleft palate, global developmental delay, and bilateral profound hearing loss. No syndromic diagnosis other than the

Klinefelter's was made on the basis of clinical and genetic testing. The patient underwent cochlear implantation at about 18 months of age. Conclusion: Otolaryngologists should be cognizant of the presence of profound sensineural hearing loss in some patients with Klinefelter's syndrome. To the best of our knowledge, this has not been reported before. Cochlear implantation can be considered in these cases. A better awareness of this condition should enable earlier diagnosis and help to decrease the impairment in language development. P122

Laryngeal Tuberculosis Revisited Alan R Burningham MD (presenter); Ajay E Chitkara MD; Alexander G Chiu MD; Edward Krowiak MD Washington DC; Arlington VA,"Bethesda MD; Washington DC

Objectives: The incidence of tuberculosis infections in the United States has been decreasing since a surge in the early 1990s, but new cases of laryngeal tuberculosis are still being diagnosed every year. Often there is a significant delay in diagnosis because the condition presents with nonspecific complaints and physical findings. The following case illustrates the clinical presentation of laryngeal tuberculosis and the time lapse between initial presentation and final diagnosis. Methods: Case study. Results: An 85-year-old African American male with a history of COPD and gastroesophageal reflux was referred for evaluation of progressive hoarseness, dysphagia, and sore throat for more than 1 month. He complained of a chronic cough with white sputum production, occasional dyspnea, and decreased appetite. He had a 30 pack-year history of tobacco use and a history of heavy alcohol use but quit both 30 years ago. Physical examination revealed poor dentition but no lesions or masses in his oral cavity. Flexible fiberoptic nasopharyngoscopy revealed an ulcerative lesion on the laryngeal surface of the epiglottis with no evidence of vocal fold dysfunction. There was no palpable lymphadenopathy. A C T scan of the neck showed narrowing of the supraglottic airway and no evidence of a mass. Over the next month, the patient's symptoms continued to worsen in severity, and odynophagia developed. He became unable to tolerate oral liquids or solids and was eventually admitted to the hospital secondary to mild dehydration and weight loss. Chest x-ray on admission showed bilateral hyperinflation, patchy densities in the left upper lobe, calcified grannloma in the right apex, and a left basilar infiltrate. He was taken to the operating room for panendoscopy and biopsy, which showed diffuse edema and erythema of the epiglottis and irregular, friable mucosa on the laryngeal aspect of the epiglottis, bilateral arytenoids, false vocal folds, and true vocal folds. Biopsies revealed acute and chronic inflammation, poorly formed granulomas with necrosis, epitheliod

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histocytes, and multinucleated giant cells. Acid-fast bacilli were found on special staining. The patient was started on antituberculosis therapy almost 3 months after initial presentation and has some subjective improvement of his hoarseness and sore throat. Conclusion: This case illustrates how the presentation of laryngeal tuberculosis can mimic many other disorders managed by the otolaryngologist and should be addressed promptly to help initiate proper therapy and limit exposure to the public and health care professionals. P123

Occult Supraglottic Lymphatic Malformation Presenting As Obstructive Sleep Apnea James Chan MD (presenter); Abbas Younes MD; Peter J Koltai MD Cleveland Hts OH; Shaker Heights OH; Cleveland OH

Objectives: Obstructive sleep apnea (OSA) is commonly encountered in children. Most cases result from adenoidal or adenotonsillar hypertrophy. Lymphatic malformations (LMs) are considered rare tumors that usually present in the cervicofacial region. Isolated LMs of the larynx are even less common. We describe a child with OSA secondary to an occult supraglottic LM, initially attributed to adenoidal hypertrophy. Methods: A review of the child's history and evaluation is presented, including the role of appropriate imaging. We review the literature and discuss the management of supraglottic LMs including the use of endoscopy, carbon dioxide laser, the decision to avoid a tracheostomy, and the need for long-term follow-up. Results: The patient underwent endoscopic carbon dioxide laser excision of the lesion. Intraoperative imaging is presented. The majority of the lesion was endoscopically removed. Good visualization of the vocal cords and an open airway at the end of the case suggested that a tracheostomy could he avoided. The patient was allowed to awaken, was successfully extubated, and was transferred to the pediatric intensive care unit for observation. He had no further snoring, apneas, or desaturations overnight in the intensive care unit. The following day, he was given a standard diet and transferred to a regular nursing floor. On his second postoperative day, he was discharged home. Conclusion: Occult supraglottic LMs without laryngeal symptoms may be overlooked in the routine evaluation of a child for OSA. Fiberoptic laryngeal examination should be considered in cases where the examination findings are inconsistent with the clinical symptoms; however, it is not a necessity in the routine exam. Laser endoscopy is an elegant and effective method for treating isolated supraglottic LMs and enables avoidance of tracheostomy. Potential recurrence requires close follow-up.

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Treacher-Collins: Audiological Aspects Manoel Nobrega MD (presenter); Claudia S Souza MD; Roberta R Almeida MD; Raque] Paganini Pereira MD; SiMa B Longhitano MD; Rita A F dos Santos; Luc Louis Maurice Weckx MD PhD; Rejane Abdala Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil; Vila Clementino Brazil; Vila Clementino Brazil," Sao Paulo Brazil; Vila Clementino Brazil

Objectives: To describe the clinical and audiological characteristics of the Treacher-Collins syndrome in patients of the Hearing Deficiency Outpatient Service of the Hospital S~o Paulo (HDOSHSP) (Ambulat6rio de DeficiSncia Auditiva do Hospital S~o Paulo-UNIFESP/EPM). Methods." This study analyzed the clinical and audiological findings in 6 patients, 5 males and 1 female, with ages varying from 3 months to 4 years and 3 months, diagnosed with Treacher-Collins syndrome at the HDOSHSR a specialized outpatient referral center. All individuals were submitted to a genetic evaluation, answered a standard questionnaire, underwent otorhinolaryngologic examinations, and were counseled for audiologic evaluation, rehabilitation, and selection of hearing aids. Results: Hearing deficiency caused by genetic factors corresponds to 12.4% of the etiologies found at our service. The Treacher-Collins syndrome occurred in 6 patients, representing 9.4% of all the cases with genetic causes. All 6 presented with malformation of the auricular pavilions, atresia of the external auditory canal, micrognathia, and preauricular appendix. In the audiologic findings, the hearing loss varied from moderate mixed to severe progressive bilateral loss, and from light conduit loss to moderate bilateral loss. Conclusion: The Treacher-Collins syndrome represents 9.4% of the genetic cases (6/64) and 1.1% of all cases (6/519) of hearing loss in our service. In these 6 cases, in addition to the syndrome-specific findings, the hearing loss occurred in 100% of the cases, varying from light to moderate bilateral conduit loss, to mixed moderate to severe, progressive, bilateral loss. P125

Horizontal Semicircular Canal BPPV after Posterior Semicircular Canal Occlusion Samuel Lin MD (presenter); Robert A Baffista MD Chicago IL' Hinsdale IL

Objectives: To present the case of a patient who developed horizontal semicircular canal benign paroxysmal positional vertigo (BPPV) after posterior semicircular canal occlusion for posterior BPPV. To date, conversion to another form of BPPV has not been reported after posterior semicircular canal occlusion. Methods: A 72-year-old man with a 1-year history of pos-

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terior semicircular canal BPPV refractory to canalith repositioning maneuvers underwent posterior semicircular canal occlusion. The patient developed horizontal semicircular BPPV within 2 weeks of surgery. The horizontal BPPV was refractory to canalith repositioning maneuvers for horizontal BPPV (log-roll maneuver). Gentamicin middle ear perfusion was used to treat the symptoms of horizontal BPPV. Results: Surgery cured the symptoms of posterior BPPV, and gentamicin cured the symptoms of horizontal BPPV. After gentamicin perfusion, the patient developed imbalance, which was successfully treated with vestibular rehabilitation. Conclusion: Horizontal semicircular canal BPPV may develop after posterior semicircular canal occlusion. Posterior semicircular canal occlusion does not prevent utricular debris (canaliths) from falling into the horizontal semicircular canal. P126 Cochlear Implantation in a Patient with Bilateral Temporal Bone Fractures Jeffrey P Simons MD (presenter); Mark Edward Whitaker MD; Barry E Hirsch MD Pittsburgh PA,"Pittsburgh PA; Pittsburgh PA

Objectives: Temporal bone fractures through the otic capsule frequently cause sensorineural hearing loss. Patients with bilateral temporal bone fractures and profound bilateral sensorineural hearing loss can benefit from cochlear implantation. However, certain pathologic processes associated with temporal bone fractures, such as labyrinthitis ossificans and loss of spiral ganglion cells, can prevent successful cochlear implantation and/or subsequent aural rehabilitation. Methods: We present the case of a 25-year-old male who developed sudden complete bilateral hearing loss and severe vertigo after a fistfight resulting in a fall and occipital trauma. Audiometry established that the patient had bilateral profound sensorineural hearing loss. The demonstrated temporal bone CT scan revealed bilateral fractures involving the otic capsules with evidence of bilateral pneumolabyrinth. Vestibular testing showed that the patient also had absent caloric responses bilaterally. Approximately 1 year after the injury, the patient underwent a left cochlear implant procedure through a facial recess approach. Results: The cochlear implant procedure was successful, and the patient was able to understand speech and learn to talk on the telephone, once the implant was programmed. For example, Iowa Sentence Test scores improved from 0/88 words recognized correctly before the implant to 72/88 words recognized correctly 6 months after initial programming. Similarly, CID Sentence Test scores improved from 1/200 before surgery to 174/200 6 months after initial programming. Conclusion: This case demonstrates that cochlear implantation in a patient with bilateral profound sensorineural hearing loss caused by bilateral temporal bone fractures can be a very effective method of aural rehabilitation.

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Warthin's Tumors Presenting as Bilateral Laryngoceles Nima Pahlavan MD (presenter); Katherine A Kendall MD Sacramento CA; Sacramento CA

Objectives: This report describes a unique case of bilateral Warthin's tumors of the laryngeal saccule presenting as laryngoceles in an adult female. Warthin's tumor is a benign salivary gland tumor, usually found in the parotid gland, that represents 6% of all salivary gland tumors. Warthin's tumors of the laryngeal saccule are extremely rare. Laryngoceles are cystic lesions that arise from enlargement of the appendix of the laryngeal ventricle due to obstruction of the saccular drainage or due to increased air pressure at the level of the ventricle. Laryngoceles can be air- or fluid=filled and can present with hoarseness, dyspnea, and airway obstruction. Laryngoceles that extend beyond the confines of the thyroid cartilage may present as neck masses. Methods: A 60-year-old female was treated at an outside facility after presenting with airway obstruction and a neck mass. She underwent a tracheotomy and drainage of what was thought to be a right neck abcess. Endoscopy revealed smooth swelling of the supraglottic structures. After referral, physical examination and MRI scan of the neck confirmed bilateral laryngoceles. Results: Resection of the laryngoceles via an external approach was performed. Pathological evaluation revealed bilateral Warthin's tumors of the laryngeal saccules. The patient subsequently regained normal laryngeal function and was successfully decannulated. Conclusion: Tumors of the saccule are usually considered in the differential diagnosis of unilateral laryngoceles. The presence of bilateral external laryngoceles due to bilateral saccular Warthin's tumors is a unique clinical presentation but must also be considered. P128

Update and Review of Malignant Melanoma of Head and Neck Rajendra D Bhayani MD (presenter); Corinne Elisabeth Horn MD; Lanny Garth Close MD; Hector P Rodriguez MD New York NY; New York NY; New York NY; New York NY

Objectives: Management of malignant melanoma of the head and neck region continues to remain challanging. We review the literature and update the current trend and issues in the management of this neoplasm. Methods: A MEDLINE search for malignant melanoma of the head and neck region was carried out. Extensive review of literature was done and current research and management issues are discussed. Results: Every hour, one American dies from skin cancer. About 35,000 new cases of skin melanoma are diagnosed every year. Out of these, about 25% of cases are in the head and neck region. Etiology, risk factors, clinical presentation,

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and classification of melanoma depending on pathology are discussed. Histological features and special stains are reported. Methods of clinical diagnosis including biopsy techniques and staging systems (Clark level, Breslow level, AJCC TNM staging) based on depth of invasion are discussed. Management of primary lesion, extent of neck dissection, role of elective neck dissection, and indications for parotidectomy and sentinel node biopsy are clarified. The roles of radiation therapy, chemotherapy, immunotherapy, melanoma vaccine, and monoclonal antibodies in management are stressed. Management of mucosal melanoma is briefly outlined. Conclusion: In spite of recent advances in surgery, radiation therapy, chemotherapy, and immunotherapy, the prognosis in patients with malignant melanoma continues to remain poor. Depth of invasion and nodal invalvement are the most important prognostic factors in skin melanoma. Thickness of the primary lesion is not prognostic for mucosal melanomas, and elective neck dissection is not indicated in managing the mucosal melanoma. Continued research may improve outcomes in the future. P129

Sudden Deafness Treatment Guillermo Til-Perez MD; Carlos Magri-Ruiz; Gabriel JaumeBauza MD (presenter); Manuel D Tomas-Barberan MD; Pedro Sarria Echegaray MD; Lidia Riera-Guasch MD Palma de Mallorc Spain; Palma deMaflorca Spain; Islas Baleares Spain; Palma de Mallorc Spain; Baleares Spain; Palma de Mallorc Spain

Objectives: Sudden deafness is a relatively common pathology within the group of diseases seen in the ENT emergency unit. We conducted a retrospective study of all sudden deafness diagnosed in our hospital, which covers a population of around 700,000 inhabitants, between 1990 and 2000. We analyzed treatment given and patient progression. Methods: Sudden deafness was diagnosed in 89 patients. They were all advised to come to our unit to receive IV treatment according to protocol. Audiometry was performed on admission, on day 3, and upon discharge (usually on day 5). All patients underwent a series of serological tests on admission. All patients were referred to outpatient clinics for follow-up after discharge. Hospital stay, treatment given, and their tolerability and audiometric improvement were analyzed. Results: Of 89 patients diagnosed, 85 were admitted in our unit. Treatments given included methylprednisolone, chloride-dextran, and pentoxiphiline. Methylprednisolone was the best tolerated drug. We did not see any severe complication. We measured audiometric improvement in frequencies ranging from 125 to 8000 Hz and time to improvement. Conclusion: After 10 years of study and the literature review, we consider that the best treatment schedule should

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include IV corticosteroids, chloride-dextran, and carbogen gas. Treatment should be given for 5 days in the hospital. P131

Thyroglossal Duct Cyst Carcinoma As a Lateral Neck Mass Timothy Alexander Kelsch MD (presenter); Timothy J Downey MD; Douglas M Sorensen MD Tacoma WA; Tacoma WA; Tacoma WA

Objectives: A thyroglossal duct cyst (TDC) is the most commonly encountered congenital midline neck mass; however, it can present as a lateral neck mass in 10% of cases. Carcinoma is found in less than 1% of TDCs, and it is papillary carcinoma 75% to 85% of the time. Approximately 150 cases have been reported, but controversy surrounds the management of the thyroid gland and cervical lymph nodes. We present a case that presented atypically, and we discuss the surgical and medical management of the tumor and remaining thyroid gland. Methods: A 57-year-old female presented with a 1-month history of rapidly enlarging right posterior submandibular and upper jugular neck mass. The patient had no other symptoms and had a previous history Of adenocarcinoma of the breast. The patient presented with a 5-cm heterogeneous cystic mass that was nontender and immobile. Fiberoptic exam revealed evidence of extralaryngeal supraglottic displacement. FNA showed atypical cells consistent with carcinoma. CT scan showed a mass extending from hyoid, thyrohyoid membrane, and laryngeal cartilage to the angle of the mandible with invasion of thyroid cartilage. Results: The patient underwent a right modified radical neck dissection and Sistrunk procedure with histopathology demonstrating TDC with papillary carcinoma. No metastasis to the cervical lymph nodes was present. Four weeks later, a total thyroidectomy showed 3-mm foci of papillary carcinoma of the left lobe. Conclusion: TDC papillary carcinoma is rare, and the literature shows a 30% incidence of occult carcinoma in the thyroid. Discussion of total thyroidectomy and 131I treatment leads to some controversy. Considering the low incidence of complications, we support a total thyroidectomy to facilitate radioactive 131Itherapy in addition to long-term surveillance. P132 H e a d a n d Neck Manifestations of Rosai-Dorfman Disease ScoNe B Roofe MD (presenter) Fort Polk LA

Objectives: To describe a case of cervical lymphadenopathy in an infant with Rosai-Dorfman disease and to review the literature regarding the head and neck manifestations of this rare disorder. Methods: Case presentation and literature review of oto-

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laryngologic manifestations of Rosai-Dorfman disease (sinus histiocytosis with massive lymphadenopathy). Results: This case involves a 6-month-old infant of African (Nigerian) descent who presented with prominent cervical adenopathy. Characteristic clinical, radiographic, and pathologic findings are presented. The etiology, epidemiology, diagnosis, and management of this uncommon entity are reviewed. The discussion includes a review of both nodal and extranodal manifestations of this disease. Conclusion: Rosai-Dorfman disease is a rare entity that commonly involves lymph nodes, with a predilection for children. Its natural history is most often benign and selflimiting. Extranodal involvementmay be seen in approximately 43 % of cases, with 75% occurring in the head and neck. In contrast to the nodal cases of Rosai-Dorfman, extranodal involvement of vital organs may be life-threatening. Diagnosis should be based on pathologic evaluation, noting distinctive cytologic features of the histiocytes, fibrosis, and immunoreactivity for S-100. Surgical management is generally limited to biopsy, significant cosmetic deformity, or for cases of organ infiltration, which may cause morbidity or mortality. Patients with progressive disease may be treated more aggressively with chemotherapy or radiation therapy. P133

Temporal Bone Chondroblastic Osteosorcoma: A First Case Krista Olson MD (presenter); Herman A Jenkins MD; Mary L Ostrowski MD

Houston TX; Denver CO. Houston TX

Objectives: Osteosarcoma (OS) is the most common nonhematopoietic primary malignant tumor of bone, but a rare temporal bone tumor. Three histologic variants of the conventional OS exist, including the chondroblastic, osteoblastic and fibroblastic subtypes. This is the first reported case of a chondroblastic OS of the temporal bone. Methods: Case report and literature review. A 13-year-old boy presented with a 9-month history of hoarseness and a fixed right true vocal fold. MRI revealed a mass at the jugular foramen with extension into the mastoid, petrous bone, and cerebellopontine angle cistern. CT showed extension of the destructive process to the petrous pyramid. A transmastoid biopsy revealed a moderately differentiated chondroblastic OS. Results: The patient received induction chemotherapy with cisplatin, doxorubicin, and methotrexate. He then underwent subtotal removal of remaining tumor via a translabyrinthine and transcochlear approach. Tumor was removed from the petrous apex with a small portion adherent to dura. Tumor encased the vertical segment of the facial nerve. Final pathology revealed chondroblastic OS. The patient completed postoperative chemotherapy and is doing well at 1-year follow up. Conclusion: We present a first case report of a chondroblastic OS of the temporal bone and discuss the diagnostic eval-

uation, role of surgical intervention, and medical management of this patient. We also present a literature review of OS of the temporal bone. P134

Treatment of Osteoradionecrosis of the Cervical Spine Umesh Marathe MD (presenter); Robert E Johnson MD Kailua HI Objectives: Osteoradionecrosis (ORN) is a serious complication of radiation therapy for malignancies of the head and neck. The mandible is the most common site involved, but there have been reports of ORN of the temporal bone, the occipital bone, and the hyoid bone. ORN of the cervical spine has been reported only once in the literature, and it was associated with a morbid outcome. Methods: A case report format will be utilized, describing a case of debilitating and life-threatening ORN of the cervical spine that was successfully treated and reconstructed. Results: A 62-year-old male presented to the Otolaryngology Head and Neck Clinic with neck pain, paresthesias of both upper extremities, and severe cervical kyphosis. His medical history was significant for a left radical neck dissection and radiation therapy for a TxN3Mo squamous cell carcinoma in 1978. Imaging studies demonstrated complete destruction of the C6-7 disk space and severe erosion of C6 and C7. He was taken to the operating room for a C6-7 corpectomy, resection of the vertebral bodies of C6 and C7 with a fibular free flap reconstruction of his cervical spine. He was treated with postoperative hyperbaric oxygen and intense rehabilitation. He did well after a prolonged hospital course with a stable cervical spine and no neurologic impairments. Conclusion: ORN of the cervical spine is an extremely rare complication. With aggressive surgical management, including the use of free bony tissue transfer and hyperbaric oxygen, it can be successfully treated with minimal morbidity. P135

Transnasal Endoscopic Surgery of the Orbit Alaa Hamed (presenter) Cairo Egypt Objectives: Because ENT conditions that can produce ophthalmological symptoms are relatively unusual, they often escape early detection. So it is important to have an ENT examination in arriving at the correct diagnosis. Trasnasal endoscopic surgery may be a successful treatment modality for such cases. Methods: This is review of 29 patients with ophthalmological symptoms secondary to ENT pathology in the past 2 years (1999-2000) referred from the ophthalmological department. All patients were treated with transnasal endoscopic surgery. Results: As orbital complications of sinusitis, 3 patients had medial subperiosteal abscess and 2 had orbital cellulitis, and of those with the more benign preseptal disease, 2 patients

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had cellulitis of the eyelids. All scanned to differetiate preseptal from more serious postseptal conditions. Transnasal endoscopic surgery was performed, as they did not respond to antibiotics or when abscess was confirmed by CT. 4 cases with extesive nasal polyposis, single case of intranasal glioma, 7 cases with frontoethmoidal mucoceles, 4 cases with fungal sinusitis and unilateral proptosis. Transnasal endoscopic surgery was performed in all cases with satisfactory results. Four cases with nasopharyngeal carcinoma and 2 cases with lymphoma had CT and endoscopic biopsy to confirm diagnosis. Conclusion: This is a limited sample of cases with ophthalmological conditions due to different ENT etiologies to show the importance of ENT examination when they have nasal symptoms or signs in order not to overlook systemic conditions that can involve both orbit and nose. Transnasal endoscopic surgery was performed in all cases (inflammatory & benign) with satisfactory results. Good knowledge of anatomy and endoscopic experience are important for better results. In malignancy, the endoscopic role may be limited to diagnosis and biopsy. P136

Benign Cystic Lymphangioma in a Pediatric Sphenoid Sinus Garrett H Bennett MD (presenter); Max M April MD; Andrew Huvos MD New York NY,"New York NY; New York NY

Objectives: Unique presentation of a benign cystic lymphangioma in the sphenoid sinus of a pediatric patient. Methods: A 9-year-old male presented with a severalmonth history of worsening nasal obstruction. The patient denied facial pain, nasal discharge, or recurrent sinusitis. Complete physical and otolaryngologic exam revealed a large right nasal mass. CT showed that the mass filled the right nasal cavity and both posterior nasopharyngeal choanae and deviated the septum to the left. Under general anesthesia the nasal mass was retracted inferiorly through the era! cavity. The mass was endoscopically visualized to be tethered through an enlarged right sphenoid sinus ostium. The attachment was incised and the mass delivered through the oral cavity. The mass was yellow-tan with an indurated nasopharyngeal and anterior nasal surface and a polypoid midportion. The anterior wall of the right sphenoid sinus was completely removed. Polypoid tissue and cholesterol granuloma in the right sphenoid sinus were excised. The postoperative course of the patient was uneventful, with a 6-month follow-up nasopharyngoscopy showing no recurrence. Results: Microscopically, the indurated portions of the mass contained inflammatory cells and thickened basement membrane. The polypoid portion contained thin-walled strawcolored fluid-filled compartments. Diagnosis, based on histologic architecture of hematoxylin and eosin-stained sections, was benign cystic lymphangioma.

Conclusion: To our knowledge, this is the first case of a lymphangioma arising from the sphenoid sinus in the English literature and the first such pediatric case in the international literature. P137

Facial Nerve Schwannoma Presenting As Conductive Hearing Loss Mary-Louise Montague MRCS (presenter); Mufta EIjamel FRCS; Syed Shah Musheer Hussain FRCS Dundee United Kingdom; Dundee United Kingdom," Dundee United Kingdom

Objectives: Facial nerve schwannomas are rare tumors. These may arise from any segment of the nerve. The typical presentation is of progressive facial paralysis, sensorineural deafness, tinnitus, and vertigo. This case report highlights conductive hearing loss as a presentation of facial nerve schwannomas. The problems associated with tumor multicentricity and imaging are discussed. Methods: We report a case of a 30-year-old Caucasian female presenting with a mass behind an intact tympanic membrane and unilateral 35-dB conductive hearing loss between 500 and 4000 Hz and with normal hearing on the contralateral side. CT and contrast MRI demonstrated a single tumor mass. An extended transmastoid approach was used to microscopically excise the tumor, which was found to be multicentric but confined to the middle ear cleft. The two large portions were excised with preservation of the nerve. The small fragment in the vicinity of the stylomastoid foramen required division of the nerve. The nerve was transposed with end-to-end primary repair. Frozen section and histology confirmed the diagnosis. Results: Complete facial paralysis followed. Electrophysiological studies demonstrated evidence of early regeneration of nerve. A House-Brackmann grade Ill was recorded at 18 months. No further improvement in facial function has occurred. The patient retains the 35-dB conductive loss. Conclusion: Conductive hearing loss is a rare presentation of facial nerve schwannomas and implies an intratympanic extension. Accurate preoperative diagnosis is crucial to proper patient management and preservation of facial nerve function. Despite playing an important role in the detection and characterization of facial nerve schwannomas, MRI may not be able to determine the limits of the tumor in all cases and may fail to forewarn the surgeon of a tumor's multicentricity. P138

Arteriovenous Malformation of the Jugular Bulb Causing Erosion of the Jugular Foramen Samuel Lin MD (presenter); Robert A Balffista MD; Carlos R Esquivel MD Chicago IL; Hinsdale IL; Skokie IL

Objectives: To present the case of a patient with an arteri-

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ovenous malformation (AVM) of the jugular bulb with symptoms and findings consistent with a glomus jugulare tumor. Methods: A 54-year-old woman presented with left-sided pulsatile tinnitus and otalgia. CT and MR//MRA revealed a vascular mass in the region of the left jugular bulb with erosion of the jugular foramen. These radiographic findings were suggestive of a glomus jugulare tumor. Angiography demonstrated high-flow fistulas from the occipital, ascending pharyngeal, and auricular branches of the external carotid artery to the jugular bulb. Results: The patient's pulsatile tinnitus and otalgia resolved completely after the fistulas were successfully embolized. Surgical exploration was performed in view of the erosion found on CT/MRI. Transmastoid exploration of the jugular foramen revealed a mass of tissue in the region of the jugular bulb consistent with an AVM. Conclusion: Erosive lesions Of the jugular foramen may include AVMs. An AVM of the jugular foramen may mimic the symptoms and findings of a glomus jugulare tumor. P139

Delayed Laryngeal Paralysis after Thyroidectomy Debbie Ritchie RN (presenter); Robert P Zitsch III MD; Gregory J Renner MD Sturgeon MO; Columbia MO; Columbia MO

Objectives: Postoperative recurrent laryngeal nerve paralysis related to thyroidectomy has been extensively reviewed in the medical literature. One common theme in most of these reviews is the importance of nerve identification at the time of surgery and the need for pre- and postoperative assessment through laryngoscopic examination. However, our review of the medical literature did not reveal any reported cases of delayed postthyroidectomy recurrent laryngeal nerve paralysis. We report 2 cases of delayed recurrent laryngeal nerve paralysis, which occurred following thyroid surgeries. Methods: Case report. Results: Both patients identified sudden onset of hoarseness, shortness of breath, and dysphagia occurring more than 3 days after their thyroid surgery. Laryngoscopic examination demonstrated vocal cord paralysis, which completely resolved weeks later. Conclusion: To the best we can determine, these cases strongly suggest postthyroidectomy recurrent laryngeal nerve paralysis manifesting sometime after the day of surgery rather than immediately following surgery. This situation has, heretofore, not been previously reported. P140

Pathophysiology and Treatment of Pediatric Thyroid Abscess Eloy Villasuso III MD (presenter); Raymond Lee MD; Frank C Astor MD Miami FL" Miami Beach FL; Miami FL

Objectives: To review possible embryologic mechanisms

that may lead to the formation of low anterior neck abscesses in children. To define potential relationships that may exist between persistent branchial cleft systems and a thyroid abscess. The microbiology of these infections will be discussed, particularly the role of atypical pathogens such as actinomycetes. The case study presents clinical, radiological, intraoperative, and pathologic findings of an acute thyroid abscess in a 6-year-old child. Surgical approaches and medical therapies are discussed. Methods: A retrospective case study from a large tertiary referral center. Findings on physical exam, fine needle aspiration, and preoperative CT scan are reviewed. The patient underwent hemithyroidectomy and treatment with long-term intravenous antibiotics. Results: Findings at surgery included near complete replacement of the left lobe of the thyroid gland with abscess, which when opened, contained foul-smelling sulfur granules. Histopathology confirmed infection with actinomycetes. Patient's voice and swallowing function improved postoperatively, and at 6-month follow-up, the patient remains free of infection. Conclusion: Unusual presentations of neck abscess in children warrant further investigations to look for a possible embryologic anomaly contributing to the infectious process. Failure to recognize such anatomy could lead to recurrent or persistent infections. P141

Massive Brown Tumor of the Palate James Peter Lacey MD (presenter); Karla R Brown MD; Andrew Nemechek MD New Orleans LA; New Orleans LA; New Orleans LA

Objectives: Brown tumors, or "osteoclastomas" are histologically benign lesions that develop as a complication of hyperparathyroidism. The incidence of skeletal brown tumors in patients with chronic renal failure is estimated between 1% and 13%. These tumors present as expansive, osteolytic masses of brownish tissue and bone and may dramatically distort the morphology of the involved bone. Methods: Case report and review of the literature. Results: We present the unusual case of a massive palatal tumor in a 20-year-old female with 3 failed kidney transplantations and secondary hyperparathyroidism. Digital photographs and CT scans highlight this case report. The patient's history, physical findings, and clinical course are discussed. Operative resection of the palatal tumor included a bilateral total maxillectomy and prosthetic reconstruction. Conclusion: The initial management of these patients involves medical control of their hyperparathyroidism. More advanced cases or those refractory to medical therapy may require surgical intervention. Surgical treatment involves partial or complete parathyroidectomy, as well as resection or debulking of the tumor.

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Osteogenesis Imperfecta with Laryngomalacia As a Cause of Obstructive Sleep Apnea Tuan Jen Fang MD (presenter); Hsueh-Yu Li MD Taipei Taiwan (Republic of China)," Taipei Taiwan (Republic of China)

Objectives: Introduction: the mechanism of obstructive sleep apnea (OSA) appears to be multifactorial. Anatomic narrowing may vary in levels with common location in soft palate and tongue base. Although the incidence is low, laryngomalacia has been reported to contribute to adult OSA. We present an osteogenesis imperfecta case with OSA caused by laryngomalacia Methods: Case report: A 24-year-old man, a victim of osteogenesis imperfecta, had shortness of breath, snoring, and gasping during sleep for 6 years. Oral examination revealed a short uvula, small tonsils, patent velopharyngeal space, and an extremely long epiglottis with upper tip touching the uvula. Fiberscopic examination showed that the epiglottis was tilted posterior against the pharyngeal wall, and redundant mucosa of arytenoids was drawn into laryngeal inlet during inspiration. Polysomnography study demonstrated a respiratory disturbance index (RDI) of 21 events per hour, snoring index (SI) of 98 events per hour, and 89.1% of minimum arterial blood oxygen saturation (MSAT). Epworth Sleepiness Scale (ESS) was 9. The patient was scheduled for supraglottoplasty. General anesthesia with endotracheal intubation was carried out. Partial epiglottidectomy was performed with monopolar diathermy. A broad-lumen laryngoscope was carefully inserted, allowing the arytenoids to fall into view. Redundant mucosa of the arytenoids was resected by using the CO 2 laser Results: There was no postoperative complication. Symptoms, including cough, dyspnea, snoring, and gasping during sleep, were significantly improved. Fiberoptic examination 3 months after operation revealed significant reduction of epiglottis and arytenoids; no collapse of supraglottic tissue was found during inspiration. Polysomnography was re-performed 6 months after operation. The result showed that RDI decreased from 21 to 6.9 events per hour, SI decreased from 98 to 1.9 events per hour, and MSAT increased from 89.1% to 92.7%. The patient also responded to the questionnaire. ESS was reduced from 9 to 5. Conclusion: With regard to the surgical treatment of OSA caused by laryngomalacia, the significant reduction of RDI and SI revealed that abnormal long and lax epiglottis with redundant mucosa of arytenoids might be the causes not only of laryngomalacia but also some cases of OSA. P143

Hepatocellular Carcinoma Metastatic to the Temporal Bone in the Liver Transplant Nell E Brown MD (presenter); Douglas A O'Brien MD; Cliff A Megerian MD Boston MA; Norwood MA; Worcester MA

Objectives: The temporal bone is a potential site for meta-

static spread of certain cancers. The most common include prostate, breast, and renal cell carcinoma. Here we present the case of a hepatocellular carcinoma metastatic to the temporal bone. The patient is a 50-year-old male with a history of cirrhosis, who underwent a successful liver transplantation in May of 1998. Nineteen months later, he began to experience imbalance and hearing loss in his right ear. He then suffered acute right-sided facial paralysis 2 months later. An audiogram demonstrated profound sensorineural hearing loss on the right. Imaging studies revealed a large right-sided petr0us apex lesion involving the clivus and right jugular foramen. This presentation will outline the clinical implications and relevant literature regarding this unique case of metastatic hepatocellular carcinoma to the temporal bone. Methods: Case study and extensive review of the otolaryngology literature. Results: The patient was taken to the operating room in April of 2000 for a biopsy of the right petrous apex lesion through a postauricular infracochlear approach, which demonstrated a hepatocellular carcinoma. Although his hepatic transplantation was performed for benign disease and his transplanted liver demonstrated no evidence of malignancy, subsequent pathologic examination of his excised cirrhotic liver demonstrated a small focus of he patocellular carcinoma. Conclusion: After careful review of the English literature, there have been only 3 cases of metastatic spread of hepatocellular carcinoma from a temporal bone study involving 864 patients. However, this is the first report in the literature of this disease process manifesting in a living patient. It also underscores the potential for an otherwise dormant lesion (2 years) to aggressively manifest in the face of immunosuppression after transplantation. This has important ramifications in the expanding field of hepatic transplantation, especially in patients demonstrating new otologic symptomatology. P144

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Lingual Osseous Choristoma: A Case Presentation

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Jamie Rebecca Steger MD (presenter); Chad Bender MD; Paulino E Goco MD Dupont WA; Little Rock AR; University Place WA

Objectives: A case of a 10-year-old female with a lingual osseous choristoma is presented. This rare lesion should be included in the differential diagnosis of midline tongue lesions. The key factors in diagnosis and treatment of these rare lesions are discussed. Methods: The clinical findings, pathology of the lesion, and review of literature are discussed. Results: Choristoma is defined as a tumor that consists of histologically normal tissue that is found at a site other than its native organ. Lingual osseous choristoma is a choristoma typically found in the posterior third of the dorsum of the tongue. It has been reported that 81% are found in females with, peak pre-

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sentation in the third to fourth decades. It is a relatively rare finding, with less than 60 cases being documented in the literature. Conclusion: The pathology in this case revealed a mass measuring 0.8 cm x 0.5 c m x 0.3 cm, which consisted of a transparent white lining, less than 0.1 cm in greatest thickness, surrounding a central calcified nodule. The final diagnosis was lingual osseous choristoma. This diagnosis should be considered whenever a raised or pedunculated lesion is found on the dorsal posterior third of the tongue. The treatment of choice is surgical excision, with no reported cases of recurrence or malignant transformations. P145

Pediatric Intraparotid Castleman's Disease Daniel Sharya Samadi MD (presenter); Marta Guttenberg MD; Lawrence W C Tom MD Philadelphia PA; Philadelphia PA. Philadelphia PA

Objectives: Castleman's disease is a rare pathologic entity of unknown etiology primarily occurring in the thorax. When seen in the head and neck area, these lesions are mostly of the hyaline vascular type (98%). The plasma cell variant of Castleman's disease is rarely seen in the head and neck region. The differential diagnosis includes reactive iymphadenopathy, lymphoma, and distal nodal metastasis. Since it was initially described, approximately 80 cases have been reported worldwide in children. The incidence of these lesions is extremely rare in the head and neck region of children. To our knowledge, this is the first reported case of pediatric intraparotid Castleman's disease. Methods: We report a case of a 12-year-old male with a 6-year history of a left parotid mass. He denied any constitutional symptoms including weight loss, fever, sweats, or fatigue. His parents denied any recent changes in the size of the mass. On physical examination, there was a 5 x 3-cm firm, nontender, mobile mass in the left parotid region. Facial nerve function was intact. A preoperative contrast CT scan revealed a well-defined mass within the deep lobe of the parotid adjacent to the great vessels. The patient underwent a total parotidectomy with preservation of the facial nerve. Results: Histological evaluation demonstrated a 4.5 x 2.5-cm well-encapsulated mass, consisting of germinal centers surrounded by a zone of mature lymphocytes in concentric layers. Immunohistochemical evaluation revealed polycolonal cellular expansion consistent with hyaline vascular variant of Castleman's disease. Conclusion: In the pediatric population, Castleman's disease is an extremely rare lesion within the head and neck region. Due to its indolent clinical course and subtle histological differences from other lymphoproliferative disorders, there may be a tendency towards underreporfing and misdiagnosis. Surgical excision is the treatment of choice, and recurrence is rare.

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Challenging Pediatric Airway Foreign Bodies Daniel D Vukas MD (presenter); Albert H Park MD Chicago IL; Maywood IL

Objectives: Each pediatric airway foreign body presents unique challenges and requires a thoughtful approach for safe, effective removal. We report 3 particularly challenging cases and discuss the strategies employed in their management. Methods: Three difficult cases of airway foreign bodies in pediatric patients are reported. Details pertaining to each patient's clinical presentation are discussed, and key findings, including relevant radiographs and photographs, are presented. Results: A 2-year-old female presented with a latex balloon occluding her right main stem bronchus. Management involved bilateral chest tube placement and endoscopic removal of the balloon. Next, a 1-year-old male presenting with an obstructing subglottic nut fragment required tracheotomy. Removal of nut required a combination of open and endoscopic techniques. Finally, an 8-month-old male ingested a lapel pin and subsequently developed supraglottic edema requiring emergent tracheotomy and endoscopic removal of the pin. Conclusion: The otolaryngologist must be prepared to utilize a variety of techniques in managing foreign bodies of the pediatric aerodigestive tract. As our cases illustrate, tremendous variability exists in the character, size, and location of the foreign object. The characteristics are often unknown to the surgeon prior to direct visualization in the operating room. However, the priority in such cases remains obtaining secure access to the patient's airway in a timely manner. Once this is achieved, a variety of techniques may be employed to remove the offending object. P147

GABHS in Pharyngotonsillitis in Children: A Brazilian Study Shirley Shizue N a g a t a Pignatari MD (presenter); Luc Louis Maurice Weckx MD PhD; Odimara Paes Santos MD; Antonio Carlos Pignatari MD Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil

Objectives: To study the prevalence of group A betahemolytic streptococcus (GABHS) in children in Brazil and to compare different sampling methods of GABHS detection. Methods: Samples from 50 children (ages between 1 and 12 years) with acute pharyngotonsillitis were obtained simultaneously with oropharyngeal swabs for culture, molecular assay, and rapid GABHS antigen detecting tests. All children were clinically examined at the Division of Pediatric Otorhinolaryngology of the Federal University of Sao Paulo. Diagnostic criteria were based on signs and symptoms includ-

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ing sore throat, fever, and presence of oropharyngeal purulent secretion. Children under previous antibiotic treatment were excluded. Results: Overall, combining the 3 methods, prevalence rate of BHGAS was 34%. GABHS was positive in 30% of the cultures, in 23% of the samples by using molecular nucleic acid hybridization method, and in 22% of the cases tested with rapid antigen detecting test. There was no significant statistical difference when these 3 methods were compared. Conclusion: Prevalence of BHGAS in Brazil seems to be similar to international data, and the 3 tested methods of BHGAS detection were shown to be equivalent. P148

Ectopic Intratracheal Thyroid Tissue: A Case Report Joao Paco MD PhD (presenter); Hugo Estibeiro MD; Antonio Ferreira Marinho MD

Lisbon Portugal; Odivelas Portugal; Lisbon Portugal

Objectives: The presence of ectopic thyroid tissue inside the tracheal lumen is very rare. The authors describe the symptoms, the diagnosis, and the treatment of this unusual pathology. Methods: The authors report a case of a 35-year-old woman with irritating cough and slowly progressive stridor, which was aggravated with effort, without dysphonia, and with no relief with bronchodilators and antiinflammatory therapy. On videolaryngoscopy, a round, regular, nodular formation was visualized at about 2 cm below the vocal cords. The treatment was done with a YAG laser, under general anesthesia with jet ventilation. Results: The histologic examination disclosed normal thyroid tissue under a layer of respiratory epithelium. Conclusion: Ectopic thyroid tissue is uasually found along the thyreoglossal tract. It is difficult to explain the presence of thyroid tissue outside the normal migration route of the thyroid gland. However, it has been already described in various locations: intralaryngotracheal, paratracheal, paraesophageal, lateral cervical, in the mediastinum and within the pericardium. Two explanations were advanced to explain the presence of intratracheal thyroid tissue: the malformation theory, which states that the thyroid gland would be arrested and divided by the developing tracheal cartilage in the first weeks of embriogenic developement; and the invagination theory that postulates a possible growth of the thyroid gland through a continuity solution on a laryngotracheal wall. P149

Frontal SinusitisCaused by Bone Wax Robert C Wang MD; Neri M Blanco MD (presenter)

Las Vegas NV; Las Vegas NV Objectives: Previous research in the canine model suggests that nasofrontal duct obstruction alone does not produce

sinusitis or mucocele but that implantation of bone wax in the frontal sinus does promote sinusitis (Schenck and Rauchbach, 1976). A case of recurrent frontal sinusitis in a patient, caused by the introduction of bone wax into the sinus 8 years prior, is presented. Methods: Following cerebral aneurysm clipping in two separate left frontal craniotomies 8 years ago, a 55-year-old woman began having recurrent frontal sinusitis with periorbital cellulitis and sinocutaneous fistula responsive to antibiotics and decongestants. CT scan revealed complete opacification of the left frontal sinus. Through a left frontal sinusotomy approach, the sinus was found to be impacted with bone wax. After bone wax removal, mildly edematous mucosa was present without purulent secretions or complete obstruction of the nasofrontal duct. The interfrontal sinus septum was removed, and endoscopic exposure of the left frontal recess to the nasofrontal duct was performed. Results: Uneventful recovery and no further episodes of sinusitis have been noted, with more than 24 months' followup. CT scan shows the left frontal sinus to be aerated with minimal mucosal thickening. Conclusion: This case provides confirmation of past canine research showing the capability of bone wax implanted in the frontal sinus to cause sinusitis. The pathophysiology of this process is discussed. Introduction of bone wax into sinus cavities should be avoided. Previous research in the canine model suggests that nasofrontal duct obstruction alone does not produce sinusitis or mucocele but that implantation of bone wax in the frontal sinus does promote sinusitis (Schenck and Ranchbach, 1976). This case provides confirmation of this past research, showing the capability of bone wax implanted in the human frontal sinus to cause sinusitis. P150

Cochlear Implantation in Camurati-Engelmann Disease Robert James Tibesar MD (presenter); Anthony E Brisselt MD; Jon K Shallop PhD; Colin L W Driscoll MD

Rochester MN; Rochester MN; Rochester MN; Rochester MN

Objectives: Camurati-Engelmanndisease (progressive diaphyseal dysplasia) is a rare hyperostosis disorder in which the diaphyses of long bones and the skull exhibit diffuse cortical thickening and sclerotic bony overgrowth. Bony hyperplasia of the skull base can cause nerve foraminal stenosis leading to a variety of cranial nerve deficits. Sensorineural hearing loss (SNHL) due to bony compression of the internal auditory canal (IAC) presents a particularly difficult challenge. Presented here is a 58-year-old male with progressive bilateral SNHL and Camurati-Engelmann disease. Electrophysiologic audiometry combined with radiologic imaging confirmed bilateral IAC stenosis as the likely etiology. The surgical procedures employed in this case and postoperative results are discussed and evaluated.

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Methods: One adult patient with Camurati-Engelmanndisease and profound SNHL was studied. Staged surgical intervention consisted of IAC decompression followed by cochlear implantation. Subjective and objective measurements of the patient's treatment response were reviewed. Results: Complete preoperative and postoperative electrophysiology, audiometry, radiology, and subjective survey results are compared and presented. Results demonstrate a favorable outcome in this case. Conclusion: This patient with profound SNHL and Camurati-Englemanndisease represents a diagnostic and therapeutic challenge. A broad differential diagnosis supported by detailed andiologic and radiologic testing was necessary to obtain the diagnosis and customize surgical therapy. In this case, IAC decompression followed by cochlear implantation proved to be beneficial, demonstrating the utility of such a staged surgical intervention. Furthermore, it challenges our current understanding of IAC stenosis as a possible contraindication to cochlear implantation. P15t

Sphenoid Fungal Sinusitis: A Late Complication of Transphenoidal Pituitary Resection Christopher Donovan Lansford MD (presenter); Nadia D Friedman; Samuel R Fisher MD Durham NC; Durham NC; Durham NC

Objectives: The transphenoidal approach to the resection of pituitary tumors with fat graft obliteration of the sphenoid sinus is a commonly performed procedure with infrequent complications. This case report presents a previously undescribed complication of sphenoid fungal sinusitis 11 years following a successful transseptal-transphenoidal resection of a pituitary adenoma with mucosal stripping and fat obliteration of the sphenoid sinus. Methods: A case report is presented and the literature reviewed. Results: An immunocompetent 50-year-old woman who had undergone successful transseptal-transphenoidal resection of a pituitary microadenoma 11 years earlier returned with a 2year history of progressive headache symptoms and a sphenoid mass on magnetic resonance imaging. Endoscopic sphenoid sinusotomy was undertaken with confirmation and successful extirpation of an AspergiIlus sphenoid fungus ball. Radiographic findings, laboratory results, infectious disease considerations, and successful treatment options are discussed. Conclusion: Delayed fungal sphenoid sinusitis is a newly described and important complication following transphenoidal hypophysectomy obliterated with a fat graft. Diagnosis is based on clinical presentation and radiologic imaging. Endoscopic sphenoidotomy for this complication should include total removal of the fungus infection and diseased mucosa with establishment of adequate drainage of the sinus if no cerebral spinal leak is identified.

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Acute Airway Distress from Endotracheal Intubation Injury in the Pediatric Aerodigestive Tract Maria T Pena MD (presenter); Sukgi S Choi MD; George H Zalzal MD Silver Spring MD; Washington DC; Washington DC

Objectives: Severe acute postintubation trauma in children is rare. As a result, these injuries frenquently can go unrecognized. Two unusal cases of pediatric aerodigestive tract trauma with subsequent compications are described along with discussion of mechanism of injury and managment options. Methods: Retrospective chart reviews of two acute aerodigestive tract injuries (retropharnygeal perforation and dissection and posterior tracheal laceration) from endotracheal intubation in children at a tertiary care center. Retropharyngeal perforation and dissection from endotracheal injury has not been reported in the literature, to the best of our knowledge. Results: A 9-year-old female scheduled for elective surgery underwent attempted nasotracheal intubation. She sustained a retropharyngeal laceration with dissection and received positive pressure ventilation before the injury was noted. She developed pneumomediastinum. The child was managed conservatively and did well. A 9-year-old male sustained a 4-cm laceration of his posterior trachea and developed pnuemomediastinum after intubation. Upon transfer to this institution, he underwent direct laryngobronchescopy and was reintubated wtih the tip of the endotracheal tube distal to the injury. In the ICU, the child's sedation was lightened. He accidentally pulled his tube and coughed, resulting in severe subcutaneous emphysema with increased pneumomediastinum. An emergent tracheotomy was performed. The patient subsequently did well. Conclusion: Although both patients recovered without sequelae, they had more complicated courses due to failure to recognize that an airway injury had occurred and/or subsequent errors in management. A higher index of suspicion and more careful surveillance of these patients may have prevented further complications. P153

Poststapedectomy Aggressive Granulation Tissue Joseph Sniezek MD; Jennifer Madaiene Bager MD (presenter); Charles A $yms III MD Kailua HI; Mililani HI; San Antonio TX

Objectives: Stapedectomy is a commonly performed procedure that normally has minimal morbidity. A rare complication, which can result in vertigo and hearing loss at 1 week after surgery, is poststapedectomy granulation tissue. We report on a very early and aggressive form of granulation tissue that resulted in postoperative vertigo and hearing loss. Methods: A 54-year-old male developed total sensorineural hearing loss and acute vertigo with nystagmus the morning after an uneventful laser stapedectomy. A re-exploration

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revealed diffuse granulation tissue filling the middle ear. The prosthesis was replaced in good position after all granulation tissue was removed. Radiologic, pathologic, and intraoperative studies and photos are provided. Results: The patient suffered from persistent dizziness and imbalance and sustained a permanent, total sensorineural hearing loss in the operated ear. Three months postoperatively, a repeat exploration and labyrinthectomy were performed as a result of radiologic study that showed a middle ear mass and destruction of the bony labyrinth. Intraoperative findings were granulation tissue filling the mesotympanum and labyrinth with expansion and destruction of the semicircular canals and vestibule. Conclusion: Stapedectomy remains a safe procedure with excellent postoperative results. We report a case of postoperative vertigo and hearing loss due to an early, aggressive type of granulation tissue that has never been described. P154

Laryngectomy for Fungal Abscesses of the Larynx Annie Lapointe MD (presenter); Ellen M Friedman MD; Craig Morriss MD; Robert B Parke Jr MD MBA

Houston TX; Houston TX; Houston TX; Houston TX

Objectives: Invasive fungal infections are known deadly complications of immunosuppression. Prompt diagnosis and appropriate management improve overall outcome. In the head and neck, disfiguring or debilitating procedures may be required. This often generates uncertainty as to the utility of proceeding in an already very ill child. We present the first case described in the literature of a massive Aspergillus subglottic abscess in a child with acute myeloid leukemia treated with bone marrow transplantation, in which a total laryngectomy was performed for control of the disease. Methods: The literature concerning laryngectomy in children and otolaryngologic invasive fungal infections will be discussed. Results: The patient was successfully treated with the procedure and is free of fungal disease after 6 months of followup. The difficult decision to pursue aggressive surgical intervention must be weighed carefully and is based on a negative preoperative metastatic workup, a multidisciplinary tumor conference, and fully informed consent. Conclusion: The mainstay of treatment continues to be a combination of antifungal antibiotics and aggressive surgical debridement. Nevertheless, in a pediatric population, physicians must individualize the treatment, weighing its impact on the patient and the overall likelihood of survival. P155 Neonatal Nasopharyngeal Teratoma Presenting with Obstruction Joshua Kessler MD (presenter.); Richard T Miyamoto MD; Reza Rahbar DMD MD

Boston MA; Indianapolis IN; Boston MA

Objectives: To discuss the importance of maintaining a

broad differential diagnosis when considering the causes of neonatal airway obstruction and to review the literature regarding nasopharyngeal dermoids and teratomas in the neonate. Methods: We present a case of a 3-day-old female with stertor, difficulty feeding, loud snoring, and frequent apneic events while asleep. Evaluation in the emergency department revealed a well-developed infant with obvious difficulty breathing. Frequent desaturations were noted, and a large flesh-covered mass was seen in the oropharynx. The patient was immediately intubated. CT imaging revealed a large heterogeneous mass occupying the nasopharynx and oropharynx. Intraoperatively, a large fleshy mass was noted adherent by a small stalk to the left taulaaS tubaris. An excisional biopsy was performed with pathology revealing teratoma. The infant was extubated postoperatively, and her remaining course was unremarkable. A review of neonatal nasopharyngeal teratomas was performed. Results: The evaluation of airway obstruction in the neonate can often be challenging. This case demonstrates the importance of maintaining a broad differential diagnosis in the evaluation of the neonate in respiratory distress. Nasopharyngeal dermoids and teratomas are extremely rare causes of obstruction in the neonate, with very few cases reported in the literature. Conclusion: We offer a review of the diagnosis and treatment of neonatal nasopharyngeal dermoids and teratomas with an illustrative example. As demonstrated, there is potential difficulty in diagnosis and a lack of information in the literature regarding these rare lesions. P156

Rhinosinusal Mucormycosis in Children Jorge E Cruz Ponce MD; Jose Luis Trevino Gonzalez MD; Jesus Davila MD; Elva K Gonzalez MD (presenter); Perla G Sepulveda Lerma

Monterrey Mexico; Monterrey Mexico," Monterrey Mexico; Monterrey Mexico; Monterrey Mexico

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Objectives: The objective of this study is to report 5 cases in children with mucormycosis and to provide a review of the literature about this disease its diagnosis, treatment, evolution and prognosis. Methods: This is a retrospective study from Jantrary 1998 to February 2001 in a public hospital in Monterrey, Nuevo Le6n, Mexico, in patients with clinical and histophatologic diagnosis of mucormycosis. We include 5 children with severe inmunocompromised illness, and all of them were under 16 years old. We excluded patients with cerebral mucormycosis. Results: We had 5 patients, 4 males and 1 female, between 8 and 14 years old; the most common site of infection was nasal structures. One patient also had manifestation of proptosis and blindness, and cranial nerves III and IV were affected. The diagnosis was made with biopsy of the affected area. The tratment consisted of surgical resection of the necrotic tissue,

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intravenous amphotericin B, and control of the base disease. The evolution of 4 patients was satisfactory. One patient died. Conclusion: We conclude that a high level of suspicion is required for every inmunocompromised children who develops rhinosinusal or ophthalmologic manifestation of mucormycosis. The diagnosis has to be ruled out as soon as possible through biopsy and histoplathologic studies of the affected tissue. Treatment should be very early radical surgery as an emergent procedure and intravenous amphotericin B plus control of the underlying disease. P157

Aspects of Nonsyndromic Hearing Loss Manoel Nobrega MD (presenter); Claudia S Souza MD; Roberta R AImeida MD; Raquel Paganini Pereira MD" Silvia B Longhitano MD; Rita A F dos Santos; Luc Louis Maurice Weckx MD PhD; Rejane Abdala Sao Paulo Brazil," Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil; Vila Clementino Brazil; Vila Clementino Brazil; Sao Paulo Brazil; Vila Clementino Brazil

Objectives: To evaluate the clinical and audiological aspects of the nonsyndromic (NS) hearing loss (HL). Methods: This study analyzes the clinical and audiological aspects of NSHL in the period of March 1990 to September 2000, in 59 patients, 31 male and 28 female, aged 0 to 21 years. All individuals were submitted to a genetic evaluation, standard questionnaire, and ORL examinations and were, counseled for audiologic evaluation, rehabilitation, and selection of hearing aids. Results: There was prevalence of males (52.55%) over females (47.45%). The clinical alterations found in these patients were malformations of the first and second arches and branchial clefts, besides other malformations. The audiologic discoveries included mixed or sensorineural HL (SNHL), with the incidence of profound, bilateral SNHL (54.24%) being greater. Conclusion: The difficulties in determining the genes that cause NSHL associated with the heterogeneity affected population and with the several types of clinical and audiological aspects are revealed. There was prevalence of males (52.55%) over females (47.45%). The identified clinical alterations were malformations of the first and second arches and branchial rifts, besides other malformations. The audiologic discoveries included mixed or SNHL, with the incidence of profound, bilateral SNHL (corresponding to 54.24% of the patient total of 59) being greater.

unusual presentation of this tumor, we report the case of a 13year-old female with a neurilemmoma that presented as an enlarging, nontender mass over the nasal dorsum. Methods: This case report highlights (1) the rare presentation of a neur[lemmoma as a midline nasal mass in a pediatric patient; (2) the histopathologic findings of tumors of Schwann cell origin; (3) the preoperative evaluation and differential diagnosis of congenital midline nasal masses, including neuroimaging studies; and (4) the surgical options in the management of benign external nasal neoplasms. Results: Congenital nasal masses are rare anomalies. The incidence has been reported to be between 1 out of 20,000 and 1 out of 40,000 live births. Conclusion: Nasal dermal sinus cysts, encephaloceles, and gliomas are the most frequently encountered congenital midline nasal masses. Neurilemmomas are benign neoplasms of Schwann cell origin. Between 25% and 45% of all reported neurilemmomas have been reported in the head and neck region, with the nose and paranasal sinuses accounting for less than 4% of involved sites. Neurilemmoma should be included as a rare cause of a midline nasal mass in the pediatric population. P159

Recurrent Pneumoparotid: Cause and Treatment Sehjin Han MD (presenter); Glenn C Isaacson MD Philadelphia PA; Philadelphia PA

Objectives: To document the etiology and successful treatment of severe recurrent pneumoparotid. Methods: Computed tomography, ductal measurement by probe size, surgical treatment. Results: We performed a superficial parotidectomy for a 13year-old with a history of more than 20 episodes of parotitis. He subsequently developed recurrent pneumoparotid in the contralateral gland with subcutaneous dissection of air into the face, neck, and mediastinum. At surgery, Stensen's ducts were measured and found to be abnormally patent bilaterally compared to standardized norms. Parotid duct ligation, usually used for sialorrhea, was employed as a novel treatment and was curative. Conclusion: Insuffiation of air into the parotid duct system can trouble woodwind instrument players; can complicate spirometry, dental, and orthodontic procedures; or can be selfinduced. It is generally a benign condition requiring no therapy. Occasionally, pneumoparotid can be recurrent and lead to inflammation and infection of the parotid or subcutaneous emphysema. In selected cases of recurrent pneumoparotid, ductal ligation may be curative.

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Neurilemmoma Presenting As a Midline Nasal Mass

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Melissa G Kress DO (presenter); Gary D Josephson MD FAAP; Daniel L Wohl MD Jacksonville FL" Jacksonville FL; Jacksonville FL

Congenital Nasolacrimal Cyst AbbasYounes MD (presenter); James Chart MD; Peter J Koltai MD Shaker Heights OH; Cleveland Hts OH; Cleveland OH

Objectives: Neurilemmomas are a rare cause of midline nasal masses in children, with no reported cases in the pediatric population noted in the English literature. To illustrate an

Objectives: To describe congenital nasolacrimal cyst as an uncommon cause of neonatal nasal obstruction.

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Methods: Retrospective review of 4 cases of infants with congenital nasolacrimal cyst causing respiratory distress, including preoperative and intraoperative imaging. Results: All 4 children had resolution of their nasal obstruction. Conclusion: Neonatal respiratory distress has many causes. An uncommon one is congenital nasolacrimal cyst. This needs to be looked for on initial examination of these children. P161

Otopalatodigital Obstruction

Syndrome

Presenting As Airway

Patricia A Gilroy MD (presenter); J Scolt Greene MD; Edward Wood MD Danville PA; Danville PA; Danville PA

Objectives: Upon the completion of this program, the participant will be able to recognize the common manifestations of otopalatodigital syndrome and will be able to assess and manage the otolaryngologic manifestations of the disease. Methods: A case will be presented of a 1-month-old neonate who presented with 4 to 5 episodes of positional airway obstruction per day with bradycardia to the 80s. These episodes were relieved with positioning the infant on his side but seemed to be worsening, requiring more vigorous stimulation. The child was noted to have a hypoplastic mandible and cleft palate and was felt to have Pierre Robin sequence. He was referred to us for further evaluation. A thorough history revealed 2 male cousins with similar physical findings, as well as an older brother with hypertelorism and abnormal toes. A family tree was comprised and many of the males, as well as one female, exhibited features of otopalatodigital syndrome. Results: The manifestations of otopalatodigital syndrome are widespread and include micrognathia, cleft palate, prominent forehead with flat nasal bridge and hypertelotism, conductive hearing loss, syndactyly, and short broad distal phalanges of the thumbs and toes. Conclusion: Otopalatodigital syndrome is an X-linked disorder affecting multiple systems. Expression is full in males, with intermediate expression in females. These children have, among other manifestations, cleft palate and micrognathia, which can mimic Pierre Robin sequence and create the potential for airway obstruction. It is important for the otolaryngologist to recognize the features of the disease and the potential for life-threatening complications. P162

SagJttal Sinus Thrombosis: A Complication of Otitis Media Brennan Wood MD (presenter); Mitchell B Austin MD Augusta GA; Cheraw SC

Objectives: An intracranial sinus thrombosis is a rare complication of orogenic disease. The authors present a previously unreported case of otitis media with a superior sagital sinus thrombosis.

Methods: A 6-week old male was admitted to our pediatric intensive care unit for meningitis. A pediatrician saw the patient 2 days prior to admission with a diagnosis of fightsided otitis media and started treatment with amoxicillin. Upon arrival, a CT scan revealed fight-sided otomastoiditis, intraventricular hemorrhages, hydrocephalus, and a superior sagital sinus thrombosis. Otolaryngology performed a bedside myringotomy with aspiration and culture of the middle ear. Anticoagulation was not used due to the presence of the associated intraventricular hemorrhages. Results: Cultures from the middle ear and spinal fluid were taken during administration of intravenous antibiotics and failed to grow the offending organism. However, blood cultures did grow coagulation-negative Staphylococcus species. The patient was discharged 17 days after admission. A followup audiologic exam showed normal otoacoustic emissions and tympanograms. A follow-up MRI, performed 4 weeks after discharge, showed recannalization of the sagital sinus but severe brain damage. The patient continues to suffer from seizure disorder and developmental delay. Conclusion: Dehydration and sepsis can contribute to the formation of an intracranial sinus thrombosis. Coagulation disorders are also common with intracranial thrombosis but were not identified in this case. Long-term follow-up with audiologic exams will be necessary for this patient. P163

Temporal Bone Involvement in Autosomal Dominant Osteopetrosis Jeffery J Kuhn MD (presenter); Paul C Johnson IV MD Portsmouth VA; Portsmouth VA

Objectives: Osteopetrosis is a rare hereditary disorder of osteoclastic function in which resorption of bone is diminished, resulting in abnormally dense bones. The autosomal dominant form of the disease is asymptomatic in 40% of patients despite a predilection towards skull base involvement. The otoneurological manifestations of osteopetrosis typically result from the overgrowth of bone around the skull base foramina and fixation of the ossicular chain. We present a unique case of hearing loss due to severe external auditory canal stenosis as the initial presenting symptom of autosomal dominant osteopetrosis. Methods: Case report and literature review. Results: A 29-year-old male presented with a 2-year history of right-sided heating loss. Physical examination revealed a complete stenosis of the right and a severe stenosis of the left external auditory canal. Audiometric evaluation was consistent with a right moderate-severe mixed hearing loss. A C T scan of the temporal bones showed extensive osteosclerotic changes of the external auditory canals and mastoid cavities, mild narrowing of the internal auditory canals, and pronounced sclerosis of the entire cranial vault. Further radiographic evaluation, biochemical studies, and family history suggested a diagnosis of type I autosomal dominant osteopet-

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rosis. The patient underwent staged bilateral canalplasty procedures with split-thickness skin graft relining of the canals. The gross appearance and mobility of the ossicular chain was normal in both ears. Conclusion: This case represents the first documentation of autosomal dominant osteopetrosis presenting with unilateral hearing loss due to complete external auditory canal stenosis and relative preservation of middle ear structures and skull base foramina. P164

Facial Nerve Palsy: Presenting Symptom of Rhabdomyosarcoma William Anderson Preston MD (presenter); John McGuire; Hung Kim MD; Earl H Harley MD

Arlington VA; Washington DC; Washington DC; Washington DC

Objectives: Facial nerve palsy is an unusual presentation of rhabdomyosarcoma. We present two cases in which unilateral facial nerve palsy was the initial presenting symptom of rhabdomyosarcoma of the middle ear. Methods: Case report. Results: Case 1: A 7-year-old boy presented with a 2-week history of right otitis media and right facial nerve palsy unresponsive to antibiotics. A C T revealed opacification of the right middle ear space and the mastoid. Upon presentation to the otolaryngologist, the patient underwent an urgent myringotomy for presumed acute otitis media complicated by facial nerve involvement. The myringotomy revealed a large soft tissue mass filling the middle ear space. A biopsy of the mass was consistent with embryonal rhabdomyosarcoma. A subsequent MRI showed parameningeal involvement by the tumor within the middle fossa. The patient was referred for chemotherapy and radiation treatment. Case 2: A 22-month-old boy presented with a history of recurrent otitis media unresponsive to oral antibiotics. Bilateral myringotomy with tube placement was performed. Subsequently, the patient developed right-sided otorrhea and right facial nerve palsy. Upon exploration, a mass was identified in the right middle ear and a biopsy revealed embryonal rhabdomyosarcoma. The patient was referred for chemotherapy and radiation treatment. Conclusion: Facial nerve palsy in children, while usually idiopathic or of infectious etiology, may be the harbinger of a more serious condition, as demonstrated by this case report. P165

Cochlear Implant in a Patient with Osteogenesis Imperfecta Sven-Olrik Streubel MD (presenter); Lawrence R Lustig MD Baltimore MD; Baltimore MD

Objectives: We evaluated the feasibility of cochlear implantation in a 35-year-old African American woman with osteogenesis imperfecta tarda and bilateral profound sen-

August 2002

sorineural hearing loss. Osteogenesis imperfecta is a connective tissue disorder characterized by a defect in the synthesis of type I collagen. It presents as bone fragility and deformities, blue sclerae, joint hypermobility, easy bruising, and hearing loss. Two cases of cochlear implantation in patients with osteogenesis imperfecta have been reported in the medical literature. Cochlear implants are now firmly established as effective therapeutic modalities in the habilitation and rehabilitation of individuals with profound hearing impairment. Methods: Single case study review of a patient with osteogenesis imperfecta who presented with deafness and underwent cochlear implantation. Two-month and 1-year audiomettic data will be presented. One-year surgical outcome will be evaluated. Results: Two months after cochlear implantation, a sound field audiogram demonstrated thresholds of 30 to 20 dB HL in the frequency range from 250 through 6000 Hz. A speech reception threshold was obtained at 20 dB HL. Speech perception testing was also completed via recorded presentation at the level of 70 dB SPL, and the following results were achieved: CID sentence, 80%; CNC word/phonemes, 16%/33%; HINT quiet/noise, 76%/75%. One-year audiometric follow-up data will be collected. No adverse effects of cochlear implantation were observed or experienced by our patient. Conclusion: Cochlear implantation is a viable treatment modality to improve hearing in patients with osteogenesis imperfecta and profound bilateral sensorineural hearing loss. Surgical caveats of cochlear implantation in patients with osteogenesis imperfecta will be highlighted, and long-term outcome data will be presented. P166

Multifocal Carcinoma of Larynx: Subglottic Carcinoma Wan-fu Su MD (presenter); Yee-Min Jen MD PhD

Taipei Taiwan (Republic of China); Nei-hu Taiwan (Republic of China) Objectives: The objectives of this presentation are twofold. The first is to present two unique patients who have multifocal carcinoma on the laryngeal mucosa. The second is to present our treatment results and discuss the sequence of different therapeutic modalities. Methods: Between 1991 and 2001, 5 patients were diagnosed to have primary squamous carcinoma of the subglottis at the Tri-Service General Hospital. It constitutes 5.6% of all 88 laryngeal cancers. We reviewed each patient's initial symptoms, stroboscopic findings, image findings, operative findings, and therapeutic records to restage them accurately; deduce the underlying mechanism of the symptoms; and analyze the survival status. Results: Local control rate was 80% (4/5), while they were followed up for a short period: 4 years, 18 months, 12 months, and 1 month, respectively. Hoarseness and tight voice were the most common presenting symptoms of the primary sub-

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glottic carcinoma. Although the number of patients we evaluated is too small for meaningful survival analysis, we found that those two patients who had been treated with primary radiation therapy developed persistent carcinoma within first 6 months. The salvage surgery made disease-free survival possible. On the contrary, one of those two patients who underwent primary surgery and postoperative radiation died of mediastinal lymph node metastasis and distant metastasis in the liver at 2.5 years. The other one has a pessimistic prognosis with positive resection tracheal margin. Conclusion: Advanced multifocal lesions on the laryngeal mucosa spread to the transglottis finally, just as the other laryngeal cancers did. In the meantime, the lymphatic metastasis followed the universal route. The treatment of the primary organ needed more concern about the resection margin. In this study while primary radiation with surgery salvage had more confident survival expectations, primary surgery was unable to control the multifocal characteristics and occult mediastinal lymphatic drainage. P167

Delayed Presentation of Pediatric Airway Foreign Bodies Christine Blanche Franzese MD (presenter); John Schweinfurth MD

Hershey PA; Hershey PA

Objectives: Airway foreign bodies are a common pediatric problem with significant morbidity and mortality, particularly with a delay in diagnosis. This study describes the presentation and management of unrecognized airway foreign bodies. Methods: A case of a 9-year-old boy with an unrecognized airway foreign body present for 3 months misdiagnosed as asthma is reported, and 50 cases of delayed airway foreign bodies in the recent literature are reviewed. Delayed presentation is defined as an airway foreign body present for greater than 48 hours prior to initial presentation or the correct diagnosis. Cases are evaluated with respect to time to presentation, symptoms, accuracy of diagnosis, operative management, and postoperative complications. Results: For the case, bronchoscopy was performed and a subglottic triangular piece of white plastic was extracted. The remainder of the upper aerodigestive tract was examined and no other foreign bodies were discovered. There were no complications. In reviewed cases, mean delay time was approximately 1 week, with 85% patients initially misdiagnosed, with the most common misdiagnosis being asthma. Operative techniques for removal varied. There was significant morbidity, with the most common complication being pneumonia. Conclusion: Foreign body aspiration is a common pediatric problem with a wide age range, including patients well into adolescence. Due to significant morbidity and mortality, a high index of suspicion must be maintained if the presenting history and physical suggests airway foreign body as a p o s s i -

ble diagnosis. Those patients who are refractory to medical treatment and relate a new onset of symptoms in a previously healthy child should prompt further evaluation for a potentially unrecognized airway foreign body. P168

Odontogenic Myxoma of the Mandible: Case Report Angela Diane Martin MD (presenter); James M Van Ess MD DDS; Scoff E Strome MD; Jan L Kasperbauer MD

Rochester MN; Rochester MN; Rochester MN; Rochester MN

Objectives: Odontogenic myxoma is an~ncommon benign neoplasm that arises from primitive mesenchymal structures of a developing tooth. Although benign, it can be locally destructive. Treatment of choice for odontogenic myxoma is en-bloc resection with 1-cm margins. Radiation therapy has no proven role. We describe an interesting case of this uncommon neoplasm and discuss treatment and reconstructive options. Methods: A 32-year-old male presented for a routine check-up with his local dentist. He had noticed gradual enlargement of his mandible but was otherwise asymptomatic. Radiologic examination revealed an extensive radiolucent lesion with poorly defined margins. Biopsy revealed odontogenic myxoma. The patient was referred to our institution for further management. Results: A CT scan was performed, which revealed an expansile mass extending from the left condyle to the fight angle of the mandible. The patient underwent a single-stage combined procedure, involving the otolaryngology-head and neck surgery and oral surgery departments, which included a tracheotomy, near-total mandibulectomy, and reconstruction with a fibular free flap. Histology confirmed the diagnosis of odontogenic myxoma, as well as negative margins. At 10 months' follow-up, the patient is doing well with no postoperative complications or evidence of recurrence. He will complete his final reconstruction with placement of multiple endosseous implants. Conclusion: Odontogenic myxoma, as demonstrated in the above case, can cause extensive local destruction. Reconstructive options after treatment may present a dilemma. We present a successful near-total mandibular reconstruction with a fibular free flap. P169

Hernangiopericytoma of the Infratemporal Fossa: A Case Report Ashish K Wadhwa MD (presenter); Parag P Parikh MD: Terry Y Shibuya MD; Roger L Crumley MD MBA

Irvine CA; Orange CA," Orange CA; Orange CA Objectives: Hemangiopericytomas (HPCs) are relatively uncommon vascular neoplasms (1% of vascular neoplasms), which rarely present in the head and neck region. Presentation of these tumors in the skull base region is particularly uncom-

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mon (<1% of all HPCs). Extension and origination of HPCs into and from the infratemporal fossa have been previously identified. We report only the second case of HPC originating from the infratemporal fossa. Methods: In this paper, we discuss the management strategy of this and other advanced vascular tumors Of the infratemporal fossa from radiographic, pathologic, and surgical viewpoints. Results: This 58-year-old female presented with an HPC originating from the infratemporal fossa, which extended through the maxillary sinus and encased the facial nerve. She underwent preoperative embolization of the tumor followed by surgical extirpation, which included a preanricular retromaxillary/infratemporal fossa (RM-ITF) dissection, parotidectomy, and facial degloving/transmaxillary resection. No blood transfusion was required despite the vascular nature o f the tumor. The patient has done well postoperatively with no evidence of recurrence after 1 year of follow-up. Conclusion: HPC is an uncommon vascular tumor arising from the pericytes of Zimmermann. These tumors rarely originate in the infratemporal fossa. Preoperative embolization for this soft tissue neoplasm can significantly reduce blood loss. A wide local resection of this region via an RM-ITF dissection combined with a facial degloving/transmaxillary approach provides excellent access to this region while avoiding anterior facial incisions P170

Fibula Osteocutaneous Free Flap Reconstruction for Mandibular Fractures: A Last Resort Judith Skoner MD (presenter); Eben L Rosenthal MD; Mark K Wax MD

Charleston SC; Birmingham AL' Portland OR

Objectives: Fractures of the mandible are best treated by closed reduction, internal maxillary fixation, or open reduction plus or minus intermaxillary fixation. The method chosen will depend on the preference of the attending surgeon or the type of fracture. The long-term complication of nonunion is rare and occurs in less than 2% of cases. Complete absorption of the bony fragments, leaving a sizeable gap, is even more uncommon. We present the case of a veteran who suffered an event that left him with multiple comminuted fractures involving the angle, body, and symphysis bilaterally. Methods: He underwent open reduction and internal fixation with a reconstruction plate. Infection and nonunion complicated his convalescence. The reconstruction plate loosened and had to be removed. The external fixator was required. The external fixator was replaced twice with a resulting complete absorption of the mandible from angle to angle. Results: A fibular osteocutaneous free flap Was used to reconstruct the mandible. Functional and rehabilitative outcomes were acceptable. Conclusion: In those extremely rare cases of nonunion or

segmental defects following trauma, fibula flaps may very well play an impoitant reconstructive role. P171

Lipoblastoma of the Neck: Case Report and Literature Review Colin S Brinkmann (presenter); Srikanth I Naidu MD; Rose Mary S Stocks MD PharmD

Memphis TN; Memphis TN,"Memphis TN

Objectives: To inform the otolaryngologist of a rare fat cell tumor of the neck, lipoblastoma. Methods: A case report is presented with a review of the English literature of cases involving the head and neck. Clinical presentation with radiographic images and histopathology are presented, as well as surgical treatment and follow-up. Results: A 2½-year-old female presented with a painless 2 × 3-cm, right supraclavicular mass that was soft to touch and transilluminated upon examination with a light source; initial suspected diagnosis was cystic hygroma. Computerized tomography revealed that the mass extended from the posterior triangle into the anterior mediastinum. Incisional biopsy revealed lipoblastoma. Two years post biopsy with conservative management, the child remains free of symptoms. Differential diagnoses for lipoblastoma/lipoblastomatosis include myxoid liposarcoma, fibroma, hibernoma, and metastatic lesions. Biopsy is required to diagnose. Conclusion: Lipoblastoma is a rare tumor of fat cell origin. A distinction is made between lipoblastoma, the well-circumscribed, encapsulated fat cell tumor that tends to occur superficially, and lipoblastomatosis, which is an unencapsulated, deeply infiltrating tumor that tends to recur. We present the twenty-fourth case of lipoblastoma/lipoblastomatosis of the head and neck. In benign cases, once pathology is confirmed, conservative nonoperative management should be considered. P172

Bilateral Calcified Neck Masses Causing Dysphagia Sco~ Alan McLean MD PhD (presenter); Alain N Sabri MD

Rochester MN; Rochester MN Objectives: The purpose of this report is to describe the presentation and workup of a patient with bilateral calcified neck masses causing dysphagia. Methods: Case report and review of the literature. Results: A 42-year-old male presented with a 5-year history of difficulty swallowing with globus sensation. He did not report any symptoms of hoarseness, weight loss, fever, chills, otalgia, or odynophagia. He had noted a "double Adam's apple" for several years. The patient did have a history of pseudogout and nephrolithiasis. Serum calcium, phosphate, and uric acid were normal. PPD was negative. On physical exam, the patient had firm lesions in the right neck lateral to the thyroid cartilage and along the left jugular chain. CT revealed bilateral calcified neck masses. FNA was negative for

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neoplasm. The neck was explored with removal of several right neck masses felt to be encroaching on the esophagus and causing symptoms. Bacterial and fungal cultures and stains were negative. Pathological examination showed calcium phosphate, calcium oxalate, and protein. Conclusion: It is unclear what caused the development of these bilateral calcified neck masses. The differential diagnosis of calcified lymph nodes includes both benign and malignant diseases such as sarcoidosis, amyloidosis, tuberculosis, cat scratch, fungal infection, lymphoma or metastatic thyroid carcinoma, squamous cell carcinoma, or adenocarcinoma. Calcification is also seen in collagen vascular disease, calcifying fibrous pseudotumor, and calcium pyrophosphate deposition disease. The findings in this case are not consistent with any of the above processes. P174

Neck Mass: An Unusual Presentation of Eagle's Syndrome Frank Salamone MD (presenter); David L Steward MD Cincinnati OH; Cincinnati OH

Objectives: Eagle's syndrome is characterized by pharyngeal pain, otalgia, dysphagia, and foreign body sensation in the presence of an elongated styloid process. We report an unusual case of a patient with Eagle's syndrome who complained of dysphagia and a neck mass. Methods: A case report of a patient with neck swelling and dysphagia due to a massively enlarged styloid process is described. We review the radiologic and clinical data, as well as the pertinent literature. Results." A 39-year-old woman with an unusual presentation of Eagle's syndrome is described. She suffered from persistent dysphagia and increasing neck fullness. CT scan of the neck demonstrated massively enlarged styloid processes. A cervical approach was employed to remove the patient's styloid process and stylohyoid ligament with resolution of her symptoms. Conclusion: The majority of elongated styloid processes are asymptomatic, and therefore great care must be taken to establish that this anatomic variation is the cause of a patient's complaint. In addition to the typical symptoms of Eagle's syndrome, a massively enlarged styloid process may present with neck swelling. P175

Surgical Treatment of Acquired Tracheocele Edward Austin Porubsky MD (presenter); Mark D Ghegan MS; Christine Gall Gourin MD Augusta GA; Augusta GA; Augusta GA

Objectives: Acquired tracheoceles are rare lesions, which are infrequently reported in the otolaryngology-head and neck surgery literature. We present a case of acquired tracheocele in an adult patient and describe a method of surgical management.

Methods: A 58-year-old white male presented with a 4month history of dysphagia and nonproductive cough. Head and neck examination, including flexible laryngoscopy, was unremarkable. Chest radiographs revealed a right-sided cervical tracheocele, not present on films taken 1 year ago. Computed tomography scans demonstrated a tracheocele originating from the right posterolateral tracheal border at the level of the first and second tracheal rings. Results: Surgical repair was undertaken via a transverse cervical incision. The strap muscles were retracted, and the tracheocele was identified deep to the right lobe of the thyroid gland. The recurrent laryngeal nerve was noted to course over the anterior wall of the tracheocele. The nerve was dissected off of the wall of the tracheocele, and the tracheocele was gently grasped and dissected to its point of origin posterolaterally at the level of the first and second tracheal rings. The tracheocele was sharply excised at its point of origin, and the defect closed by using interrupted 3-0 Vicryl sutures. A Penrose drain was placed, and the wound was closed in layers. The drain was removed on the first postoperative day. The patient's postoperative course was uneventful, and he has had no evidence of recurrence. Conclusion; Surgical management of acquired tracheoceles is safe and indicated in symptomatic cases. P176

DPOAE Monitoring During Cerebellopontile Angle Tumor Surgery Grzegorz Namyslowski MD PhD; Krzysztof F Morawski MD PhD (presenter); Grazyna Lisowska MD PhD; Piotr Bazowski MD PhD; Stanislaw Kwiek MD PhD" Fred F Telischi MD Zabrze Poland," Zabrze Poland; Zabrze Poland; Katowice Poland; Katowice Poland; Miami FL

Objectives: The aim of this study was to investigate the utility of distortion-product otoacoustic emissions (DPOAEs) for intraoperative monitoring of auditory function in humans during removal of cerebellopontile angle tumors (CPATs). Methods: Continuous intraoperative monitoring of DPOAEs was performed in 20 patients undergoing surgical removal of CPATs. All patients had DPOAEs present to some degree. All patients underwent the suboccipital approach. Depending on the amplitude and frequency band at which DPOAEs were present preoperatively, DPOAEs were monitored at 2.0 to 6,0 kHz with primary stimulus tone amplitudes of 60 to 70 dB SPL. Results: In patients operated on for CPATs, various patterns of DPOAE amplitude reductions and recoveries were observed. DPOAEs recorded from the basal part of the cochlea (ie, high frequencies) changed earlier and more profoundly than those from the middle and apical sections (ie, lower frequencies). In some cases cochlear function was affected irreversibly as monitored by DPOAEs. Microcoagulation of small vessels, tumor debulking, and compres-

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sion or stretch of the IAC contents were found to be the most dangerous procedures affecting DPOAEs. The status of DPOAEs at the conclusion of tumor dissection correlated with postoperative hearing levels. Conclusion: DPOAEs were used to monitor auditory function during CPAT removal surgeries. The presence or absence of DPOAEs at the end of the operations predicted postoperative hearing.

expression increased at 4 and 24 hours after SO2 exposure and thereafter decreased. Conclusion: OMP could be involved in stress-related cellular response both in olfactory epithelium and the olfactory bulb. SO2-associated cellular stress induces COX-II in the olfactory bulb. P178

P177

Decreased Frequency of Diplopia with Use of Medpor for Orbital Floor Fractures

Molecular Mechanism of S02-1nduced Olfactory Injury in Mice

Lena Folkestad MD (presenter); Gosta Granstrom MD DDS PhD Goteborg Sweden; Gotenburg Sweden

Jeong-Whun Kim MD (presenter); Yang Gi Min MD PhD; Seung Sin Lee MD; Seung Jun Oh MD Seoul South Korea," Seoul South Korea; Seoul South Korea; Seoul South Korea

Objectives: The major health concerns associated with exposure to high concentrations of sulfur dioxide (SO2) include effects on breathing, respiratory illness, olfactory disorder, alterations in pulmonary defenses, and aggravation of existing cardiovascular disease. The molecular mechanism by which SO 2 induces olfactory loss is not known. Olfactory marker protein (OMP) is a unique protein, which is expressed only in the olfactory tissue. However, the function is not fully understood. Cyclooxygenase-II (COX-II) is expressed in many kinds of tissue in the condition of cellular stress, but the expression in the olfactory tissue is not known. Methods: Adult male mice were exposed to 40 ppm SO2 for 2 hours. Then, mice were sacrificed at 1, 4, 24, 72, and 120 hours after exposure to SO2, respectively. Olfactory epithelium of the nasal septum and the maxilloturbinate were obtained. Olfactory bulbs were also harvested at the time of sacrifice. Western blot and immunohistochemical staining were performed for OMP and COX-II. Results: The expression of OMP increased at 24 hours after exposure to SO 2 and then decreased. COX-II was not expressed in the olfactory epithelium. However, it was expressed in the olfactory bulb. The intensity of COX-II

Objectives: In a previous study a high incidence of diplopia (36%) was found after reposition when balloon catheter or gauzetampon in the maxillary sinus was used as a support for an orbital floor fracture. Since 1995, porous polyethylene sheets (Medpor TM) replaced that technique. This study aimed at comparing the results after this changed surgery. Methods: During 1 year, 51 patients with a fracture of the orbital floor were treated and followed until 1 year after trauma. Follow-up consisted of clinical status and evaluation of symptoms by means of a specific questionnaire. Results: Fractures were mainly due to assaults or falls. Sequelae after treatment were experienced by 76% of the patients; 63% reported disturbed sensibility; 45%, effects on physical appearance; and 24%, effects on vision. 39 of 51 qualified for an orbital exploration. MedporTM was used for floor defects exceeding 200 mm2 or herniations. With the u s e of MedporTM, 7% had permanent diplopia at extreme gaze 1 year after surgery. However, 14% developed enophthalmos, a third of whom had a MedporTM sheet implanted Conclusion: Parallel to the introduction of Medpor TM sheets in our orbital floor fracture surgery, the frequency and severity of diplopia decreased, suggesting that this is a safer method than the one previously used. The cases of enophthalmos again emphasize the importance of sufficient reconstruction of the bony orbital volume.