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Chronic sinusitis: A quantitative analysis of symptoms and correlation with computed tomographic scan findings
Otolaryngology Head and Neck Surgery P 166
August 1995
Scientific Posters
12
Negative Pressure Pulmonary Edema in the Otolaryngoiogy Patient JOHN D. GOLDENBERG, MD, LOUIS PORTUGAL, MD, RANDALL T, WEINGARTEN, and BARRY L. WENIG, MD, Chicago, III.
It is estimated that approximately 11% tO 12% of all patients requiring active intervention for acute upper airway obstruction develop negative pressure pulmonary edema (NPPE). This pathologic process typically has a benign and rapidly resolving clinical course with the prompt use of mechanical ventilation and positive end-expiratory pressure. However, a review of the literature has revealed a morbidity and mortality rate of up to 11% in many series. During the years 1991 through 1993, six patients were identified who developed NPPE after various otolaryngologic procedures. Five of the six patients (84%) had complete resolution of the pulmonary edema within 24 hours, whereas the sixth patient progressed to prolonged mechanical ventilation and eventual death. In an effort to further understand the pathophysiology Of this disease, a cardiac evaluation was performed using echocardiography on all six patients. In three of the six patients, studies revealed an underlying cardiac anomaly not previously identified on history or physical examination. Findings included one case of hypertrophic cardiomyopathy and two cases of pulmonary and tricuspid valvular insufficiency. The 16% complication rate in this series is not significantly different than the 11% complication rate noted in the literature. To the best of our knowledge, this is the first study to implicate an underlying cardiac etiology for the generation of NPPE. The 50% incidence of cardiac anomalies in our patient series is striking in contrast to the less than 1% incidence of these anomalies in the general adult population. Based on this study, we recommend that echocardiography be a part of the routine evaluation of all patients who manifest NPPE. 13 WITHDRAWN 14 Cervical Necrotizing Fasciitis: Factors Influencing Survival SANJAY KANTU, MD, BHUVANESH SINGH, MD, GADY HAR-EL, MD, and FRANK E. LUCENTE, MD, Brooklyn, N.Y.
Cervical necrotizing fasciitis (CNF) is an uncommon disease that carries mortality rates of 30% to 70%. In our review of the English literature, only 59 cases of CNF, mostly isolated case reports, have been found. We present a series of six patients with CNF, including four men and two women ranging in age from 25 to 73 years. This isone of the largest case series of patients with CNF reported. All six patients
were found to have a predisposing odontogenic source of infection. The most common presenting symptoms were neck swelling and dysphagia. Four patients had mediastinal involvement. In spite of aggressive surgical debridement and antibiotics, two patients died, one had a history of alcoholic cirrhosis, and one had a history of diabetes. On the basis of our experience, we recommend early and very aggressive debridement of the neck in CNF, with special attention to possible thoracic spread of disease. We examine factors that may predispose patients to acquiring this disease as well as factors influencing survival.
15 Chronic Sinusitis:A Quantitative Analysis of Symptoms and Correlation With Computed Tomographic Scan Findings MICHAEL A. SHTERNFELD,MD, and THOMAS R. PASIC, MD, Madison, Wis.
The symptoms of chronic sinusitis are usually but not always clearly recognizable. For example, in some patients the symptoms of allergic rhinitis are remarkably similar to the symptoms of chronic sinusitis. In these patients computed tomographic (CT) scans are often used to differentiate between the two diagnoses. However, the relationship between symptoms of chronic sinusitis, allergic rhinitis, and CT scan findings is not clear. For these reasons, we wished to (1) characterize the symptoms of chronic sinusitis, (2) relate the symptoms of chronic sinusitis with C T scan findings, and (3) investigate the relationship between symptoms of chronic sinusitis and allergic rhinitis. We prospectively collected information on the frequency and severity of 10 common symptoms of sinusitis in 49 patients with chronic sinusitis who also had CT scans available for review. CT scans were rated in accordance with three previously published rating scales and the degree of sinus opacification. Cluster analysis, correlation analysis, and ordinal logistic regression of the data were performed. The 10 symptoms separate into three clusters of symptoms. The first cluster consists of nasal congestion, hypogeusia, hyposmia, and asthma exacerbation. The second cluster includes rhinorrhea and postnasal drainage, and the third symptom cluster includes facial pain, headache, decreased energy, and ,'all symptoms together." Reduction from 10 symptoms to three symptom groups preserves 67% of the variance in the data. The first cluster of symptoms reliably correlates with CT scan stage and the degree of sinus opacification. This symptom group correlates better with CT scan findings than does any single symptom. The two other symptom clusters do not reliably correlate with CT scan findings. Patients with allergic rhinitis have higher scores in the first cluster than do patients without allergic rhinitis, even after controlling for severity of CT scan findings. In conclusion, a quantitative analysis of symptoms indicates that (1) symptoms of chronic sinusitis can be categorized into three groups or clusters, (2) CT scans correlate
Otolaryngology H e a d a n d N e c k Surgery V o l u m e 113
Scientific Posters
Number 2
with some but not all of the symptoms of chronic sinusitis, and (3) symptoms of allergic rhinitis are similar to some of the symptoms of chronic sinusitis but are not reflected in CT scan findings. 16
Total Quality Management for the Otolaryngologist RICHARD RAJARATNAM, MD, FRCS, FACS, Riverside, Calif.
Since the time of Edward Demming in the 1950s, the industrial environmenthas endeavored to focus on quality. These techniques are now being transposed into the medical care fields. Otolaryngology is not exempt from these methods. Total quality management (TQM) is a process for meeting and exceeding customer requirements. Our patients are our external customers. The traditional components of TQM are as follows: (1) patient-focused, continuous improvement, (2) analytic implementation, and (3) interpersonal strategies. These principles are encompassed in the following: (1) process recognition, (2) data collation, (3) root cause assessment, (4) options for continuous improvement, (5) implement of change, (6) measure of change, and (7) future planning. The poster will depict how the industrial model is applied to otolaryngologic patients. I will illustrate this as otitis media in children, which is undergoing changes in its management in recent times. This will be illustrated in the form of a quality road map as shown in the following summary: 1. Process recognition: Problems of otitis media in children 2. Data collation: History, physicial examination, and diagnostic tests 3. Root cause assessment; Treatment plans 4. Options: Medical/surgical therapy selection 5. Implement change: Implementation of selected therapy 6. Measure change: Follow-up 7. Future plans: Prevention of any complications The purpose of the poster is to help otolaryngologists use the TQM tools in the practices and to have this as template for other TQM projects in improving the care of their patients.
P 167
We report a case of fatal malignant degeneration of juvenile onset recurrent laryngotracheobronchial papillomatosis in a non-smoking, nonirradiated, 26-year-old patient. HPV type 6 was found within the patient's bronchial papillomas and a metastatic mediastinal lymph node. Prior reported cases of spontaneous malignant degeneration of recurrent respiratory papillomas are reviewed. Potential risk factors for the development of invasive carcinoma are assessed. The implications of currently available viral studies are discussed.
18 Normal Microbial Colonization of the Human Larynx MICHAEL G. MENDELSOHN, MD, HENRY D. ISENBERG, PHD, ALLAN L. ABRAMSON, MD, and BETTIEM. STEINBERG, PHD, New Hyde Park, N.Y.
The normal microbial flora has been documented in various body sites, including skin, conjunctive, oral cavity, pharynx, intestinal, and genitourinary tract. A few reports describe the presence of microbes in the larynges of laboratory animals but no similar human studies. Many have assumed that the larynx is either sterile or harbors very few organisms. Using a specially designed sheathed Culture swab (3.8 mm Accu Culshure Swab, Medical Laboratory Automation, Inc.), cultures were obtained from the larynges of 29 patients undergoing direct laryngoscopy. In 20 of these patients, cultures were also obtained from the pharynx using the same technique. Diagnoses included laryngeal papillomatosis, vocal cord polyps/nodules, squamous carcinoma, verrucous carcinoma, and structural abnormalities. Larynx cultures revealed the presence of microbes in 86% of patients. There were a surprisingly large number of species (26), including gram-positive aerobes, gram-negative fecal organisms, and yeasts. Streptococcus and Staphylococcus species predominated. Although pharynx cultures showed similar organisms, there was a discordance of 80% (16/20) when comparing pharynx versus larynx for the same patient. We conclude that there is a well-established microbial flora in the larynx that may be independent of the microorganisms in the pharynx.
17
Spontaneous Malignant Degeneration of Recurrent Respiratory PapiUomatosis 9LAURA A. GOGUEN, MD, SEEMA BYAHATTI, MD, and GREGORY GRILLONE, MD, Boston, Mass.
Recurrent respiratory papillomas are the most common benign laryngeal lesions in children. The lesions are now known to result from human papilloma virus infection, usually types 6 and 11. Progression to invasive carcinoma is a rare phenomenom and is most commonly associated with radiation therapy, tobacco use, or the two in combination. Less often malignant degeneration occurs without obvious 9inciting factors.
19
The Use of Laser-Assisted Uvulopalatoplasty for the Treatment of Snoring: Comparing Risk Factors to Results JOSEPH J. DONZELLI, MD, REGINA PALOYAN WALKER, MD, and ABHAY M. VAIDYA, MD, M a y w o o d , III.
An estimated 40 million people in the United States snore. Laser- assisted uvulopalatoplasty (LAUP) is increasingly being performed for the treatment of snoring. There is, however, relatively little reported data on the success of LAUP with respect to snoring. We have evaluated 541 patients for LAUP, 170 of whom have completed treatment. Of these 170 patiemts, 65 were
09 rv LLI I-r
O n
August 1995
Scientific Posters
12
Negative Pressure Pulmonary Edema in the Otolaryngoiogy Patient JOHN D. GOLDENBERG, MD, LOUIS PORTUGAL, MD, RANDALL T, WEINGARTEN, and BARRY L. WENIG, MD, Chicago, III.
It is estimated that approximately 11% tO 12% of all patients requiring active intervention for acute upper airway obstruction develop negative pressure pulmonary edema (NPPE). This pathologic process typically has a benign and rapidly resolving clinical course with the prompt use of mechanical ventilation and positive end-expiratory pressure. However, a review of the literature has revealed a morbidity and mortality rate of up to 11% in many series. During the years 1991 through 1993, six patients were identified who developed NPPE after various otolaryngologic procedures. Five of the six patients (84%) had complete resolution of the pulmonary edema within 24 hours, whereas the sixth patient progressed to prolonged mechanical ventilation and eventual death. In an effort to further understand the pathophysiology Of this disease, a cardiac evaluation was performed using echocardiography on all six patients. In three of the six patients, studies revealed an underlying cardiac anomaly not previously identified on history or physical examination. Findings included one case of hypertrophic cardiomyopathy and two cases of pulmonary and tricuspid valvular insufficiency. The 16% complication rate in this series is not significantly different than the 11% complication rate noted in the literature. To the best of our knowledge, this is the first study to implicate an underlying cardiac etiology for the generation of NPPE. The 50% incidence of cardiac anomalies in our patient series is striking in contrast to the less than 1% incidence of these anomalies in the general adult population. Based on this study, we recommend that echocardiography be a part of the routine evaluation of all patients who manifest NPPE. 13 WITHDRAWN 14 Cervical Necrotizing Fasciitis: Factors Influencing Survival SANJAY KANTU, MD, BHUVANESH SINGH, MD, GADY HAR-EL, MD, and FRANK E. LUCENTE, MD, Brooklyn, N.Y.
Cervical necrotizing fasciitis (CNF) is an uncommon disease that carries mortality rates of 30% to 70%. In our review of the English literature, only 59 cases of CNF, mostly isolated case reports, have been found. We present a series of six patients with CNF, including four men and two women ranging in age from 25 to 73 years. This isone of the largest case series of patients with CNF reported. All six patients
were found to have a predisposing odontogenic source of infection. The most common presenting symptoms were neck swelling and dysphagia. Four patients had mediastinal involvement. In spite of aggressive surgical debridement and antibiotics, two patients died, one had a history of alcoholic cirrhosis, and one had a history of diabetes. On the basis of our experience, we recommend early and very aggressive debridement of the neck in CNF, with special attention to possible thoracic spread of disease. We examine factors that may predispose patients to acquiring this disease as well as factors influencing survival.
15 Chronic Sinusitis:A Quantitative Analysis of Symptoms and Correlation With Computed Tomographic Scan Findings MICHAEL A. SHTERNFELD,MD, and THOMAS R. PASIC, MD, Madison, Wis.
The symptoms of chronic sinusitis are usually but not always clearly recognizable. For example, in some patients the symptoms of allergic rhinitis are remarkably similar to the symptoms of chronic sinusitis. In these patients computed tomographic (CT) scans are often used to differentiate between the two diagnoses. However, the relationship between symptoms of chronic sinusitis, allergic rhinitis, and CT scan findings is not clear. For these reasons, we wished to (1) characterize the symptoms of chronic sinusitis, (2) relate the symptoms of chronic sinusitis with C T scan findings, and (3) investigate the relationship between symptoms of chronic sinusitis and allergic rhinitis. We prospectively collected information on the frequency and severity of 10 common symptoms of sinusitis in 49 patients with chronic sinusitis who also had CT scans available for review. CT scans were rated in accordance with three previously published rating scales and the degree of sinus opacification. Cluster analysis, correlation analysis, and ordinal logistic regression of the data were performed. The 10 symptoms separate into three clusters of symptoms. The first cluster consists of nasal congestion, hypogeusia, hyposmia, and asthma exacerbation. The second cluster includes rhinorrhea and postnasal drainage, and the third symptom cluster includes facial pain, headache, decreased energy, and ,'all symptoms together." Reduction from 10 symptoms to three symptom groups preserves 67% of the variance in the data. The first cluster of symptoms reliably correlates with CT scan stage and the degree of sinus opacification. This symptom group correlates better with CT scan findings than does any single symptom. The two other symptom clusters do not reliably correlate with CT scan findings. Patients with allergic rhinitis have higher scores in the first cluster than do patients without allergic rhinitis, even after controlling for severity of CT scan findings. In conclusion, a quantitative analysis of symptoms indicates that (1) symptoms of chronic sinusitis can be categorized into three groups or clusters, (2) CT scans correlate
Otolaryngology H e a d a n d N e c k Surgery V o l u m e 113
Scientific Posters
Number 2
with some but not all of the symptoms of chronic sinusitis, and (3) symptoms of allergic rhinitis are similar to some of the symptoms of chronic sinusitis but are not reflected in CT scan findings. 16
Total Quality Management for the Otolaryngologist RICHARD RAJARATNAM, MD, FRCS, FACS, Riverside, Calif.
Since the time of Edward Demming in the 1950s, the industrial environmenthas endeavored to focus on quality. These techniques are now being transposed into the medical care fields. Otolaryngology is not exempt from these methods. Total quality management (TQM) is a process for meeting and exceeding customer requirements. Our patients are our external customers. The traditional components of TQM are as follows: (1) patient-focused, continuous improvement, (2) analytic implementation, and (3) interpersonal strategies. These principles are encompassed in the following: (1) process recognition, (2) data collation, (3) root cause assessment, (4) options for continuous improvement, (5) implement of change, (6) measure of change, and (7) future planning. The poster will depict how the industrial model is applied to otolaryngologic patients. I will illustrate this as otitis media in children, which is undergoing changes in its management in recent times. This will be illustrated in the form of a quality road map as shown in the following summary: 1. Process recognition: Problems of otitis media in children 2. Data collation: History, physicial examination, and diagnostic tests 3. Root cause assessment; Treatment plans 4. Options: Medical/surgical therapy selection 5. Implement change: Implementation of selected therapy 6. Measure change: Follow-up 7. Future plans: Prevention of any complications The purpose of the poster is to help otolaryngologists use the TQM tools in the practices and to have this as template for other TQM projects in improving the care of their patients.
P 167
We report a case of fatal malignant degeneration of juvenile onset recurrent laryngotracheobronchial papillomatosis in a non-smoking, nonirradiated, 26-year-old patient. HPV type 6 was found within the patient's bronchial papillomas and a metastatic mediastinal lymph node. Prior reported cases of spontaneous malignant degeneration of recurrent respiratory papillomas are reviewed. Potential risk factors for the development of invasive carcinoma are assessed. The implications of currently available viral studies are discussed.
18 Normal Microbial Colonization of the Human Larynx MICHAEL G. MENDELSOHN, MD, HENRY D. ISENBERG, PHD, ALLAN L. ABRAMSON, MD, and BETTIEM. STEINBERG, PHD, New Hyde Park, N.Y.
The normal microbial flora has been documented in various body sites, including skin, conjunctive, oral cavity, pharynx, intestinal, and genitourinary tract. A few reports describe the presence of microbes in the larynges of laboratory animals but no similar human studies. Many have assumed that the larynx is either sterile or harbors very few organisms. Using a specially designed sheathed Culture swab (3.8 mm Accu Culshure Swab, Medical Laboratory Automation, Inc.), cultures were obtained from the larynges of 29 patients undergoing direct laryngoscopy. In 20 of these patients, cultures were also obtained from the pharynx using the same technique. Diagnoses included laryngeal papillomatosis, vocal cord polyps/nodules, squamous carcinoma, verrucous carcinoma, and structural abnormalities. Larynx cultures revealed the presence of microbes in 86% of patients. There were a surprisingly large number of species (26), including gram-positive aerobes, gram-negative fecal organisms, and yeasts. Streptococcus and Staphylococcus species predominated. Although pharynx cultures showed similar organisms, there was a discordance of 80% (16/20) when comparing pharynx versus larynx for the same patient. We conclude that there is a well-established microbial flora in the larynx that may be independent of the microorganisms in the pharynx.
17
Spontaneous Malignant Degeneration of Recurrent Respiratory PapiUomatosis 9LAURA A. GOGUEN, MD, SEEMA BYAHATTI, MD, and GREGORY GRILLONE, MD, Boston, Mass.
Recurrent respiratory papillomas are the most common benign laryngeal lesions in children. The lesions are now known to result from human papilloma virus infection, usually types 6 and 11. Progression to invasive carcinoma is a rare phenomenom and is most commonly associated with radiation therapy, tobacco use, or the two in combination. Less often malignant degeneration occurs without obvious 9inciting factors.
19
The Use of Laser-Assisted Uvulopalatoplasty for the Treatment of Snoring: Comparing Risk Factors to Results JOSEPH J. DONZELLI, MD, REGINA PALOYAN WALKER, MD, and ABHAY M. VAIDYA, MD, M a y w o o d , III.
An estimated 40 million people in the United States snore. Laser- assisted uvulopalatoplasty (LAUP) is increasingly being performed for the treatment of snoring. There is, however, relatively little reported data on the success of LAUP with respect to snoring. We have evaluated 541 patients for LAUP, 170 of whom have completed treatment. Of these 170 patiemts, 65 were
09 rv LLI I-r
O n