Scientific Posters

Scientific Posters

1 Hoarseness, Dysphagia, and Cervical Lymphadenopathy as the Presentation of Multiple Myeloma JAMES K FORTSON MD, Tucker GA

Objective: The objective of this paper is to present an unusual manifestation of multiple myeloma and review the head and neck manifestations of this disease. The workup, etiology, clinical presentation, differential diagnosis, treatment options, prognosis and survival rates will be discussed. Methods: A case report of a 71-year-old male with a one year history of hoarseness, dysphagia, and left shoulder pain is presented. Physical examination revealed left sided deviation of the tongue, left vocal cord paralysis, and cervical lymphadenopathy. CAT scan and MRI revealed a left skull base mass: a moderate normochromic normocytic anemia. Panendoscopy confirmed a left sided vocal cord paralysis. Cervical node biopsy and bone marrow aspirate revealed multiple myeloma. The patient was started on chemotherapy and radiation but died six months after the initial diagnosis. Results: Multiple myeloma is a malignant disease of plasma cells with a poor overall prognosis. The medical survival rates range between one to two years. Our patient died six months after the initial diagnosis. Conclusions: Multiple myeloma is the most common plasma cell cancer of the osseous system. The peak age is between the fifth to sixth decade of life with a slight female predominance. Bone marrow biopsy is essential for diagnosis. The base of skull may be affected with neoplastic infiltration of plasm cells. Hoarseness, dysphagia, and cervical node metastasis are uncommon presenting signs of multiple myeloma. Treatment options include chemotherapy and radiation for palliation depending on the stage of the disease at the time of diagnosis. Median survival rates range between one to two years. 2

The poster presentation shows a meta analysis of case reports, gives an overview of recent basic research on paragangliomas, presents basic and advanced diagnostic tools and illustrates a variety of treatment options by case reports from a Norwegian University Clinic. Methods: A meta analysis of relevant publications in the period 1980-1995 put together by standard statistical methods reveals significant differences in treatment procedures, a variety of anatomical locations and the difficulties in the prediction of malignant tumors. Case reports illustrate the issue as tympanic paraganglioma, supraglottic laryngeal lesion, tumor in the carotic bifurcation and a parapharyngeal extension of a glomus jugular tumor. A radiotherapy (RT) regimine with 3D axial CT/MRI reconstruction is presented. Diagnostic and methodological issues are discussed as 111-In-octreotide scintigraphy, MRI angiography, superselective arterio-venous angiography and PET. Results: Paragangliomas represent less than 0.5% of tumor lesions in the head and neck; about 4-5% are malignant (evaluated by the clinical course in the individual patient). The meta analysis reveals various, specific and individualized treatment procedures as radical reconstructive surgery, CO2-laser surgery in the larynx, otomicrosurgery in the tympanic space, radiation therapy in some advanced tumors or elderly patients and palliation-chemotherapy in malignant tumors. There is an improvement both in long term survival and functional outcome (preservation of cranial nerve function) and post treatment quality of life for the individual patient as well. Conclusions: Diagnosis and treatment of paragangliomas in the head and neck are a challenge both to clinical observation, differential diagnostic evaluations and a choice of therapeutic intervention in the individual patient. In recent years there has been improvement in diagnostics by scintigraphic methods, advanced MRI and angiology; likewise there are more treatment options in larynx surgery by use of laser and in RT by axial computed and precise targeted EX-RT. The exact histopathologic differentiation between benign and malignant paraganglioma lesions is still unsolved.

Paragangliomas in Head and Neck: Challenges to Diagnosis and Treatment

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HELMUT ABENDSTEIN MD, Trondheim Norway

Jugular Diverticulum: Clinical Significance

Objective: Paragangliomas in the head and neck region are rare lesions arising from nonchromaffine glomus bodies as glomus caroticum, jugular, laryngeus or in the tympanic space. August 1998

HUSSAM K EL-KASHLAN MD, Ann Arbor MI

Objective: A high riding jugular bulb extending into the middle ear is not uncommon. A jugular diverticulum, considOtolaryngology–Head and Neck Surgery

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POSTERS

The scientific posters provide an opportunity for visual presentation of charts, drawings, and photographs, supplemented with one or two pages of text. Authors will post the times they will be available for questions. The posters will be open from 7:00 am to 8:00 pm.

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Scientific Posters

ered a true venous anomaly, is however rare with only eighteen cases reported in the English literature. This paper reports on three patients who presented with pulsatile tinnitus and were found to have jugular diverticula. The presentation of jugular diverticulum with pulsatile tinnitus has not been previously reported. Methods: The three cases are presented and the literature is reviewed. Results: Jugular diverticulum is an out-pouching of the jugular bulb that extends superiorly, medially and posteriorly in the temporal bone often causing bone remodeling. Depending on the degree of extension, the cochlear and vestibular aqueducts, the endolymphatic sac, the posterior semicircular canal and the internal auditory canal can be involved. Presenting symptoms can include sensorineural hearing loss, vertigo, and tinnitus. The pulsatile tinnitus is likely due to turbulent blood flow in the diverticulum. High resolution computerized tomography with bone algorithm and 1.0 or 1.5 mm thick sections is the method of choice to evaluate the vascular anatomy of the temporal bone. This is of special importance if transtemporal surgery is contemplated to avoid inadvertent injury of anomalous vascular structures. Conclusions: Whether the diverticulum represents a stable congenital anomaly or a pathologic progressive process that is capable of expanding is still unclear. Follow-up imaging studies are needed to clarify this issue.

5 Nonpenetrating Extracranial Internal Carotid Artery Pseudoaneurysm Presenting as a Horner's Syndrome STEVEN F ISENBERG MD, Indianapolis IN

Objective: To present the clinical presentation and surgical repair of an extracranial false aneurysm in a patient involved in a fist fight. Methods: The case of a 39-year-old male patient presenting with an ipsilateral ptosis and miosis (Horner's syndrome) 36 hours after blunt trauma is presented. A pseudoaneurysm of the extracranial internal carotid artery is diagnosed with arteriography. The diagnosis was missed with intracranial and cervical magnetic resonance angiography. Results: A high cervical pseudoaneurysm of the internal carotid artery was repaired without the need for mandibular dislocation. Conclusions: Traumatic nonpenetrating extracranial false aneurysm of the internal carotid artery is rare and difficult to diagnose. While it is often associated with neurologic findings, this case reports an unusual presentation with an isolated Horner's syndrome. A high index of suspicion with appropriate radiologic imaging is required. When surgical repair is indicated, oversewing of the false aneurysm can be safely accomplished utilizing a vascular shunt. Temporary mandibular subluxation may be required for adequate exposure.

6 4 Anterior Longitudinal Temporal Bone Fracture Causing Facial Nerve Paralysis: Report of Two Cases JEFFERY J KUHN MD, Virginia Beach VA

Objective: Longitudinal temporal bone fractures are classically described as originating in the posterior aspect of the temporal squama and extending anteromedially along the long axis of the petrous bone towards the clivus. Although the anteromedial extent of the fracture is often consistent in its location, the lateral extent may occur at various locations along a vertical plane from the zygoma anteriorly to the mastoid bone posteriorly. Longitudinal fractures resulting from isolated trauma to the zygoma are rare and their association with facial nerve paralysis is extremely uncommon. We report two cases of immediate onset facial nerve paralysis following acute traumatic injuries to the pre-auricular region resulting in fractures of the zygoma and glenoid fossa extending to the perigeniculate area. Methods: Surgical exploration was undertaken in both cases following evidence of greater than 90% degeneration of facial nerve fibers on electroneuronography. Injured segments of the facial nerve were explored by the transmastoid-middle cranial fossa approach in one case and by a wide canalplastymiddle cranial fossa technique in the other. Approaches were selected on the bases of temporal bone computed tomography and audiologic findings.

Clinical Manifestations of the Variants of the Nasal Aerodynamics YURI PETROVICHE ULIYANOV MD PHD, Moscow Russia

Objective: With the advent of a special device (Y.P. Ulyanov, P.P. Polivanov, 1988), the study of the nasal aerodynamics has acquired an ever-increasing value, because the following questions have been already worked out: the normogram of the nasal aerodynamics has been determined; two extreme variants of the nasal aerodynamics have been detected ("the northern and the southern"); a plastic surgical method has been developed to convert the "southern" variant into the "northern"; twelve types of the "physiological bridge" near the nasal valve have been identified (Y.P. Ulyanov, 1977). Methods: To study transitional forms of the nasal aerodynamics, 1,000 patients who suffer from frequent fits of common cold and 300 practically healthy people, aged 2 to 86 years, have been selected. The proportion of men to women was approximately equal. On the basis of the nasal aerodynamics, seven groups have been chosen with a difference of ten conditional units (CU) entering at the inspiration through the medial nasal passage: from 20 CU of the "southern" type to 80 CU of the "northern" type. The subsequent comparison of various groups of the nasal aerodynamics and their clinical manifestations has led to establishing a number of coincidences whose complex reflects certain principles of correlation between clinical manifestations and variants of the nasal aerodynamics.

Otolaryngology– Head and Neck Surgery Volume 119 Number 2

7 Delayed Blindness after Functional Endoscopic Sinus Surgery WILLIAM R SPENCER MD, New York NY

Blindness as a result of endoscopic sinus surgery is a major concern to the head and neck surgeon. Loss of vision is an uncommon complication which is usually immediate, temporary, and unilateral; however permanent bilateral blindness has been reported. Frequently the cause of iatrogenic blindness is felt to be the result of intraoperative sequelae. Most often a check of visual acuity is performed in the immediate postoperative period and if the vision is normal, blindness is no longer felt to be a risk. Here we present a case of a patient who underwent endoscopic sinus surgery with normal vision postoperatively who subsequently developed blindness not as a result of optic nerve sequelae, but as a result of a postoperative psuedomonas infection.

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8 On Contraindications to Septoplasty YURI PETROVICHE ULIYANOV MD PHD, Moscow Russia

Objective: Modern septoplasty really leads to improvement in the nasal breathing, recovery of which serves as a criterion of the efficiency of surgery. However, due to the development of our knowledge of the nasal aerodynamics with detection of the "northern" and the "southern" types, each of which provides for the nasal breathing to its full extent but possesses differing protective possibilities, criteria of the efficiency of septoplasty and indications to the same demand a reconsideration. Methods: An examination was carried out in 150 patients with distorted nasal septum who have been offered septoplasty due to complaints of disturbed nasal breathing. The age range was from 16 to 37. There were 97 males. After congestion of the nasal mucosa was stopped, in all patients the nasal aerodynamics were assessed. This has permitted determination of three main differences with traditional indications to septoplasty shown in the following three cases. Results: The examination of the nasal aerodynamics has detected: Case 1. When the nasal breathing was disturbed at the right, there was a distortion of the nasal septum to the right with a "physiological bridge" being formed near the nasal valve typical for the "northern" type of the nasal aerodynamics. Disturbed breathing at the right is caused by inflammatory congestion. Case 2. When the nasal breathing was disturbed at the right, a spine of the nasal septum at the right has been found which reached the inferior turbinate bone to form a kind of the airdirecting "steering gear" at the nasal valve dividing the inferior and medial nasal passages according to the type of the "northern" variant of the nasal aerodynamics. Disturbed nasal breathing is caused by inflammatory congestion. Case 3. A distortion of the nasal septum to the right forms the "physiological bridge," whereas hypertrophy of the inferior turbinate bone to the left, reaching the nasal septum, also forms the "physiological bridge" according to the type of the "northern" variant of the nasal aerodynamics. Disturbed nasal breathing is caused by vasomotor congestion. Conclusions: 1. If a distortion of the nasal septum forms the "northern" variant of the nasal aerodynamics, septoplasty must not be carried out in order not to destroy the already formed protective mechanism of the nasal aerodynamics. 2. With the increased spine of the nasal septum to reach the inferior turbinate bone at the nasal valve, the air-directing “steering gear" is formed (cicatricial bridges and unions in this area also form the air-directing "steering gear") typical for the "northern" type of the nasal aerodynamics. It is impermissible to remove this spine (scars, unions) to avoid destruction of the protective mechanism of the nasal aerodynamics. 3.When the nasal septum is deformed in such a way that the "northern" type of the nasal aerodynamics appears at one side with the "southern" one being formed at the opposite side, to recover the protective function of the nose at the opposite

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Results: The most striking criterion of difference between various groups of the nasal aerodynamics has turned out to be distribution of the airflow between the inferior and medial nasal passages, making up 100% of CU in every group, so that when 20 CU enter the medial nasal passage, 80 CU enter the inferior nasal passage, etc. As a result, along with the transition of the airflow from the medial nasal passage to the inferior one, clinical manifestations change, reflecting a decrease in the protective properties of the nasal aerodynamics. The moment of the transition of the main airflow at inspiration from the medial nasal passage to the inferior one has turned out to be the critical one, as the value from 80 to 60 CU at inspiration entering through the medial nasal passage means that patients are practically healthy and catch a cold very seldom (once in 4-5 years), whereas the value from 50 to 20 CU means that they catch cold several times every year (from one to four). At the same time, the subatrophic process of the mucosa of the superior inspiratory ways (SIW) develops and increases at the values from 60 to 30 CU, whereas at 20 CU the atrophic process of the mucosa of the SIW arises. This is evidence of the increasing decline in the protective properties of the nasal aerodynamics with corresponding clinical manifestations: otitis in the groups with 50 to 30 CU, sinusitis in the groups with 50 to 20 CU, vasomotor rhinitis in the groups with 60 to 30 CU, tracheobronchitis in the groups with 40 to 20 CU, laryngospasms in the groups with 30 to 20 CU, bronchial asthma in the groups with 30 to 20 CU, pneumonia in the groups with 40 to 20 CU, and ozena in the group with 20 CU. Recommendations have been presented. Conclusions: The detected results of the direct correlation between clinical manifestations and alterations in the nasal aerodynamics confirm the significant role of the features of distribution of air flows between the inferior and medial nasal passages, which is important and should be considered in screening for the groups of risk, in professional tests, and while performing endosurgery of the nose, to preserve the protective properties of the nasal aerodynamics.

Scientific Posters

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Scientific Posters

side, surgical construction of a new air-directing "steering gear" is indicated to unite the anterior edge of the inferior turbinate bone with the nasal septum and to separate the inferior and medial nasal passages in order to form thereby the “northern” type of the nasal aerodynamics also at this side. 4. When there is a compensatory distortion of the nasal septum, when the nasal breathing, after stopping nasal mucosal congestion at both sides, restores and corresponds to the "northern" type, septoplasty must not be performed to avoid destruction of the existing protective mechanism of the nasal aerodynamics. 9 Endoscopic Assisted Adenoidectomy (EAA) C RON CANNON MD, Jackson MS

Objective: Adenoidectomy is a commonly performed procedure. The advent of endoscopic sinus surgery has popularized the use of endoscopes. EAA is a natural progression of this technology, allowing a more complete adenoidectomy. Methods: Two hundred fifty patients undergoing adenoidectomy were evaluated using an endoscopic technique. A routine transoral adenoidectomy was performed first. Then a 4 mm 0˚ telescope was used transnasally and residual adenoid tissue removed from the anterior superior nasopharynx. Results: Invariably residual adenoid tissue was found after transoral adenoidectomy. The EAA technique is minimally invasive, adds less than five minutes to the procedure and is not associated with excessive bleeding. Commonly used telescope and endoscopic equipment are used. Conclusions: The EAA technique is advocated for use as an adjunct to more complete adenoidectomy. 10 Endoscopic CSF Rhinorrhea Repair: Is a Lumbar Drain Necessary? ROY R CASIANO MD, Miami FL

Objective: To determine the necessity for lumbar drains during endoscopic cerebrospinal fluid (CSF) rhinorrhea repair. Methods: Twenty-three patients underwent repair of a spontaneous iatrogenic cerebrospinal fluid (CSF) leak without a lumbar drain over a 5-year period. The size of the dural defect ranged from a micro-leak (less than 1 mm dural defect) to a 3 cm dural defect of the anterior skull base. Results: All of the patients with small defects (less than 5 mm) were performed on an outpatient basis. Twenty-two patients (96%) had complete resolution of their CSF leak after one procedure without any recurrences after a minimum of 6 month follow-up. Conclusions: A lumbar drain is not routinely necessary for successful closure of CSF rhinorrhea of any size. Smaller dural defects can safely be performed on an outpatient basis with no complications.

11 Site of Lesion and Voluntary Eye Movement Deficits ELINA ISOTALO MD, Helsinki Finland

Objective: Lesions in the central vestibular system are considered to disturb tracking eye movements, whereas saccades are affected to some extent only. The aim was to study the extent of disturbances of voluntary eye movements that can be related to the site of lesion. Methods: Constant saccades (CS), pseudorandom saccades (PRS) and pseudorandom pursuit eye movements (PRPEM) were tested in 45 healthy controls, 35 patients with cerebellopontine-angle (CPA) tumor, 20 patients with hemangioblastoma, 20 patients with infarction of cerebello-brainstem and 34 patients with Meniere's disease. Controls were grouped healthy. The CPA tumor patients were grouped into the brainstem group or to the peripheral group according to the size of tumor. Hemangioblastoma and infarction patients were grouped according to the MR findings into the brainstem, cerebellar or cerebello-brainstem group. Meniere patients were grouped into the peripheral group. Discrimination analysis was done. Results: With CS 48% of all cases, with PRS 49% of all cases, and with PRPEM 40% of all cases could be placed into the correct groups determined by the site of lesion (i.e. nonaffected, brainstem, cerebello-brainstem, cerebellar, peripheral). In both saccade tests, healthy subjects were correctly classified as non-affected in 80% of cases, whereas in PRPEM only 45% of healthy subjects were classified so. In CS, 47% of cerebellar cases were correctly classified into the cerebellar group. In PRS, 53% of cerebellar cases and 58% of cerebello-brainstem cases were correctly classified into the right groups. With PRPEM 53% of peripheral cases were correctly placed into the peripheral group. Conclusions: Based on saccade tests (CS and PRS) healthy subjects could be differed accurately from patients with peripheral or central lesions, whereas PRPEM was poor in this task. That was caused from the fact that there was a large variability (caused by vigilance, interest) in the results of PRPEM of even healthy controls. The meaning of voluntary eye movement tests is a minor one in predicting the site of lesion in vertigo patients.

12 Reconstruction of Inferior Turbinate ZAIN U KADRI MD, Anaheim CA

Objective: Loss of inferior turbinate due to disease, trauma, or surgical resection has a severe adverse impact on nasal function. In order to restore the normal functions of inferior turbinate a surgical procedure has been devised by the author to reconstruct the inferior turbinate. Methods: The procedure consists of an auricular cartilage graft to substitute the lost turbinate concha and covering it with a buccal mucosal flap tunneled through the pyriform aperture.

Otolaryngology– Head and Neck Surgery Volume 119 Number 2

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Results: The buccal mucosal flap provides sufficient moisture in the nose. There is also increased nasal resistance due to the bulk created by the cartilage. There is marked decrease in patient's symptoms of dryness, headache, and postnasal discharge. Conclusions: This procedure appears to be an effective method of reconstructing the lost inferior turbinate. This procedure restores normal structure of the inferior turbinate by providing a core of firm tissue surrounded by mucosa.

with relocation of the submandibular duct. This provides safe and effective management of oral cavity ranulas with good long-term results.

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Objective: Cricotracheal resection is a recently described procedure to treat pediatric subglottic stenosis. One of the morbidities of this operation is injury to the recurrent laryngeal nerves (RLN). This study evaluated different techniques and the efficacy of RLN monitoring during this procedure. Methods: Nine felines with bilateral mobile vocal cords underwent cricotracheal resections. Using electromyography (EMG) electrodes, the left vocal cord of each feline was monitored by one of three nerve monitoring techniques. The function and pathology of the vocal cords and RLNs were evaluated postoperatively. Results: One-third (33%) of the felines demonstrated a unilateral vocal cord paresis/paralysis postoperatively. One-ninth (11%) of the control cords were affected; whereas, two-ninths (22%) of the monitored cords were affected. Of the three nerve monitoring techniques used, direct placement of electrodes into the vocal cords via the thyroid cartilage was the most efficacious. Conclusions: In this study more injury to the RLNs occurred on the monitored side versus the control side. Future studies are needed to evaluate the efficacy of RLN monitoring during cricotracheal resections using a larger population size and previously operated patients. The best method of RLN monitoring was placement of EMG electrodes into the vocal cords via the thyroid cartilage.

NATHAN MONHIAN MD; ADITI H MANDPE MD; ANDREW H MURR MD, San Francisco CA

Objective: Many systemic illnesses have associated head and neck manifestations. This report presents an unusual initial presentation of syphilis with oral and nasal lesions. Methods: A young man with tongue plaques and nasal papules presented for evaluation. The diagnosis of syphilis was confirmed by biopsy and serologic studies. Clinical and pathological photographs are provided for review. Results: The patient was treated with intramuscular penicillin with rapid and complete resolution of symptoms. Conclusions: The differential diagnosis of oral and nasal lesions is quite extensive. Otolaryngologists should remain aware of syphilis—“the great masquerader”—in the management of these lesions since special studies are often required for confirmation of diagnosis.

14 Surgical Management of the Pediatric Ranula with Oneyear Follow-up RAJIV T PANDIT MD; ALBERT H PARK MD, Oak Park IL; Maywood IL

Objective: A multitude of surgical techniques in the management of ranulas have been described in the literature, including excision of the cyst, excision of the ipsilateral sublingual gland, marsupialization, or less commonly, cryosurgery and CO2 laser. However, few studies have described a technique involving resection of the sublingual gland with anatomic preservation of the lingual nerve and relocation of the submandibular duct. Methods: All patients in our series underwent resection of the sublingual gland, relocation of submandibular duct, and removal of the cyst. Results: We report on our experience in the surgical management of ranulas in the pediatric population with emphasis on surgical approach and technique. One-year follow-up showed no recurrences or complications. We also review the differential diagnosis, etiology, and operative management of pediatric oral cavity ranulas. Conclusions: Optimal management of ranulas should include excision of the cyst and ipsilateral sublingual gland

Recurrent Laryngeal Nerve Cricotracheal Resections

Monitoring

During

KEVIN C CAVANAUGH MD; ALBERT H PARK MD, Chicago IL; Maywood IL

16 Giant-cell Reparative Granuloma of Nasal Cavity and Paranasal Sinuses TUNCAY OZCELIK MD; ALP PERCIN MD; BARKIN GURCAN MD; NURI OZGIRGIN MD, Ankara Turkey

Objective: Giant-cell granuloma, originally called “giantcell reparative granuloma” is an uncommon bone lesion of unknown cause. Involvement of the paranasal sinuses and nasal cavities is rarely encountered. Histologic differentiation between giant-cell lesions—namely giant-cell reparative granuloma, Brown tumor of hyperparathyroidism and true giant-cell tumor—may be difficult. Two cases are presented which illustrate giant-cell granulomas in the maxillary, ethmoid and/or sphenoid sinuses and nasal cavities. The clinical and pathological aspects are discussed here to clarify features of the various associated conditions which cause confusion in diagnosis. Methods: Case 1: A 14-year-old male was referred because of a progressive swelling over the right side of the hard palate

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Oral and Nasal Lesions as the Initial Manifestations of Syphilis

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for approximately three months. Examination revealed right lateral nasal wall fullness. The teeth appeared normal but a mass occupied the right portion of the hard palate filling the entire palatal vault. This mass was firm to palpation and did not appear to be covered by bone. Case 2: A 15-year-old female had been aware of a painless swelling over the right cheek, nasal obstruction and intermittent nose bleeding for approximately four months. Examination revealed a swelling of the right cheek with loss of the nasal labial groove. The mass was palpable extending into the sublabial area bulging the right lateral nasal wall with intact mucosa. Results: Paranasal sinus tomography demonstrated a mass apparently within the right antrum, the nasal cavity and ethmoid sinuses in the first case and additionally sphenoid sinus involvement in the second case. Ossification or calcification is revealed in the lesion. In each case, endoscopic examination revealed brown friable and vascular mass in the right nasal cavity. Serum calcium, phosphorus, ionized calcium and parathyroid hormone levels were within normal limits. Histologic examination of the biopsy specimens was reported as “giantcell reparative granuloma.” Right lateral rhinotomy and peripheral ostectomy was done. Complete removal was accomplished by curretage. Satisfactory hemostasis was obtained by packing the operation cavity for 2 days. The patients had no evidence of tumor recurrence in follow-up of 4 years. Conclusions: Giant-cell reparative granuloma is rarely encountered in nasal cavity and paranasal sinuses. Giant-cell granulomas are either central or peripheral. The central lesions arise within usually the mandible and maxilla. The peripheral lesions occur in the oral cavity on the gingiva or alveolar mucosa and have been called "giant-cell epulis." Radiographically, a lytic lesion in the jaws may be multilocular. Differential diagnosis between giant-cell lesions may be difficult. The treatment of central giant-cell granuloma is local excision by curettage with peripheral ostectomy. The incidence of recurrence is less if the tumor site is re-examined after meticulous hemostasis has been achieved. 17 Embolization in the Treatment of Pulsatile Tinnitus: Case Report of a Dural A-V Fistula ANDREA CHIARAMONTE MD; AMY D LAZAR MD; CHARLES B MACDONALD MD; INSUP CHOI MD, Boston MA; Boston MA; Boston MA; Burlington MA

Objective: An illustrative case report of a 64-year-old woman with a complex sigmoid sinus arterial-venous fistula is reported. The lesion presents with unilateral pulsatile tinnitus, mild mastoid tenderness, and spontaneous pulse-synchronous tympanic membrane movement. An in-depth discussion of the use of interventional radiologic embolization for dural A-V fistula is undertaken. Methods: Case presentation including history, physical examination, and radiologic investigation is reported. A systematic review of radiologic anatomy by CT scan, MRI, and pre- and post-embolization super-selective digital subtraction angiography over a 2-year follow-up period is presented.

Results: Fistula embolization with polyvinyl alcohol particles provides relief of tinnitus and mastoid tenderness. Conclusions: Imaging is important in the investigation of pulsatile tinnitus. Current technique, and our radiologic colleagues, provide the otolaryngologist with appropriate, nonoperative choices in the therapy of pulsatile tinnitus. This case illustrates the use of such technology to obtain a positive outcome.

18 Oxygenation of Lymph Node Metastases Predicts Response to Radiotherapy BERNHARD VANSELOW MD; ANDREAS DIETZ MD; VOLKER RUDAT MD; HAGEN WEIDAUER MD PHD, Heidelberg Germany

Objective: Oxygenation of malignant tumors is assumed to be a determinant of the response to radiation therapy. The degree of tissue oxygenation can be measured in vivo by invasive pO2 histography. The oxygenation of lymph node metastases in advanced head and neck cancer is investigated prospectively and correlated with the initial clinical tumor response to accelerated radio-therapy and radiochemotherapy. Methods: The pretreatment oxygenation status of cervical lymph node metastases of 27 patients with advanced carcinoma of the oro- and hypopharynx was evaluated by polarographic pO2 histography. Subsequently 14 patients received combined accelerated radiochemotherapy; 13 accelerated radiotherapy only. The primary response was evaluated, by restaging, 6 weeks after the end of radiation course. Results: Low pO2 values before treatment (median 10.2 mmHg, average 16.4 mmHg) and a hypoxic fraction (pO2<10 mmHg) of 56.4% indicated manifest tumor hypoxia. Looking at the primary response of the lymph node metastases to the therapy revealed significantly (p<0.05) worse oxygenation for non-responders (n=8, median 4.7 mmHg, average 11.2 mmHg, HF 67.4%) than for carcinomas with complete or partial therapeutic response (n=19, median 13.5 mmHg, average 18.5 mmHg, HF 51.7%). Conclusions: The data indicate a predictive value for tumor-oxygenation measurement by pO2 histography with regard to the response to radiation therapy and combined radiochemotherapy. pO2 histography is expected to be of importance for an enhanced predictive assay in the multimodal treatment of advanced head and neck cancer.

19 Nuchal Fibroma: A Clinicopathologic Review SHARYAR SAMADI MD; ANDREW N GOLDBERG MD; LAURIE LOEVNER MD; VIRGINIA A LIVOLSI MD; ROBERT B MCLAUGHLIN JR MD, Philadelphia PA

Objective: Nuchal fibroma, or collagenosis nuchae, is an uncommon soft tissue tumor arising in posterior cervical subcutaneous tissues. The differential diagnosis for this lesion includes several benign (keloid, fibrolipoma, nodular fasciitis) and rare malignant entities (fibrosarcoma, fibroliposarcoma).

Otolaryngology– Head and Neck Surgery Volume 119 Number 2

20 A New Subtype and Modified Classification Scheme for Usher's Syndrome CHRISTIAN R OTTERSTEDDE MD; ANITA BLANKENAGEL; CHRISTOPH REISSER MD, Heidelberg Germany

Objective: Usher's syndrome is a rare hereditary disorder characterized by severe to profound sensorineural hearing loss and retinitis pigmentosa. Three types are distinguished otologically according to the present classification. Usher's syndrome type I (USH1) is characterized by deafness and absent peripheral vestibular function. Usher's syndrome type II (USH2) presents with stable, moderate to severe hearing loss and regular peripheral vestibular function. Type III (USH3) is similar to USH2 but is identified by progression of hearing loss. Methods: A total of 74 patients from 68 families with Usher's syndrome were examined over the last eight years. All patients underwent thorough otologic and otoneurologic testing including pure tone audiometry, stapedius reflex audiometry, otoacoustic emissions, electronystagmography or videonystagmography, respectively, caloric vestibular testing and posturography when available.

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Results: On grounds of the audiometric results and the present classification scheme 26 patients were attributed to have USH1, 48 to have USH2, none to have USH3. Most interestingly, nine of the patients (35%) believed to have USH1 showed a regular vestibular response to caloric testing. In all of these patients deafness was diagnosed in early childhood or infancy. Conclusions: We identified a new subtype of Usher's syndrome. Characteristic is the combination of deafness similar to USH1 but with regular peripheral vestibular response to caloric stimuli. This combination has not been previously described. Since 35% of the patients with missing cochlear function or 12% of all Usher patients are affected by this type it represents a frequent subtype among the German Usher population. Therefore, we suggest a modified classification scheme for Usher's syndrome. 21 The Role of Live and Killed Bacteria in the Continuum of Otitis Media JUSSI JERO MD; ANNI VIROLAINEN MD, Helsinki Finland; Helsingin Finland

Objective: It has been suggested that otitis media with effusion (OME) is a continuum of acute otitis media (AOM). After acute bacterial infection, the inflammation continues in the middle ear mucosa, although the role of bacteria in the maintenance of this mucosal inflammation is still unclear. In this study we compared the results of routine bacterial culture and pneumococcal pneumolysin PCR in AOM and OME, so as to clear the role of live or killed bacteria in the etiology and pathogenesis of otitis media. Methods: A newly developed pneumococcal pneumolysin PCR assay was compared with routine bacterial culture for detecting Streptococcus pneumoniae (Pnc) in 180 middle ear effusion (MEE) samples of 125 children with AOM and 123 MEE of 123 children with OME. For PCR assay, DNA from MEE samples was extracted by phenol-chloroform in AOM and by QIAamp blood kit in OME. The outer primers used amplified a 348bp region of the pneumolysin gene, and the inner primers a 208bp region. Results: Pnc was cultured in 33 (18%) MEE samples in AOM and 14 (11%) of those in OME. Pneumolysin PCR was positive for 51 (28%) of 180 MEE samples in AOM and 57 (46%) of the 123 MEEs in OME. The use of PCR, in addition to culture, increased the proportion of the MEEs with possible Pnc involvement from 22% to 34% in AOM and from 11% to 46% in OME. OME children with no AOM attacks at all during the previous 6 months had never culturable Pnc, but still positive pneumolysin PCR in 24% of the MEE samples. Conclusions: The use of PCR indicated that Pnc involvement is more common in MEE of OME than in MEE of AOM. It is possible that in OME nonviable Pnc and other bacterial antigens could provoke and maintain the mucosal inflammation in the middle ear cleft; they are nondetectable by the means of culture only.

POSTERS

Since initially identified in 1988, fifteen patients with nuchal fibroma have been described. No cases have been reported in the otolaryngologic literature. Gender was specified in thirteen patients, with a male preponderance noted (85%). Eleven nuchal fibromas (73%) were localized to the midline in the posterior neck. Pain was the most common presenting symptom (27%). All were managed by surgical resection with only one instance of recurrence. Results: We report a case of a 40-year-old male with an 11year history of a midline posterior cervical neck mass who presented with a 2-month history of postauricular pain. Ten years prior to evaluation, an incisional biopsy performed at an outside hospital was interpreted as a desmoid tumor. He denied any recent changes in size of the mass, history of abnormal scar formation, previous neck trauma, and constitutional complaints. Physical exam was otherwise unremarkable. An MRI scan showed a non-enhancing fibrous subcutaneous mass with low signal intensity on both T1 and T2 weighted images measuring 4 × 2 × 3 cm. Excisional biopsy revealed a white, rubbery mass with a clear tissue plane between the lesion and the underlying muscle; however, infiltration of the overlying skin was evident. Histopathologic examination revealed unencapsulated dense fibrous tissue composed of hypocellular and focal elastic fibers consistent with the diagnosis of nuchal fibroma. At 2 years’ follow-up, the patient remains free of recurrence. Conclusions: Nuchal fibroma is a benign lesion often presenting in male patients in the posterior cervical subcutaneous tissues of the neck. Due to its indolent clinical course and subtle histological differences from other benign processes, there may be a tendency towards under-reporting and misdiagnosis. Surgical excision is the treatment of choice, and recurrence is rare.

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22 The Role of TGFB-1 and BMPs in Metaplastic Bone Formation in Nasal Polyps ANDREW A JACONO MD; ANTHONY P SCLAFANI MD; RAYMOND WINICKI MD; THOMAS R VAN DE WATER PHD; STEVEN MCCORMICK MD; DOROTHY A FRENZ PHD, West Hempstead NY; New York NY; New York NY; Bronx NY; New York NY; Bronx NY

Objective: Metaplastic bone formation in mucosal polyps has been reported in the external auditory canal, tongue, intestines, and stomach, but the histogenesis of ossification is not well understood. This study reports a case of metaplastic ossification of a nasal polyp, which was found in a patient with a clinical diagnosis of chronic sinusitis. As transforming growth factor beta-1 (TGFB-1) and bone morphogenetic proteins have been shown to induce ectopic bone formation when injected in subdermal tissues in animal models, we investigate their presence in the surgical specimen. Methods: Polyclonal antibodies raised against bone morphogenetic proteins 2 and 2-4, and anti-TGFB-1 antibodies were used to immunostain the surgical specimen obtained by the affected patient. Results: Immunohistochemical staining for bone morphogenetic proteins and TGFB-1 in these ossified nasal polyps reveals a possible role for these growth factors in the pathogenesis of metaplastic bone formation. Conclusions: Bone morphogenetic proteins 2 and 2-4, and TGFB-1 may play a role in the pathogenesis of ossified nasal polyps and suggests de-differentiation of cells to pluripotential cells in the setting of chronic sinusitis. To better understand their role, further in vitro studies of mucosal polyps are necessary.

and mature secretory granules which may indicate a slight decrease in the mitotic activity were seen in the sections obtained from this group. Conclusions: The findings in this study emphasize, that astemizole may decrease the secretory activity of the salivary glands, but administration in usual doses for a long period do not affect the secretory activity of the glands. We conclude that astemizole can be used in the recommended doses without occurrence of side effects such as mouth or pharynx dryness. 24 Role of Sinus CT in Patients with Normal Nasal Endoscopy PAUL E LAPCO MD; BERRYLIN J FERGUSON MD, Pittsburgh PA

Objective: To evaluate the role of sinus computed tomography (CT) in patients with a strong history of chronic rhinosinusitis (CRS) and normal physical and nasal endoscopic examination. Methods: Prospective study. Fifteen consecutive patients who met the American Academy of Otolaryngology–Head and Neck Surgery Rhinosinusitis Task Force Guidelines for CRS by history and had a normal physical examination, including rigid nasal endoscopy, were enrolled. A coronal sinus CT was obtained on the day of evaluation in all patients. Results: Out of 15 patients with CRS by history and normal rigid nasal endoscopy, 11 had normal sinus CT, 2 had maxillary retention cyst, and 2 had sinus CT findings consistent with CRS (Lund-MacKay score greater than 4). Conclusions: Based on this preliminary analysis, sinus CT provides additional information in only a limited number of patients with normal nasal endoscopy.

23 The Effect of Astemizole in Salivary Glands of Rats GURSEL DURSUN MD; AYSE DURSUN MD, Ankara Turkey

Objective: The primary objective of this animal research was to determine whether the use of astemizole could cause any damage to salivary gland function. Methods: An astemizole stock solution was used subcutaneously on 36 adult albino male rats. The subjects were divided into four groups, each composed of nine rats. One of the groups was considered as a control group. The experimental groups were given daily doses of 0.11 mg/kg (x), 0.33 mg/kg (3x) and 0.036 mg/kg (x/3) respectively. The subjects in the control group were given only saline. Three rats from each group were sacrificed following the 5th, 12th and 20th days to allow the histopathologic investigation of the parotis and submandibulary salivary glands by light and transmission electron microscopy. Results: No abnormality including the staining or morphological characteristics was noted in the light microscopic investigation. Electron microscopic evaluation revealed the only pathologic observation at 12th and 20th days in the subjects which were given 3x doses. A swollen mitochondrion

25 Contralateral Hearing Loss After Removal of Vestibular Schwannoma ILMARI PYYKKO MD; GORAN BLOMSTEDT; HILLA LEVO MD, Stockholm Sweden; Helsinki Finland; Helsinki Finland

Objective: Sympathetic cochleolabyrinthitis is a newly recognized disorder where the contralateral hearing starts to deteriorate after surgical intervention of ipsilateral inner ear. We examined whether contralateral hearing loss occurs after vestibular schwannoma (VS) surgery and whether it is different depending on operative approach of the VS removal. Methods: We reviewed case histories and followed up 364 consecutive patients with operated unilateral VS. In addition to audiometry we examined the postural stability with posturography. From the patients 31 were operated on with translabyrinthine (TL) approach (mean age 58.4 years, mean follow up time 7.6 years, mean tumor size 14.3 mm) and 333 retrosigmoidal (RS) approach (mean age 47.8 years, mean follow up time 8.2 years, mean tumor size 22.5 mm). Results: When compared with preoperative audiometry,

Otolaryngology– Head and Neck Surgery Volume 119 Number 2

Scientific Posters

26 Allergic Fungal Sinusitis with Unilateral Blindness TIMOTHY N CHRISTIANSEN MD; BRUCE M STERMAN Wauwatosa WI; Milwaukee WI

MD,

Objective: Allergic fungal sinusitis is thought to account for approximately 7% of chronic sinusitis. It may present with orbital involvement in the form of proptosis and diplopia. However, only one case of decreased visual acuity is reported in the literature. Methods: We report a case of a 20 y.o. female with allergic fungal sinusitis and a three week history of left-sided blindness. Ophthalmologic exam revealed optic atrophy. The patient was placed on systemic steroids, Unasyn, and Itraconazole. On hospital day #4, the patient underwent a bifrontal craniotomy with frontal sinus obliteration in conjunction with endoscopic sinus surgery and bilateral Caldwell-Lucs. Results: The patient was discharged on postoperative day #3. Medications included nasal saline, topical steroids, and oral steroids. Itraconazole irrigations will begin at the first postoperative visit. Three weeks after surgery, the patient has reported minimal improvement in her vision with only minimal light perception. Conclusions: Decreased vision is a rare complication of allergic fungal sinusitis. The etiology may be inflammation or optic nerve compression. This case illustrates the importance of a high index of suspicion for the disease so that appropriate treatment with steroids and sinus surgery can be instituted and the use of toxic systemic antifungals can be avoided. If steroids are initiated promptly, the deterioration in vision may be arrested or even reversed.

27 Intracranial/extracranial Epidermoid Cyst Presenting as Scalp Mass LISA POSEY MD; BRUCE M STERMAN MD, Wauwatosa WI; Milwaukee WI

Objective: Our objective is to review the pathologic entity of epidermoid cysts, specifically those of the skull. We would like to familiarize the reader with the origin and subsequent presentation of epidermoid cysts and encourage that they be included in the differential diagnosis of head and neck masses, particularly those of the scalp. Methods: A case which presented at our institution to the Otolaryngology Department is reviewed. The patient's diagnosis, clinical course, radiographic and pathologic findings are discussed. Literature on skull epidermoids is reviewed. Results: A 41-year-old white male presented with the complaint of a right temporal mass which had been gradually enlarging over 16 yrs and was asymptomatic. The patient was taken to the operating room for excision of the 6×8 cm moderately firm, circumscribed mass. The mass was found to contain squamous tissue and extend intracranially through a bony defect. The extent of the lesion was further assessed using CT scan, which revealed a 6×7 cm intracranial component. This was successfully resected by neurosurgery via a craniotomy approach at a later date. Conclusions: Epidermoids are benign masses resulting from inclusion of epithelial nests within subcutaneous tissue and are usually adjacent to bony suture lines or diploë. Most common are primary epidermoids which, result from closure of the neural tube between the 3rd and 5th weeks of embryonic life. They are relatively rare and are responsible for less than 1% of intracranial masses. They should be considered in the differential diagnosis of any mass overlying the skull.

28 Management of Middle Ear Hemangiomas DAVID HECHT MD; C GARY JACKSON MD; KENNETH M GRUNDFAST MD, Arlington VA; Nashville TN; Washington DC

Objective: Hemangioma, the most common head and neck tumor in children, rarely presents as an isolated middle ear lesion. Since childhood hemangiomas usually regress spontaneously, surgical excision is not always necessary. However, a hemangioma in the middle ear can be complicated by infection and hearing impairment. We present two cases which illustrate contrasting management strategies, both with successful outcomes. Methods: The medical records of two children with middle ear hemangioma were reviewed. The case histories, otoscopic findings, and audiograms are compared and contrasted. Imaging, operative and histopathologic photographs for each case are presented. Results: A six month old female and a four year old male who presented with unilateral otitis media and hearing impairment were found to have concomitant mesotympanic hemangiomas

POSTERS

the hearing of contralateral ear in patients with TL approach was deteriorated at 500 Hz 5.3 dB HL, at 1 kHz 6.0 dB HL and at 2 kHz 5.9 dB HL. In patients with RS approach the hearing loss of contralateral ear was 0.9 dB HL, 1.1 dB HL and 1.7 dB HL, respectively. The speech discrimination score worsened on average 2.7% and 0.8% in TL group and RS group, respectively. The differences in hearing loss were statistically significant between TL and RS groups. The patients with TL approach had worse postural stability on posturography when compared with RS patients both in visual and nonvisual conditions. In TL group 2 and in RS group 5, patients developed greater hearing loss than 20 dB at speech frequencies. Conclusions: The findings in TL group indicate poorer hearing in contralateral ear and poorer vestibular compensation although TL patients had smaller tumor size and less stressful operation than RS patients. In TL surgery when the cochlea is opened a possibility for autoimmune reaction for inner ear tissues may occur. Nevertheless, a contralateral hearing loss may also follow RS surgery when the endolymphatic sac is drilled exposing the inner ear to immunologically active elements. The contralateral hearing loss after VS surgery seems to mimic the occurrence of sympathetic ophthalmia.

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on examination. The first child's symptoms responded to medical therapy and subsequently underwent incisional biopsy confirming the suspected diagnosis, while the residual tumor involuted over the following year. The second child, however, was refractory to medical therapy and developed a chronic tympanic membrane perforation requiring tympanoplasty, at which time the hemangioma was removed. Subsequently, hearing improved and there were no further infections. Conclusions: Since hemangioma of the middle ear is unusual, there has been little discussion about alternatives for management. Once a tissue diagnosis is made, they can be treated expectantly (wait for spontaneous resolution) or surgically. If growth of a middle ear hemangioma appears to be causing complications refractory to conservative therapy, then early surgical excision may be indicated. 29 Angiomatous Polyp Differentiation by MRI

or

Juvenile

Angiofibroma?

DORY G DURR MD; CELINE BARD MD; MARTIN DESROSIERS MD, Outremont PQ Canada; Montreal PQ Canada; Montreal PQ Canada

Angiomatous polyp is a rare disease entity and little has been written on the subject. According to Batsakis and Sneige, angiomatous polyp is a benign polyp which occurs following a vascular compromise within an antrochoanal polyp. The clinical presentation, physical and pathological findings of such a polyp can mimic those of juvenile angiofibroma. The surgeon confronted with such dilemma needs an accurate diagnosis to further proceed in the management as biopsy entails the possibility of severe bleeding, and surgical management is radically different for the two entities. We present an illustrative example of this unusual disease, focusing on magnetic resonance imaging findings that allow preoperative differentiation of angiomatous polyp from juvenile angiofibroma. 30 Further Study of the Acoustic Otoscope

ated to determine agreement between the two data sets. The data were analyzed specific to positive otitis media indications with the EarCheck PRO in the presence or absence of otitis media. Comparisons with outcome of the present study were made to previous studies with version three. Conclusions: The data detail the sensitivity of the EarCheck PRO, but outcomes are weighed against otoscopy and tympanometry. Specific recommendations are based on these outcomes with reference to the population being tested. 31 Phase I Clinical Trial of the Vibrant Soundbridge DERALD E BRACKMANN MD; CHARLES M LUETJE II MD, Los Angeles CA; Kansas City MO

Objective: Clinicians have spent 25 years in search of a surgical treatment for sensorineural hearing loss that uses an implantable system of amplification. The Vibrant® soundbridge is the first such system to complete an FDA-approved Phase I clinical trial. This trial was designed to determine the safety of the implant and to begin to collect data to determine its effectiveness. Methods: Five patients were selected according to strict selection criteria listed in the clinical protocol. Patients were evaluated both aided and unaided prior to implant surgery and at regular intervals following surgery. All patients were experienced hearing aid wearers who were no longer satisfied with acoustic amplification. The implant portion of the soundbridge was placed during a two-hour-long outpatient procedure. Healing time, before fitting of the external amplifier, was 8 weeks. Results: All patients were safely implanted with no adverse sequelae. All patients had a positive, useful functional gain in the frequencies being amplified. Performance of the soundbridge was equal to the patient's presurgery hearing aids when evaluated with a SPIN test. All patients reported superior performance and benefit when evaluated with a modified PHAB self-assessment test. Conclusions: The Vibrant soundbridge appears to be a safe method of providing a surgical treatment for sensorineural hearing loss. An expanded clinical trial is under way to further determine the safety and effectiveness of the system.

L CLARKE COX PHD; CHARLES B MACDONALD MD, Boston MA

Objective: Three versions of the acoustic otoscope have been studied and reported in the literature. The fourth version, the EarCheck PRO™, is now available. In a previous study we detailed the history of the acoustic otoscope and reported on the sensitivity of version three in detecting otitis media. In this study we report on the changes in version four and assess the sensitivity of the unit in detecting otitis media in the pediatric patient. Methods: Pediatric patients age 6 months to 12 years were tested with the EarCheck PRO. At the time of evaluation, otoscopic examination by a seasoned pediatric otolaryngologist was effected, blind to the EarCheck data. Also a group of patients were tested in the operating room just prior to placement of ventilating tubes. Results: The data from the EarCheck PRO and otoscopic examination or operating room tympanocentesis were evalu-

32 Study on the Immune Status of Patients with Laryngeal Carcinoma YUMING LI MD; CHE ZHIXIANG MD; JING XUEMEI MD, Jinan Shandong China

Objective: In this study, we try to find out the internal relationship between occurrence of the laryngeal carcinoma and body immune state so as to find out the probable therapeutics and the mechanism of treating this tumor with immune therapy. Methods: The immunoassays were carried out on 68 patients before operation by using the methods of RID, APAAP and LDH. IgG, IgA, IgM and CD3+, CD4+, CD8+ cells and ratio of CD4+/CD8+ were measured in group I, which contained 36 patients, and natural killer cell activity (NKCA) was measured

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in group II, which contained 32 patients. At the same time 61 healthy persons by two groups received the same measurements, results of which were compared with patient groups. The results were analyzed based on different stages of laryngeal carcinoma and dealt with statistically. Results: Compared with normal group, CD3+, CD4+ cells and NKCA were much lower (p < 0.01) and were getting lower and lower with the development of tumor; CD3+ cell slightly increased (p > 0.05) and IgG, IgA and IgM were lower but this decrease had no significant statistical difference (p > 0.05). Conclusions: It shows that the low level of cellular immunity and decrease of the ratio of CD4+/CD8+ cells inhibit the function of patient's body immune system. It is the internal factor that makes the laryngeal carcinoma develop easily. With the development of tumor, the increase of various suppressor factors and the further inhibition of immune system suppressed future, the tumor can spread and metastasize much more easily. So to improve the capacity of NK, CD4+ and other body immune cells, the function of patient's immune in anti-tumor must be strengthened.

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Thyroid and Tracheal Carcinomas: Collision of Separate Primaries

increased pharyngeal pressures. Review of the literature indicates that it may occur in musicians who play wind instruments without demonstrable pathology. This report illustrates a case of SVPI in a patient with previously undiagnosed Chiari I malformation. Case Report: A 15-year-old white female presented with a six year history of nasal emission after playing the clarinet. This progressed to the point where nasal emission would occur after five to ten minutes of playing. She denied nasal reflux or speech changes. Complete examination of the head and neck (to include cranial nerve examination and nasopharyngoscopy) was normal. Results: Modified barium swallow demonstrated nasal reflux with clarinet playing. In addition, moderately diminished pharyngeal contraction was demonstrated, as well as laryngeal penetration without aspiration. MRI of the brain demonstrated a type I Chiari malformation with a small syrinx in the cervical spinal cord. Conclusions: Chiari I malformation is often diagnosed in adulthood and may progress in severity if untreated. Common symptoms are exertional headache, extremity pain and weakness, neck pain, paresthesia, and ataxia. Bulbar palsy is infrequent. This case illustrates a subtle presentation of Chiari malformation. The importance of thorough workup for SVPI is stressed.

MICHAEL D STALFORD MD; CHRISTOPHER K SINHA Columbia MD; Olney MD

35

33

Objective: Extrathyroidal extension of papillary thyroid carcinoma occurs in 4%-16% of cases with only 1%-13% of cases presenting with airway invasion. We present a case of an elderly female with a large thyroid mass diagnosed as papillary thyroid carcinoma on fine needle aspiration, and symptoms of airway obstruction. Methods: The patient’s chart was reviewed, including the laboratory, radiographic and pathologic studies. Results: The presentation and pre-operative diagnostic studies in this case are most consistent with papillary thyroid carcinoma with airway invasion. Final pathology, however, ultimately demonstrated two separate primary neoplasms: Papillary thyroid carcinoma and a poorly differentiated primary tracheal carcinoma immediately adjacent, masquerading as papillary thyroid carcinoma with tracheal invasion. Conclusions: Patients presenting with a large thyroid mass confirmed to be papillary thyroid carcinoma on FNA with symptoms of airway obstruction most likely have direct extension of the papillary thyroid carcinoma into the airway. After an extensive review of the literature, this is the first case of a primary tracheal carcinoma immediately adjacent to a papillary thyroid carcinoma. 34 Chairi Malformation with Stress Velopharyngeal Incompetence IRA DAVID URETZKY MD; CHRISTOPHER K SINHA MD; LAURA E WEILAND, Spring MD; Olney MD; Washington DC

Objective: Stress velopharyngeal incompetence (SVPI) is a mild form of velopharyngeal incompetence elicited by

Influence of Extracapsular Spread and Desmoplastic Pattern in the Neck MARIA P PRIM MD; D HARDISSON MD; JUAN I DE DIEGO MD; JAVIER GAVILAN MD, Madrid Spain

Objective: To study the influence of extracapsular spread (ECS) and desmoplastic pattern in metastatic neck lymph nodes on the survival and neck recurrence of patients with laryngeal cancer. Methods: The study includes 128 patients with squamous cell carcinoma and lymph node metastasis of the larynx surgically treated between 1984 and 1992. No one received other treatments prior to surgery. The results were studied from two major standpoints: survival and neck recurrence. The KaplanMeier method was used for survival analysis and neck recurrence–free curves. The comparison among survival curves and curves of neck recurrence was made by means of the Mantel-Cox (log-rank) test. Results: Mean of age was 57.6 years (range, 40 to 83 years). All but 3 patients were men. The 3-year survival rate was as follows: patients without ECS (73.4%), and with ECS (28.9%) (p < 0.001); patients without desmoplastic pattern (76.9%), and with desmoplastic pattern (43.3%) (p < 0.03). Also, the 3-year recurrence rate in the neck showed significant differences: patients without ECS (23.5%), and with ECS (58.3%) (p < 0.001); patients without desmoplastic pattern (20%), and with desmoplastic pattern (47.7%) (p < 0.03). Conclusions: According to these results, both ECS and desmoplastic pattern have an adverse prognostic significance when present in lymph node metastasis of laryngeal cancer.

POSTERS

MD,

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36 Transverse Cervical-superior Anastomosis: A Cadaver Study

Laryngeal

Nerve

LCDR BRIAN J MCKINNON MD; DANIEL W KARAKLA MD, Virginia Beach VA; Portsmouth VA

Objective: Greater auricular–superior laryngeal nerve microanastomosis has been proposed for the restoration of laryngopharyngeal sensation. The objective of this investigation is to define the transverse cervical nerve's anatomy to determine the feasibility of transverse cervical nerve–superior laryngeal nerve anastomosis. Methods: A fresh cadaver model was used for studying anatomy of the transverse cervical nerve. Seven fresh cadavers, five male and two females, were used, varying in age from 58 to 85 years of age. The relationships evaluated included the nerve's position relative to the thyroid cartilage, and the internal branch of the superior laryngeal nerve. The caliber of the transverse cervical nerve was compared to the internal branch of the superior laryngeal nerve, and microneurorrhaphies were performed. Results: The transverse cervical nerve's branches have a predictable course in the anterior neck over the superior laryngeal nerve and thyroid cartilage. The caliber of the distal branches compared favorably to the caliber of the internal branch of the superior laryngeal nerve. Tension free microneurorrhaphies were achieved in the cadavers. Conclusions: The investigation documented the predictable anatomy of the transverse cervical nerve. The predictable course and caliber suggests that a tension-free microanastomosis can be performed between the distal branches of the transverse cervical nerve and the internal branch of the superior laryngeal nerve. Further clinical studies are ongoing to determine the utility of transverse cervical–superior laryngeal nerve microanastomosis in restoring laryngopharyngeal sensation. 37 Long-term Follow-up of Cartilaginous Tumors of the Larynx ROBERT THOME MD; DANIELA CURTI THOME MD, Sao Paulo SP Brazil

Objective: Cartilaginous tumors of the larynx are uncommon; the cricoid cartilage is the most common site of occurrence. As with any rare pathology, experience with these tumors accumulates slowly. The purpose of this 27-year retrospective study is to evaluate the results of the surgical treatment of 5 patients with cartilaginous tumors of the larynx. Methods: Four patients with chondromas from cricoid cartilage and 1 patient with low-grade chondrosarcoma from thyroid cartilage were reviewed. All patients were male and the age at surgery ranged from 38 to 64 years, with an average age of 49.6 years. Surgical treatment used in these 5 patients included 1 total laryngectomy for the massive low-grade chondrosarcoma and conservative surgery for the 4 chondromas: 2 of them via a laryngofissure exposure and complete resection of the tumor; and 2 through a total cricoid cartilage

resection followed by a thyrotracheal anastomosis. Follow-up period varied from 6 to 27 years (average, 16.8 years). Results: One of the 4 patients with chondroma who received a total cricoid resection with thyrotracheal anastomosis required further total laryngectomy to treat recurrence 8 years later. Of the 5 patients, 3 are alive with no evidence of disease and 2 died, 6 and 8 years after surgery, free from disease. Conclusions: In spite of the small number of cases, treatment of chondroma by conservative surgery, with total laryngectomy reserved for recurrence and for low-grade chondrosarcoma, in whom conservative surgery is not feasible, is supported. 38 Minimally Invasive Surgery of the Skull Base MIEN-CHI CHEN MD; DAVID W KIM MD; JEFFREY P HARRIS MD PHD, San Diego CA; La Jolla CA; San Diego CA

Objective: Minimally invasive surgery of the skull base has distinct advantages over extensive craniofacial approaches in offering patients less morbid and extensive surgery while improving the chance of preserving vital neurovascular structures and more rapid recovery. The advent of microscopic, radiological, and endoscopic techniques has enabled head and neck surgeons to operate on tumors previously thought unresectable without major morbidity. This is particularly true in the skull base, where extensive craniofacial resection has traditionally been advocated. Methods: A case series of four patients with a variety of skull base disorders is presented and individualized surgical approaches pertinent to each case are discussed. These pathologies included a clival chordoma, which was resected via a transsphenoid-transclival approach with sparing of all cranial nerves while avoiding an infratemporal fossa approach; one case of cholesterol granulomas of the petrous apex, which was resected via an endoscopic, transnasaltranssphenoid approach with a stent placement; a jugular foramen schwannoma treated via a transmastoid-transcervical resection, avoiding the need for facial nerve rerouting; and a juvenile angiofibroma originating in the lateral wall of the nasopharynx, which was resected using a transnasal-endoscopic approach without resorting to extensive craniofacial resection. Results: None of the patients sustained any cranial nerve injury, hemorrhage or meningitis as the result of surgery. All patients were discharged within one week following the surgery. Little or no postoperative complications were encountered with the exception of the patient with clival chordoma, who developed cerebral spinal fluid leak requiring surgical intervention. No death occurred in this series. Conclusions: Minimally invasive skull base surgery utilizing microscopic/endoscopic technique can be considered for favorable lesions, with a high likelihood of preservation of cranial nerves and vital vascular structures, with minimal morbidity and rapid recovery. Thorough preoperative radiographic evaluation, attention to surgical details, judicious use

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of endoscopic and microsurgical instrumentation and an individualized approach are critical for the success in minimally invasive surgery of the skull base.

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ment may help in decreasing the cicatricial changes. Once the disease has arrested, surgical reconstructive measures, including laser therapy, help in re-instituting function. The literature on this subject will be reviewed.

39

MARK K WAX MD; DAVID DONALDSON MD; JAY S RECHTWEG MD, East Amherst NY; Buffalo NY; Amherst NY

Objective: Acute upper-airway obstruction of infectious origin is a life threatening condition. The majority of these infections arise in the oral cavity or oropharynx (eg peritonsillar abscess and epiglottis). Rarely is the larynx the primary site of origin. When the larynx is the primary site of origin for the airway obstruction, malignancy is the most common cause. Further evaluation may then determine that the cause of the obstruction is due to a rare infectious process of the larynx. Methods: Four cases of atypical infections presenting with acute airway compromise necessitating emergent intervention are discussed. Results: All patients had a presumptive diagnosis of carcinoma. One patient had a lingual tonsillar and pre-epiglottic space abscess due to beta-hemolytic group C streptococcus. One patient had a lingual tonsillar abscess and suprahyoid space injection with marked epiglottic edema due to grampositive cocci. One patient had a diagnosis of actinomyces of the right pyriform space. The final patient had herpes zoster of the superior lingual nerve. All four patients went to the operating room for airway management and biopsy. Conclusions: Acute upper airway obstruction in the supraglottic region due to infectious causes is uncommon. The evaluation, diagnosis, and treatment of patients is discussed.

40 Cicatricial Pemphigoid Complications

and

Management

of

Its

STEPHEN A GOLDSTEIN MD; DIRAN O MIKAELIAN MD, Philadelphia PA

Objective: To present a case of cicatricial pemphigoid (CP), its complications, management and review of the literature. Methods: We present a case of a 50-year-old female with long standing history of CP. The cicatricial complications which this patient had (laryngeal stenosis, bronchial stenosis, nasopharyngeal stenosis, lacrimal duct stenosis, etc.) will be presented. Treatment with YAG and CO2 lasers will be presented. Results: The management of CP, including medical treatment and surgical intervention of cicatricial complications will be elaborated. Conclusions: CP is a rare, chronic slowly progressing autoimmune disorder affecting the mucous membranes of the body. The disease has a chronic course, but medical manage-

41 Congenital Cholesteatoma Involving the Petrous Apex BRIAN LEBOVITZ MD; DIRAN O MIKAELIAN MD, Philadelphia PA

Objective: To educate and report upon a case of congenital cholesteatoma with involvement of the petrous bone. Methods: We present the case of a 29-year-old male who presented with total loss of hearing. His subsequent workup revealed a congenital cholesteatoma involving the petrous bone with destruction of the labyrinthine and cochlear structures. Facial nerve function was intact. Results: A transmastoid middle-ear approach was used to excise the cholesteatoma. Facial nerve integrity was maintained postsurgery. Conclusions: The initial presentation as well as the surgical findings are elaborated upon. Studies are presented from both initial presentation and at four year follow-up. These cases are very rare. Appropriate diagnosis, treatment, and follow-up are essential to the successful management of these cases.

42 Radiographic Analysis of the Relationships Between the Middle Turbinate, Nasal Septum, and Frontal Sinus RAVI PRAKASH AGARWAL MD; DONALD C LANZA MD; DANIEL BECKER MD; LAURIE LOEVNER MD, Philadelphia PA; Narberth PA; Philadelphia PA; Philadelphia PA

Objective: To study the anatomy of the superior insertion of the anterior aspect of the middle turbinate, and of the insertion of the nasal septum to the floor of the frontal sinus. Recent focus on endoscopic approaches to the frontal sinus has led to a renewed interest in the anatomy of this region. While current anatomic teaching maintains that the superior insertion of the middle turbinate occurs at the junction of the cribriform plate and the fovea ethmoidalis, it has been our impression that the anterior portion of the middle turbinate typically inserts anterior to the cribriform plate to either the ascending process of the maxilla or the floor of the frontal sinus. Additionally, we have found that the nasal septum occasionally appears to bifurcate into a Y-shaped configuration at its insertion upon the frontal sinus floor. Methods: A non-blinded, retrospective radiographic analysis was undertaken. Fifty consecutive coronal sinus CT scans were reviewed with a neuroradiologist. CT scans were discarded if the contiguous 3 mm thick coronal images were not perpendicular to the cribriform plate bone. Thirty-five of the 50 scans reviewed were suitable for study. The anterior-superior insertion of the middle turbinates was evaluated. In addition, the superior insertion of the nasal septum at the level of the frontal sinuses was evaluated to determine whether it was straight or Y-shaped.

POSTERS

Unusual Infectious Laryngeal Processes Presenting with Airway Obstruction, Mimicking Carcinoma

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Results: In 13 patients (37%) the superior insertion of the anterior middle turbinate was the anterior 2 mm of the cribriform plate. In 22 patients (63%), the superior insertion of the middle turbinate was anterior to the cribriform plate. In 6 patients (17%), the superior insertion was into the floor of the frontal sinus. The nasal septum was noted to be Y-shaped at the level of the frontal sinus floor in 3 patients (9%). Conclusions: The superior insertion of the anterior middle turbinate at times inserts more anteriorly than previously reported. Additionally the nasal septum occasionally bifurcates into a Y-shaped configuration at its insertion upon the floor of the frontal sinus. The critical clinical relevance of these anatomic points in the endoscopic surgical management of this region will be discussed. 43 A Comparison of Donor Site Morbidity for the Lateral Arm Flap and Radial Forearm Flap FRANCISCO J CIVANTOS MD; DONALD T WEED MD; CRAIG A RICHMAN MD; TERRY KIERNAN, Miami FL; Miami FL; Miami Beach FL

Objective: The radial forearm flap and the lateral arm flap are alternative sources of relatively thin tissue for oral and oropharyngeal reconstruction. For similar sized flaps, the lateral arm donor site can be closed primarily while the radial forearm donor site requires a skin graft placed over the paratenon of the forearm tendons. We sought to compare donor site morbidity in an objective fashion. Methods: Over a 4 year period 22 radial forearm flaps and 33 lateral arm flaps were performed. Of greater importance was the issue of arm function after healing. Eight patients from the lateral arm flap group and five from the radial forearm group underwent objective pre-operative and post-operative testing in our occupational therapy department. Using machines commonly used in occupational therapy, range of motion and strength of the various muscle groups were tested. Results: Peri-operative donor site complications in these patients were few. No patients had to return to surgery due to donor site complications. Minor open wounds were more common in the radial forearm flap patients, but all eventually healed. In the radial forearm group mild to moderate decreases in range of wrist extension were common. Grip weakness also occurred. In the lateral arm group decreased strength of arm extension was common. In both groups function was quite good post-operatively. Numerical data for changes in strength and range of motion will be presented. Conclusions: Donor site morbidity was low in both groups. The lateral arm flap was remarkable for the near-absence of donor site morbidity. 44 The Optical Properties of Upper Aerodigestive Tract Tissues RAHUL K SHAH; DONALD F PERRAULT JR BS; STANLEY M SHAPSHAY MD, Brookline MA; Boston MA; Boston MA

Objective: Despite the widespread use of lasers in otolaryngology, the optical properties of tissues of the upper

aerodigestive tract have yet to be determined. Knowledge of these optical properties (absorption coefficient, scattering coefficient, and anisotropy) permits modeling and understanding of tissue response to laser irradiation. Methods: The optical properties of tissues from the tonsils, nasal turbinates, trachea, and soft palate were determined using a double integrating sphere system and the adding doubling method at wavelengths of 810 nm (diode laser) and 1064 nm (ND:YAG laser). Human and canine tonsillar tissue was measured and canine nasal turbinates, trachea, and soft palate were measured. Results: The optical properties with their corresponding standard errors and the depth of penetration of the lasers in the tissues are reported. The depth of penetration of the laser is similar in canine and human tonsillar tissue at 810 nm (1.2 mm penetration) and 1064 nm (1.8 mm penetration). Further, the ND:YAG laser penetrates deeper in all of the tissues compared to the diode laser. Conclusions: The optical properties of upper aerodigestive tract tissues facilitates modeling laser applications and calculating laser penetration depth prior to clinical application. This results in a reduction of preclinical animal experiments, previously necessary to find an optimum dosimetry and facilitates further refinement of existing procedures leading to safer and more efficacious laser applications.

45 Fine Needle Aspiration Biopsy (FNAB) in Head and Neck Lymphoma C RON CANNON MD; DOUGLAS RICHARDSON MD, Jackson MS

Objective: Both Hodgkin’s (HL) and non-Hodgkin’s lymphoma (NHL) may present in the head and neck region. Although the presentation may be varied, lymphoma commonly presents as a neck mass. A retrospective study was undertaken to evaluate the efficacy of FNAB in the group of patients. Methods: A three year retrospective study of all patients undergoing FNAB revealed ten patients undergoing FNAB with a diagnosis of lymphoma. FNAB was performed in an office setting. If FNAB cytology was suspicious for lymphoma an aspirate specimen was submitted for flow cytometric and DNA analysis. Results: Flow cytometry can identify B cell clonality and abnormal nuclear DNA distribution in patients with many forms of non-Hodgkin’s lymphoma. Nine of the patients had non-Hodgkin’s lymphoma. FNAB with flow cytometry was diagnostic adjunct in eight of these nine patients. Additionally, FNAB was useful in diagnosing recurrent disease in two of the patients. Conclusions: FNAB with flow cytometric analysis is valuable in the diagnosis of non-Hodgkin’s lymphoma, especially in low grade well differentiated lymphoma in which cytomorphologic changes are equivocal. With flow cytometry FNAB is also useful in the diagnosis of recurrent lymphoma.

Otolaryngology– Head and Neck Surgery Volume 119 Number 2

Cutaneous Mucormycosis of the External Ear STEPHEN J WALL MD PHD; DOUGLAS C BIGELOW MD; KENNETH H LEE PHD, Philadelphia PA; Philadelphia PA; Boston MA

Introduction: Mucormycosis encompasses rhinocerebral, pulmonary, disseminated, cutaneous, and gastrointestinal types. The rhinocerebral form is the most frequently observed with 200 cases identified since 1970. Mucormycosis of the middle ear and temporal bone is less common and is believed to occur secondary to extension from the sinus or nasopharynx. We report the first case in the English literature of cutaneous mucormycosis arising in the external ear. Case History: A 43-year-old diabetic female with chronic myelogenous leukemia underwent allogenic bone marrow transplantation. Her course was complicated by a hypercoagulable state, respiratory and hepato-renal failure. An area of ecchymosis noted on the right pinna was attributed to trauma from a digital thermometer. The ear was cool to the touch and exhibited poor capillary refill. Otoscopy demonstrated bleeding and blebs involving the external auditory canal skin and tympanic membrane. Nasal mucosa was disease-free on endoscopy. In the ensuing 48 hours, the skin necrosis advanced rapidly in a concentric manner from the auricle to the lateral canthus. Leading edge biopsies were remarkable for broad, non-septate hyphae at right angles and vascular invasion. A CT scan showed bilateral mastoid opacification without bony erosion. The patient quickly expired and autopsy identified pulmonary mucormycosis as a second manifestation of the disease. Discussion: Mucormycosis has recently emerged as a concern with the increasing prevalence of immunocompromised states including: diabetic ketoacidosis, hematologic malignancy, AIDS, and post-organ transplantation. Cutaneous mucormycosis frequently involves structures of the head and neck (14%). Two clinical presentations are noted: superficial with an indolent course, and gangrenous with fulminant progression. Signs and symptoms include ulceration, purpura, visual changes, sinusitis, edema, and pain. The gold standard for diagnosis, however, remains histopathological evidence of vascular invasion by fungal elements. Management includes wide surgical resection and amphotericin B. Although mortality rates are significant, a high index of suspicion and early diagnosis by the otorhinolaryngologist may improve the opportunity for successful treatment.

47 Results of Surgical Treatment of Ear Canal and Middle Ear Carcinoma MILAN STANKOVIC MD; DUSAN R MILISAVLJEVIC MD; LJILJANA MILISAVLJEVIC MD PHD; DRAGOLJUB POPOVIC MD, Serbia Yugoslavia; Nis Serbia Yugoslavia; Nis Serbia Yugoslavia; Serbia Yugoslavia

Objective: Primary carcinoma of temporal bone is rare, but it has considerable malignant potential. Carcinoma of external

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ear canal is less aggressive and has bigger five-year survival rate than the carcinoma of middle ear. Critical evaluation of therapeutical results of these tumors is difficult because of unequal classification. Methods: To analyze the results of surgical and radiation therapy of these carcinomas we divided them according to Arriaga et al. (1990). In total, 6 external canal and 9 middle ear carcinoma were studied. There were 4 tumors without bony erosion (group A), 6 confined to middle ear space (group B) and 5 with further propagation (group C). Results: Partial temporal bone resection was done in 4 patients, subtotal resection (petrosectomy) in 9 and total temporal bone resection in 2 patients. Postoperative irradiation with 6000 cGy in 30 fractions during 6 weeks was also applied. Five-year survival rate for the carcinoma of external ear canal amounted to 50%, and for the carcinoma of the middle ear only 22%. All the patients with involved margins of resection died of disease. Conclusions: It can be concluded that prognosis of temporal bone carcinoma directly depends on the propagation of tumor. Computerized tomography is a reliable method for determination of the propagation and for planning the treatment. Temporal bone resection with postoperative irradiation is the method of choice of temporal bone carcinoma. 48 Treatment of Deep Neck Space Infections ZORAN DIMIC MD; DUSAN R MILISAVLJEVIC MD; LJILJANA MILISAVLJEVIC MD PHD; DRAGOLJUB POPOVIC MD, Serbia Yugoslavia; Nis Serbia Yugoslavia; Nis Serbia Yugoslavia; Serbia Yugoslavia

Objective: The aim of this study was to point out the frequency of deep neck infections, its diagnosis and treatment. Methods: We present in our report, 13 cases of deep neck infections treated at our clinic in the period from 1988 to 1997. Out of 13 patients, 9 patients were male and 4 female. Anatomic location of the abscess was recorded by the radiography and CT, admitting history and physical examination. All patients were admitted in our clinic and began receiving empirical antibiotics. In 4 cases the situation was very drastical. Clinical, endoscopical, x-ray examination showed deep neck abscesses which spread in retroesophageal prevertebral space; consequently swallowing was very impaired in them. Results: Tracheotomy was done in one patient in local anesthesia for airway control. In 3 patients access was lateral cervicotomy along posterior line of sternocleidomastoid muscle to hypopharynx. In one patient infection descended in mediastinum, so we had to perform together with thoracic surgeon lateral thoracotomy; retroesophageal access has been performed with double drainage. Out of 13 patients, infections in 12 patients were cured either by surgical intervention or by antibiotic therapy, one patient died 12 days after his arrival in our clinic. Conclusions: Despite the wide use of antibiotics available to treat early infections of the head and neck, infecting organisms continue to cause abscesses in the deep neck spaces. Very difficult complications of deep neck abscesses are still present and require prompt diagnosis and treatment.

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49 Preoperative Evaluation of Radial Forearm Vasculature Using the Objective Allen's Test DOUGLAS A NUCKOLS MD; E B TOBY MD; TERANCE T TSUE MD; DOUGLAS A GIROD MD, Overland Park KS; Kansas City KS; Kansas City KS; Kansas City KS

Objective: The Objective Allen's Test (OAT) was used prior to head and neck reconstruction to assess forearm vascularity in anticipation of harvesting a radial forearm free flap (RFFF). The conventional Subjective Allen's Test (SAT) is problematic because of its subjective nature. We feel a more reliable, objective and safe method is needed to accurately avoid hand ischemia after major vasculature interruption in RFFF harvest. In addition, an objective test could alleviate fears in patients with equivocal SATs, avoiding unnecessary harvest of more difficult and time-consuming reconstructive flaps. To this end the utility of the OAT was examined. Methods: Retrospective analysis of 64 patients undergoing preoperative SAT and OAT was completed. The OAT uses both Doppler and photoplethysmography to determine the completeness of the palmar arch as well as forearm vascularity and individual digit perfusion based on radial and ulnar inflow. Results: In 64 patients (127 forearms) both SAT and OAT were performed preoperatively. The sensitivity and specificity of the SAT compared to the OAT were only 62% and 81%, respectively. The SAT's positive predictive value was 93%, while the negative predictive value was only 36%. In 40 patients with at least one forearm with a positive SAT, 1 (2.5%) patient was found by OAT to have vasculature which would not have allowed safe RFFF harvest. In contrast, of the 24 patients with equivocal or negative SATs in both arms, 17 (71%) were found by OAT to be safe for RFFF harvests and went on to have a successful RFFF. Conclusions: The OAT is an objective measure of forearm vasculature and is superior to conventional Allen's testing in RFFF donor site selection. The OAT is most useful in those patients with equivocal preoperative SATs and often the RFFF may still be used despite an unfavorable SAT. Using the OAT has resulted in no vascular complications such as digit ischemia, ulceration, or cold intolerance. No radial artery harvests have necessitated vein graft reconstruction to maintain hand perfusion. Vascular abnormalities, including radial artery retrograde flow and thrombosis, were also determined by the OAT, thereby reducing operative morbidity and allowing improved surgical outcome. 50 The Vomeronasal Organ: An Objective Anatomic Analysis JOHNNY WON MD; ERIC A MAIR MD; WILLIAM E BOLGER MD, Rockville MD; Rockville MD; Bethesda MD

Objective: The vomeronasal organ (VNO) has been examined previously and its prevalence in humans published. Reported prevalences have varied widely between previous studies most likely due to the small size and poorly defined structure of the VNO. Our objective was to better define the

organ using rigid nasal endoscopic examination correlated with histologic confirmation of cadaveric specimens followed by determination of VNO prevalence with nasal endoscopy of human subjects. Nasal endoscopy was not a method that was previously used for this purpose. Methods: Thirty fresh cadaver heads were examined with an endoscope and structures suspected to be VNOs characterized by appearance and location. Suspected VNOs were then removed for histologic examination and correlated with the endoscopic evaluation. With the data gained from the cadaver study, the angled rigid endoscope was used to closely examine and video document the VNO in 100 human subjects to estimate its prevalence. Results: Preliminary results characterize the VNO as extremely variable in size, shape, and color. Sizes ranged from less than 1 mm × 1 mm to 7 mm × 3 mm. Shapes also ranged from well defined craters to extremely shallow indentations to tiny pits. Color was also variable from hyperpigmented to hypopigmented. In contrast, the location was very constant as most VNOs were located on the nasal septal mucosa approximately 2 cm proximal to the nasolabial angle and 1 cm cephalad to the nasal floor. All VNOs overlie the cartilaginous septum within 5 mm of the bony-cartilaginous junction. Prevalence was determined to be greater than 75%. Conclusions: Previous studies determined the prevalence of the VNO utilizing examination methods poorly suited for such a small and variable structure. We utilized a method capable of examining fine nasal mucosal structures to characterize the VNO and then confirmed our observations with histologic examination. We then determined the prevalence in human subjects with a better understanding of the anatomic character of the VNO. 51 Triple Synchronous Primary Head and Neck Squamous Cell Carcinomas SREEKUMAR SUBRAMANIAN MD; ERIC J MOORE MD; JOSEPH BRENNAN MD; KURT J SHULER MD, Travis AFB CA; Davis CA; Davis CA; Vacaville CA

Objective: Field cancerization refers to the heightened susceptibility of the entire aerodigestive tract epithelium to develop cancer after exposure to this theory. We present a rare case of triple synchronous primary squamous cell carcinomas of the head and neck, and review the theory of field cancerization. Methods: The chart of a 52-year-old man with synchronous primary tumors of the anterior floor of mouth, glottis and pyriform sinus was reviewed. The radiographs have been prepared for presentation. MEDLINE and Knowledgefinder were searched to find all relevant articles on multiple primary head and neck tumors and field cancerization. Results: Multiple (>2) synchronous primary squamous cell carcinomas of the head and neck are extremely rare, with only several documented cases. After preoperative panendoscopy and biopsy, our patient underwent a total laryngectomy, a bilateral modified radical neck dissection, and a composite resection of the anterior floor of mouth and ventral tongue with a pectoralis major myocutaneous flap.

Otolaryngology– Head and Neck Surgery Volume 119 Number 2

52 Comparative Analysis of Postoperative Complications among Patients Treated in a Chemoradiation Protocol Versus Standard Care K THOMAS ROBBINS MD; EVA GAIL PROCTOR, Memphis TN

Objective: To compare the complication rate of patients undergoing targeted chemoradiation with those receiving standard care, i.e. primary surgical therapy. Methods: Review of fifty patients treated with targeted chemoradiation (RADPLAT) and forty-nine patients undergoing primary surgical therapy. Results: All patients had stage III or IV disease (AJCC). Both groups showed similarities in gender, comorbidities, T classification and location of primary. The groups differed statistically in age, classification of nodal disease and two versus three layer closure of the surgical incision. Complication rates were further subdivided into wound (infection, dehiscence, fistula, graft failure, hemorrhage and carotid rupture) and medical (pneumonia, vascular and cardiac). There was one hospital death in each group. Two patients in the RADPLAT group had failure of a myocutaneous flap while the control group had a failure of an osseous myocutaneous flap, a myocutaneous flap, and a skin graft. Conclusions: Overall the groups did not differ in the percentage of wound or medical complications. After adjustment for age, nodal disease and surgical closure, no difference was seen between groups. This study shows that use of the RADPLAT protocol does not increase postsurgical morbidity. 53 Treatment of Lacrimal Sac Carcinoma KEVIN E MCLAUGHLIN MD; FORD D ALBRITTON IV MD; SUSAN MULLER DMD; WILLIAM J GRIST MD, Atlanta GA

Objective: Primary tumors of the lacrimal sac are rare with less than 300 cases reported. The majority are of transitional cell origin and approximately 60% are malignant. Five year survival has been reported at approximately 50% with failure strongly associated with local recurrence secondary to inadequate primary resection. Methods: A 47-year-old white female was unsuccessfully treated for chronic dacryocystitis with epiphora for one year at which time she underwent a planned dacryocystorhinostomy. The procedure was aborted when a mass was discovered and biopsy revealed transitional cell carcinoma. Two weeks later the patient underwent a joint otolaryngology/oculoplastics procedure including dacryocystectomy, complete excision of the nasolacrimal duct, external ethmoidectomy, medial maxillecto-

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my, and medial canthoplasty. All margins were free of tumor. The patient is free of disease one year postoperatively. Results: The epithelial lining of the lacrimal sac is of pseudostratified columnar (transitional) type. Similar to tumors in the nasal cavity and paranasal sinuses, transitional cell tumors of the lacrimal sac can involve the mucosa diffusely and may extend to the nasolacrimal duct and nasosinal cavity. Simple excision of the nasolacrimal system is associated with increased mortality. Wide local excision of the contiguous nasosinal tissue is associated with improved survival. Conclusions: Lacrimal sac carcinomas are rare. These tumors are best treated jointly by ophthalmology and otolaryngology. Dacryocystectomy with external ethmoidectomy and medial maxillectomy has been associated with increased survival. 54 Preservation of an Inferomedial Bony Strut During Orbital Decompression Minimizes Postoperative Diplopia ERIN D WRIGHT MD; FRANCOIS CODERE MD; MARTIN DESROSIERS MD, Montreal QU Canada; Montreal QC Canada; Montreal PQ Canada

Objective: With the increasing sophistication and safety of endoscopic orbital decompression, more patients are requesting decompression, especially for cosmetic reasons. As a result, complications such as postoperative diplopia assume greater significance. Preservation of an inferomedial bony strut has been postulated to reduce the incidence of postoperative diplopia in endoscopic orbital decompression for dysthyroid ophthalmopathy. Methods: We present a series of 12 subjects (24 eyes) who underwent either entirely endoscopic (n = 7) or combined medial endoscopic and inferior transconjunctival decompression (n = 5) of the orbits bilaterally. Ophthalmologic, surgical and cosmetic data were prospectively recorded in these patients. All cases were performed under general anesthesia. Results: Preservation of the strut was possible in 11 of 12 subjects (22/24 eyes). Visual acuity was preserved or improved in all 12 subjects (100%). There were two cases of transient postoperative diplopia. Average ocular recession based on Hertel measurements was 3.0 mm and there were no surgical complications. Conclusions: These results indicate that preservation of an inferomedial bony strut results in acceptable decompression while reducing the incidence of postoperative diplopia 55 Viral Classification Related to Laryngeal Papillomas and Cancer in HVP MERCEDES B DE ALFORD MD; GERALDINE CAIBE ROJAS MD; RICARDO M D'ALBANO MD; EFRAIN G PRATO MD, Caracas Venezuela

Objective: To detect through molecular method of genetic engineering (polymerase chain reaction, PCR) the human

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Conclusions: The routine use of preoperative panendoscopy has increased the detection of synchronous aerodigestive tract tumors. However, the presence of three or more synchronous squamous cell carcinoma primaries in the head and neck is extremely rare. Early detection and aggressive combination therapy may offer the best chance for cure.

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papilloma viruses (HPV) involved in laryngeal papilloma and laryngeal cancer. Methods: Forty patients from the otolaryngology service of the hospital Universitario De Caracas underwent biopsy under general anesthesia and direct microlaryngoscopy between July 1994 and July 1996. These biopsy specimens were analyzed histopathologically; those with criteria suggestive of HPV were selected and sent for nucleic acid detection of HPV and viral classification using the PCR method with the genomic DNA types 6, 11, 16, 18, 31, 33 and 35. Results: Twenty-five patients (62.5%) were diagnosed as having laryngeal papilloma. The remaining 37.5% (15 patients) were diagnosed as having epidermoid laryngeal cancer with changes suggestive of HPV infection. Mean age was 21.92 years within a range between 4 and 58 years. HPV types 6 and 11 were the most frequently involved in laryngeal papilloma, HPV types 16 and 18 were the most frequently involved in laryngeal cancer. Conclusion: There is evidence suggesting the relationship between clinical evolution and prognosis against the HPV infecting type in laryngeal papilloma and laryngeal cancer. The viral classification according to the genomic types nowadays represents an uncillary diagnostic tool with both clinical and prognostic value. 56 Infiltrative Pleomorphic Adenoma of Nasal Cavity BRADFORD J DYE MD; GILBERTO O ALEMAR MD; VINOD K ANAND MD, Ridgeland MS; Ridgeland MS; Jackson MS

Objective: Pleomorphic adenomas rarely occur in the nasal cavity, and the vast majority remain confined to the nasal cavity. Erosion of the bony floor is extremely rare. A case of infiltrative pleomorphic adenoma of the nasal cavity is reported. Methods: The pathologic diagnosis of pleomorphic adenoma was established during endoscopic sinus surgery at an outside hospital. CT and MRI scans revealed 8 × 4 × 2.5 centimeters nasal floor mass eroding the nasal septum and the hard palate. lntraoperatively, tumor was found to have filled both nasal cavities, was adherent to the palatal mucosa, and had eroded the bony palate. Results: Surgical resection of the tumor was performed using bilateral Lefort I osteotomies and a midface degloving approach. Removal of portions of the hard palate, nasal septum and inferior turbinates was required and reconstruction was performed with a palatal prosthesis. The patient is disease free six months following surgery. Conclusions: Pleomorphic adenoma of the nasal cavity can be extensive and invasive. Adequate surgical exposure is required to achieve total resection.

57 Kikuchi-Fujimoto Disease: A Clinicopathological Report ENRICO PATUNDI MD; GREGORY A GRILLONE MD; DANIEL K SMITH MD, Boston MA; Boston MA; Stoneham MA

Objective: To describe the clinical course and histologic features of this uncommonly diagnosed form of lymphadenopathy.

Case History: A 24-year-old female of Asian origin but residing in the USA since the first months of life, presented with high grade fever, odynophagia, malaise and progressively enlarging bilateral cervical nodes for the last two weeks. The patient had a negative medical history with absence of risk factors for human immunodeficiency virus (HIV). The physical exam was positive for oropharyngeal edema and multiple tender enlarged cervical nodes involving levels I-V bilaterally. Hematologic tests were in the normal range and a test for heterophil agglutinins was negative. After completion of a 10 day course of antibiotics, the adenopathy and malaise were unchanged. Excisional biopsy of an enlarged supraclavicular node was performed and the pathology report was consistent with Kikuchi-Fujimoto disease (KFD). Discussion: KFD was described for the first time in 1972. This disease is characterized by acute onset of cervical lymphadenopathy with fever and malaise unresponsive to antibiotics. A female preponderance, young age of onset, and normal blood tests are observed in most cases. The etiology is unknown. Spontaneous resolution of the adenopathy in 1-3 months is the usual course; however, progression of KFD to systemic lupus erythematosus (SLE) has been described. The differential diagnosis based on physical findings is extremely vast and the excisional biopsy of the affected node is the only reliable diagnostic tool. The histologic differential diagnosis of KFD includes non-Hodgkin's lymphoma and SLE. Most of the cases of KFD are diagnosed in the Asian countries and the familiarity of otolaryngologists with this disease remains low. An awareness of the clinicopathological features of KFD is essential to differentiate it from severe diseases with similar presentation.

58 Acoustic and Laryngeal Tremor Characteristics of Phonation in Adductor Laryngeal Dystonia GEORGE L CHARPIED PHD; GREGORY A GRILLONE MD, Boston MA

Objective: Laryngeal dystonia is a devastating voice disorder essentially of unknown etiology. The adductor type (ALD) is characterized by strain-strangle voice with frequent phonatory breaks and effortful speech. It appears that at least some patients with ALD also have associated vocal tremor. However, little is known about the prevalence or acoustic nature of the tremor in this group of patients. The objective of this study was to define the prevalence and characteristics of vocal tremor in ALD patients’ acoustic signal and correlate it with videoendoscopic evidence. Methods: Twenty-eight patients with a clinical diagnosis of ALD were studied. Voice recordings and analysis were made using a computerized system. The low frequency portion of sustained /a/ phonation was demodulated to determine rate and magnitude of tremor. Digitized videoendoscopic and videoendostroboscopic segments were analyzed with a computerized procedure. Variation of glottal open phase and extraneous arytenoid movement during sustained phonations were

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59 Comparison of Speech Valve Prosthesis laryngectomy Voice Rehabilitation

in

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GEORGE L CHARPIED PHD; GREGORY A GRILLONE MD, Boston MA

Objective: Recent advances in plastics and design have provided prosthetics that return serviceable voice to the laryngectomy patient. Using both subjective and objective data, this study prospectively evaluated several parameters of the rehabilitated voice in patients with either the Blom-Singer or Provox tracheoesophageal speech valve. Methods: Ten males and two females (mean age 54; 38-72 years) status post total laryngectomy, neck dissection and radiation or chemotherapy who were outfitted with either the Blom-Singer or the Provox speech valve. The rehabilitated voice was evaluated using a protocol derived from the 1988 Groningen Conference that included clinician and patient subjective assessment determinants and acoustic analysis of the neo-voice. Age and sex matched normal voice was the standard. Outcome variables including latency between laryngectomy and onset of voicing, on-demand voicing, intelligibility, strain, word per minute rate, syllable per breath rate, fundamental frequency, dynamic range, and harmonic to noise ratio, as well as reasons for failure, were examined. Results: Both the Blom-Singer and Provox speech valves were effective at voice emulation. The chief cause of valve failure for both types was leakage due to Candida colonization, but this was easily managed with frequent cleaning. Significant differences for outcome variables included longer phonation time, greater word per minute rate reduced strain, improved degree of voicedness, and improved HNR for the Provox. Patients had less difficulty with care and cleaning of the Provox, reduced number of reports of valve displacement (0 vs. 5), and better long-term useful life (60-90 versus 20-30 days)

Conclusions: This study compared two types of alaryngeal speech valves. The Provox prosthesis had superior results in the majority of the outcome variables tested. In clinical practice the Provox may be the more dependable and produce a voice that is satisfactory to the patient. 60 A Case of Recurrent Angiomyoma (Vascular Leiomyoma) of the Larynx TIMOTHY D ANDERSON MD; GREGORY S WEINSTEIN MD, Philadelphia PA

Objective: Angiomyoma is a benign tumor of smooth muscle origin with abundant vascularity that most often occurs in the skin of the extremities. Several cases of upper airway angiomyomas have been reported including ten within the larynx. Complete surgical excision via direct laryngoscopy for small tumors or external approach for larger ones seems to be the therapy of choice. No recurrences have been reported in the larynx after excision. We describe an unusual case of recurrent angiomyoma of the larynx. Methods: Case report of recurrent laryngeal angiomyoma with review of the relevant literature. Results: The patient originally presented at age 39 with a three year history of hoarseness. Physical exam revealed a healthy male in no distress, with a hoarse voice. On laryngoscopy the right vocal fold was found to be displaced towards the midline with a cherry red mass attached to the undersurface of the right vocal fold. The patient was taken to the operating room for micro direct laryngoscopy. The CO2 laser was used to completely excise the lesion and to control bleeding. Pathologic examination of the specimen revealed a collection of vascular spaces separated by interlocking fascicles of smooth muscle. The patient returned 12 years after primary excision with recurrent hoarseness of 6 weeks’ duration. Microscopic direct laryngoscopy found a right sided subglottic mass. The lesion was completely excised using microlaryngeal instruments and the bleeding easily controlled with oxymetazoline soaked pledgets. Postoperatively the patient did well with significant improvement in his voice quality. Histologic examination of the mass again revealed irregular, dilated vascular channels surrounded by smooth muscle bundles, suggesting recurrent angiomyoma. Conclusions: This unusual case of recurrent laryngeal angiomyoma demonstrates that patients should be monitored for recurrence after surgery despite complete resection.

61 Primary Malignant Melanoma of the Larynx: A Case Report HESHAM M AMIN MD MSC; GUY J PETRUZZELLI MD PHD; ALIYA N HUSAIN MD; BRIAN J NICKOLOFF MD PHD, Maywood IL

Objective: Primary malignant melanoma of the larynx is a rare clinical entity. To date, only 53 cases have been reported in the medical literature. The present report describes a case of pri-

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quantified. The control group consisted of 60 subjects with no known vocal or neurologic pathology. Results: Pathologic tremor, defined as a time-varying oscillation of fundamental frequency (F0) greater than 3 Hz and intensity greater than 5 Hz were found in 66% of ALD patients. The mean F0 tremor rate was significantly higher than for the control group. There was no significant difference in intensity tremor rate. The percent of signal modulated for both F0 and intensity was significantly higher in the ALD group. Correlating digitized videoendoscopic and videoestroboscopic with acoustic data was problematic when using the regular/regular and regular/irregular tremor classification, but quantification did bear information that will be discussed. Conclusions: Acoustic tremor in ALD is more common than previously thought. It also appears that ALD F0 and intensity tremor rates, as well as the magnitude of signal modulated, combine to produce an acoustic signal that contributes to the overall acoustic output that is perceived as strained and harsh in the ALD patient.

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mary malignant melanoma arising in the larynx and diagnosed on histologic examination of an excisional biopsy specimen. Methods: A 53-year-old man with a history of heavy smoking and hoarseness underwent a laryngoscopic examination which revealed the presence of an exophytic lesion involving the entire left true vocal cord without deep penetration or extension into the laryngeal ventricle. The mass was locally excised by carbon dioxide laser and submitted for histologic examination. Histologic sections stained with hematoxylin and eosin (H and E), S-100, HMB-45, cytokeratin, vimentin, and iron were examined. Results: Extensive clinical and radiographic evaluations did not demonstrate the presence of any other suspicious melanocytic lesion. H and E sections showed abundant cytoplasmic and nuclear brown pigment in the tumor cells. Many mitotic figures were present. Focally dispersed atypical melanocytes could be identified within the epithelium and the junctional zone between the epithelium and submucosa. Immunohistochemical studies were positive for S-100, HMB45, and vimentin; and negative for cytokeratin and iron. Conclusions: Based on the clinical and histopathologic findings, diagnosis of primary malignant melanoma of the larynx was established. 62 SCCHN Induces Immune Dysfunction Through Apoptosis of Lymphocytes BRIAN R GASTMAN MD; HANNAH RABINOWICH PHD; JONAS T JOHNSON MD, Pittsburgh PA

Objective: Patients with SCCHN are often immunosuppressed. These tumors express Fas ligand (FasL) in situ and in culture, which is capable of triggering an intrinsic cell death program in Fas-expressing T cells. Our goal is to show that tumor-mediated apoptosis (TUMAP) of lymphocytes is through the Fas pathway and that caspases are intrinsically involved in lymphocyte death. Methods: SCCHN cell lines, including PCI-13 and PCI-52, were established from tumor biopsies in our laboratory. Fassensitive or Fas-resistant Jurkat T cell lines, or normal PBL, activated in vitro were used as targets. JAM assays were used to measure apoptosis in [3H]-TdR-labeled Jurkat or PBL targets co-incubated with SCCHN cells for 18h at various E/T ratios. Also, TUNEL and PARP cleavage assays were used to measure apoptosis in lymphoid cells. Results: TUMAP of T cells was Fas-mediated, as it was: a) inhibited by blocking of either Fas on lymphocytes or FasL on tumor cells by specific antibodies; b) Fas-resistant Jurkat cell variant was not killed; c) enhanced by pre-treatment of SCCHN with metalloproteinase inhibitors, which prevent the enzymatic cleavage of surface FasL. Caspases were involved in this TUMAP, as it was: a) blocked by tetrapeptide aldehydes Z-YVAD or Z-DEVD; b) involved pro-caspase-3 activation and cleavage of PARP; c) blocked in Jurkat cells overexpressing the caspase inhibitor, CrmA. Overexpression of BCL-2 in T cells was not protective against TUMAP. Conclusions: Thus, SCCHN can induce cell death in T cells via the Fas pathway, and this process is caspase-dependent

and BCL-2 independent. The immune status of patients with SCCHN is dependent on the ability of the tumor to kill immune effector cells. 63 Carcinoma In Situ of the Larynx: Management with Transoral CO2 Laser Surgery MICHAEL DAMM MD; HANS EDMUND ECKEL MD; MICHAEL SHEPPEL MD; MARKUS JUNGEHUELSING MD, Cologne Germany

Objective: Carcinomas in situ (CIS) are tumors in which malignant cells have not penetrated the basement membrane and therefore have no metastatic potential. Treatment strategies of CIS are topics of the ongoing discussion. The aim of this study was to evaluate the results of carbon dioxide laser therapy in laryngeal CIS. Methods: From 1986 to 1996, 27 patients with glottic CIS were treated with transoral carbon dioxide laser surgery. After an initial biopsy, the transoral laser treatment of glottic CIS followed three different categories of surgical procedures. Follow up was 88 months in mean. Results: A complete removal of the tumor was possible with laser-vocal cord stripping in 20 patients, with laser cordectomy in 5 patients. In 2 patients an extended laser cordectomy was performed. Four patients required repeated laser surgery for local recurrences. There was no tumor related death in this series. No patient required laryngectomy or radiotherapy. Conclusions: The results presented here are superior to those previously reported with radiotherapy. They add further support to the observation that surgery is the better treatment option for CIS of the larynx. Based on the results of this study, recommended treatment for CIS is CO2 laser surgery in combination with a meticulous follow up for early recognition of local recurrence. 64 Congenital Saccular Cyst: Airway Obstruction

A Rare Cause of Neonatal

P TODD NICHOLS MD; HASSAN H RAMADAN MD; HUMA A QURAISHI MD, Morgantown WV

Stridor is a common presenting symptom of airway obstruction in infants. Among the differential diagnosis is the congenital laryngeal saccular cyst. They result from an abnormal dilation of the saccule due to obstruction at its orifice. Mucous accumulation within the saccule leads to expansion and compromise of the laryngeal lumen. Lateral saccular cysts extend posteriorly and superiorly into the false vocal cord and aryepiglottic fold. Anterior saccular cysts bulge inferiorly and medially between the false and true vocal cords. Treatment options include aspiration, marsupialization, and excision. Because of frequent recurrence, patients typically require multiple endoscopic procedures, and occasionally tracheostomy. Excision via an external approach has been recommended for those patients who fail endoscopic management.

Otolaryngology– Head and Neck Surgery Volume 119 Number 2

We present a case of a six month old who presented with stridor since birth and failure to thrive. Flexible and direct laryngoscopy revealed an anterior saccular cyst. After multiple attempts at conservative endoscopic management, the patient required excision through an external surgical approach. The embryology, clinical presentation, radiologic evaluation, and surgical management of these lesions will be reviewed.

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tance from the individual stability limits), but the difference was not significant due to large inter-subject variation. Conclusions: The VFP is a novel method to evaluate active postural control during vestibular rehabilitation therapy. Static sway velocities were not improved during repeated tests, whereas in the evaluation of dynamic active parameters of the VFP training effects must be considered. 67

Congenital Nasal Pyriform Aperture Stenosis: A Clinical Review RICK A FORNELLI MD; HASSAN H RAMADAN MD, Morgantown WV

Objective: To present this rare midface anomaly that results in airway obstruction in infants, and discuss associated endocrine abnormalities and chromosomal defects. Additionally, clinical presentation and treatment options will be discussed. Methods: Case report of a female infant who developed respiratory distress shortly after birth. Clinical presentation, physical findings, computed tomography, and treatment options will be included. Results: The patient has had an excellent clinical response with no residual symptoms following sublabial repair over one year ago. Conclusion: Nasal pyriform aperture stenosis is rare, and a high index of suspicion is necessary for proper diagnosis when evaluating respiratory distress in infants. We conclude that computed tomography is the study of choice to aid in diagnosis, and treatment depends on severity of symptoms. 66 Training Effect in Visual Feedback Posturography TIMO P HIRVONEN MD; HEIKKI AALTO PHD; ILMARI PYYKKO MD, Helsinki Finland; Helsinki Finland; Stockholm Sweden

Objective: Visual feedback posturography (VFP) can be used to evaluate active postural control on a force platform. However, training effect must be considered when repeated measurements are compared. The objective of this study was to determine the influence of training on different VFP parameters. Subjects and Methods: Eleven healthy subjects were measured five times with a force platform. Static measurement included determination of body sway velocity in eyes open, eyes closed and visual fixation conditions. In visual feedback condition subjects (by leaning to chosen direction on the platform) moved their center of gravity (COG) marker to eight targets, which were displayed on a computer screen in front of them. Sway velocities to and within the targets as well as hit delays and hold percentages were measured. Results: Neither static sway velocities nor visual feedback hold velocities within the targets improved significantly with repeated tests. A tendency of improvement was found in the hit velocities to the targets and balance index (at the 50% dis-

Paranasal Sinuses Management

Mucoceles:

Diagnosis

and

RICHARD L VOEGELS MD; ITALO ROBERTO T DE MEDEIROS MD; PATRICIA P SANTORO MD; OSSAMU BUTUGAN PHD, Sao Paulo Brazil; Sao Paulo SP Brazil; Sao Paulo SP Brazil; Sao Paulo Brazil

Objective: Mucoceles of the paranasal sinuses are expansive pseudocystic formations, made from altered sinusal mucosa containing mucus and inflammatory exudate. They have a tendency to distend and erode the bony walls. Their pathogenicity is still misunderstood, although it might be due to an association of inflammation, ostium closure and hypersecretion. The objective of this paper is to present the authors’ experience with 71 cases of mucoceles of the paranasal sinuses diagnosed and treated from 1987 to 1997. Methods: A retrospective study of 71 patients with mucoceles of the paranasal sinuses was performed. Attention was directed to preoperative symptoms, prior operation or trauma, radiology findings, surgical technique and follow-up. Results: There was a slight predominance of males (52.11%) and the average age was 43.89 years. The most important symptoms found were facial deformity (66.2%), severe headache (36.6%), nasal purulent secretion (33.8%) and obstruction (33.8%). Other signs and symptoms were ocular pain, facial pain, proptosis, decreased visual acuity, diplopia. Treatment consisted of surgery (endoscopic sinus surgery, Caldwell-Luc, external frontoethmoidectomy and combinations of these techniques) associated with antibiotic therapy in all cases. Recurrence occurred in 4 patients and a second procedure was performed. Conclusions: Mucoceles of the paranasal sinuses is a relatively rare condition with the potential to erode bone and spread to surrounding structures. Prompt diagnosis and treatment are necessary to avoid complications. CT scans have proven to be an excellent diagnostic tool and are essential in surgical planning. The advent of endoscopic sinus surgery allowed excellent results with very low morbidity. The few recurrences may be treated with a second procedure. 68 Clinical Evaluation of Childhood Vertigo: Analysis of 91 Cases LAZARO GILBERTO FORMIGONI MD; ITALO ROBERTO T DE MEDEIROS MD; PATRICIA P SANTORO MD; ROSELI SARAIVA MOREIRA BITTAR MD, Sao Paulo SP Brazil

Objective: To study the prevalence and risk factors in children with vestibulopathy.

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Methods: Ninety-one children with vestibular syndrome were studied between January 1990 and June 1997 with ages between 4 months and 12 years, to determine the most prevalent signs in the child with a vestibular system disease. Results: The main results were: familiar migraine (90%), headache (84.6%), dizziness (84.4%), behavior disorders (84.2%), cinetosis (77.3%), sleep disorders (77.1%), irritability (72.3%), unknown cause of crying (71.4%), cesarean (71.4%), convulsion (69.2%), tendency to stay in cradle (61.1%), school problems (61%), otologic disease (60%), abdominal pain (59.4%), tinnitus (44%), falls (43.9%), perinatal anoxia (43%), fear of darkness (42.3%) among others. Conclusions: Supported by our clinical experience, we can say that vertigo in childhood has completely diverse symptoms from adults, deserving a separate chapter in otoneurology. 69 Magnetic Resonance Angiography in Pulsatile Tinnitus TANIT G SANCHEZ MD; ITALO ROBERTO T DE MEDEIROS MD; PATRICIA P SANTORO MD; RICARDO F BENTO MD, Sao Paulo SP Brazil

Objective: Pulsatile tinnitus is frequently associated with a treatable cause. Although paraganglioma is the most important cause, one needs to be prepared to find normal otoscopy with this complaint, being essential to differentiate other diagnoses such as arteriovenous malformations or fistulas, intra or extracranial aneurysms, high or dehiscent jugular bulb, persistent stapedial artery, etc. The authors evaluated the effectiveness of MRA as a screening method to perform the etiologic diagnosis of pulsatile tinnitus with normal otoscopy. Methods: The authors studied prospectively 16 patients with pulsatile tinnitus and normal otoscopy from January 1995 to June 1997. There were 15 female patients and 1 male patient. The age ranged from 25 to 71 years old (average 42.5 years). All patients underwent a complete evaluation by magnetic resonance angiography. Results: Radiologic findings showed vascular malformations in 12 patients (75%) and increased intracranial pressure in 1 patient (6.25%), making it possible the lesions responsible for pulsatile tinnitus in 81.25% of the cases. Conclusions: The authors comment on the importance of making an etiologic diagnosis in patients with pulsatile tinnitus and normal otoscopic findings and confirm that MRA is an excellent primary screening modality in these cases. 70 Presentation and Treatment of Post-traumatic Pseudomeningocele of the Superior Orbit DANIEL K SMITH MD; IVAN H EL-SAYED MD; ENRICO PAFUNDI MD; ROBERT W DOLAN MD, Stoneham MA; Somerville MA; Boston MA; Boston MA

Objective: To discuss the presentation and treatment of a patient with a pseudomeningocele (PM) of the superior orbit following facial trauma with fracture of the orbital roof.

Case History: A 71-year-old male presented with facial fractures following a motorcycle accident. Initial examination revealed diffuse soft tissue swelling and ecchymosis involving the right side of the face, which limited the evaluation of the bony anatomy. Computed tomography revealed a minimally displaced right tripod fracture and a sagittal fracture of the orbital roof. The orbital roof fracture was reported to be associated with an intraorbital soft tissue density consistent with hematoma. The soft tissue swelling decreased over 72 hours revealing a persistent swelling limited to the right upper eyelid that was ballotable and manually reducible. In addition, the mass dramatically enlarged with a Valsalva maneuver. Results: A magnetic resonance image demonstrated a pseudomeningocele of the right superior orbit. Neurosurgery was consulted and performed a closed ventriculostomy shunt. This remained in place for 5 days and resulted in a reduction in the size of the PM. The PM resolved completely 4 weeks later. Discussion: Post-traumatic PM occurs rarely in the head and neck. A MEDLINE review of the last twenty years identified no reported cases of a PM of the orbit following facial trauma. PM is formed by extravasation of cerebrospinal fluid into soft tissue, and as noted in this report, may produce only subtle clinical and radiographic findings. Differential diagnosis includes an encephalocele, meningocele, hematoma, fat herniation, subcutaneous emphysema, orbital abscess, and foreign body. Clinical aspects of the exam which assist with diagnosis include a soft, reducible mass that enlarges with a Valsalva maneuver. Diagnosis is confirmed by magnetic resonance imaging. The recognition of this abnormality is essential prior to open reduction of an orbital fracture. 71 Laryngeal Epidermolysis Bullosa Acquisita with Acquired Factor VIII Coagulopathy DANIEL HURLEY MD; JAMES H BOYD MD FACS; CHARLES EBY MD, St Louis MO

Introduction: We examined a patient with an acquired Factor VIII inhibitor which presented in conjunction with epidermolysis bullosa acquisita (EBA) of the oral cavity and larynx requiring a tracheostomy for airway control. Coincidental presentation of these rare diseases has not been reported. Case History: A 60-year-old female presented with an iliopsoas hematoma as well as vesicles on her pre-tibial regions and soft palate, with intermittent hoarseness. She was diagnosed with an acquired neutralizing autoantibody against factor VIII. Her coagulopathy responded to immunosuppression therapy, however the oral involvement worsened prompting an ENT evaluation. Examination showed blistering and ulceration of the larynx with progressive restriction of the airway. Biopsies of her skin lesions came back positive for EBA. She continued her treatment with cytoxan and steroids with intermittent partial airway obstruction responding to bursts of steroids. In 12/97, she was noted to have almost complete obstruction of her airway on exam and underwent tracheostomy. Discussion: EBA is a rare skin disorder caused by antibod-

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ies to the skin basement membrane. It most commonly affects extensor skin surfaces with oral cavity involvement in 50% of cases. This case is unusual in that the skin involvement is minor compared to the laryngeal involvement. Unique to this case is the concurrent presentation of EBA with an acquired factor VIII inhibitor which is also an autoimmune disorder. The connection between these two rare diseases is strengthened by the coincidental presentation as well as previous reports of acquired coagulopathies with other blistering autoimmune dermatologic disorders such as bullous pemphigoid.

referred for otolaryngologic evaluation whose various disabilities had been diagnosed as psychiatric or behavioral disorders. Results: Each child had previously failed behavioral or pharmacotherapy. In all three cases perilymphatic fistula was demonstrated during exploratory tympanotomy. Temporalis muscle packing of the oval and round windows resulted in resolution of each patient's otologic and behavioral difficulties. Conclusions: These cases highlight the difficulty of making the diagnosis of PLF even in patients who operatively had very clear findings consistent with severe leaks.

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Phase II: Ifosfamide and Carboplatin for Relapsed or High-Risk Head and Neck Cancer

The Diagnostic Dilemma Vesiculobullous Disease

FRANK R DUNPHY II MD; JAMES H BOYD MD FACS; BRENDAN C STACK JR MD; TERESA L DUNLEAVY RN BSN, St Louis MO

ANDREW A JACONO MD; JAY N DOLITSKY MD, West Hempstead NY; New York NY

Objective: To identify activity of ifosfamide and carboplatin in patients with relapsed or high risk head and neck cancer. Methods: Twenty-seven patients were treated with four courses of ifosfamide and carboplatin every 21-28 days. Ifosfamide was given over one hour for 3-5 days at doses ranging from 1.2 to 1.5 gm/m2/day. Carboplatin was administered over 1 hour on day 1 at mean dose of 373 mg/m2 (range 200-640). Patients were divided into two groups. Group 1 had history of squamous cell and had measurable disease. Group 2 were high-risk for recurrence based on surgical criteria. Results: Twenty were evaluable for response. Group 1 was observed to have a response rate of 17% and a shorter median survival than group 2 (28 versus 90 weeks). However, the observed improved median survival for group 2 was not sustained compared to group 1 (p=0.374). Sites of disease progression did not differ between the groups. Ifosfamide (1.3 gm/m2/d ×3) and carboplatin dose of AUC 6.0 were identified as safe. Conclusions: This is an active combination for relapsed head and neck cancer. Median survival improved for squamous cell cancer patients who were surgically disease free at the time of relapse as compared to those deemed unresectable. Local-regional control of tumor was better in patients treated with surgery followed by chemotherapy than those treated with chemotherapy alone. Chemotherapy was of marginal benefit in preventing subsequent distant metastases.

Objective: Refractory pediatric vesiculobullous disease presents a diagnostic dilemma. Once common causes of erosive oropharyngeal lesions, such as herpes gingival stomatitis, herpangina, medication induced stomatitis, and mycotic stomatitis, are clinically ruled out, the diagnosis of autoimmune vesiculobullous disease must be entertained and aggressively pursued with oral cavity mucosal biopsy. To date there are only 28 well documented cases in the literature of pemphigus vulgaris in children under the age of 17. We present a case in a 14-year-old girl. Methods: 1) Biopsy of oral cavity. 2) Pathologic evaluation. 3) Immunohistochemical analysis for IgG and C3. Results: We present a case of pemphigus vulgaris in a 14year-old girl with a history of chronic erosive oral cavity lesions which went undiagnosed for eight months despite consultation with dermatology. After the diagnosis was made by oropharyngeal mucosal biopsy and immunohistochemical analysis, the patient was treated with oral steroids and experienced resolution of symptoms within 3 days. Specific mention will be made to familial forms inherited in an autosomally dominant fashion with incomplete penetrance. Clinical photographs depict the disease and pathologic slides show diagnostic staining. Conclusions: The aggressive pursuit of a diagnosis in the pediatric patient with vesiculobullous disease of the oral cavity is mandatory. This often will require biopsy of the oropharyngeal mucosa. These diseases have systemic manifestations which must be monitored and treated. If not treated they can lead to significant morbidity and possibly mortality.

73 Perilymphatic Fistula Psychiatric Disease

Masquerading

as

Pediatric

HILARY H TIMMIS JR MD; CHRISTOPHER POST MD, Pittsburgh PA

Objective: Perilymphatic fistula is an abnormal communication between the inner and middle ears causing a wide variety of audiologic and vestibular symptoms. A child may have difficulty describing these symptoms in a coherent fashion resulting in the diagnosis of a psychiatric condition. Methods: Careful chart review, as well as interviews with families and therapists, was performed for three children

of

Refractory

Pediatric

75 Toxin Wash-out Masquerading as Advancing Cellulitis in a Patient with Streptococcal Cellulitis and Toxic Shock MICHAEL D POOLE MD PHD; JENNIFER KEIR-GARZA Houston TX

MD,

Head and neck surgeons are occasionally called upon to debride necrotic tissue in critically ill patients with necrotiz-

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ing infections of the head and neck. Those due to betahemolytic streptococci are among the most common and the most aggressive. This case involved a 72 yr old previously healthy (non-diabetic) woman who developed massive facial cellulitis, focal epidermolysis with necrosis, and toxic shock syndrome due to group A beta-hemolytic streptococcus. Because of visibly advancing skin erythema descending down the neck and upper trunk, the infectious disease service strongly recommended radical debridement of “the entire skin and muscles” of the head and neck, arguing that this viable tissue was the source of the toxin and/or bacteria, and that the patient's demise was otherwise inevitable. The otolaryngology service persistently declined, with perhaps a better understanding of the course of this particular case and the impact of effective anti-microbial activity. The patient made a complete recovery without the recommended debridement. Photos, schematics, and clinical details are provided for this illustrative case. The key components and findings of this case include: 1) prompt suspicion of infection with toxigenic betahemolytic streptococci, 2) addition of clindamycin to her antibiotic regimen (which results in prompt cessation of bacterial toxin formation), 3) the stabilization (and subtle improvement) in her cardiac and non-oliguric renal failure, 4) the reduction in the amount of local erythema and edema and the original sites of involvement (right eyelids and auricle) despite the radial diffusion and gravity dependent spread of the edema and erythema, 5) the absence of any regional necrosis in deep or superficial tissues. Although existing literature abounds with series and cases that would suggest the critical role of radical debridement in these types of infections, we could carefully examine such suggestions, particularly in the absence of necrosis and nonviable tissue. Advancing erythema may simply represent diffusion of erythrogenic toxin(s) away from the original (and improving) primary site of infection, without persistent infection, toxin production, or progression of illness.

chemo and radiation experienced sensorineural hearing loss. The changes in hearing sensitivity varied from slight to substantial, and in one case word recognition was affected as well. Specific changes for each patient will be documented relative to the treatment. Conclusions: Patients with nasopharyngeal CA treated with chemo and radiation therapy are at risk for sensorineural hearing loss.

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Hearing Loss Associated Nasopharyngeal CA

with

Treatment

of

L CLARKE COX PHD; JOHN R STRAM MD, Boston MA

Objective: Sensorineural hearing loss has been reported in patients with head and neck CA who underwent chemo and radiation therapy. We report on four patients treated for nasopharyngeal CA who experienced sensorineural hearing loss following treatment. Methods: Patients diagnosed with nasopharyngeal CA as a primary site of lesion were followed audiometrically. Data were obtained before and after treatment. In some cases audiometric results were available for several years after treatment which allowed us to see the long term effects of treatment on hearing. Results: Virtually all patients treated with a combination of

77 Physical Rehabilitation of the Acoustic Neuroma Patient SRINIVAS B MUKKAMALA MD; JOHN P LEONETTI MD, Oak Park IL; Maywood IL

Objective: The phenomenon of sudden unilateral total loss of peripheral vestibular function, as seen in patients undergoing surgery for the treatment of acoustic neuromas, can be very debilitating. This study is designed to analyze the role of physical therapy in the rehabilitation of these patients. Methods: A protocol was established for all patients undergoing acoustic neuroma surgery. This begins with a preoperative assessment of the patients' symptoms using a questionnaire and physical exam. Selected neurotologic testing is performed as well. The patient is seen by the physical therapist preoperatively as well to further develop their rehabilitation plan. Postoperatively the patients are seen by the therapist to begin exercises. These range from simple eye exercises to gait training. These are continued through discharge and as an outpatient for three months. Response to the protocol is measured by vestibular testing and answers to questionnaires. Results: The program is in its infancy and long term results are not yet available. The early suggestion is that patients recover from their symptoms of vertigo sooner. There are also signs that recovery may be more complete with the use of physical therapy. Conclusions: The use of the rehabilitation protocol in patients undergoing acoustic neuroma surgery seems to be of benefit with regards to easing the very debilitating symptoms that accompany the sudden unilateral loss of vestibular function.

Comparison of RAST, SET, Prick/Intradermal, and Multi Test in Single Antigen Tests DOUGLAS A O'BRIEN MD; JOHN R STRAM MD, Arlington MA; Boston MA

Objective: Testing for inhalant allergy by many techniques tends to confuse the fact that positive test results can be compared. Methods: Volunteer allergy test subjects were tested by four methods using single antigen results. Photographs of the skin tests as well as RAST results are presented for comparison. Results: Positive test results are compared and suggest methods of planning treatment protocols. Conclusions: Positive allergy test results can be compared and treatment plans can be formulated.

Otolaryngology– Head and Neck Surgery Volume 119 Number 2

Drill Generated Noise Levels in Otologic Surgery SRINIVAS B MUKKAMALA MD; JOHN P LEONETTI MD; BRIAN WACHTER MD, Oak Park IL; Maywood IL; Maywood IL

Objective: Noise levels produced by drilling during otologic surgery can reach high levels. This study evaluates these levels and compares them to the recommendations of the Occupational Safety and Health Administration (OSHA) regarding occupational noise exposure. Methods: The sound-pressure-level (SPL) produced by three commonly used pneumatic drills were measured intraoperatively during a variety of otologic surgical cases. In addition, measurements were taken and comparisons were made among the various drill bit types and sizes. The results of these samplings were analyzed and compared to current OSHA recommendations. Results: The SPL produced by the various drills and drill bit combinations were all within the normal operation limits according to OSHA policy. In general, cutting bits produced higher noise levels than diamond bits, and larger bits produced higher noise levels than smaller ones. Conclusions: The sound levels produced during normal operation of high-speed drills in otologic surgery do not violate current OSHA guidelines. 80 Presentation of a Prototype Disposable Myringotome and Aspirator-collector MONTAGUE CARR MD; JOHN R STRAM MD, Boston MA

Objective: In anticipation of an eventual need for non antibiotic treatment of otitis media, a disposable self contained myringotome and aspiration/collection device was developed to facilitate middle ear fluid samplings. Methods: This device was used to obtain middle ear fluid specimens in adults and children. Its use and effectiveness are demonstrated and photographically portrayed. The specimens obtained were suitable for bacteriologic culture and organism capsule typing. Results: A prototype disposable myringotome and middle ear aspirator/collection device is presented and its use demonstrated.

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Methods: The chart recording a case of bilateral PTA was reviewed and an extensive search of the literature was conducted to establish incidence, diagnostic modalities used and potential complications. Results: This is the fourth known reported case of bilateral PTA in the world literature. Initial diagnosis was severe diffuse tonsillopharyngitis due to bilateral presentation and initial lack of fluctuance. A CT scan conclusively showed bilateral PTA which was then confirmed with needle aspiration and drainage. The patient responded quickly and was discharged to home in less than 24 hours after drainage without complications. Conclusions: Bilateral PTA is a rare complication of acute tonsillitis. Due to the atypical presentation and presence of multiple collections of suppuration within the neck, the potential for life-threatening complications is high: airway obstruction, perforation into the parapharyngeal space with resultant mediastinitis. 82 Rhinophyma: Ablation with CO2 Laser PAUL E LOMEO DO; JOHN EDWARD MCDONALD DO; JUDITH FINNEMAN LPN-CST, Muskegon MI

Objective: Rhinophyma is an acne rosacea which primarily affects the midface of elderly men, and causes disfigurements as well as obstruction. There are numerous ways of treating this condition and, in our institution, a CO2 laser is the treatment of choice. Methods: In our series, a CO2 laser, with a setting of 15 watts in the continuous mode, was used to ablate the disease. The entire procedure took approximately 15 minutes. The patient was discharged and returned to our clinic the following day. Results: CO2 ablation produced an aesthetically pleasing result with no complication related to scarring or destruction or loss of nasal cartilage. Re-epithelialization usually occurs within 6 weeks. Conclusions: Rhinophyma is a disfiguring discoloration disease predisposed primarily by acne rosacea. Laser is the treatment of choice with an aesthetically pleasing result and no complications. 83

81 Bilateral Peritonsillar Abscess MICHAEL D STALFORD MD; JOHN F ALBURGER CDR MC, Columbia MD; Potomac MD

Objective: Peritonsillar abscess (PTA) is a complication of untreated or partially treated acute tonsillitis. Diagnosis is made by history and physical exam and confirmed with incision and drainage. PTA is almost exclusively unilateral in presentation. This case report of a bilateral peritonsillar abscess stresses the importance of early diagnosis and treatment despite the unusual presentation to avoid possible life-threatening complications.

Nonadjacent Mass Compression Dizziness and Hearing Loss: A Case Report BRETT D GERWIN; JOHN M GERWIN MD; L CLARK SIMPSON MD; KENNETH S GERWIN MD, Evanston IL; Birmingham AL; Birmingham AL; Morristown NJ

Objective: The objective is to present a case report of a 56-year-old female who presented with nonvertiginous disequilibrium and unilateral hearing loss with tinnitus. The report is illustrated with serial audiograms and an MRI scan. Methods: Initial evaluation documented a left unilateral sensorineural hearing loss with a 16% discrimination score.

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An MRI scan showed a 3 cm extra axial mass along the left parietal convexity adjacent to the midline. The mass was removed by a consulting neurosurgeon. The patient has been followed postoperatively with serial audiograms for one year. She received medications for her labyrinthine symptoms. Results: The pathology of the mass was meningioma. The patient returned to work although her initial symptoms persist. Serial audiograms have documented improvement in her speech discrimination score from 16% up to 80%. Conclusions: These presenting labyrinthine symptoms so commonly seen in otolaryngology practice in this case were caused by the mass compressive effect of a non-cerebellopontine angle parietal meningioma. Compression relief resulted in improvement in speech discrimination over a one year period.

84 Presentation of a Step Saving (Time Saving) Technique of Serial Endpoint Titration Allergy Skin Testing DANIEL K SMITH MD; JOHN R STRAM MD, Stoneham MA; Boston MA

Objective: Serial endpoint titration skin testing for allergy diagnosis and treatment starting dose determination is safe and accurate but time consuming for office staff and patients. A time saving technique is presented that preserves the sensitivity and quantitative specificity of serial endpoint titration skin testing. Methods: Patients undergoing allergy testing were tested by the time saving method. Selected positive antigens were tested at another setting by the conventional skin endpoint titration technique. Results: All positive antigens had endpoints at the same endpoint by both techniques. There was no anaphylaxis. There were no severe local reactions. Up to three injections per antigen were eliminated. Time saved was up to twenty minutes per antigen. Conclusion: A short time saving method of achieving the results of serial endpoint titration is effective and as safe as conventional allergy testing or serial endpoint titration testing by standard techniques. 85 Metastatic Crohn's Disease: Case Report and Literature Review KEITH M ULNICK DO; JONATHAN A PERKINS DO, Spanaway WA; Tacoma WA

Objective: Crohn's disease is a granulomatous inflammatory bowel disease with pathological findings of noncontiguous chronic inflammation along with noncaseating granulomas. Even though any segment of the gastrointestinal tract can be involved, it is uncommon to find it elsewhere. In this article we present a case of extraintestinal Crohn's disease with qui-

escent involvement of the lower gastrointestinal tract but florid involvement of the nasal cavity, supraglottic structures and skin. Methods: A 45-year-old black male with known Crohn's disease, presented for evaluation of nasal obstruction. Physical examination revealed bilateral anterior nasal stenosis. Between 1985 and 1997, in conjunction with aggressive medical management the patient underwent laser procedures to correct this stenosis. None of these procedures was curative, but in combination with intensive medical therapy the frequency of surgical therapy was decreased. Follow-up visits demonstrated progressive hoarseness, and physical examination revealed erythema and granulation tissue involving his supraglottic structures along with non-healing ulcerations of the scalp. Results: A CO2 laser was utilized to open the nasal passages by removing scar tissue. Direct laryngoscopy revealed edematous tissue with areas of granulation involving the false vocal folds and epiglottis. Histologically this was Crohn's disease. Postoperatively, his 6-mercaptopurine was increased twofold. The patient is still with disease but has noted improvement in his nasal airway over the past 11 months and only recently is experiencing nasal symptoms. The skin lesions are quiescent with pigmental changes remaining. Laryngeal examination reveals no change in the extent of supraglottic edema and erythema. Conclusions: This case is unusual in that the disease process failed the standard medical management of systemic and topical steroids along with 6-mercaptopurine. With surgical intervention this process was slowed, but it remains a difficult management problem. This aggressive manifestation of Crohn's disease, which can be classified as metastatic Crohn's disease due to its intestinal and extraintestinal involvement, demonstrates the need to be aware of the existence of the disease and the requirement to be proactive in the management of these patients. 86 Cementoblastoma Causing Facial Asymmetry RAYMOND WINICKI MD; JORDAN C STERN MD; DR SUZANNE STUCKI-MCCORMICK DDS; BARBARA ZEIFER MD; STEVEN MCCORMICK MD, New York NY

Cementoblastoma is a rare tumor of mesenchymal odontogenic origin arising from the cementum of the tooth root and comprises less than 1% of odontogenic tumors. Less than 100 cases have been reported. These lesions most commonly involve the mandible and usually arise from the first molar or second premolar. Cementoblastomas appear to be more common in patients under the age of 30 but no definite sex predilection has been established due to the paucity of reported cases. Radiographically, cementoblastomas appear as well calcified round radiopaque lesions surrounded by a thin radiolucent rim. Microscopically, the mass consists of sheets of cementum-like tissues with active growth areas containing cementoblasts. Treatment consists of enucleation of the mass usually with the involved tooth although the tooth remains vital. We present a case of a 15-year-old Hispanic female with

Otolaryngology– Head and Neck Surgery Volume 119 Number 2

a four month history of an enlarging, mildly painful swelling over the right maxillary region resulting in marked facial asymmetry. The sharply defined lesion originated in the maxillary alveolar ridge expanding all of the maxillary sinus walls with extension into the middle meatus. The cementoblastoma was removed via a Caldwell-Luc approach with excision of the anterior maxillary wall. The pathohistological and radiological characteristics will be presented and contrasted with other odontogenic calcifying lesions.

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patients have been converted to open cavities and 3 patients remain canal up. In the audiometric results, there were no significant differences between canal up and down procedures. Conclusions: Based on the information obtained in this review, in most cases, we strongly consider a canal down procedure as the technique of choice in pediatric cholesteatomas.

89 Nonrecurrent Inferior Laryngeal Nerve JESUS HERRANZ-GONZALEZ MD; JOSE MARTINEZ-VIDAL MD, La Coruna Spain

Objective: Although infrequent, a nonrecurrent right inferior laryngeal nerve is an anatomic variation that has to be always considered during thyroid surgery. Due to its low frequency not every head and neck surgeon has the chance to see this anomaly. The objective of this poster is to present the surgical pictures of three different nonrecurrent right side inferior laryngeal nerves. Methods: The surgical pictures of three different right side inferior laryngeal nerves are presented. Anatomic landmarks of the surgical field are clearly identified and labeled. Results: Our incidence of nonrecurrent inferior laryngeal nerve in 427 patients operated for thyroid pathology is 0.7%. Conclusions: Inferior laryngeal nerve identification is an essential surgical step to avoid injuries. Anatomic variations, although infrequent, are possible. Surgeons should always follow a standard method for nerve identification. No structure should be divided, ligated or coagulated prior to nerve identification. When no nerve identification is obtained in its usual anatomic location the possibility of a nonrecurrent laryngeal nerve should be considered.

88 Cholesteatoma in Children: A Review of 135 Patients M J BERNARDO; JOSE LUIS LLORENTE PENDAS MD; CARLOS SUAREZ MD; M MORO, Oviedo-Asturias Spain; Oviedo-Asturias Spain; Oviedo Spain; Oviedo-Asturias Spain

Objective: This study evaluates our results of surgical therapy for pediatric cholesteatoma to get guidelines that could be used for surgical decision making in childhood cholesteatoma. Methods: A retrospective review of charts of 135 children treated surgically for cholesteatoma from 1975 to 1996. The age ranged from 4 to 15 years and 129 were unilateral and 6 bilateral. Initially, 102 (75%) patients received a canal down procedure, and 33 (25%) patients underwent a canal up tympanomastoidectomy. Seventeen (12%) patients had no middle ear reconstruction. The minimum follow up was 2 years. Results: Control of the disease was achieved in 119 patients (88%) and pathological failure (residual + recurrent cholesteatoma) occurred in 16 patients (12%). Out of 16, 13

Cutaneous T-cell Lymphoma of the Larynx Presenting with Acute Airway Obstruction: Case Presentation and Literature Review ANDREW J MYRTUE MD; JOSEPH BRENNAN MD; KURT J SHULER MD; ERIC J MOORE MD, Travis AFB CA; Davis CA; Vacaville CA; Davis CA

Objective: We will present a patient with cutaneous T-cell lymphoma of the larynx presenting with acute airway obstruction. A review of the literature on lymphomas of the larynx will also be discussed. Methods: A fifty-one year old white male was admitted for preliminary intervention and diagnosis of a laryngeal mass found on fiberoptic nasolaryngoscopy after presenting with progressive dyspnea and stridor. His clinical presentation, laryngeal photographs, and a review of the literature using Knowledge Finder, PubMed MEDLINE query, and Ovid search tools are presented. Results: The patient underwent emergent awake tracheostomy and biopsy of the laryngeal mass. The biopsy was consistent with cutaneous T-cell lymphoma. The patient had a history of cutaneous T-cell lymphoma occurring on the skin of the medial thigh diagnosed six months prior to this presentation that was treated with radiation therapy. A review of the literature produced multiple cases of non-Hodgkin's lymphoma of the larynx. However, only one case of cutaneous Bcell lymphoma of the larynx, and no cases of cutaneous T-cell lymphoma were found in our review. Conclusions: A review of the literature shows that invasion of the larynx by cutaneous T-cell lymphoma is exceedingly rare. Once the patient's airway was secured, diagnostic staging of his cancer confirmed stage II disease. He is currently scheduled to undergo CHOP chemotherapy followed by radiation therapy to the larynx.

90 Surgical Management of Nasopharyngeal Cicatricial Pemphigoid DEVIN M CUNNING MD; JOSEPH P ATKINS MD; RAVI PRAKASH AGARWAL MD; ERIN C SARGENT, Philadelphia PA

Objective: Cicatricial pemphigoid is a chronic autoimmune disorder characterized by vesiculobullous lesions within the basement membrane. Previously known as benign mucous membrane pemphigoid, this relatively unusual condition is heralded by mucosal bullae formation often resulting in scar-

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ring and stenosis. When occurring in the head and neck region, cicatricial pemphigoid typically involves the oral and conjunctival mucosa and rarely involves the nasopharynx. Although the management of nasopharyngeal cicatricial pemphigoid typically involves both medical and surgical therapies, there have been few reports in the literature of the surgical management of this condition. We provide a brief discussion of the clinical presentation, radiographic findings, histopathology, and management. Methods: Two patients with the diagnosis of cicatricial pemphigoid, including presentation and surgical management, are reviewed. Both patients were males age 60 to 70. Their presentations of worsening nasal congestion and airway compromise were similar in nature and duration. They were both ultimately managed surgically after failure of medical treatment. A review of pertinent literature was performed. Results: The patients were both managed surgically with a staged endoscopic KTP laser resection, palatoplasty, and full thickness skin grafting. Postoperative courses were unremarkable. Conclusions: Cicatricial pemphigoid, when rarely involving the nasopharynx, poses a management challenge. Treatment consists of both medical and surgical interventions with variable results. We describe a unique technique of surgical management for nasopharyngeal cicatricial pemphigoid and discuss a detailed review of the relevant literature. 91 Thyroplasty Type I: Short Versus Long-Term Results DONNA S LUNDY MA; JUN WU XUE MD; ROY R CASIANO MD, Miami FL

Objective: Significant improvement has been reported in objective measures of vocal function following thyroplasty type I. The purpose of this investigation was to compare the short- vs long-term results in patients undergoing thyroplasty type I. Methods: Data on 26 patients who had undergone a thyoplasty type I were compared from pre-surgery to the shortterm (1-month) and long-term (greater than 1 year) postoperative assessments points. Statistical analysis included paired t-tests to assess the significance of between group differences. Results: Significant differences were found between the pre-operative and both post-surgery evaluations for the measures of glottal flow rate, maximum phonation time, jitter, shimmer, and harmonic to noise ratio. However, no significant differences were found between the 1-month and greater than 1 year assessment points. Conclusions: The results of thyroplasty type I appear to reach maximum improvement within one month post-surgery. It is possible that the effects of time including the normal aging process, hormonal changes, or other alterations in general health may require longer follow-up to better address these issues.

92 Chondroma Resulting in Tracheal Compression: A Case Report RICK D GROSS MD; KAREN K NAUSCHUETZ MD; ROBERT E JOHNSON MD, Kailua HI; Tripler AMC HI; Tripler AMC HI

Objective: To present the only known case of a primary soft tissue extramedullary chondroma causing near total airway obstruction secondary to tracheal compression. To review the management of this case and review the literature regarding tracheal cartilaginous tumors. Methods: A case report format with a review of the pertinent literature. Preoperative, intraoperative, and postoperative photos and CT scans will be presented. Results: A 66-year-old male had an incidental CT finding, which revealed a large calcified mass extending from the manubrium and right clavicle severely compressing the trachea. The patient described a history of gradually worsening dyspnea on exertion. Treatment consisted of excision of a calcified bone-like lobulated mass, extending posteriorly from the clavicle and manubrium to involve the cricoid and severely compressing the trachea. He underwent laryngo-tracheal sleeve resection and hyoid release, with primary reanastomosis. Histological examination revealed a proliferation of benign appearing hyaline cartilage with ossification and areas of benign lamellar bone. Literature review yields a single report of osteochondroma of the trachea. This lesion was most likely a chondroma with ossification similar to the lesion we encountered, but originating primarily from within the trachea (unlike our case which was extrinsic to the trachea). Six months postoperatively patient is asymptomatic and CT scanning reveals a widely patent trachea with no sign of recurrence. Conclusions: We present a previously undescribed entity consisting of a extramedullary chondroma with ossification that involved the cricoid and caused severe tracheal compression. This lesion was most likely a remnant of Reichert's cartilage. It was successfully managed with a tracheal sleeve resection and anastomosis. 93 The Use of Laser Ablation Instead of Traditional Tonsillectomy MICHAEL CATTEN MD; KELVIN C LEE MD; ADITI H MANDPE MD; MOHAN VISWANATHAN, San Francisco CA

Objective: The carbon-dioxide laser has been previously described for tonsil surgery by other authors for either ablation of tonsil crypts or use in laser assisted serial tonsillectomy (LAST). Surgeons have described a marked reduction of patient morbidity peri-operatively using this technique. We review our initial experience of using near total ablation of both tonsils using the carbon-dioxide laser for obstructive tonsil disease and/or recurrent tonsillitis in 16 patients. Methods: Laser ablation was performed under local or general anesthesia during a single sitting. Patients receiving

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94 Investigations of the Inner Ear Disorders by 3D Fast-spin Echo MRI TAKAO YABE MD; KENTARO IMON MD; YASUHITO SASAKI MD; YUTAKA YOSHIMOTO, Tokyo Japan

Objective: 3D fast spin echo (3D-FSE) MRI is accepted as the method of choice to search for abnormalities in patients with sensorineural hearing loss (SNHL) and/or disequilibrium. We employed 3D-FSE MRI to investigate inner ear disorders and reported the results, focusing on the efficiency of this method in detecting the lesions. Methods: 3D-FSE MRI was carried out in 20 patients with SNHL and/or disequilibrium in whom findings could be obtained: 9 were female and 11 were male. Mean age was 12 years (4-28 years). MRI was obtained from T2-weighted MIP imaging. Results: In 8 patients with unilateral profound SNHL, inner ear anomalies such as hypoplasia of the cochlea, common cavities of the cochlea and vestibule and aplasia of the vestibulocochlear nerve were identified. In 5 patients with disequilibrium, aplasia and hypoplasia of the semicircular canal were identified. Imaging results were consistent with the findings of the caloric test and off-vertical axis rotation test. In 5 patients with bilateral profound SNHL after meningitis, the low-density area of the hook portion and stenosis of the cochlea were identified, indicating the value of this technique in indications for cochlear implantation. In 2 patients with bilateral fluctuating SNHL, a large vestibular aqueduct was identified. Conclusions: These results suggested that investigation by 3D-FSE MRI was an efficient diagnostic procedure for detecting abnormalities in patients with SNHL and/or disequilibrium. Otolaryngologists may consider this procedure as one of the diagnostic methods of choice for this entity.

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95 Coexistence Carcinoma

of

Medullary

and

Papillary

Thyroid

SREEKUMAR SUBRAMANIAN MD; KURT J SHULER MD; JOSEPH BRENNAN MD, Travis AFB CA; Vacaville CA; Davis CA

Objective: The simultaneous occurrence of discrete foci of medullary and papillary thyroid carcinoma is rare, with fewer than 15 reported cases. We present a patient with coexisting metastatic papillary and occult medullary thyroid carcinoma. The embryologic basis for this uncommon entity is reviewed. Methods: A 65-year-old man presented to our institution with a 10 × 7 cm right lateral neck mass. Fine needle aspiration was highly suspicious for metastatic papillary carcinoma of the thyroid, and a CT scan revealed a lesion in his right thyroid lobe. The patient underwent a total thyroidectomy with a right modified radical neck dissection. Results: Frozen section and permanent pathologic analysis confirmed the diagnosis of metastatic papillary carcinoma of the thyroid, with a 1.5 × 1.2 cm primary lesion in the right thyroid lobe. In addition, a separate 0.2 cm focus of medullary carcinoma was identified in the ipsilateral lobe. This was confirmed by diffuse strong immunoreactivity of the neoplastic cells for calcitonin and chromogranin. Conclusions: Concomitant neoplastic transformation of follicular and parafollicular C cells may, in rare cases, lead to discrete foci of medullary and papillary thyroid carcinoma. The usual presentation is a primary medullary carcinoma coexisting with an occult papillary carcinoma. The converse may occur, but is exceedingly rare.

96 Paget's Disease of the Temporal Bone Causing Hydrops JOSHUA KESSLER; L CLARKE MACDONALD MD, Boston MA

COX

PHD;

CHARLES

B

Objective: Paget's disease may involve any portion of the skull including the temporal bone. Two cases are presented in which Paget's disease involving the vestibular aqueduct and endolymphatic sac resulted in a clinical picture of endolymphatic hydrops. Methods: The audiologic, electronystagmographic, and CT data are presented for two cases of Paget's disease resulting in sensorineural hearing loss and episodic vertigo. Results: Both patients have strong evidence of endolymphatic hydrops caused by Paget's involving the vestibular aqueduct and endolymphatic sac. Sac decompression was considered; however total decompression of the vestibular aqueduct is not technically feasible. Both patients had resolution of vestibular symptoms when medicated with hydrochlorothiazide/triamterine. Conclusions: Paget's involvement of the vestibular aqueduct and endolymphatic sac in two cases resulted in the clinical picture of hydrops. Vestibular symptoms resolved on medical therapy; however hearing loss was unchanged.

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laser ablation also received peri-operative antibiotics and steroids. Patient charts were reviewed retrospectively and additional follow-up information was obtained through telephone interviews. Information concerning post-op recovery time as measured by pain medications taken, length of time off work, time to regular diet and post-op complications was obtained. Recurrence of symptoms was also analyzed. Results: Follow-up varied from 1-20 months. All patients had complete resolution of their symptoms. Most patients required pain medications for 2-3 days post-operatively and returned to a regular diet in 4 days. Most patients returned to work within 4 days. One complication of post-operative bleeding was reported in a child with undiagnosed von Willebrand's disease. Conclusions: Our findings support the use of laser tonsil ablation as an alternative to traditional tonsillectomy for both obstructive tonsil hypertrophy and recurrent tonsil infection.

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97 A Sharp Partial Denture Embedded in the Esophagus at the Thoracic Inlet RALPH P TUFANO MD; LARRY R KAISER MD; RANDAL S WEBER MD, Philadelphia PA

Objective: Dental prostheses with sharp metal clasps are a challenge to manage as esophageal foreign bodies due to the risk of esophageal perforation. While some may be managed with rigid endoscopy, those prostheses lodged within the esophageal wall at the thoracic inlet pose a unique treatment challenge due to difficult surgical access. An algorithm to treat these esophageal foreign bodies is presented and the utility of the open trans-cervical approach in management is discussed. Methods: A 61-year-old male swallowed his partial denture while eating. Neck and chest x-rays revealed a radiopaque object with sharp clasps at the thoracic inlet. Rigid endoscopy demonstrated the clasps to be embedded in the esophageal wall and gentle attempts to remove the denture were unsuccessful. Otolaryngology and thoracic surgery opted for an open cervical approach to the denture with mobilization of the thoracic esophagus. Results: A cervical approach to the foreign body with mobilization of the thoracic esophagus was performed. Distal cervical esophagotomy allowed for successful removal of the denture, and inspection of the esophagus did not reveal any perforation. The patient had an unremarkable postoperative course. A liquid diet was started on postoperative day 3 and the patient was discharged the following day on a regular diet. Conclusions: Management of sharp dentures in the esophagus at the thoracic inlet poses a challenge. Management considerations include rigid endoscopic removal, trans-cervical and trans-thoracic esophagotomy. If difficulty is encountered endoscopically, an open cervical approach to the esophagus at the thoracic inlet with mobilization of the thoracic esophagus is indicated. We formulate an algorithm for managing sharp esophageal foreign bodies at the thoracic inlet, discuss the benefits of an open cervical vs. thoracic approach and review the literature. 98 Mastoidectomy of Facial Nerve Identification in Benign Parotid Tumors ERIC J KEZIRIAN MD; LAURIE LOEVNER MD; ROBERT B MCLAUGHLIN JR MD; ARA A CHALIAN MD; DOUGLAS C BIGELOW MD; ANDREW N GOLDBERG MD; GREGORY S WEINSTEIN MD, Seattle WA; Philadelphia PA; Philadelphia PA; Philadelphia PA; Philadelphia PA; Philadelphia PA; Philadelphia PA

Background/Objectives: Safe identification of the facial nerve utilizing extratemporal landmarks can be hindered in cases of surgery for benign parotid disease. The purpose of this study is to review possible clinical predictors and preoperative magnetic resonance (MR) imaging findings for cases

in which a mastoidectomy was required to safely identify the facial nerve during parotidectomy for benign disease. Methods/Patient Population: The medical records of 77 cases of parotid surgery performed for benign disease at this institution between 1992 and 1996 were retrospectively reviewed. Three (4%) patients required a mastoidectomy for facial nerve identification. Each case was reviewed to determine if there were clinical indicators suggesting the need for mastoidectomy, including histopathology, revision surgery, and facial nerve function. Preoperative MR scans were retrospectively reviewed by a head and neck radiologist for the following criteria: tumor size; tumor location (deep and/or superficial parotid lobes); proximity to the stylomastoid foramen, mastoid process and posterior belly of the digastric muscle; and enhancement or thickening of the intratemporal facial nerve. Results: All three patients requiring mastoidectomy for facial nerve dissection had pleomorphic adenomas, two of which were recurrent requiring revision surgery. On preoperative MR imaging, all three had tumor abutting both the mastoid process of the temporal bone as well as the posterior belly of the digastric muscle at the level of the mastoid process. In two cases, tumor extended to the stylomastoid foramen. Tumor was present in the deep and superficial lobes of the parotid in two cases, and only the deep lobe in one patient. Enhancement and thickening of the facial nerve were not found in any of the cases, and facial nerve function was normal. Conclusions: The value of mastoidectomy to safely identify the facial nerve may be suggested by certain preoperative clinical and radiologic findings. MR criteria which may indicate a need for mastoidectomy include tumor abutting the mastoid process of the temporal bone and the posterior belly of the digastric muscle as well as tumor or scar in the region of the stylomastoid foramen. Clinical factors which may indicate the value of mastoidectomy include a history of prior parotid surgery and histopathology. 99 Laryngeal Involvement in Rheumatoid Arthritis DUSAN R MILISAVLJEVIC MD; LJILJANA MILISAVLJEVIC MD PHD; DRAGOLJUB POPOVIC MD; MISKO ZIVIC MD; MILAN STANKOVIC MD, Nis Serbia Yugoslavia; Nis Serbia Yugoslavia; Serbia Yugoslavia; Serbia Yugoslavia; Serbia Yugoslavia

Objective: Rheumatoid arthritis (RA) is a systemic inflammatory disease of connective tissue, the cause of which is still not known but which is characterized by the progressive chronic or subacute progression with exacerbations and remissions or without them. Its most prominent and significant changes are manifested in the form of proliferative sinovitis, which slowly but steadily lead to destruction, instability, deformation and ankylosis of joints. The aim was to examine and assess whether there were any, whatsoever, laryngeal changes in patients with RA. Methods: One hundred patients with RA were examined by applying the standard otolaryngologic examination. The

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100 Chronic Ear Disease after Stapedectomy ERIC E SMOUHA MD; LOUIS LEONARD SOBOL MD, Stony Brook NY; Port Jefferson S NY

Objective: To discuss the diagnosis and management of the spectrum of chronic ear disease after stapedectomy. Methods: Presentation of a series of cases. Results: Six cases are reviewed illustrating the spectrum of chronic ear disease from chronic suppurative otitis media to cholesteatoma. Principles of management are reviewed. Conclusions: Chronic ear disease on an ear with a prior stapedectomy is uncommon. Prevention of labyrinthitis is of primary concern. Surgery is indicated when there is cholesteatoma or extrusion of prosthesis. Improvement of hearing, when feasible, is of secondary concern.

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101 Pheochromocytoma of the Neck ANTHONY NGUYEN MD; LUCIA BALOS MD; PETER J PONS MD; MARK K WAX MD, Buffalo NY; Buffalo NY; Buffalo NY; East Amherst NY

Objective: Functioning paragangliomas of the head and neck are rare. When they occur, they are usually associated with the carotid body. Vagal and glomus jugulare are the next most common locations. Functioning pheochromocytomas occurring in other locations in the neck are exceedingly rare. When they are associated with a pheochromocytoma in the abdomen, they are either metastatic or associated with a congenital syndrome. We report our experience with a patient presenting with pheochromocytomas of the neck and abdomen. Methods: A single case review and report. Results: A 22-year-old male with a history of functioning pheochromocytoma in an extra-adrenal region was felt to have MEN2A. Neck exploration for removal of his thyroid gland (which was normal RET oncogene negative) and parathyroid exploration (hyperplasia) revealed a 6 × 5 cm mass posterior to the common carotid artery. Pathologic examination revealed this to be a functioning pheochromocytoma. Conclusions: We present an unusual case of a patient with a pheochromocytoma of the neck. Differential diagnosis of von Hippel-Lindau, or MEN2A is discussed. Pertinent molecular genetic analysis is also discussed.

102 Epithelial Cells from Nasal Polyps Express In Situ and Secrete In Vitro the Vascular Endothelial Growth Factor ANDRE COSTE MD; LYDIA BRUGEL MD; BERNARD MAITRE MD; SANDRINE BOUSSAT MD; C CORDONNIER MD; S ADNOT MD; ROGER PEYNEGRE MD; E ESCUDIER MD, Creteil France

Objective: The vascular endothelial growth factor (VEGF), an angiogenic and pro-edematous factor potentially secreted by inflammatory and epithelial cells, could be involved in the tissue remodeling occurring in nasal polyps (NP). The aim of this study was: 1) to evaluate and to compare the expression of VEGF in situ in NP and control nasal mucosa (CM); 2) to quantify the in vitro secretion of VEGF by epithelial cells from NP and to evaluate its modulation by transforming growth factor-ß1 (TGF-ß1), another important factor of tissue remodeling in NP. Methods: NP were sampled during ethmoidectomy in 15 patients with nasal polyposis, and CM were sampled during turbinectomy in 6 snorers. VEGF was detected in tissues using immunohistochemistry and its expression in inflammatory cells, epithelium and vessels was evaluated in a semi-quantitative way. In primary cultures of epithelial cells from NP placed at air-liquid interface, VEGF protein was quantified in the supernatants using ELISA and VEGF mRNA was detected in dissociated cells using RT-PCR, after or not TGF-ß1 treatment (5 ng/ml for 24 hours at different times of culture). Results: In NP, VEGF was frequently expressed in

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control group consisted of 40 healthy persons of similar age and sex. The examinations were performed from 1994 to 1997. What was of particular interest for us was to see the findings of laryngologic examination by indirect laryngoscopy and videostroboscopy. With a videostroboscopy, it has been possible to investigate all our patients. It is a superior tool when the vocal cord motions are investigated. In the examined group, out of 100 patients suffering from RA, there have been 80 patients of female and 20 patients of male sex, with an average period of suffering from RA of 7.1 years (ranging from 1 to 29 years). According to the American Rheumatism Association's functional classification 25 belonged to class I, 41 to class II, 19 to class III, and 15 to class IV, which is the most disabled. Results: We have detected in 17 patients paralysis of plicae vocalis. A localized erythema of the mucosa over the arytenoids was found in 23 of the RA patients but none in the control group. Impaired abduction of the vocal cords was observed in 17 patients. In four of them bilateral limitation of abduction was presented and in the remaining 13 patients unilateral limitation was found. Using the videostroboscopic examination it has been constated the presence of affected mucosal wave in patients with vocal cord paralysis. All 17 patients with laryngeal paralysis had an unambiguous asymmetry of laryngeal vibration demonstrated videostroboscopically. The normal vocal fold traveling wave has a greater velocity than that of the paralyzed fold and traverses farther over the surface of the vocal fold mucosa. The symmetry ratio data were presented to document the greater excursion of the vocal fold margin on the nonparalyzed side. Conclusions: Although several previous reports have drawn attention to the presence of RA in the larynx, our study emphasizes that the small joints of the larynx may be involved by the full spectrum of pathologic changes and that both cricothyroid and cricoarytenoid joints are equally prone to the various stages of inflammation, joint destruction and ankylosis that characterize the RA elsewhere. Acquired results suggest and call for the need for analysis of larynx changes in patients with RA.

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inflammatory cells (10/15) and epithelial cells (9/15) while it was rarely expressed in inflammatory cells (3/6) and epithelial cells (1/6) in CM. In NP and CM, VEGF was exceptionally detected in the wall of vessels. At basal conditions, VEGF concentrations in the supernatants of cultures increased from day 2 to day 4, decreased until day 7 and then became undetectable. The VEGF concentrations increased about 1.5 fold in presence of TGF-ß1 when compared to controls. Conclusions: This study shows for the first time that VEGF protein is highly expressed in human NP where it is mainly detected in inflammatory cells but also clearly in epithelial cells. Moreover, epithelial cells from NP are able to synthesize and secrete in vitro VEGF. This secretion is increased in the presence of TGF-ß1. VEGF could be involved in the inflammatory process of NP via the local induction of edema and angiogenesis. 103 Myasthenia Gravis Presenting as Obstruction: A Report of Three Cases

Acute

Airway

ROBERT HENRY YARBER JR MD; MANISH K WANI MD; ERIN J SIMMS MD; GAYLE E WOODSON MD, Memphis TN

Objective: To make otolaryngologists aware of their importance in the diagnosis of patients with myasthenia gravis. The literature is reviewed and 3 cases presented of myasthenia gravis presenting as acute upper airway obstruction. Methods: Case series, retrospective. Conclusions: Patients with myasthenia gravis classically present with ocular symptoms, particularly ptosis and diplopia. Other cranial nerve findings which may appear at presentation include dysphagia, dysarthria, and rarely bilateral vocal cord paralysis. We introduce 3 unusual cases of myasthenia gravis initially presenting with acute upper airway obstruction. Respiratory compromise typically described with myasthenia gravis involves weakness of intercostal and diaphragmatic musculature. Therefore, myasthenia gravis should be considered for some cases of acute upper airway obstruction, especially with other findings of cranial nerve weakness. 104 Prevalence of Sensorineural Hearing Loss in Family Members AURA DIAZ DE PALACIO MD; MARIA I D'ALMADA MD; MERCEDES B DE ALFORD MD; NELSI MAR PALACIOS, Caracas Venezuela

Objective: The purpose of this paper is to study the prevalence rate of hearing impairment among family members of Macanao, Margarita Island, Venezuela. Methods: A random survey of 24 families (329 individuals) was carried out from 1995 to 1997. Each patient had an extensive questionnaire as well as an audiological test. The results of these tests were then collected and compared using the appropriate statistical methods. Results: There is a high prevalence of sensorineural hearing

loss in these families 1.38 × 1000, we observed 15 deaf blindness. All of these had profound hearing impairment and retinitis pigmentosa, characteristics of Usher syndrome. The prevalence of consanguineous marriages was of 15/24 families. Conclusions: This study showed that consanguinity is widely practiced in this community. The geographic factor is very important. The little town is located in Margarita Island and the people have little communication with their neighbors. P105 Waldenstrom’s Macroglobulinemia and Sensorineural Hearing Loss MARIA E ARCILA MD; MARK J SYMS MD; MICHAEL R HOLTEL MD, Honolulu HI

Waldenstrom’s macroglobulinemia (WM) is a neoplastic disease that involves the abnormal proliferation of B cells and plasma cells, leading to the synthesis and release of large amounts of IgM. The concentration of macroglobulin in the serum results in increased blood viscosity which, in turn, leads to disorders of the central nervous system, slower blood flow, thrombosis and bleeding. Patients with WM typically present in the sixth or seventh decade of life with complaints of fatigue, weakness, episodic bleeding from mucosal surfaces and GI tract, characteristic retinal lesions, lymphadenopathy, hepatosplenomegaly, sensory motor peripheral neuropathy, worsening normochromic anemia, increased sedimentation rate and extremely high serum viscosity leading to symptoms and signs of hyperviscosity syndrome. One of the rare neurological presentations of the hyperviscosity syndrome secondary to WM is sudden hearing loss. It is therefore important for the otolaryngologist to be aware of WM as a diagnostic possibility since early diagnosis and treatment are crucial in the reversal of sensory neural deficits. Marked elevations of total protein and globulin of serum should raise strong suspicion of the disease. Definitive diagnosis is made by serum electrophoresis with serum IgM producing a tall, narrow peak that migrates to the gamma region on the serum electrophoresis pattern. We describe a patient diagnosed with WM whose initial presenting symptoms were hearing loss and progressive sensory peripheral neuropathy with subsequent development of lymphadenopathy and hyperviscosity syndrome. Management with fludarabine led to improvement of her hearing and neurological deficits, as well as resolution of her other hyperviscosity related symptoms. 106 Congenital Cartilaginous Rests of the Neck B JOSEPH TOUMA MD; MARK A ARMENI MD, Morgantown WV

Objective: Congenital cartilaginous rests of the neck are rare congenital abnormalities that are poorly understood but have been described since early Greek mythology. Three case presentations as well as the controversy behind the etiology of this entity are discussed. Methods: Three children presented to our institution over

the past 3 years with congenital cartilaginous rests of the neck. Patient evaluation, differential diagnosis, audiologic assessment, management and follow-up for each of these patients is described. Results: Patients with both unilateral and bilateral cartilaginous rests are reviewed. No significant related physical findings including audiometric abnormalities were present. Surgical intervention was undertaken in only one case and surgical findings as well as histopathology are demonstrated. Conclusions: Congenital cartilaginous rests of the neck are found usually in the lower portion of the neck, overlying or in close proximity to the anterior belly of the sternocleidomastoid. While it is debated whether this is of bronchial arch or auricular hillock etiology surgical excision is the treatment of choice and associated abnormalities are usually not present.

107 Laryngeal Carcinoma in a Patient with Myotonic Dystrophy: DNA Analysis RYUICHI OSANAI MD; MASANOBU KINOSHITA MD; KAZUHIKO HIROSE MD; ISUZU KAWABATA MD, Saitama Japan; Kawagoe Saitama Japan; Fuchu Tokyo Japan; Saitama Japan

Objective: Myotonic dystrophy (DM) is an autosomal dominant neuromuscular disease characterized by muscular atrophy, myotonia and widespread systemic manifestations. The molecular basis of DM is the unstable expansion of a CTG triplet repeat in the gene encoding the myotonin protein kinase. Patients with DM often have benign or malignant neoplasms. This study clarifies the DNA abnormalities of the laryngeal carcinoma in a patient with DM. Methods: A 66-year-old male patient with DM underwent a total laryngectomy for laryngeal cancer (T4N0M0). Genomic DNAs were extracted from the laryngeal carcinoma, normal laryngeal mucosa and white blood cells, and Southern blot analysis was performed. Results: The size of the Eco RI-digested DNA fragment in each tissue was as follows: white blood cells (WBC), 8.6/9.9 kb; normal laryngeal mucosa, 8.6/9.9 kb; laryngeal carcinoma, 8.6/9.9/19.4 kb. Conclusions: The size of the expanded DNA fragment (EF) of the WBC and normal laryngeal mucosa in this patient was slightly longer than in normal subjects. On the other hand, EF was extraordinarily longer in the laryngeal carcinoma. These results may support the hypothesis that elongation of the CTG repeat can occur during acquired cell proliferation and can cause cancer.

108 Central Giant Cell Granuloma of the Mandible: A Case Report P TODD NICHOLS MD; MICHAEL K HURST MD DDS, Morgantown WV

Objective: Central giant cell granulomas are unusual benign tumors of the mandible. Histologically they appear as intraosseus fibrous tissue with aggregates of multinucleated

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giant cells. The majority of reports regarding this entity appear within the oral surgery literature, and it is rare as a presenting complaint to the otolaryngologist. The clinical behavior and presentation vary significantly, from slow growing, circumscribed lesions which respond to simple curettage, to aggressive tumors which cause bone resorption and have a high recurrence rate. Radiographic imaging often reveals a multiloculated radiolucency of the mandible with occasional erosion of the cortex. Computed tomography may also be beneficial in defining the extent of the lesion. Patient evaluation must include metabolic investigation for hyperparathyroidism, as these lesions are histologically indistinguishable from brown tumors. The treatment is surgical excision/curettage. Methods: We present a case of a large central giant cell granuloma of the mandible which presented as a painful, ulcerative mucosal lesion on the alveolar ridge, which had been present for one year. There was a history of a previous dental extraction in the region, as well as a distant history of nephrolithiasis. Results: Panorex revealed a radiolucent lesion of the mandible with cortex erosion, while defined the extent of tumor expansion. Biopsy provided the diagnosis. Calcium, phosphate, and parathyroid hormone levels were normal. Conclusions: Conservative resection and curettage resulted in recurrence of the lesion, with eventual surgical control. He has been free of the lesion for one year. The clinical, radiographic and histopathologic presentation of these lesions will be discussed, along with a review of the literature. 109 Neurosarcoidosis: An Unusual Case Presenting as a CPA Tumor MANISH K WANI MD; MICHAEL J RUCKENSTEIN MD, Memphis TN

Objective: To describe a rare presentation of sarcoidosis as a cerebello-pontine angle tumor with clinical, radiological, and histological correlation. The case is made more unusual by the fact that on histology, many of the granulomata are necrotizing, a feature of sarcoidosis that is being appreciated with increasing frequency in the pulmonary literature. Methods: Retrospective review of a case report with description of radiological and pathological features. Also a brief review of the literature on neurosarcoidosis. Results: A 38-year-old BM presented with bitemporal headaches and horizontal diplopia. An MRI revealed an enhancing 3×2×l cm mass within the right CPA. The lesion was exposed using a retrolabyrinthine approach and was found to be solid, grayish white in color with minimal vascularity. The surface of the lesion was cobblestone in appearance. Intra-operative biopsies revealed granulomatous disease with no evidence of neoplasm. Conclusions: The diagnosis of sarcoidosis is difficult when neurological involvement is the only manifestation of the disease. However, the diagnosis should be considered when confronted with a young adult patient presenting with cerebral tumor syndrome and unusual features. The pathology from

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this case was reported as necrotizing granuloma, an atypical finding for sarcoidosis. 110 Fetal Goiter and Propothiouracil in Maternal Grave's Disease DAVID RICHARD FRIEDLAND MD; MICHAEL A ROTHSCHILD MD, Hastings-on-Huds NY; New York NY

Objective: Large fetal goiters can complicate labor and lead to life threatening airway obstruction at delivery. As with many types of congenital neck masses, prenatal sonography has allowed for better preparation of personnel and equipment to secure the airway at the time of parturition. Furthermore, an increasing awareness of the effects of maternal Grave's disease and pharmacological therapy have led to improved prenatal management of such goiters. Methods: A large fetal goiter was detected at 34 weeks gestation in a mother treated with propylthiouracil for Grave's disease. Cordocentesis was performed and in addition to the persistent 3×6 cm goiter the fetus was found to be hypothyroid. The fetus was treated with intraamniotic synthroid and cesarean section with a multidisciplinary operative team was scheduled. Results: Cesarean section took place 11 days after the last sonogram, which showed a persistently large and obstructing goiter. The otolaryngology service was present in the OR with equipment for emergency intubation, bronchoscopy and tracheotomy. Upon delivery, the fetus was found to have no evidence of goiter and no airway compromise. Conclusions: Dramatic response to synthroid resulted in rapid resolution of the fetal goiter and avoided the need for urgent airway management. 111 Cochlear Implantation: The Ethics of Surrogate Decision Making RUI NUNES MD PHD; MIGUEL RICOU PHD; ALEXANDRA ANTUNES PHD; HELENA MELO, Porto Portugal

Objective: Cochlear implantation is a well accepted therapy for postlingually deafened adults. However, some controversy surrounds its use in deaf children. The objectives of this study are: a) to analyze the ethical dilemmas involved in cochlear implantation in prelingually deafened children as far as the doctrine of respect for personal autonomy is concerned; and b) to evaluate the concept of informed expressed consent in auditory (re)habilitation. Methods: The authors make a comprehensive report on the ethics of surrogate decision-making stating that vertical acculturation is an accepted doctrine in law and ethics. This assumption is made referring to Tristram Engelhardt's morality of mutual respect. This theory holds that parents should determine which standard of best interest to use in a specific circumstance. They are the proper judges of what (re)habilitation process is best for their deaf child. Results: It is argued by the authors that although Deaf

Culture should be accepted in a secular pluralistic society every child must be considered as a full member of it and his or her consent should be presumed following an accepted standard of best interest. If the parents belong to the hearing world it is not surprising that they choose an aural/oral approach. Cochlear implantation is a welcomed expectation of these families. Conclusions: The authors conclude by stating that parents are the legitimate surrogate decision makers on behalf of their children. Notwithstanding the proclaimed rights of minority groups deaf children should not be deprived of cochlear implantation if it is considered a technically safe procedure. However, to be ethically acceptable it must be scientifically proved that the implanted child not only has audiological perception but also improves his or her communicating ability. 112 The Chronic Rhinitis Patient: When To Operate? CARLOS CUILTY-SILLER MD; MIGUEL A GONZALEZ MD, Chihuahua Mexico; Nuevo Leon Mexico

Rhinitis is one of the most frequent diagnoses made by the otolaryngologist. The incidence and prevalence has been increasing over the last three decades and it is often associated with an upper airway resistance syndrome. Poor quality of life is observed in a large number of these patients. Although it is believed by many physicians that chronic rhinitis is often allergen mediated, this relationship has not been clearly defined. It seems that environmental pollutants and toxins are more related to intranasal non-allergic inflammatory response rather than an IgE mediated reaction. There are several reports about the estimated incidence of allergic rhinitis worldwide; however the incidence of nonallergic chronic rhinitis has not been well determined. Most of these patients suffer from chronic engorgement of the inferior turbinates with increased nasal airflow resistance mainly in the valve region. Endoscopically it is commonly observed mucosa thickening in the middle meatus in association with infundibulitis. The purpose of this article is to illustrate a surgical technique for nasal congestion secondary to chronic inflammatory non-allergic rhinitis. We prospectively evaluated the results of endoscopic surgical treatment in 25 patients with chronic inflammatory non-allergic rhinosinusitis. The nasal endoscopy revealed hyperplastic nasal mucosa with poor response to topical decongestant. The main symptom was nasal congestion, usually in response to temperature and humidity changes, but also to body position variations. All patients described themselves as chronic users of topical decongestants and antihistamines for a minimum of one year, as the only way to feel some relief to the symptoms. None of them described good quality of life with medical treatment, wich included topical and systemic decongestants, topical and systemic steroids and antihistamines. A total of 25 patients receive clear information about the steps of the surgical technique. They were also informed about a non-standard, non-approved surgical technique to relieve nasal congestion for chronic inflammatory rhinitis.

Otolaryngology– Head and Neck Surgery Volume 119 Number 2

113 Clinical and Cost Utility of Temporal Bone CT Scans in Head Trauma HILARY H TIMMIS JR MD; MOISES A ARRIAGA MD, Pittsburgh PA

Objective: High resolution CT scan of the temporal bone provides definitive assessment for temporal bone integrity. Few temporal bone injuries require immediate surgical intervention. In the interest of cost savings, can specific temporal bone imaging be deferred until otologic surgery is necessary? Methods: This study reviewed 50 consecutive patients suffering head trauma for whom otologic consultation was requested. The role of temporal bone CT in patient management decisions was recorded for each patient. Results: In addition to confirming the location of fractures, facial nerve status, ossicular status, and possible sites of cerebrospinal fluid leakage, temporal bone CT identified potential life-threatening injuries to the carotid canal which were not visualized on CT. Conclusions: Early temporal bone CT is helpful for guiding patient management in patients suffering head injury and possible temporal bone fracture by the identification of potentially life-threatening injuries to the carotid canal and the full documentation of the injuries suffered for medicolegal concerns.

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114 Sinus Histocytosis with Massive Lymphadenopathy PHILOMENA M BEHAR MD; N WENDELL TODD MD; SUSAN MULLER DMD, Atlanta GA

Objective: Sinus histiocytosis with massive lymphadenopathy (SHML), also known as Rosai-Dorfman disease, is a rare disorder of reactive lymphadenopathy occurring primarily in children and adolescents. It may resemble lymphoma or rhabdomyosarcoma in its clinical presentation. Symptoms include fever, weight loss, and malaise accompanied by massive lymph node enlargement. Any lymph node group can be affected; however, patients frequently present with massive bilateral, painless, cervical adenopathy. In the majority of cases, the disease is self limited. Some patients may require intervention because of airway compromise or extranodal involvement. Standard, proven therapies do not exist. Treatments include chemotherapeutic agents, surgery or radiation therapy. We present a case of SHML causing airway obstruction and failure to thrive treated with combination chemotherapy. Methods: A 5-year-old, African American female presented with a 9 month history of failure to thrive, fever and progressive airway obstruction associated with massive cervical and retropharyngeal adenopathy. Excisional biopsy of an affected cervical lymph node revealed dilated sinuses infiltrated with histiocytes and emperipolesis, supporting the diagnosis of SNML. The patient was treated with prednisone, methotrexate and vinblastine. Results: An excellent clinical response was noted over a 3 month period. The child experienced weight gain, regression of the adenopathy and resolution of her airway obstructive symptoms. No significant side effects were noted. Conclusions: There is little information available regarding the management of patients with SNMLW. Corticosteroids and/or cytotoxic agents may play a role in the treatment of patients with a protracted course, airway compromise, or extranodal manifestations. 115 Transient Facial Paralysis Resulting from Flight REZA RAHBAR MD DMD; NIKOLAS H BLEVINS MD; MARK S VOLK MD DMD, Newton MA; Boston MA

Objective: Facial paralysis associated with air flight is a rare phenomenon. This study presents a new case, review of literature, possible etiology and treatment protocols. Methods: Extensive literature search has revealed only three reported cases of facial paralysis associated with air flight. We present a new case of a seventeen year old female with two episodes of temporary facial nerve paralysis after ascent to altitude. Results: Facial nerve injuries during ascent are uncommon, since expanding middle ear gases passively vent through the eustachian tube, thereby not producing a significant pressure differential across the tympanic membrane. However, if expanding gases vent unequally, there will be overpressure in middle ear causing facial nerve paralysis.

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Written consent was obtained from all patients prior to surgery. First, the uncinate process was removed preserving mucus membrane to reduce the risk of scarring. Second, a microdebrider submucosal resection of the inferior turbinates was performed using a 3.5 mm cutting blade. Data about intranasal airflow was obtained before and after surgery in order to measure intranasal resistance variations. A total of 25 surgical procedures were done in the same number of patients for chronic rhinitis complaints. The average age was 33.7 years, and 15 patients were male and 10 were female. Chronic nasal congestion was the main complaint and was present in 100% of the patients. Other symptoms included rhinorrhea in 12 (48%) patients and chronic headache in 9 (36%) patients. Postoperative antibiotics were used 5 days after surgery. Hypertonic saline solution irrigations were prescribed immediately after surgery and maintained for at least 10 to 15 days. All patients reported clinical improvement in nasal congestion immediately after surgery. An increase in quality of life was experienced by all patients. Clean out was carried out on days 2, 5 and 10 after surgical procedure, for debridement of fibrin clots and crusts. The effectiveness of this combined technique should be considered in patients with chronic inflammatory non-allergic rhinitis who complain of severe nasal congestion. A decrease in airflow resistance in the nasal-valve region, combined with an increase in nasal receptor exposure to airflow in the middle meatus, has been demonstrated to be effective to relieve nasal congestion symptoms.

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Anatomical variants which may predispose to this phenomenon and possible mechanisms of neuroparaxia are discussed. Conclusions: Definitive treatment guidelines are difficult to formulate based upon one case and review of few cases in the literature. However, a reasonable approach is to equalize the ear (self-autoaeration or myringotomy). If the facial paralysis persists, patients should be treated according to the established protocols for idiopathic facial nerve paralysis.

116 Chondromyxoid Fibroma of the Mastoid Presenting with Facial Paralysis ROBERT A BATTISTA MD; PAULO GATTUSO MD, Hinsdale IL; Chicago IL

Objective: We present the case of a 23-year-old man with a 9-month history of facial paralysis caused by a chondromyxoid fibroma (CMF) of the mastoid. Only 4 cases of CMF involving the temporal bone have been previously reported. This case serves to illustrate the need to consider a neoplastic process in cases of long-standing (greater than six months) facial paralysis. Methods: A complete history and physical examination of the patient was performed. A CT of the temporal bone and a bilateral carotid/ cerebral angiogram were obtained. After surgical excision, the specimen was fixed in formalin, stained with hematoxylin-eosin and evaluated with light microscopy. Results: Histologically, the specimen was composed of a proliferation of spindle cells surrounded by a chondroid stroma consistent with CMF. One year postoperatively, MRI showed no evidence of tumor. Conclusions: Long-standing (greater than six months) facial paralysis may be caused by a neoplastic process. As a result of this case report, the differential diagnosis for neoplastic causes of facial paralysis should include CMF.

117 Pediatric American Burkitt's Lymphoma of the Sphenoid Sinus WILLIAM B LEWIS MD; PHILIP W PERLMAN MD; NASSER RAZACK MD, Rochester NY; Manhasset NY

Objective: In 1958, a mandibular malignancy found in African children was described as Burkitt's lymphoma (BL). The nonendemic or American form of the disease differs from the original African form in that its most common site of presentation is in the abdomen or bone marrow. American BL does manifest in the head and neck area, but it is seen here in less than a quarter of the reported cases and among those it usually presents as cervical adenopathy. Other common sites of involvement in the head and neck area are the mandible, tonsil, maxilla and nasopharynx. Primary disease limited to

the sinuses is uncommon, and that limited to the sphenoid sinus even more uncommon. Methods: Here we present the case of a four year old boy who presented with headache, vomiting, mental status changes, lethargy and left ptosis. MRI of the head, neck and sinuses revealed a large mass completely obliterating the sphenoid sinus. Endoscopic biopsy of this mass was found to be inconclusive. Subsequent CT scan of the abdomen showed large lesions in the liver and spleen. On liver biopsy, diagnosis of BL was made. Lumbar puncture revealed no disease in the spinal fluid and bone marrow aspiration was negative. EBV titer was negative, and LDH level was elevated. Results: The patient was treated with high dose, intense chemotherapy, and he is presently disease-free. He was given no radiotherapy. Conclusions: In the management of such a tumor we recommend dedicated MRI of the area involved as well as abdominal CT scan to evaluate distant spread of disease. The primary lesion should be biopsied directly if possible, conceivably via the endoscope, and lumbar puncture, bone marrow aspiration, chromosomal studies, and complete lab profile should be performed including LDH level and EBV titer. We also recommend high dose chemotherapy without radiotherapy as the best treatment with the least morbidity.

118 Rhabdomyosarcoma of the External Auditory Canal CRAIG A RICHMAN MD; PHILIP BIRD FRACS; FRED F TELISCHI MD, Miami Beach FL; Merivale Christ New Zealand; Miami FL

Objective: Rhabdomyosarcoma (RMS) is the most frequent soft tissue sarcoma in the pediatric population, with a propensity for head and neck sites. When arising within the ear, these tumors are rarely amenable to complete surgical excision due to involvement of unresectable margins. We report a case of RMS involving the external auditory canal (EAC). Included is a literature review with a discussion of the merits of complete resection versus the morbidity associated with cosmetic and functional deficits. Methods: Presented is the case of a four-year-old boy with drainage and a polypoid mass in the right ear. Histologic analysis of a biopsy specimen taken from the EAC demonstrated embryonal RMS. Most unusual was the complete lack of middle ear involvement. The patient was subsequently referred for definitive treatment. Results: Surgical resection with negative margins was performed via lateral temporal bone resection. The resulting specimen consisted of the entire EAC in continuity with the tympanic membrane and ossicles. After an uneventful recovery from surgery, the patient was treated with induction chemotherapy followed by concomitant radiation and maintenance chemotherapy per the intergroup rhabdomyosarcoma studies (IRS) protocol. Now at 10 months’ follow-up, the patient continues to do well, with no evidence of local recur-

Otolaryngology– Head and Neck Surgery Volume 119 Number 2

119 The Possible Role of Anticoagulation in Rhinocerebral Mucormycosis RAYMOND H HONG; R JAMES KOCH MD, Stanford CA; Redwood City CA

Objective: Rhinocerebral mucormycosis is an aggressive fungal disease which is commonly fatal. Thrombosis of blood vessels occurs; this introduces localized acidosis, tissue ischemia, and necrosis, which facilitates further growth of the saprophytic organism. Radical surgical debridement and amphotericin B comprise the standard treatment. We report the possible role of anticoagulants in the treatment of mucormycosis. Methods: The presentation, diagnosis, treatment, and clinical course of rhinocerebral mucormycosis in a diabetic patient were reviewed. The distinguishing factor in this case was that the patient had a preexisting coagulopathy secondary to Coumadin use. Results: Because the patient had a mechanical heart valve, he was taking anticoagulants. At the time of initial presentation his PT was 14.2 (INR = 1.22). The patient underwent surgical debridement and was found to have mucormycosis in his retro-orbital contents. He then completed a course of amphotericin B. The patient remains disease free after 3 years. Conclusions: To our knowledge, this is the first reported case in which anticoagulants may have played a role in combating mucormycosis. Mortality rates in rhinocerebral mucormycosis have ranged from 15% to 79%. In this patient's case, the disease had spread to his optic nerve and retro-orbit, yet he recovered. Similar to that in cavernous sinus thrombosis, anticoagulation may have played a positive role. Such implications and a review of the literature are presented.

120 The Masking Effect of Tinnitus upon Hearing: Does It Exist? TANIT G SANCHEZ MD; RICARDO F BENTO MD; AFONSO CELS ALEGRE MD, Sao Paulo SP Brazil

Objective: Most tinnitus patients have hearing loss and think that tinnitus is responsible for their hearing impairment. They also report some difficulties performing behavioral

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audiometry, especially when their tinnitus is similar to one of the pure tones. The study was conducted to evaluate the possible masking effect of tinnitus upon hearing. Methods: Fifty-four patients with and without tinnitus underwent behavioral audiometry and ABR in the same day. All 108 ears were divided into four groups: T1 (tinnitus ears/average up to 20 dBHL), C1 (control ears/average up to 20 dBHL), T2 (tinnitus ears/average greater than 20 dBHL), and C2 (control ears/average greater than 20 dBHL). The correlation between behavioral/ABR thresholds was compared between each tinnitus group and its respective control group. Results: T1 group showed a significant increase of ABR thresholds when compared to C1, which didn’t happen between T2 and C2. An explicative model was created to justify our findings. Conclusions: There wasn’t any evidence of masking effect of tinnitus upon hearing but the findings suggest that the small group of patients with tinnitus and normal hearing sensitivity may be the key to understanding the mysteries of tinnitus, once the changes provoked by hearing loss seem to cover the tinnitus effects, as in the present methodology.

121 Thoracic Duct Cyst Presenting as a Neck Mass DANIEL W TODD MD; ROBERT P ZITSCH MD, Columbia MO

Cystic dilation of the thoracic duct is an extremely unusual phenomenon. The vast majority of thoracic duct cysts are mediastinal, and there have been only a handful of reports of supraclavicular thoracic duct cysts in the literature. Congenital, degenerative, and traumatic etiologies have been postulated for the thoracic duct cyst. The natural history of these lesions currently remains unknown. However, it is generally felt that larger cysts should be resected to avoid the serious complications which may result from rupture or inflammation. A recent encounter with this rare entity has inspired a review of the anatomy, pathogenesis, diagnosis and management of supraclavicular chylous cysts.

122 Appearance, Presentation, and Treatment of Polymorphous Low-grade Adenocarcinoma of the Larynx DOUGLAS A O'BRIEN MD; ROBERT W DOLAN MD; JOHN E GOOEY MD, Arlington MA; Boston MA

Objective: This poster depicts an unusual presentation of polymorphous low-grade adenocarcinoma (PLGA) of the head and neck involving the supraglottic larynx. This lesion has never been reported to involve this site. Methods: The patient is a 61-year-old previously healthy male who presented with 18 months of dysphagia. A lesion was noted on the right arytenoid during upper GI endoscopy for gastroesophageal disease. Results: On direct laryngoscopy, the lesion appeared as a

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rence or metastasis. Conclusions: Due to the difficulty obtaining negative margins with RMS involving the middle ear, incomplete or no resection is generally the rule. Tumors limited to the EAC may be more readily resected in their entirety, although such cases are rare. This case illustrates that selected patients with RMS of the ear may undergo complete resection with limited cosmetic and functional deficit, thereby improving their survival probability in accordance with the IRS.

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mucosalized, pedunculated mass measuring 1.5 × 1.5 cm on the right arytenoid. The patient underwent curative excisional biopsy with clear histologic margins. Histologic findings are reported. Conclusions: We report a case of PLGA of the head and neck that involves the supraglottic larynx. This is the first reported case for this location. The gross and histologic appearance of this tumor is illustrated. 123 Operative Versus Nonoperative Management of Acoustic Schwannoma: Cost, Comorbidity, and Patient Satisfaction in a Single Neurotologist Practice TERRANCE J KWIATKOWSKI Philadelphia PA

MD; ROBERT T SATALOFF MD,

Objective: Management of acoustic schwannoma (AS) has historically been that of surgical extirpation, whereas non-surgical management has typically been reserved for a select group of patients. Because additional considerations such as patient satisfaction, cost of management and post-management morbidity are factors of increasing interest within the current healthcare milieu, we sought to examine and compare these variables within a single neurotologist's practice. Methods: A retrospective chart review in a single neurotologist's practice revealed 20 patients with AS managed non-operatively. These patients were then compared with patients taken from a database of operated ASs within the same practice. Data were recorded regarding tumor size and location, growth rate, hearing status, facial nerve status, (±) tinnitus, (±) vestibular changes, number of years followed, comorbidities, cost of management, non-operative and supportive procedures. The total cost of management adjusted to current norms was calculated for each patient and each group. Additionally, utilizing a standard questionnaire, a telephone survey of each patient was undertaken to determine both individual and group satisfaction with each management scheme and to assess and compare postoperative vs. post-non-operative morbidity. Results: Patients managed non-surgically had significantly greater comorbidities both individually and as a group when compared with controls managed surgically. Patients were generally satisfied with their management in each of the groups. Conclusions: Comparisons of management cost and postmanagement morbidities for each group are graphically displayed. The advantages and disadvantages of non-surgical management of AS should be given serious consideration in each individual case in order to optimize ultimate patient outcome.

124 MRI-guided Procedures in the Head and Neck Using Contemporaneous Imaging in an Open Configuration System STEVEN J WANG MD; ROBERT B LUFKIN MD; JOEL A SERCARZ MD; MARILENE B WANG MD, Los Angeles CA, Los Angeles CA; Santa Monica CA; Los Angeles CA

Objective: The concept of magnetic resonance imaging to guide minimally invasive procedures in the head and neck was first developed in the mid 1980's. Its application had previously been limited by technical difficulties, including the need for MRI compatible instruments, slow image acquisition time, and the closed nature of conventional MRI scanners. The recent development of open configuration MRI systems with in-room, contemporaneous imaging has greatly increased the potential for MRI-guided interventional procedures. We evaluate our clinical experience using this technology with application to the head and neck region. Methods: An open design 0.2T magnet (Siemens OPEN) combined with an in-room monitor was used for twenty-four MRI-guided procedures in the head and neck. Success of the procedures was based on the ability to accurately position the instrument in the target region to allow biopsy and/or treatment. Results: The open design magnet allowed the physician to directly access the patient as the procedures were performed. The in-room monitor provided contemporaneous imaging feedback during the procedures for successful placement of the instrument in the target region. Twentythree biopsies and one treatment procedure were performed. In all cases the technique resulted in successful placement of the instrument within the target tissue in order to complete the procedure. Conclusions: MRI-guided procedures in an open design magnet with in-room, contemporaneous image monitoring offer advantages over previous conventional interventional MRI systems by allowing interactive guidance with near real-time imaging feedback. As a result, procedure time is reduced and accuracy of instrument positioning is increased.

125 Massive Cervicofacial Necrotizing Reconstructive Challenge

Fasciitis:

A

PAULUS DARCY TSAI MD; ROBERT E JOHNSON MD, Alea HI; Tripler AMC HI

Objective: To present and discuss the management of a case of advanced necrotizing fasciitis involving the face, neck, chest and arm. Methods: A case report with review of the literature. Perioperative photos are presented. Results: Necrotizing fasciitis is a potentially life-threatening polymicrobial infection. The diagnosis is suggested by skin erythema and edema progressing to a blue-gray appearance, accompanied by systemic toxicity and pain. It often results from dirty wounds in diabetics. Prompt medical and surgical treatment is imperative. We present the case of a 42year-old Micronesian male with diabetes and inadequately managed necrotizing fasciitis resulting from a dental infection. Immediate aggressive debridement was followed by a rocky course of medical problems to include ARDS and septic shock. Final closure of all wounds took three months, fol-

Otolaryngology– Head and Neck Surgery Volume 119 Number 2

126 Effects of Cochlear Implantation on Vocal Function in Deafened Adults EDIE W SWIFT; ROBIN A SAMLAN; KATHRYN A BREWER; GARROLD M PYLE MD, Madison WI; Middleton WI

Objective: Studies of speech production benefits of cochlear implants in adults have a limited history. Few have focused on measures of laryngeal function that reflect changes in vocal effort or voice quality, changes that might be expected with improved auditory feedback. This study investigated the interactions between improved auditory input and a spectrum of speech production skills. Methods: Four post-linguistically deafened adults were prospectively studied before implantation and at one year after implantation of a Nucleus 22 cochlear implant device. All participants completed a therapy program emphasizing auditory perception. Acoustic timing measures, laryngeal and velopharyngeal resistance, visual videostroboscopic, and auditory perceptual measurements were made. Comparisons of the preimplantation and postimplantation test results for each subject were used to construct a laryngeal function profile and to examine individual variations. Results: Laryngeal function profiles clearly demonstrated the study participants had different communication skills preimplant even though their degree of hearing loss was similar. After implantation, laryngeal timing characteristics normalized for all speakers; stroboscopic and aerodynamic changes were mixed. Perceptual judgments of voice quality and consonant precision improved across subjects. Conclusions: Deafened adults with a similar degree of hearing loss exhibit significantly heterogeneous communication profiles. Grouping them to analyze treatment results cannot be legitimately accomplished without threatening statistical integrity. Nevertheless, some results crossed all subjects. The Nucleus 22 implant appeared to be an effective tool for improving voice timing characteristics and vocal quality even when behavioral management was not focused directly on these parameters. Laryngeal hyperfunction present at 1 year may be indicative that further improvement could be achieved with behavioral therapy directed toward reduction of vocal effort.

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127 Ossification of the Lateral Nasal Wall from 12 to 22 Weeks of Gestation NORBERTO LOPEZ SERNA MD; RODOLFO MAR BURCKHARDT MD; ALFREDO NUNEZ CASTRUITA MD; MIGUEL ANGEL AREOLA SALINAS; GUADALUPE DE ARREOLA ARREDONDO MD, Nuevo Leon Mexico; Monterrey N L Mexico; Nuevo Leon Mexico; Nuevo Leon Mexico; Nuevo Leon Mexico

Objective: Analyzing the ossification process of the lateral nasal wall gives a better understanding of the development of its structures. Methods: A retrospective and descriptive study was made using 30 human fetuses with normal external characteristics from the twelfth to twenty-second weeks of morphologic age. Fetuses from 12 and 13 weeks were cut on the frontal plane and stained with hematoxylin and eosin. Fetuses from 14 to 22 weeks were submitted to frontal and axial plane cuts and stained with alizarin red. Conceptuses were revised under light and stereomicroscopy. Results: The beginning of the ossification process was observed in the following structures: inferior turbinates (14 weeks); middle and posterior third of the middle turbinate and ethmoidal bulla (17 weeks); uncinate process and the union of the ossification centers of the ethmoidal bulla (18 weeks); anterior ethmoidal cells and superior turbinate (20 weeks); posterior ethmoidal cells and the full extension of the superior, middle and inferior turbinates (22 weeks). Conclusions: The analyzed material showed that the ossification process of the lateral nasal wall was begun at the 14th week of intrauterine life at the inferior turbinate level and at posterior ages and in a progressive manner in the ethmoidal bulla, uncinate process, anterior ethmoidal cells and posterior ethmoidal cells from the fifteenth to the twentysecond week.

128 Muscle Fiber of Human Thyroarytenoid Muscle: The Single Fiber Gel Electrophoresis Technique YA ZHEN WU MD; ROGER L CRUMLEY MD; MR MICHAEL J BAKER; VINCENT J CAIOZZO PHD, Irvine CA; Orange CA; Irvine CA; Irvine CA

Objective: The objective of this study was to analyze the myosin heavy chain (MHC) isoform content of single muscle fibers in the medial and lateral regions of human thyroarytenoid thyroarytenoid muscle, (n=4). This study evaluated the distribution of muscle fiber types in both regions of the thyroarytenoid muscle, and examined the MHC isoforms in thyroarytenoid muscle. Methods: Forty single muscle fibers are microdissected from the two distinct regions (medial, lateral) of each thyroarytenoid muscle. Sodium dodecylsulfate polyacrylamide gel electrophoresis (SDS-PAGE) was then performed on each fiber in order to separate the three adult human MHC isoforms (type IIX, type IIA, and type I). The MHC content of single muscle fibers in both regions was then compared using ANOVA.

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lowing nutritional therapy, and debridement of colonized granulation tissue. Wound coverage was accomplished by regional transfer of a large latissimus dorsi myocutaneous flap to cover his neck and lower face and split thickness skin grafting to cover his chest and arm. After four months of hospitalization, he was returned to his wife and six children in the Marshall Islands. Conclusions: Necrotizing fasciitis of the cervicofacial region is a devastating and frequently deadly disease. In this case, aggressive management of the disease process and several attendant life-threatening medical problems, followed by a thorough approach to reconstruction, resulted in success.

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Results: Fibers from the lateral region contained a higher percentage (28.5%) of fast twitch type IIX MHC than fibers from the medial region (16.1%, P ≤ 0.05; see Figure 2). No regional difference was found when comparing the slow type I and fast type IIA MHC isoforms. Of the fibers from both regions, 23.5% expressed exclusively the slow type I MHC isoforms, 26.2% expressed exclusively the fast type IIA MHC isoforms, and 2.9% expressed exclusively the fast type IIX MHC isoforms (see Figure 1). Additionaly, some fibers of the human thyroarytenoid exhibited polymorphic expression: I/IIA (5.1%); I/IIX (0.8%); IIA/IIX (33.9%); and I/IIA/IIX (7.4%). Conclusions: These results showed that there is no difference in expression of the slow type I and fast type IIA MHC isoforms in the two regions of human thyroarytenoid muscle, but the lateral region of the human thyroarytenoid muscle contained a higher percentage of fast type IIX MHC isoform than the medial. Additionally, some fibers of the human thyroarytenoid exhibited polymorphic MHC expression, possibly allowing for adaptation in response to stimuli. 129 Fitting Hearing Aids: Unusual Complications DARIUS KOHAN MD; RONALD A HOFFMAN MD; MARC D GOTTLIEB MD; STEPHEN MARRA MD, New York NY; New York NY; Queens Village NY; New York NY

Objective: Recent advances in auditory amplification technology and an aging population have resulted in a marked proliferation of hearing aid dispensers. Proper fitting of hearing aids following established guidelines rarely results in serious complications. This study is the first to present unusual complications which required surgical management. Methods: Four otologists at a major university center with a combined 60 year experience performed a retrospective analysis of their surgical practice. Five patients were identified to have had severe complications from improper mold fittings requiring surgical intervention. Results: Two patients with canal wall down mastoidectomy defects and narrow external ear canals required a canaloplasty for removal of the impacted mold material. Two patients with presbycusis and normal ear canals developed eardrum perforations, conductive hearing deficits, and were noted to have the mold partially filling the middle ear cleft. Another patient's traumatic tympanic membrane perforation healed spontaneously resulting in a maximum air bone gap. A cast of mold material within the middle ear cleft was removed via a tympanomastoidectomy. Conclusions: Proper fitting of hearing aids by well trained medical professionals has resulted in a very low incidence of complications. Impactions of mold material within a mastoid bowl or middle ear (via a traumatic tympanic membrane perforation) may be successfully managed with standard otologic surgical techniques.

130 Calciphylaxis: A New Head and Neck Manifestation of a Systemic Disorder KEVIN E MCLAUGHLIN MD; RONNIE E SWAIN MD; SUSAN MULLER DMD; JOHN M DELGAUDIO MD, Atlanta GA; Mobile AL; Atlanta GA; Atlanta GA

Objective: Calciphylaxis is an uncommon syndrome of ischemic necrosis associated with vascular calcification. Virtually all of the reported 105 cases are associated with chronic renal failure with concomitant secondary or tertiary hyperparathyroidism. Potentially lethal, ulcerative lesions almost exclusively involve the extremities and back. Although controversial, parathyroidectomy is associated with significant improvement in survival. Only one case (from Europe) has been reported to arise in the head and neck area (tongue) and was diagnosed post-mortem. We present a case of calciphylaxis of the tongue that was successfully treated with subtotal parathyroidectomy. The etiology, clinical manifestations, illustrative photographs and radiographs, pathology, and treatment will be presented. Methods: A 62-year-old man who was receiving dialysis for end stage renal disease presented to our clinic complaining of a two week history of a tongue mass. Examination revealed multiple, firm, sessile lesions of the midline dorsal tongue with ulceration. Similar lesions were present on the back. Results: Biopsy specimens were consistent with calciphylaxis revealing small vessel calcification with superimposed endovascular fibrosis and vascular stenosis. Laboratory evaluation revealed elevated calcium (10.3), phosphorous (7.0), and parathyroid hormone (1900) and radiographs showed calcifications of the tongue. The patient underwent subtotal parathyroidectomy which showed impressive nodular hyperplasia. The patient's electrolyte abnormalities improved after parathyroidectomy and there has been no recurrence of tongue or back lesions in six months. Conclusions: Calciphylaxis is a potentially lethal, rare disorder that almost exclusively involves the back and extremities and manifests as spontaneously forming wounds in uremic patients with hyperparathyroidism. We describe a patient who presents with calciphylaxis of the tongue. This disorder can be treated with subtotal parathyroidectomy. 131 Aural Tuberculosis LANE E TURNER MD; SCOTT A ESTREM MD, Columbia MO

Objective: We describe a case of tuberculosis, the diagnosis of which was made due to aural involvement. Methods: Tuberculosis involving the ear was a common finding at the turn of the century. Improved health care, screening tests, BCG vaccine, milk pasteurization, and antitubercular drugs have all played a role in decreasing the prevalence of tuberculosis. Symptoms of the disease process may be limited to the ear, with or without pulmonary involve-

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132 Ecthyma Gangrenosum of the Face: Presentation

An Unusual

MATTHEW G BEYER MD; SHAWN D NEWLANDS MD, Ridgeland MS; Jackson MS

Objective: Ecthyma gangrenosum is a dermatologic manifestation of pseudomonal septicemia. Two cases of neonates with ecthyma gangrenosum of the midline nose and palate are presented. Methods: Treatment involved conservative debridement and intravenous antibiotics. Results: Both patients survived with stenotic nasal alae, columellar destruction and palatal defects. A review of the literature revealed few cases of ecthyma gangrenosum with involvement of similar head and neck structures in previously healthy neonates. Conclusions: Ecthyma gangrenosum must be included in the differential diagnosis of midline necrotic lesions of the nose and palate, especially in patients with compromised or immature immune systems. Prompt recognition and immediate institution of appropriate antibiotics can alter the outcome of this highly fatal disease.

133 Evaluation of Pulmonary Function in Singing Students DONNA S LUNDY MA; SOHAM ROY MD; ROY R CASIANO MD; JOSEPH EVANS; PAULA ANN SULLIVAN MS CCC-SLP, Miami FL, Miami FL, Miami FL, Coral Gables FL; Miami FL

Objective: Do singers have larger respiratory reserves or do they make better use of their breath support? A prospective study was undertaken to evaluate pulmonary functions in singing students. Methods: Sixty singing students underwent pulmonary function testing. Results were correlated with demographic factors, medical history, and singing history. Results: Pulmonary functions were not significantly different from normative data. However, gender differences were found in the mid-flow range. Conclusions: Results of this study are consistent with previous reports of pulmonary functions in professional singers. This data emphasizes the need for singers to develop optimal respiratory support. 134 The Evaluation and Management of Pediatric Sinonasal Fibromyxomas JOHN LASAK MD; STEPHEN A GOLDSTEIN MD; STEVEN P COOK MD FACS; MARK F KELLY MD, Philadelphia PA; Wilmington DE; Havertown PA

Objective: Sinonasal fibromyxomas of childhood are rare lesions that historically have presented a diagnostic dilemma. These neoplasms are not malignant, however can locally destroy bone and be mistaken for more ominous disease. Treatment ideally involves total excision, with diligent follow up to detect and treat recurrences. Over treatment with radiation and chemotherapy should be avoided to deter the untoward side effects of such therapy in children. The differential diagnosis, evaluation, and treatment options for pediatric sinonasal masses will be reviewed. Methods: We describe the evaluation and management of a 15 month old male diagnosed with a right maxillary sinus fibromyxoma with orbital extension. The presentation and treatment of this child will be compared to those previously reported in the world literature. Results: Biopsy revealed hypocellularity with spindle cells in a myxomatous background consistent with benign fibromyxoma. The tumor was approached via midfacial degloving. The lateral nasal wall and orbital floor were noted to be dehiscent. Using powered instrumentation (a microdebrider), the tumor was excised leaving periorbita intact. Facial symmetry was preserved, and cosmesis was maintained. Conclusions: Sinonasal fibromyxoma is an uncommon neoplasm that is effectively treated with complete surgical excision. One must be diligent to make the appropriate histological diagnosis to ensure proper treatment. Preservation of facial architecture with complete excision is preferred. The use of powered instrumentation to debulk the lesion greatly

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ment. A child presented to the University of Missouri Hospital and Clinics with what appeared to be chronic serous otitis media. This child was born in Korea and was adopted when she was nine months old. She had documented negative TB tine tests at the time when she moved to the United States. Her symptoms were consistent with chronic serous otitis media and she had no pulmonary or other symptoms. She failed standard medical and surgical treatment of chronic serous otitis media which prompted the clinicians to obtain acid-fast bacillus smears and cultures for tuberculosis which finally helped make the diagnosis. Mantoux test was positive at 20 mm and chest x-ray revealed evidence of healed primary tuberculosis complicated with cervico-thoracic junction spinal tuberculosis. Results: As this case demonstrates, the diagnosis of aural tuberculosis can be difficult to make. Physical examination findings can be quite variable and non-specific. Smears for acid-fast bacillus may be falsely negative and culture of mycobacterium is difficult and often takes four to eight weeks to obtain a result. False tuberculin tests may occur as a result of faulty administration, inaccurate measurement, misinterpretation of results, and anergy. Conclusions: The otolaryngologist must be familiar with this disease because its initial presentation may be aural involvement. Underdeveloped countries still encounter significant cases of tuberculosis. Complicating this disease process in the United States and worldwide are emerging strains of tuberculosis which are resistant to standard antitubercular therapy. High clinical suspicion, a history of exposure to tuberculosis, or patients from underdeveloped countries should lead the clinician to the possibility of tuberculosis.

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facilitates removal. Postoperative evaluation with nasal endoscopy, opthalmologic examination, and computed tomography is used to detect recurrence.

135 Nasal Septal Abscess with Secondary Intracranial Extension JAMES KALLMAN MD; STEVEN D HANDLER MD; HANI Z IBRAHIM MD, Philadelphia PA

Objective: Nasal septal abscess is an uncommon clinical entity that typically occurs following nasal trauma. Untreated, nasal septal abscess may ultimately progress to cranial abscess with potentially severe consequences. We present a well-documented case report of intracranial extension from a nasal septal abscess. Methods: Case report with review of the literature. Results: A dramatic case of a twelve-year-old Hispanic male with a two-week history of dull, frontal headaches and mild, intermittent epistaxis is presented. The patient and his mother denied any history of antecedent trauma or sinusitis. On physical examination, he was found to have a fleshy, round mass, which symmetrically involved the anterior-inferior nasal septum. Computed tomography and magnetic resonance imaging studies revealed a 2.0 × 2.0 centimeter rim-enhancing lesion of the anterior-inferior nasal septum consistent with a nasal septal abscess as well as anterior ethmoid sinus opacification and subdural empyema. Management of the patient included incision and drainage of the septal abscess, endoscopic surgery of the anterior ethmoid sinuses, and six weeks of intravenous antibiotics. Serial imaging studies were obtained throughout the patient's course to document the resolution of his subdural empyema and obviate the need for craniotomy. Conclusions: Nasal septal abscess is an infrequent complication of nasal septal hematoma. The practicing otolaryngologist must promptly recognize and treat this clinical entity. Our well-documented case depicts the potentially grave consequences that may follow an untreated nasal septal abscess. A brief review of the literature and a discussion of the management of nasal septal abscess are presented. 136 Assessment of Numerical Chromosome Abnormalities in Thyroid Neoplasia by Fluorescence In Situ Hybridization ANNE MARIE W BLOCK PHD; THOM R LOREE MD; WESLEY L HICKS JR MD DDS; MARK D DELACURE MD, Buffalo NY, Buffalo NY, Angola NY; Buffalo NY

Objective: Differentiated carcinoma of the thyroid gland is a neoplasm with a clinical behavior which is often paradoxical and unlike that of other human cancers. Some tumors have an indolent course. Others behave in an aggressive manner with high morbidity and mortality. These tumors may represent a model for human epithelial cell multistep carcinogenesis. In an attempt to characterize specific numerical chromosome abnormalities in thyroid carcinomas and correlate with

histology and clinical behavior we present here the preliminary findings from a prospective study of 55 patients undergoing thyroidectomy at our institution. Methods: Fluorescence in situ hybridization (FISH) studies to assess chromosomal aneuploidy were performed on fresh surgical touch prep material using centromere-specific probes for chromosomes #7, 8, 9 and 12. Samples were obtained for analysis, including normal thyroid gland (3), follicular adenoma (3), thyroiditis and/or non-toxic nodular goiter (16), papillary and papillary-follicular carcinoma (20), papillary incidental carcinoma (8), papillary variant tall cell carcinoma (3), Hurthle cell follicular carcinoma (1), anaplastic carcinoma (1). The exact versions of the Mann-Whitney (MW) test and the median test were used to compare observed distributions of the percent of cells that were diploid between each of the groups for which there was more than one observation. Results: For each of the four chromosomes studied, the percentage of diploidy and aneuploidy were determined for each sample. The mean, median and coefficient of variation for each chromosome were calculated. The mean percentages of diploid cells were 87.5, 87.1, 87.4 and 86.3 for chromosomes #7, 8, 9 and 12 respectively. Benign samples were compared to malignant samples using the median test. The number of samples above and below the overall diploid mean in each group and for each chromosome was determined. The results showed a highly significant percentage of aneuploidy for chromosomes #7, 8 and 12. The MW test was significant for all four chromosomes when benign samples were compared with papillary and papillary-follicular carcinomas. When this same group of papillary carcinomas was compared with papillary incidental carcinomas the MW test was significant for chromosomes #7 and 12. Conclusions: This finding of aneuploidy supports the suggestion that multiple chromosome changes may be contributory to the development of malignancy.

137 Sinonasal Symptoms in Patients with HIV Infection IAN SWIFT MD; THOMAS R PASIC MD, Madison WI

Objective: Patients with HIV infection commonly describe sinonasal symptoms that affect the quality of their lives. It is our goal to characterize the severity and frequency of sinonasal symptoms in HIV-infected patients and to determine if there is a relationship between their symptoms and other objective measures of their disease. Methods: We administered a sinonasal symptom questionnaire to 72 consecutive patients seen in an HIV clinic. Patients were asked to rate both the severity and frequency of ten sinonasal symptoms on a seven point scale with qualitative anchors ranging from "none/rarely" to "severe/always." Symptoms included facial pain, facial pressure, headache, nasal drainage, nasal congestion, and an overall assessment of their sinonasal symptom complex. We compared symptom scores with laboratory studies that describe their HIV status, including viral load, CD4 count, CD4-CD8 ratio, total neutrophil count and albumin.

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138 Sinusitis Screening in the Pre-Allogenic Bone Marrow Transplant Patient MICHAEL J THIELMAN MD; THOMAS R PASIC MD, Madison WI

Objective: Allogenic bone marrow transplantation (BMT) carries with it a high risk of infectious complications, including paranasal sinusitis. It is our goal to determine the incidence and clinical course of paranasal sinus abnormalities in a consecutive cohort of patients undergoing BMT. Methods: A review of 81 consecutive allogenic BMT patients was performed. Paranasal sinus CT scans were obtained in all patients prior to BMT. Radiographic findings and the patient's chart were reviewed a minimum of 6 months following BMT. CT scan findings were classified as abnormal if diffuse mucoperiosteal thickening or sinus opacification was noted. Results: The pre-BMT CT scans were classified as abnormal in 23 of 81 patients (28%). Post-BMT mortality in the initial 40 patients in this study was 22 of 40 (55%). Of the group that ultimately died, 3 of 22 (14%) had abnormal findings on the pre-BMT CT scan. Of the group that has survived, 6 of 18 (33%) had significant findings on CT scan. Conclusions: Abnormal paranasal sinus CT scan findings are common in the pre-BMT patient. Initial results indicate that pre-BMT sinus abnormalities, however, do not seem to account for early mortality rates. Additional analysis of the morbidity of sinus infections will also be presented. 139 Harlequin Syndrome: Sweating

Unilateral Facial Flushing and

MITCHELL J RAMSEY MD; THOMAS P O'MALLEY MD; MICHAEL R HOLTEL MD, Kailua HI; Rota Spain; Honolulu HI

Objective: To discuss “Harlequin syndrome,” a sympathetic defect resulting in unilateral facial flushing and sweating. This clinical syndrome, its pathophysiology, and treatment will be discussed. Methods: A case report format with clinical photographs and a review of the literature will be utilized to present Harlequin syndrome. Anatomic diagrams will be used to review the normal sympathetic physiology of facial sweating and flushing, and the potential sites of injury in Harlequin syndrome.

Results: We present the case of a 38-year-old female with an 18-month history of unilateral facial flushing and sweating following exercise. The patient was otherwise healthy when the symptoms were initially noted following exercise. Examination demonstrated right unilateral facial flushing and sweating following exertion. The remainder of the patient's neurologic and ophthalmologic exam was within normal limits. CT of the chest and MRI of the head, neck, and thorax demonstrated no abnormalities. Conclusions: Eleven cases of this unusual syndrome have been presented in the neurology literature and two independent MEDLINE searches by physicians found no citations in the otolaryngology literature. The clinical gestations of Harlequin syndrome are almost exclusively in the head and neck and therefore important for the otolaryngologist to recognize. The pathophysiology of this syndrome is a defect of the sympathetic innervation from the second or third cervical root. The etiology is variable but documented causes include cervical sympathetic sectioning, mediastinal tumors, central CNS lesions, and possibly acute vascular insufficiency. The abnormal side is the asymptomatic, non-flushing side. We will review this syndrome, the physiology of sympathetic facial flushing and sweating, and the common head and neck manifestations of sympathetic disorders

140 Unusual Bone Cyst of the Maxillary Sinus CHRISTOPHER M LONG MD; TIMOTHY N CHRISTIANSEN MD; ROBERT J TOOHILL MD; MICHAEL MURPHY MD; PETER RHEE MD; ANDRE KAJDACSY-BALLA MD PHD, Milwaukee WI; Wauwatosa WI, Milwaukee WI

Objective: A case of a 44-year-old female who presented with complaints of unilateral nasal airway obstruction, diplopia, proptosis, and unilateral facial deformity. Methods: Coronal CT of the sinus demonstrated a lesion completely filling the right maxillary and ethmoid sinuses with erosion of the inferior orbital floor as well as the medial and lateral maxillary sinus wall. The patient was taken to the operating room where a large, friable, hemorrhagic mass was excised from the right maxillary and ethmoid sinuses via an intranasal and sublabial approach. The orbital floor and lamina papryacea were then reconstructed using a temporalis fascia graft and titanium mesh. Results: Histopathological analysis demonstrated scattered multinucleated giant cells with the presence of cavernous blood-filled spaces surrounded by loose fibroblastic connective tissue. This ultimately proved to be an aneurysmal bone cyst. Only four cases of an aneurysmal bone cyst in the maxillary sinus have been reported in the literature since 1960. Conclusions: Aneurysmal bone cysts are benign, expansile lesions which occasionally present in the craniofacial area, very rarely in the maxillary sinus. Histological characteristics include blood-filled pseudocysts, fibroblastic loose connective tissue and multinucleated giant cells. Treatment is primarily surgical excision.

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Results: Seventy-six percent of the HIV-infected patients reported having sinonasal symptoms. We found that the overall severity of the sinonasal symptom complex was in the "mild" range (mean score 3.21) and frequency of symptoms in the "sometimes" range (mean score 3.19) The worst symptoms were headache (severity score 4.30, frequency score 3.57) and nasal congestion (3.33/3.67). Symptom scores did not correlate with laboratory studies of HIV infection. Conclusions: Sinonasal symptoms are common in HIVinfected patients. Symptoms tend to be mild and occur on a "sometimes" basis. Symptom scores do not correlate with laboratory studies that estimate the severity/progression of the viral infection.

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141 Postoperative Headache after Surgery of Vestibular Schwannoma ILMARI PYYKKO MD; ULF ROSENHALL; HILLA LEVO MD; GORAN BLOMSTEDT, Stockholm Sweden; Helinski Finland

Objective: Postoperative headache (POH) after vestibular schwannoma removal is a relatively common and severe symptom that may disable the patient’s life. So far its etiology is open and the course of the headache not known in detail. Further, the risk factors for development of POH have not been studied in detail. Methods: We studied retrospectively the occurrence, severity, risk factors and course of POH among patients operated on for a vestibular schwannoma between January 1979 and May 1993. The operated patients were recalled and a questionnaire was given asking specific questions on POH. The operative approach was retrosigmoidal in 327 and translabyrinthine in 36. Two hundred and fifty-one patients responded to the questionnaire. The mean follow-up duration was 9.2 years. Results: Preoperative headache was met in 122 subjects. Postoperatively 154 reported POH. After 1 year 101 subjects had headache. At the time of questionnaire 93 patients reported POH. Pain was localized to the occiput (73%) or neck (69%). POH was a major problem in 27 subjects. Sixteen expressions best describing POH were extracted with factor analysis, "sore" and "continuous" being the most commonly used. In logistic regression analysis retrosigmoidal approach (odds ratio 3.6), postoperative gait problems (odds ratio 2.9) and tumor size (odds ratio 1.1) predicted outcome of POH. Preoperative headache was a significant risk factor for POH (odds ratio 2.5), and subjects with preoperative headache suffered from more intensive POH. Conclusions: Pain character refers to neuropathic pain that levels of 18% of nonsymptomatic subject will have POH. Subjects with preoperative headache should be informed that they may develop severe and persistent headache. To avoid POH we recommend limited muscle tissue manipulation and replacement of bone flap. 142 Angiocentric Lymphoma of the Temporal Bone WILLIAM B LEWIS MD; URESH PATEL MD; JAY K ROBERTS MD; JAMES PALIS MD, Rochester NY

Objective: Primary lymphoma of the temporal bone is rare. Only two cases have been reported in the English literature, both B-cell neoplasms that presented with facial paralysis and otitis media. We present the first case of a histologically proven angiocentric T-cell lymphoma of the temporal bone. This eight month old girl presented with proptosis of the auricle, but without evidence of otitis media or external or facial paralysis. Methods: This case report reviews the literature for the existing primary temporal bone lymphomas, with a detailed description of this patient's presentation. The discussion also

focuses on the relationship of the angiocentric immunoproliferative disorders to the well-known yet confusing syndrome of "lethal midline granuloma." Emphasis is placed on a high index of suspicion for those cases of apparent inflammatory ear disease that show pain out of proportion to clinical findings, or that fail to respond to conventional treatment. Results: Histopathologic documentation is provided, along with computed tomography both at the time of presentation and in follow up, which showed complete resolution of the temporal bone destruction which was evident at the time of diagnosis. Conclusions: We present a child with primary angiocentric T-cell lymphoma of the temporal bone. Clinicians need to maintain a high index of suspicion for a neoplastic process whenever a child fails to respond to treatment or has atypical clinical features. High resolution CT imaging of the temporal bone plays a vital role in suggesting an underlying neoplasm as well as monitoring therapeutic response. 143 Atypical Meningioma: A Pediatric Case Report and Review of the Literature KEITH M ULNICK DO; VINCENT D EUSTERMAN DDS MD; VICTOR L SCHRAMM JR MD, Spanaway WA; Olympia WA; Denver CO

Objective: Meningiomas are rare in the pediatric population with an incidence of less than 2% of all primary tumors of the meninges. A rare aggressive form of meningioma, the "atypical meningioma" (WHO grade II) occurs in less than 1.2% of adults, and is considered extremely rare in the pediatric population. We present an interesting case of a large anterior cranial fossa atypical meningioma in a 9 year old female and will discuss the management, pathological diagnosis, and review of the literature. Methods: DG is a 9-year-old Hispanic female who was referred with a four-week history of unilateral proptosis and a past history significant for four years of intermittent epistaxis. Clinical exam revealed a posterior-superior nasal-septal mass and right orbital proptosis. Cranial nerve function was normal except for decreased vision in the right eye to 20/40. CT images revealed a 7 × 8 cm mass in the anterior cranial fossa with extension into the nose, orbits and cavernous sinus. Biopsy data were consistent with a poorly differentiated neoplasm, probably meningioma or carcinoma arising from respiratory epithelium (AFIP). During surgical removal the disease was cystic, and extended extradurally from the anterior cranial fossa and orbits bilaterally to involve both optic nerves at the chiasm. It extended through the dura at the cribriform and studded the dura but did not invade the brain. Final diagnosis is atypical meningioma. Results: Management of meningioma, specifically the atypical variant, presents a dilemma. Prognoses based on histologic parameters like mitotic index or brain invasion have been described. Analyses of genomic alterations have been identified in various malignancy grades and associated progression proposed. Generally, patients with benign disease do better with total excision (TE) or subtotal excision with radi-

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144 Amplification of CCD1 in Oral Cavity and Oropharyngeal Squamous Cell Carcinomas (SCCa), as Determined by FISH SERA L JACOB MD; W FREDERICK MCGUIRT MD, WinstonSalem NC

Objective: Amplification of the CCD1 gene has been demonstrated in SCCa of the head and neck. Fluorescence insitu hybridization (FISH), which has not been utilized thus far to detect CCD1, possesses certain advantages over the standard techniques used to detect amplification. The specific aims of this research were to determine if FISH technology could be applied to detect CCD1 amplification in freshly resected SCCa of the head and neck. Methods: Fresh slides from touch preparations of oral cavity and oropharyngeal SCCa tumors were quick-differential stained to identify neoplastic cells. Images of non-overlapping abnormal cells were captured and stored on an image-analysis system. These slides were then processed for routine FISH analyses with a commercially available CCD1 FISH probe. Posthybridization slides were observed under a fluorescent microscope for multicolor FISH analysis and studied for number of CCD1 gene signals. Results: The neoplastic cells in 6/14 (42.9%) patients demonstrated amplification of the CCD1 gene. The amplification rates for each stage are stage I (0/1); II (1/3); III (0/0); IV (5/10). Conclusions: This study demonstrates that the amplification of CCD1 can be studied by a simple and rapid FISH technique. Amplification of the CCD1 gene, a G1 cyclin that functions as a positive cell cycle regulator, may play an important role in SCCa. The short follow-up period of 8 months precludes correlation with prognosis at this time. 145 Sensory Recovery in Melolabial Flaps Used for Oral Cavity Reconstruction FRANCISCO J CIVANTOS MD; W JARRARD GOODWIN JR MD; JEFFREY ROTH MD, Miami FL; Lawrenceville GA

Objective: The goal of oral reconstruction is restoration of form and function. One impediment to normal oral function is persistent loss of sensation. Recent literature advocates the use of reinnervated free flaps which include a neural anastomosis between the stump of the lingual or other sensory nerve to the vascularized nerve of the flap. It has been demonstrat-

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ed that non-innervated flaps can also recover sensation. Our study attempts to assess the return of sensation to non-innervated local melolabial flaps used in oral reconstruction. Methods: Seventeen patients underwent resection of oral cavity carcinoma and reconstruction with melolabial flaps. Seven patients underwent sensory testing at intervals varying from 12 to 18 months after surgery. Results: Spontaneous return of flap sensation was documented by clinical testing in 71% of patients. Less return of sensation was seen in flaps used for defects of the buccal mucosa relative to the floor of mouth. All patients with floor of mouth defects regained touch sensation and the ability to distinguish between sharp and dull. Two of four patients with floor of mouth defects developed 2-point discrimination at 15 mm apart. Conclusions: We conclude that spontaneous return of flap sensation does occur with local melolabial flaps although it is slightly less reliable than with innervated flaps. Given the simplicity of these procedures and the fact that some sensation is regained, melolabial flaps appear to be a reasonable alternative in floor of mouth reconstruction for selected patients.

146 Mucocele of the Crista Galli JENNIFER WINGATE MD; WALTER GRAND MD; MARK K WAX MD; GUS G VARNAVAS MD, Buffalo NY, Buffalo NY, East Amherst NY; Buffalo NY

Objective: Paranasal sinus mucoceles are benign cyst like structures. They may arise from any sinus cavity. Due to their expanding nature, they may erode bone and cause pressure symptoms on orbital or intracranial structures. The crista galli is typically a midline solid intracranial bone. Rarely is it pneumatized. We report a case of a mucocele with intracranial extension and penetration of the dura into the frontal lobe, arising in the crista galli. Methods: A case presentation with review of the literature. Results: A 71-year-old female was noted to have a 1.5 × 2 cm cystic lesion arising in the crista galli with intracranial spread into the frontal lobe. She underwent excision of this lesion through a combined craniofacial approach. No communication to the nasal cavity or frontal sinus was detected. Bilateral preservation of the olfactory nerves was obtained. Histologic examination revealed a mucocele. With one year of follow up there has been no recurrence. Conclusions: While extremely rare, pneumatization of the crista galli may lead to mucocele formation. Management should be no different than that of mucoceles arising in other sinuses.

147 Pituitary Carcinoma JENNIFER WINGATE MD; WALTER GRAND MD; MARK K WAX MD; IVO P JANECKA MD; CHRISTOPHER FLETCHER MD, Buffalo NY; East Amherst NY; Boston MA

Objective: Pituitary carcinoma is a rare entity, with less than 60 cases reported in the literature. The diagnosis cannot

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ation (SE+RT). Atypical features predict a poorer outcome, suggesting possible benefit from more aggressive treatment. Our patient received combined therapy, anterior craniofacial resection followed by proton beam radiotherapy. Conclusions: Atypical mengioma is a rare variant of mengioma and extremely rare in the children. Due to its aggressive malignant nature, aggressive combined surgery and radiation are indicated. We present a case report of a 9-year-old female and include a review of the pathogenesis and current treatment theories.

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be made on histopathologic grounds, as there is a lack of correlation between the biologic behavior (propensity to metastasize) and the useful histologic tissue characteristics of malignancy. Diagnosis of malignancy is based on regional or distant metastasis. With the advent of FESS, the otolaryngologist has become the individual most likely to biopsy these lesions. Methods: A case report with review of the literature. Results: A 56-year-old female presented with an extensive malignant pituitary lesion. The lesion extended from one petrous apex to the contralateral one. Both internal carotid arteries were completely encased by tumor. Following biopsy by an endoscopic means, she underwent full course radiotherapy. Pertinent histology and immunocytochemistry will be presented. Conclusions: Pituitary carcinoma is an exceedingly rare tumor of the sphenoid sinus. It may involve the sphenoid sinus. We present an individual case with a complete literature review. 148 An Obscure Case of Upper Airway Obstruction in a Patient with Ascariasis ALAN JC BURKE MD; WILL F MCGUIRT JR MD, Winston-Salem NC

Objective: A case presentation of a patient with upper airway obstruction by Ascaris nematodes will be described. The purpose of this case report is to present an obscure cause of airway obstruction with a focus on the surrounding circumstances and the ensuing management of Ascaris helminthiasis. Methods: The patient's background, history and the manifestations of the upper airway obstruction by the ascariasis worms will be discussed. In addition, the life cycle, prevalence, pathogenicity, treatment and prevention of Ascaris nematodes will be reviewed. Results: The airway obstruction was cleared by removal of an existing endotracheal tube, clogged by Ascaris worms. Subsequent bronchoscopy was performed to investigate the status of the bronchopulmonary tree with respect to other Ascaris worms. The helminth infestation was cleared using mebendazole and piperazine medications. Conclusions: Airway management secondary to Ascaris infestation was successfully managed by a regular airway protocol. A management plan for Ascaris helminthiasis will be discussed. 149 Nodular Fasciitis of the Head and Neck in Children: A Diagnostic Dilemma SERA L JACOB MD; WILL F MCGUIRT JR MD, Winston-Salem NC

Objective: Nodular fasciitis is a rare benign proliferation of fibroblasts and myofibroblasts in the subcutaneous tissues. The rapid rate of growth, abundant cellularity, and mitotic

activity can make a differentiation from sarcoma challenging. A review of the literature and four additional cases involving the head and neck in children are presented to increase the awareness of the entity and review presentation and treatment outcomes. Methods: Four children with head and neck nodular fasciitis at a tertiary care children's facility are reviewed. Results: All four children presented with lesions of the head and neck (2-periorbital, 2-neck). All received local resection without recurrence. Conclusions: The management of nodular fasciitis requires close cooperation between the otolaryngologist and pathology consultant to confirm this difficult diagnosis. Local excision is the treatment of choice for nonrecurring lesions. 150 Parinaud's Syndrome: A Rare Presentation of an Uncommon Disease STACEY LUEKER; WILLIAM C KINNEY Mexico MO

MD, Columbia MO;

Objective: Conjunctivitis associated with ipsilateral preauricular lymphadenopathy and a protracted febrile course (Parinaud's syndrome) is a rare presentation of cat scratch disease (CSD). Recent advances in microbiology have allowed for identification of the responsible etiologic agent. We present a case with clinical findings supportive of Parinaud's syndrome and antibody formation to Bartonella henselae. A review of current literature and case report are presented to offer an update on the changing treatment strategies for CSD. Methods: Single patient case report clinically presenting with Parinaud's syndrome. Results of antibody tests for B. henselae, B. quintana, and A. felis are presented in support of the diagnosis. Results: Enzyme immunoassay of antibody to Bartonella henselae showed negative IgG and positive IgM; for Bartonella quintana negative IgG and low positive IgM; for Afipia felis negative IgG and borderline positive IgM. Conclusions: Parinaud's syndrome is an unusual presentation of CSD but one that must be considered and identified in history taking. Traditional treatment for cat scratch disease requires clinical suspicion, positive skin testing and open biopsy. With the aid of serologic testing, we conclude that the diagnosis of CSD can be made clinically without the need for open biopsy. 151 The Use of Osseointegrated Reconstruction of the Mandible

Implants

in

Fibular

JODI M KORNAK MD; WILLIAM M LYDIATT MD; GORDON K MAHANNA DDS; DANIEL D LYDIATT MD DDS; RONALD R HOLLINS MD DMD; PAUL J SHERIDAN DDS; ANDREW C FRIEDMAN MD; PERRY J JOHNSON MD, Omaha NE

Objective: Utilization of osseointegrated dental implants in the prosthetic management of edentulism is well accepted. The use of implants in patients with previous mandibular irradiation has also been reported, but is less well established.

Otolaryngology– Head and Neck Surgery Volume 119 Number 2

Bone source

Received XRT No Previous XRT # Implants Lost Retained (%) # Implants Lost Retained (%) Fibula 11 0 100 18 1 96.5 Mandible 35 3 91 4 0 100

Conclusions: These preliminary results suggest that osseointegrated dental implants are an acceptable treatment option for prosthodontic rehabilitation of patients with fibular mandible reconstruction, irrespective of prior irradiation. Updated results will be presented and discussed.

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for the various anatomic structures and sinus subsections is proposed. This would help ensure more accurate reporting of experimental data involving the rabbit model. 153 Acute Mastoiditis as a Cause (or Complication?) of Liver Abscess DAVID P LAU BMEDSC FRCS; WONG K LOW FRCS, Singapore Singapore; Outram Road Singapore

Objective: Acute mastoiditis has become uncommon with the widespread use of antibiotics. However it remains a serious infection with potentially life threatening consequences. It usually occurs following acute-otitis media although a history of preceding ear infection is not always present. Methods: An unusual case of acute mastoiditis is presented. This occurred in a 62-year-old diabetic lady with no previous otological history. She presented with otalgia and facial palsy. Her fever failed to subside despite surgical decompression and the absence of demonstrable intracranial infection. Subsequent abdominal pain led to discovery of a liver abscess which was drained. Bacteriology revealed Klebsiella from both collections. Conclusions: Distant complications of acute mastoiditis are reviewed. To our knowledge liver abscess has not been reported as either a complication or cause of acute mastoiditis. This case is not only unique in its pathology but also emphasizes awareness that disease in the ear can be linked with distant parts of the body. 154

152 The Rabbit Sinuses and Nasal Cavity: Anatomy and Nomenclature DAVID W LEONARD MD; WILLIAM E BOLGER MD, Gaithersburg MD; Bethesda MD

Objective: There has been increasing interest in recent years in the rabbit sinuses as a model for experimental sinusitis. However, the anatomy of the rabbit sinuses and nasal cavity is complex. The terminology used in describing the anatomy has not been consistent between authors, and is sometimes erroneous. The need exists to standardize the terminology used in describing the rabbit paranasal sinuses and nasal cavity. Methods: The paranasal sinuses and nasal cavities of two white New Zealand rabbits were plastinated and processed, producing serial coronal sections. Six additional rabbit skulls were prosected to demonstrate the complex sinus anatomy. High quality photographs of these anatomic specimens are presented, along with endoscopic intrasinus photographs. Results: The anatomy of the intranasal cavity and the paranasal sinuses is demonstrated. The maxillary sinus in particular is complex, containing several recesses and chambers. The anatomic structures are labeled, and a standardized terminology proposed. Conclusions: With the use of cross-sectional anatomy, prosections, and endoscopic photographs, we hope to present a clearer understanding of the complex anatomy of the rabbit paranasal sinuses and nasal cavity. A standard nomenclature

Temporal Bone Tumors Nasopharyngeal Lesions

after

Irradiation

for

YAU-HONG GOH; WONG K LOW FRCS, Singapore; Outram Road Singapore

Objective: To highlight and discuss the clinically challenging problem of radiation-associated temporal bone tumors in patients irradiated for nasopharyngeal neoplasm. Methods: A retrospective study of seven patients who were treated for radiation associated temporal bone tumors after receiving therapeutic radiation to the nasopharynx years before. Results: Seven patients (6 males and 1 female) with radiation-associated temporal bone tumors are presented (5 squamous cell carcinomas, 1 osteogenic sarcoma and 1 chondrosarcoma). The initial nasopharyngeal disease for which radiotherapy was indicated was nasopharyngeal carcinoma (6 patients) and nasopharyngeal lymphoma (1 patient). The latency period between radiotherapy and presentation of temporal bone tumors ranges from 5 years to 30 years with a mean of 14.3 years. All the patients underwent surgical tumor resection. Two patients had post-operative radiotherapy and one patient had pre and postoperative chemotherapy. Three patients died within 5 months of treatment with 4 patients alive at the time of report. Conclusions: With improving survival in patients with nasopharyngeal malignancies, more cases of post-radiation temporal bone tumors have surfaced. This paper heightens the awareness of this entity and emphasizes the importance of an early

POSTERS

Our objective is to report our experience of osseointegrated dental implant usage in patients who underwent fibular reconstruction of the mandible, with or without previous irradiation to the remaining mandible and fibula graft. Methods: We retrospectively reviewed the medical charts and radiographs of all patients treated with implantation from 1/95 to 1/97. The implants were placed in both the remaining native mandible and the fibula graft to accommodate the planned prostheses. All patients that received prior irradiation were given hyperbaric oxygen treatment prior to surgical placement of dental implants. Patients were evaluated for implant integration by physical examination and interviewed to determine acceptable function of the prostheses with respect to diet and cosmesis. Results: Twelve patients with 68 Branemark implants were followed a median of 24 months (range 10 to 35 months). The implant retention rate was comparable in both the native mandible and the fibula free graft, irrespective of prior irradiation.

Scientific Posters

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Otolaryngology– Head and Neck Surgery August 1998

Scientific Posters

diagnosis for the successful treatment of this aggressive disease. 155 Unusual Otological Manifestations of Nasopharyngeal Carcinoma WONG K LOW FRCS; YAU-HONG GOH, Outram Road Singapore; Singapore

Objective: Nasopharyngeal carcinoma (NPC) is common among Chinese. NPC presenting as middle ear effusion is a well documented otological manifestation. There are however, other less common otological presentations that the physician must be aware of. Methods: A series of case studies illustrating patients with NPC presenting with uncommon otological symptoms/signs is discussed. Results: Presentations included hemotympanum, barotrauma, peri-auricular mass, referred sensation of a mass in the peri-auricular region and tumor metastasis to the middle ear. The diagnoses of many of these cases would have been missed if not for a high index of suspicion. Conclusions: In high risk patients presenting with any unexplained otological symptoms, NPC must be excluded. 156 Racial Differences in Mastoid Size WONG K LOW FRCS; YOKE-FUN FAN FRCR; MARK THONG; PAUL A FAGAN MD, Outram Road Singapore; Singapore; Singapore Singapore; Sydney NSW Australia

Objective: There are no earlier studies on racial differences in mastoid size. This paper studies differences in mastoid sizes of Chinese and Caucasians and discusses their significance in otology. Methods: Axial CT scans (at the level of the lateral semicircular canal) of 54 Chinese and 54 Caucasian subjects were studied. Mastoid sizes were measured by planimetry and the results analyzed by t-tests. Results: The mean (± standard deviation) sizes of the mas-

toids of Chinese and Caucasians were 6.01 (±2.45) and 4.94 (±1.76) cm2 respectively (p = 0.011). Conclusions: Racial differences in mastoid sizes exist and may have significance in the pathogenesis of ear diseases and in the use of otological surgical techniques in different races.

157 Comparison Between Diagnostic Neurotologic Expert System

Algorithms

in

ERNA KENTALA MD; YRJO AURAMO PHD; ILMARI PYYKKO MD; MARTTI JUHOLA PHD, Helsinki Finland; Turku Finland; Stockholm Sweden; Kuopio Finland

Objective: To improve the reasoning method of the neurotologic expert system ONE, the knowledge based diagnostic rule was compared to rules calculated of real patients from the database of the expert system ONE. Methods: The reasoning method of the expert system ONE resembles a pattern recognition method. Case history, signs, and neurotologic and other test results are used in the reasoning process. The knowledge base of the neurotologic expert system ONE comprises precise information on how these factors correspond to the diseases incorporated in the system. This information is based on literature and human expert knowledge. The reasoning procedure scores every question independently for a different diagnosis, depending how well the answer agrees with the symptom entity of a disease. These scores given by a human expert were compared to scores calculated from 746 patients belonging to six patient groups, which were Meniere's disease, vestibular schwannoma, benign positional vertigo, traumatic vertigo, vestibular neuritis and sudden deafness. Results: The diagnostic accuracy of the neurotologic expert system could be improved by combining the earlier algorithm with information obtained from solved (=diagnosis known) patient cases. Conclusions: By combining various reasoning methods we can gain progression in the computer-aided diagnostics.