Tuesday, September 11, 2001 Scientific Sessions

Tuesday, September 11,2001 6:30 AM to 7:45 AM (breakfast provided) Adams Mark Denver, Plaza Ballroom ABC Supported by G l a x o S r n i t h K l i n e

type of procedure for the management of otorrhea will be discussed.

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Foundation AM Symposia Acute versus Chronic Rhinosinusitis: Evaluation and Treatment Differences J David Osguthorpe MD (moderator); James A Hadley MD; Michael S Benninger MD Charleston SC; Rochester NY; Detroit MI

Educational Objectives: Attendees will understand salient differences in the evaluation and treatment parameters between acute and chronic bacterial rhinosinusitis. Description of Symposium: (1) Definitions, evaluation, and surgical indication parameters, J David Osguthorpe (15 minutes); (2) differences in microbial flora and implications on therapy, Michael Benninger (20 minutes); (3) selection of antimicrobial therapy, Jack Anon (20 minutes); and (4) nonantibiotic pharmacotherapy, James Hadley (20 minutes).

6:30 AM to 7:45 AM (breakfast provided) Adams Mark Denver, Plaza Ballroom DEF Supported by A l c o n L a b o r a t o r i e s , Inc •

Foundation AM Symposia Current Trends in the Medical and Surgical Management of Otorrhea Peter S Roland MD (moderator); Charles M Myer Ill MD; David S Haynes MD Dallas TX; Cincinnati OH; Nashville TN

Educational Objectives: (1) Distinguish between the appropriate roles for topical and systemic antibiotics in the treatment of otorrhea; (2) recognize the type of systemic and topical antibiotics available for the treatment of otorrhea; (3) understand the appropriate role for and timing of surgical intervention. Description of Symposium: Both systemic and topical therapy is used to manage the draining ear. This symposium makes recommendations about when topical therapy should be used and what types of agents are available. The appropriate role of systemic agents will be presented along with an evaluation of which systemic medicines are most appropriate for the management of otorrhea. The indications for the timing of surgical intervention and the most appropriate August 2001

8:00 AM t o 9:30 AM

CCC Ballroom 4 Scientific Session: Laryngology Eduardo Diaz MD; James Boyd MD 8:00 AM LaryngealSensationand PharyngealSqueeze: A Predictor of Aspiration MichaelSetzenMD (presenter); ManderlyCohenMS; PhilipW Perlman MD; Kenneth F Mattuccl MD; Michael Ditkoff MD; Joel GussBS ManhassetNY;SyossetNY;RoslynNY;ManhassetNE' Plainview NY,"ManhassetNY

Objectives: To use both sensory and motor assessments of the swallow to determine which patients with dysphagia are at highest risk for aspiration. Methods: Prospective study of 204 consecutive patients with dysphagia who underwent flexible endoscopic evaluation of swallowing (FEESST) and an assessment of pharyngeal muscle strength (pharyngeal squeeze). The patients were divided into several groups depending on the results of sensory testing on the best performing side and motor testing of the laryngopharynx. All patients were then given 1 teaspoon of puree consistency and 5 mL of thin liquid. Incidence of aspiration for each consistency was determined. Results: A statistically significant increase in incidence of aspiration with thin liquids and puree consistencies was found for all patients with an impaired pharyngeal squeeze as degree of sensory impairment deteriorated from normal, to moderate, to absent. 137 patients exhibiting normal sensation and a norreal pharyngeal squeeze and 33 patients with a severe sensory deficit and a normal pharyngeal squeeze were also further examined. A statistically significant increase in incidence of aspiration with thin liquids was also demonstrated with those patients with severe sensory deficits even though pharyngeal squeeze was intact. Conclusion: Patients with dysphagia who exhibit impaired laryngopharyngeal sensation and pharyngeal muscle strength are at increased risk of aspiration with both thin liquid and puree consistencies as the degree of sensory impairment increases. Furthermore, as sensory impairment increases so Otolaryngology-Head and Neck Surgery P149

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does the incidence of aspiration with thin liquids even when pharyngeal muscle strength is intact.

procedure on medically high-risk patients who are not candidates for general anesthesia.

8:08 AM

8:16 AM

Glottlc Insufficiency Treated by Cymetra Injection Laryngoplasty

Surgical versus Percutaneous Dilation Tracheotomy

Adam Pearl MD (presenter); Phllip Passalaqua MD; C A Ramos Pizarro PhD CCC-SLP; Jacquellne Mojica MS CCC; Peak Woo MD New York NY," New York NY," New York NY; New York NY; New York NY

Objectives: Glottic insufficiency has been treated by thyroplasty or injection laryngoplasty using fat, collagen, or gel foam. The purpose of this study was to evaluate the benefit of injection laryngoplasty using micronized dermis (Cymetra). Methods: A prospective clinical trial was performed in 38 patients with dysphonia. Patients were evaluated by serial videolaryngostroboscopy to assess glottic closure, mucosal wave, and phase symmetry. Recordings were completed using the Kay Elemetrics Rhino-laryngeal Stroboscope (model 9100). Visual perceptual ratings were completed by 2 judges who have extensive experience in the assessment of laryngeal function using the stroboscopic assessment of the larynx form. Auditory perceptual ratings were completed by the same judges using the GRBAS scale. Twenty-four patients were injected under general anesthesia using suspension laryngoscopy and 14 patients underwent transcutaneous injection under local anesthesia with simultaneous fiberoptic nasolaryngoscopic guidance. Patients were re-evaluated postoperatively for changes in glottic function. Results: Thirty-eight patients with glottic insufficiency underwent vocal cord injection laryngoplasty with Cymetra. The average age was 59 years old (range, 22 to 87 years). Thirty patients had unilateral vocal cord paralysis, 2 had vocal cord atrophy, 2 had vocal cord scarfing, and 4 were dysphonic after partial laryngectomy. The average amount of Cymetra injected was 0.52 cc (range, 0.1 to 0.9 co). Maximum followup of 6 months showed persistent improvement of glottic competence including closure of glottic gap and return of mueosal wave in most patients. Seventy percent of patients obtained full glottic closure. Auditory perceptual judgements of vocal quality showed improvement in 27 of 35 patients (77%). Two patients had post.injection stridor that resolved within 2 hours of conservative treatment. No other complications were encountered. Conclusion: Cymetra injection laryngoplasty appears to be a viable alternative injectable substance to correct glottic insufficiency. This material may be used as primary treatment for injection laryngoplasty for vocal cord paralysis or as soft tissue augmentation for sear and glottic insufficiency. The procedure is well tolerated and can easily be performed in the operating room or office setting. An advantage of in-office Cymetra injection laryngoplasty is the ability to perform the

David Goidenberg MD (presenter); Yaron Bar-Lavie MD; Avishay Goiz MD; Avlram Netzer MD; Henry Z Joachlms MD Halfa Israel," Haifa Israel; Halfa Israel; Haifa Israel; Haifa Israel

Objectives: Percutaneous dilation tracheotomy (PDT) is becoming a popular alternative to surgical tracheotomy (ST) among the intensive care personnel. Although this procedure has been used for many years, it is still not widely accepted by otolaryngologists throughout the world. This may be due to variable complication rate and the blind technique used. We recently adopted the use of the PDT in ICU patients in order to compare this technique with the classic ST. Methods: A prospective study of 75 cases of PDTs and a retrospective study of 75 cases of STs performed at the hands of the senior author was undertaken. The age, sex, indications for surgery, waiting interval before surgery, duration of surgery, complications, and cost of the 2 procedures were compared. PDT (Seldingers technique) was performed using a Portex Y2 PDT set. The surgery was performed bedside. Intraoperative fiberoptic guidance or bronchoscopy was not used. Results: One hundred fifty tracheotomies were performed and reviewed. Indication in both groups was prolonged mechanical ventilation. There were 3 cases of mild postoperative hemorrhage in the ST group. In the PDT group, there were 2 cases of postoperative hemorrhage, 1 case of subcutaneous emphysema, and 1 case of stomal cellulitis. The average waiting interval was 2 to 5 days for ST and 1 to 24 hours for PDT. The intraoperative time was 25 minutes for ST and 5 minutes for PDT. The cost of ST was $565 and PDT was $274. Conclusion: PDT provides an easy, less expensive, convenient alternative to ST. The procedure is advantageous for the patient. Complication rates of both techniques are similar and low. PDT is a blind technique and therefore holds more potential for serious complications. This technique is suitable for many, but not all, critical care patients, and the procedure should be performed only by surgeons who are able to deal with urgent intraoperative situations should they arise. 8:30 AM Diagnosis of Laryngopharyngeal Reflux Disease with Digital Imaging Mary Essernena A Beaver MD (presenter); C Richard Stasney MD FACS; Donald T Donovan MD FACS; Robert B Parke Jr MD MBA; Weitzel MD Houston TX."Houston TX; Houston TX' Houston TX; Houston TX

Objectives: With digital videostroboscopic imaging, subtle evidence of laryngopharyngeal reflux disease (LPRD) can be

OtolaryngologyHead and Neck Surgery Scientific Sessions--Tuesday

Volume 125 Number 2

detected, and resolution of signs can be monitored closely. This study proposes that a therapeutic trial of 6 weeks of twice daily proton pump inhibitor (PPI) therapy combined with digital videostroboscopic imaging of the larynx is a sensitive and specific method for diagnosis of LPRD. The study will also propose a grading and staging scheme for LPRD that will be validated as a reproducible and reliable way to clinically stage LPRD. Methods: 50 patients with the diagnosis of LPRD as well as 20 patients with normal examinations were identified in the computerized database at the Texas Voice Center. Digital still images of the abducted larynx of LPRD patients before treatment, the LPRD patients after treatment (6 weeks of PPI), and the normal controls were printed. A complete set of the photos was evaluated by each of 3 examiners (board certified otolaryngologists) who were blind to diagnosis or treatment status. They rated the photos independently using a standard laryngopharyngeal reflux disease index (LRDI). Results: Patients diagnosed with LPRD based on digital stroboscopic imaging had a statistically significant reduction in their LRDI score after a therapeutic trial of 6 weeks of twice daily PPI therapy. Patient diagnosed with LPRD had a significantly higher score on the LRDI than normal controls. In addition, the LRDI was shown to be a valid, reproducible, and consistent scale for evaluating laryngeal inflammation. Conclusion: Digital stroboscopic imaging is a sensitive tool for detecting laryngeal inflammation. A therapeutic trial of twice daily PPIs can be used for simultaneous diagnosis and treatment of LPRD in patients with clinical signs of LPRD on digital imaging. 24-hour ambulatory pH probe testing is reserved for patients refractory to initial therapeutic trial of proton pump inhibitors. 8:38 AM

Indications for Collagen Augmentation in Parkinsonlan Patients Soo Hang Kim MD (presenter); James Keorney MD; Joseph P Atkins MD

Philadelphia PA; Philadelphia PA; Philadelphia PA

Objectives: More than 70% of Parkinsonian patients will have difficulties with speech or voice. Many of these patients will cite these abnormalities as the most debilitating deficit related to their illness. Although the use of percutaneous collagen augmentation for bowed vocal cords has been well documented, its use in the treatment of Parkinsonian hypophonia has not been well studied. A recent study found that the majority of patients with Parkinsonian hypophonia could be aided with collagen augmentation, as evidenced by patient satisfaction surveys. They did not address the issue of selecting those patients who were most likely to benefit from this procedure. To date, no study has attempted to predict which patients are most likely to have their voice strengthened by collagen augmentation.

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Methods: We have treated a series of 13 patients with Parkinsonian hypophonia. All patients had significant laryngeal dysfunction as to interfere significantly with communication, as evidenced by family members or the patients themselves. Patients with unilateral or vocal cord paralysis were excluded from the study. All patients underwent flexible nasopharyngolaryngoscopy and were noted to have bowing of the vocal cords as the cause of their hypophonia. All patients underwent percutaneous collagen injection bilaterally under direct visualization. Patients' quality of voice immediately after injection as well as several months postoperatively were recorded. Results: Ten of the 13 patients noted significant improvement in voice strength immediately after collagen augmentation that persisted for at least 2 months. Three of the 13 patients did not experience subjective improvement in voice strength or quality. These patients all had advanced Parkinsonism and had clinical features that distinguished themselves from their cohorts. One patient had severe dysphagia necessitating a gastrostomy tube prior to vocal cord augmentation. One patient had significant difficulty in speech initiation preoperatively and remained largely aphonic despite adequate vocal cord approximation after augmentation. The last of the collagen failures had marked atrophy of the vocal cords in addition to asymmetric and marked bowing. Conclusion: The majority of Parkinsonian patients will have voice deficits throughout their disease progression. The majority of these patients will have hypophonia, with or without delay in speech onset. Our study similarly finds collagen augmentation as efficacious in improving hypophonia in Parkinsonian patients. We have also identified a subgroup of patients in whom a less than optimal result might be expected. Patients with significant difficulty in speech initiation are not likely to improve with collagen injection. Also, patients in whom advanced disease has rendered their vocal cords atrophic with marked bowing of the vocal cords are not likely to be ideal responders. Lastly, patients with severe dysphagia or aspiration are not likely to have adequate neurologic reserve for adequate speech or voice production. 8:46 AM

Using Cartilage Graft In Subglottic Stenosls Repair Robert Thome PhD (presenter); Danlela Curti Thome MD

Sao Paulo Brazil; Sao Paulo Brazil Objectives: To determine the results of cartilage interposition grafting in cricoid splitting augmentation procedures on subglottic stenosis repair. Methods: Forty-three patients, 27 (63%) adults, 16 (37%) children, aged 2 to 38 years, who underwent cricoid augmentation procedure with interposition of cartilage grafting for correcting subglottic stenosis, from 1980 to 1999, were available for study. Group 1:25 (58%) patients (13 adults and 12 children) had cricoid arch splitting, costal (16) or auricular

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cartilage (9) interposition grafting, and stenting; group 2:18 (42%) patients (14 adults and 4 children) had posterior cricoid splitting, costal cartilage interposition grafting, and stenting. The stenting duration was 1 to 2 months, done through a custommade silastic solid stent, mirroring the anatomic configuration of the larynx and secured into position througil 2 parallel transtracheal sutures. Results: There were no complications related to the donor site except for unfavorable hypertrophic scar over the lower chest in 4 patients. The cartilage grafted healed well in children on both anterior and posterior cricoid splitting augmentation. In adults, 2 diabetic patients of group 1 developed a wound infection ending in removal of the exposed cartilage graft; 3 patients (2 diabetics/heavy smokers and 1 previously irradiated years before) of group 2 had costal cartilage graft resorption. In these 5 patients, the stent was left in place for an additional period until a bridge of fibrotic tissue between cricoid halves determined stabilization of the enlarged lumen framework. Conclusion: The grafting healing capacity differed in children and adults. In augmentation laryngoplasty procedures, the cartilage graft healed well in children; however, the cartilage graft healing capacity decreased in adults when coexisting pathologic conditions causing poor recipient site vascularity status were present. 9:00 AM

Comparison of Radiation-lnduced and Presbylaryngeal Dysphonia Alison Behrman PhD (presenter); Allan L Abramson MD; David J Myssiorek MD New Hyde Park NY; Syosset NY; New Rochelle NY

Objectives: The majority of patients who undergo radiotherapy for T1 glottic carcinoma are in their seventh decade of life or beyond, precisely the time at which a diminution in vocal function associated with presbylaryngeal changes often becomes apparent. Despite extensive research on the outcome of vocal function postradiotherapy, standardized assessment of patient perception of voice outcome is limited. The purposes of this study were to provide data that describe vocal function and patient perception of the voice subsequent to radiotherapy, to determine some of the factors that may be predictive of patient perception, and to compare the data to age-matched individuals who have been diagnosed with dysphonia associated with the aging process (presbylarynges) and who have no history of glottic carcinoma. Methods: Twenty patients aged 60+ years who remained free of disease at least 1 year after radiotherapy for T1 SCCA were assessed prospectively. Retrospective analysis was conducted on 46 patients aged 60+ years who presented with dysphonia due to presbylarynges and no history of glottic carcinoma. Assessment data consisted of laryngeal videostroboscopy, spectrographic analysis of the acoustic signal (har-

August 2001

monic structure and noise content), voice range profile (frequency and dynamic range), voice handicap index, and standardized patient self-assessment of dysphonia severity and vocal complaints. Results: Eighty percent of the radiotherapy patients reported a voice disorder and rated its severity similar to the presbylaryngeal patients. The complaints of hoarseness, loudness limitations, globus sensation, and vocal effort were represented equivalently in both groups. The majority of all patients presented with abnormal acoustic signals and loudness limitations. The radiotherapy patients presented overwhelmingly with incomplete glottal closure, decreased amplitude of mucosal wave vibration, and increased mucosal vascularity. Presbylaryngeal patients presented with incomplete glottal closure, decreased vibratory amplitude, decreased vocal fold mass, and supraglottal hyperfunction. Significant predictors of patient perception of dysphonia common to both groups included glottal gap, abnormal spectral features, and limited dynamic range. Conchtsion: In older individuals, radiation therapy appears to increase stiffness of the vocal fold mucosa, causing incomplete glottal closure. In contrast, vocal fold atrophy appears be the major contributor to glottal gap in the presbylaryngeal patients. The resulting functional limitations on the voice, however, appear to be substantially the same for both groups. Although the majority of older radiotherapy patients consider themselves to have a voice disorder, the dysphonia experienced by most of these patients is not significantly different from the dysphonia experienced by patients with presbylarynges. 9:08 AM

Foscan Photodynamic Therapy for Respiratory Papillomatosis Mark J Shikowitz MD (presenter); Allan L Abramson MD; Bettie Steinberg PhD; Virginia M Mullooly MSN; Kathryn Freeman PhD New Hyde Park NY; Syosset NY,"New Hyde Park NY; New Hyde Park NY; Bronx NY

Objectives: To compare efficacy of photodynamic therapy with Foscan photosensitizer to conventional surgical management of recurrent respiratory papillomatosis, using a multicentered randomized trial supported by the National Institute on Deafness and Other Communication Disorders. Methods: Patients with moderate-to-severe disease (requiring 3 or more surgeries/year) are treated by surgical removal twice at 3-month intervals to establish baseline severity scores, using a modification of the scoring system developed by Kashima et al. They are then randomized to either FoscanPDT or continued surgical removal followed by PDT 9 months later. Disease recurrence rates and scores are assessed at 3 month intervals for 18 months after randomization. The study has now been expanded to include 2 additional participating centers, with the first patients enrolled at those sites scheduled for PDT in the near future.

OtolaryngologyHead and Neck Surgery Volume 125 Number 2

Results: Sixteen patients have been enrolled to date, with 12 treated. Nine have been followed for more than I year post PDT. Initial response (3 to 6 months) showed no improvement over baseline. However, 6/7 (86%) patients with laryngeal disease were disease free at 12 months and 1/7 showed reduction in severity greater than 50%. One patient with both laryngeal and tracheal disease was free of laryngeal disease at 15 months, with a 50% reduction in tracheal score. He was free of tracheal disease at 25 months, following decannulation, and has remained disease-free for an additional 15 months. One patient with only tracheal disease showed no improvement. These results showed marked efficacy compared with our earlier PDT studies with Photofrin, where 3/50 (6%) patients achieved complete remission of disease and 50% showed no significant improvement. Conchtsion: Preliminary results suggest that photodynamic therapy with Foscan has great potential for the treatment of laryngeal recurrent respiratory papillomas. We are continuing to recruit patients into the study. 9:16 AM

Effects of Upper Airway Surgery on Vocal Quality Alison Behrman PhD (presenter); Mark J Shikowi~ MD; Seth Dailey MD; Adam Landskowsky BS New Hyde Park NY; New Hyde Park NY,"New York NY; Bronx NY

Objectives: Surgeries that alter the structures of the upper airway are commonly performed otolaryngologic procedures. Surgical correction of septal deviation and turbinate hypertrophy are therapeutic for nasal obstruction and chronic sinusitis. Uvulopalatopharyngoplasty, often in conjunction with septoplasty and tonsillectomy, is performed in the management of obstructive sleep apnea. These procedures, however, have the potential to affect vocal quality by altering the resonant characteristics of the vocal tract. The purpose of this study was to

Scientific Sessions--Tuesday

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assess selected acoustic characteristics of vocal quality in patients before and after upper airway surgery. Methods: Prospective assessment was conducted on a total of 44 surgical patients preoperatively and approximately 1 month postoperatively. Surgeries included septoplasty and turbinectomy (n = 28) and septoplasty, turbinectomy, UPPP, and tonsillectomy (n = 16). Measures included mean speaking fundamental frequency, voice handicap index score, 1st and 2nd formant frequencies (FI, F2) for the cardinal vowels (/a/, /I/,/ae/, /u/) in nonnasal and nasalized speech contexts, and two intensity-independent measures: the difference between the first formant amplitude and nasal peak amplitude (AIPI n) and the difference between first formant amplitude and low frequency peak amplitude (AI-P0) of nasalized cardinal vowels and nasal consonants/m/and/n/. Results: There were statistically significant increases after surgery in A1-Pln values for high nasalized vowels (/I/,/u/) and nasal consonants (/m/, In/) and in A I-P0 values for low nasalized vowels (/ae/, /a/). The A I - P l n and A1-P0 values were unchanged for all nonnasalized vowels. There were no significant differences in group means after surgery for the measures of mean speaking fundamental frequency, mean frequencies of FI and F2 for nonnasal and nasalized cardinal vowels, and mean VHI scores. Conclusion: Upper airway surgery can influence selected resonant characteristics of nasal consonants and nasalized vowels. In general, these surgeries may be considered to have a positive influence upon vocal quality, because the postoperative acoustic characteristics are more representative of normative data than the preoperative values. The specific effect of these resonant changes upon perceived vocal quality, however, is not clear. Nevertheless, patients should be advised of potential voice changes, especially professional voice users who may be particularly sensitive to changes in resonant features of the voice.

Save Time and Money When You Stop by Our Store Plan to do your quick-stop shopping at the Store conveniently located in the registration area--and take advantage of our meeting specials. Buy on the spot, or, if you prefer, first visit our AAO-HNSF ,/f~..~.~'~. Resource Center (Booth 1017) during exhibit hall hours. Have your purchases shipped or save shipping costs when you walk away with your purchases in a handy carrier bag.

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8:00 AM t o 9:30 AM

CCC Rooms C207/209 •

Miniseminar: Basic Principles of Craniofacial Surgery Mario J Imola MD DDS FRCSC FACS (moderator); Sherard A Tatum MD; David D Hamlar Jr MD DDS; Donald J Annino Jr MD DMD Denver CO; Syracuse NY; Minneapolis MN; Boston MA

Educational Objectives: At the completion of this miniseminar, the participant will gain an understanding of the more common craniofacial anomalies and the general approach to their management. The presentations will focus on the underlying principles of the surgical procedures used in reconstruction. Description of Symposium: Craniofacial anomalies represent a challenging, yet very gratifying reconstructive problem. The presentation will open with an overview of the most frequently encountered anomalies, both congenital and acquired. Indications, timing, and surgical techniques used to treat isolated nonsyndromic craniosynostosis as well as positional

deformities will be discussed. The surgical principles underlying hypertelorism correction and midface advancement shall be presented. The seminar will also feature recent advances in craniofacial surgery including distraction osteogenesis and resorbable plating systems. Finally an overview of the general approach and sequencing of reconstructive procedures in patients with syndromic craniofacial dysostosis (Crouzon's and Apert's) will complete the presentation. Presenters include academy members who are active in the treatment of craniofacial anomalies and hope to spark interest within the specialty at large. A course outline and printed materials are planned for distribution to participants.

Don't Miss the Special Daily Demonstrations in Our Resource Center Visit our A A O - H N S F Resource Center (Booth 1017) for hands-on displays o f n e w c o n t i n u i n g e d u c a t i o n , patient o u t c o m e s , and practice m a n a g e m e n t resources. View our latest products on banks o f video screens or explore our public website's new patient information and the m e m b e r s - o n l y portal. Take a guided tour through our practice m a n a g e m e n t database or take part in a " M e e t the Instructor" session. G r o w i n g y o u r practice? Sit in on guided discussions o f how to handle y o u r c o m m u n i t y relations, public relations strategies, and local media. C h e c k your Meeting Daily n e w s p a p e r each day for our presentation schedule.

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CCC BR1 Contemporary Surgical Management of the Frontal Sinus Timothy L Smith MD (moderator); Donald A Leopold MD; James A Duncavage MD; James A Stankiewicz MD; Todd A Loehrl MD Milwaukee WI; Omaha hiE; Nashville TN; Maywood IL; Milwaukee WI

Educational Objectives: (1) To understand the practical anatomy of the frontal recess/sinus; (2) to present the contemporary surgical options for treating frontal sinusitis; (3) to explore how and when various options are utilized by the panel. Description of Symposium: The surgical management of chronic frontal sinusitis continues to evolve. The controversy surrounding appropriate management suggests that there are many viable options. This miniseminar explores the contempo-

rary surgical management of frontal sinusitis. The panel will first describe the endoscopic anatomy of the frontal sinus and recess and provide an overview of surgical options. A series of specific approaches will follow with an explanation of rationale in an attempt to explore critical questions including: (1) When is frontal recess surgery necessary and how much? (2) When is a frontal sinusotomy necessary and how is patency maintained? (3) When can a combined endoscopic/trephination approach be used? (4) What can be done when all else fails? ¢.,O I.kl I--

New 2002 Products and Services Catalog Now Available Pick up your copy of the latest catalog from our Store in the registration area or from the Resource Center (Booth 1017). Hot off the press, our 2002 catalog is jam-packed with new and updated products for your continuing education, patient education, practice management, and patient outcomes needs. Check our the new continuing education slide lectures, SIPacs, monographs, and our always well-liked videos. Browse through your catalog in the registrations area before you buy at the Store, or take it home as a useful resource tool for future reference.

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OtolaryngologyHead and Neck Surgery August 2001

8:00 AM t o 9:30 AM

CCC Rooms C201/205 •

Miniseminar: Management of Chronic Ear Disease (Interactive) Stephen G Harrier MD (moderator); Julian M Nedzelski MD FRCS; Joseph B Nadol Jr MD; Robert K Jackler MD Rochester MN," Toronto Canada; Boston MA; San Francisco CA

Educational Objectives: (1) To review diagnostic approaches to chronic ear disease; (2) to discuss various medical and surgical management strategies; (3) to discuss surgical techniques and options. Description of Symposium: The panel is composed of 4 practicing otologists. The format is to present cases that illustrate certain questions and to have members of the panel give

their views and approaches. The topics to be addressed include diagnostic studies, medical therapy, indication for surgery, surgical canal wall, ossicular reconstruction, and approach, preservation of the posterior management of complications. There will be audience participation using electronic keypad technology.

8:00 AM t o 9:30 AM

CCC Room A207 •

Miniseminar: The Scope of Practice Squeeze: Promoting Otolaryngology to Survive James C Denneny III MD (moderator); Thomas J Balkany MD; Michael S Benninger MD; Rebecca N Gaughan MD; G Richard Holt MD MPH; J David Osguthorpe MD Knoxville TN; Miami FL" Detroit MI; Olathe KS; Alexandria VA; Charleston SC

This miniseminar will delineate the scope of practice challenges facing otolaryngologists in the treatment of hearing and balance and sinus and allergic disorders. We will present an action plan and materials suitable for the otolaryngology community to promote our expertise in these areas. •Description of Symposium: This symposium will detail the rapid expansion of scope of practice infringement facing otolaryngologists. We will discuss the various areas that both medical and paramedical providers plan to expand their practices in areas traditionally served by otolaryngology. We will

then review the actions the Sinus and Allergy Health Partnership has taken on otolaryngology's behalf and the materials available to the membership and how to utilize them in a variety of venues. The Coalition for Hearing and Balance will educate the membership as to the goals of the audiology community and describe the actions taken on behalf of otolaryngology to create and promote the "Hearing Health Care Team." We will also discuss the educational effort of the Coalition and the program to train otologic technicians. We will then encourage a lively discussion of these critical issues.

OtolaryngologyHead and Neck Surgery Volume 125 Number 2

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8:00 AM t o 9:30 AM C C C R o o m A205

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Humanitarian EffortsCommittee: H o w to Get Involved in Humanitarian Medical Services Peter H Hwang M D (moderator); TerryA Day MD; James E Saunders MD; James D Smith MD; Tapan A Padhya MD; Sylvan E Stool MD; Robert A Goldenberg MD; J Madison Clark MD Portland OR; Charleston SC; Oklahoma City OK; Portland OR," Tampa FL; Denver CO; Dayton OH; Porland OR

Providing humanitarian medical service in an underserved area locally or abroad can be an extremely rewarding experience. Planning and carrying out such an effort requires an understanding of a variety of logistic and cultural considerations. This miniseminar will provide a practical framework through which Academy members may begin to plan a humanitarian service experience.

The following topics will be addressed: (1) how to identify and arrange a service opportunity; (2) resources available through the Humanitarian Efforts Committee; (3) timelines for planning your trip; (4) cultural considerations in humanitarian service; (5) field reports from projects around the globe; (6) personal accounts from past recipients of the Distinguished Award for Humanitarian Efforts and the Post-Residency Humanitarian Efforts Award.

8:00 A M to 9:30 A M C C C BR2/3

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PediatricOtolaryngology Committee: Evaluation and M a n a g e m e n t of Pediatric Obstructive Sleep A p n e a Audie L Woolley M D (moderator); Nira A Goldstein MD; Anna H Messner MD; James D Sidman M D Birmingham AL' Port Washington NY; Palo Alto CA; Minneapolis MN

This presentation will review the causes and at-risk groups of children for pediatric obstructive sleep apnea. The role of sleep studies will be discussed, as well as the medical and surgical management of pediatric obstructive sleep apnea. At the

end of the presentation, there will be a panel composed of 4 pediatric otolaryngologists who will present the case of 4 children with pediatric obstructive sleep apnea; the evaluation and management of these difficult cases will be discussed.

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9:30 AM to 10:30 AM C C C R o o m AI 11 •

OtolaryngologyHead and Neck Surgery

Scientific Sessions--Tuesday

Scientific Session: General Otolaryngology Stan Thawley MD; William LaMear M D

9:30 AM

Incidence of Complications for Coblation-Assisted TonsilIotomy Kelvin C Lee MD (presenter); Lee A McLaughlin MD: Mark M Altenau MD; David R Barnes MD; Frank Brettschneider DO; Nadlm Blkhazl MD; Joseph M Bernsteln MD; Charles H Caplan MD New York NY," New York NY; Dallas TX; Chattanooga TN; Port Huron MI; Layton UT; New Rochelle NY; Renton WA

Objectives: Despite advances in surgical technique and postoperative care, traditional surgical approaches to tonsillar disease using subcapsular dissection continue to be associated with a significant incidence of postoperative complications. In particular, postoperative bleeding frequently requires hospital readmission and surgical control in the operating room. Coblation-assisted tonsillotomy, or the CAT procedure, has been described as a new alternative technique for the management of problematic hypertrophic tonsils. This study is designed to review the incidence of major complications of patients undergoing coblation-assisted tonsillotomy. Methods: A 10-center retrospective chart review of operative and postoperative complications of patients undergoing coblation-assisted tonsillotomy was performed. Only patients with at least 2 weeks of postoperative follow-up were included. Results: Of the over 400 patients who underwent coblationassisted tonsillotomy as performed in 10 centers, by 10 otolaryngologists, the postoperative complications compared favorably to those reported in the literature for traditional subcapsular tonsillectomy. Significant postoperative bleeding was less than 1%, and these patients did not require either hospitalization or surgical control of bleeding in the operating room. Conclusion: Coblation-assisted tonsillotomy may offer an alternative to traditional subcapsular tonsillar surgery with a decreased incidence of postoperative complications. Further study with larger numbers of patients is needed to more definitively determine the rate of complications and whether this difference is unique to coblation or subtotal tonsillar removal. 9:38 AM

A New Scanner for Pharyngeal and Laryngeal CO 2 Laser Surgery Marc J Remacle MD PhD (.presenter); Georges Lawson MD; David Cohen MD; Monique Delos Yvolr Belgium; Yvoir Belgium; Jerusalem Israel; Yvoir Belgium

Objectives: We present our clinical experience with a new scanner, Acublade, adapted for CO2 laser microdissection and microincision. The beam proceeds as a straight or curved line

August 2001

of given length. The beam penetration, which is calculated according to the laser interaction with living tissue, is adjustable. The width of the yielded incision is that obtained with the Acuspot micromanipulator, ie, 250" for a focal length of 400 nun. The flash scanner-assisted incision is more accurate than that attained manually in the single pulse mode. The beam length can range from 0.5 to 3.5 mm and the depth from 0.5 to 2 mm. Methods: Forty-two patients underwent Acublade-assisted surgery. The studied population encompassed: 24 cases of benign lesion of the vocal folds; 3 cases of Zenker's diverticulum; 7 cases of early laryngeal cancer that required cordectomy in 6 cases and endoscopic partial epiglottectomy in 1 case; and 8 cases of chronic hypertrophic laryngitis that underwent resection of the entire epithelium for histopathologic diagnosis and/or curative intent. The Acublade-assisted incision and dissection took less time than the same procedure with a manually guided beam. The coagulation depth, remaining below 50°, did not impede histopathological examination. Results: Postoperative follow-up was straightforward. In 6 of the benign lesion patients follow-up included stroboscopies every 1 to 2 days for a period of 2 to 3 weeks. This follow-up showed that the wound was completely re-epithelized within the first 2 days after surgery, and the normal vibrations returned to normal within 1 to 3 weeks. Conclusion: The Acublade-assisted incision reinforces the accuracy of the CO2 laser-assisted microdissection, previously demonstrated as safe and effective providing the appropriate laser parameters are met. 9:46 AM

The Mechanisms of Laryngeal Trauma in Motor Vehicle Crashes Nimesh N Patel MD; June Lee MPH; Stewart C Wang (presenter) London United Kingdom; Ann Arbor MI; Ann Arbor MI

Objectives: Although uncommon, laryngeal injuries from motor vehicle crashes carry a significant morbidity and mortality. We aimed to investigate the mechanism of such injuries by detailed examination of all aspects of a motor vehicle crash in order to help in the development of strategies in their prevention and management. Methods: Analysis was performed of 3 databases of automobile crash investigation: the National Highway Traffic Safety Administration'sNational Automotive Sampling System (NASS) database, the University of Michigan Transportation Research Institute (UMTRI) database, and the Crash Injury Research and Engineering Network (CIREN) database. Laryngeal injury case series were collected from each of these databases and analyzed with special reference to injury mechanisms. Results: 52 NASS laryngeal injuries were analyzed from 1995 to 1999. Laryngeal injuries were commonly fatal or an

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injury in a patient that died of other injuries (73%); 32% of patients that sustained laryngeal injuries were ejected from the vehicle. Seatbelts were used in 19% of cases; of these there was a 50% mortality compared with 80% in the nonseatbelt wearers. No seatbelt wearer sustained a serious laryngeal injury as a result of the seatbelt. Airbag deployment caused only 1 laryngeal injury when used with a seatbelt. UMRTI series crashes demonstrated large decelerating forces. CIREN series had 5 laryngeal injuries; 3 of these were caused by the failure to use or the inappropriate use of restraints. Appropriate use of restraints resulted in minor soft tissue injury. Two cases of laryngeal injury occurred due to massive intrusional deformation. Conclusion: Laryngeal injuries are uncommon but have significant morbidity and mortality associated with them. Crash analysis allows the development of prevention strategies including public safety education and better car safety features. It also helps educate the attending physician to suspect such injuries in the presence of particular features of a crash. ] 0:00 AM

Powered Laryngeal Shavers and Laryngeal Papillomatosis: How I Do It Rajan S Patel MBChB (presenter); Kenneth MacKenzieMB ChB FRCS Glasgow United Kingdom; Glasgow United Kingdom

Objectives: Carbon dioxide (CO 2) laser ablation is widely accepted as the most effective first line surgical treatment of recurrent laryngeal papillomatosis. Following their innovative use in endonasal surgery, powered laryngeal microresecting instruments have been developed for laryngeal surgery. Although data reporting their use in this area are limited, the theoretical advantage of these instruments is that they avoid laser-induced complications. Our aim was to assess the value of these new microresecting instruments in laryngeal papillomatosis. Methods: This is an ongoing prospective observational study of patients' subjective symptom scores following surgical resection of laryngeal papillomata by the senior author (KMacK). All patients had previously undergone multiple laryngeal laser ablation for histologically confirmed recurrent respiratory papillomata. All patients were interviewed 2 weeks postoperatively and scored postoperative pain and dysphonia as "better," "same," or "worse" than previous laser treatment. Results: To date, 7 patients (6 males, 1 female; mean age [SD], 42 [11 ]) have undergone 8 laryngeal shaver procedures. The mean duration of disease (SD) was 10 years (6) and the mean number of previous laryngeal laser ablations (SD) was 13 (14). All patients reported postoperative pain as the "same as" or "better than" that after laser surgery. After 2 of the 8 procedures, patients reported longer recovery of postsurgical dysphonia. The surgeon reported that though there was more

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bleeding, shaver excision of papilloma provided good clearance of disease; easy collection of pathologic samples; and a potentially safer and faster alternative to laser excision. Conclusion: The laryngeal shaver incorporates an oscillating blade, within a protected sheath, in conjunction with continuous suction. This dual action frees the operator's second hand to manipulate tissue, which optimizes the visual field and facilitates precise tissue excision. We found that topical adrenaline applied to the excision site controls hemostasis satisfactorily, and vision is enhanced by continuous suction of blood. Thermal damage is eliminated; therefore the risks of soft tissue injury and operator aerosol inhalation of infected papilloma particles are avoided. Our impression is that this technique is optimal for supraglottic papilloma clearance, but other techniques (eg, laser or fine instruments) may be necessary in glottic disease. ] 0:08 AM

The Predictive Value of Oropharyngeal Secretions for Aspiration Joseph J DonzelliMD (presenter); Susan L Brady MS: Michele W Wesling MA; Mary C Craney Wheaton IL' Wheaton IL' Wheaton IL" Wheaton IL

Objectives: The purpose of this investigation was to determine whether visualizing the amount and location of oropharyngeal secretions utilizing a 5-point secretion scale had any predictive value for the subsequent aspiration of food and/or liquid. Specific objectives are as follows: (1) Does a 5-point secretion scale have any predictive value for subsequent laryngeal penetration and/or tracheal aspiration of food/liquid? (2) Is there a relationship between the feeding status of the patient (po vs npo) and their secretion level? (3) Is there a relationship between the tracheotomy tube status and their secretion level and swallowing ability? (4) Is there a relationship between the secretion level and outcome diet recommendation? Methods: Seventy-one consecutive patients over 10 months and 4 normal/control subjects participated in this study. Prior to the presentation of any food/liquid, the patient was assigned an initial score for the presence and amount of secretions using a 5-point secretion scale. Food and liquid were dyed blue. Bolus size and consistency were not controlled. Each swallow was evaluated for the presence of laryngeal penetration and tracheal aspiration. The reliability of the 5-point secretion scale was measured using the kappa correlation coefficient between 2 experienced judges who independently rated 25 endoscopic images. Interrater reliability was 0.850 (P = 0.05). Results: 29% of hospitalized patients (n = 35) were rated as profound secretion level as compared to 17% of nonhospitalized patients (n = 36). 72% of patients with non-oral tube feedings (n = 32) were rated as either severe or profound for secretion level as compared to 26% of patients w h o were receiving oral feedings (n = 39). 59% of patients receiving

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tube feedings demonstrated aspiration, whereas 33% of patients who were receiving oral feedings demonstrated aspiration. 50% of tracheotomized patients (n = 22) were rated as profound secretion level as compared with 10% of patients without a tracheotomy (n = 49). Secretion severity levels compared with aspiration of food/liquid are as follows: normal 9%, mild 22%, moderate 57%, severe 65%, profound 100%. All subjects in the control group demonstrated normal secretion levels and swallow function. Conclusion: Hospitalized patients had a higher occurrence of profound secretions than nonhospitalized patients. Patients receiving tube feedings had a higher occurrence of severe and profound secretion levels versus patients who received oral feedings. Patients with a tracheotomy tube had a higher occurrence of profound secretion levels. Patients with severe and profound secretion levels had a higher occurrence of laryngeal penetration and tracheal aspiration of food/liquid during the examination. 10:16 AM Surfer's Ear: A Condition More Prevalent In Cold Water Suffers David Fleming Kroon MD (presenter); Craig S Derkay MD FAAP FACS; LouiseLawson;Joseph McCook BA Norfolk VA,"Norfolk VA; Norfolk VA; Norfolk VA

Objectives: To demonstrate the prevalence and severity of external auditory exostoses (EAE) in a population of surfers and to examine the relationship between these lesions and length of time surfed, as well as water temperature surfed. It was hypothesized that subjects who predominantly surfed in cold water would demonstrate more frequent and more severe exostoses. Methods: 202 avid surfers (91% male, 9% female; median age, 17 years) were included in the study. EAE were graded on the basis of the extent of external auditory canal patency. Grades of normal (100% patency), mild (66% to 99% patency), and moderate-to-severe (less than 66% patency) were assigned. Otoscopic findings were correlated with data collected via questionnaires detailing surfing habits. Results: There was a 38% overall prevalence of EAE, with 69% of lesions graded as mild and 31% graded as moderateto-severe. Predictor variables were used to calculate unadjusted odds ratios (OR), with significance being tested using Mantel-Haenszel ~2 analyses. Professional surfers (OR 3.8) and those subjects who surfed predominantly in cold water (OR 5.8) were found to be at significantly increased risk for the development of EAE. The number of years surfed was also found to be significant, increasing one's risk for developing an exostosis by 12% per year and for developing more severe lesions by 10% per year. A significant relationship between cold water surfing and more severe EAE was not observed. Conclusion: EAE are more prevalent in cold water surfers,

and additional years surfing not only increases one's risk for developing EAE but also for developing more severe lesions.

9:30 AM to 10:30 AM CCC Room Al12 •

Scientific Session: General Otolaryngology Tucker Woodson MD; Toni Ganzel MD

9:30 AM Use of Nebulized Antibiotics for Acute Infections in Chronic Sinusitis Winston Vaughan MD (presenter); Gerard Carvalho MD Palo Alto CA; Menlo Park CA Objectives: Acute infections in chronic sinusitis patients even after surgeries continue to challenge otolaryngologists. Nebulized antimicrobials may offer a treatment option. Using endoscopy and standardized outcome measures, the utility of culture-directed nebulized antimicrobials, side effects, prospective and retrospective microbiology, endoscopic changes, and symptomatic outcomes were studied. Methods: Patients seen over a 12-month period with previous endoscopic sinus surgery, chronic sinusitis, and an acute infection were offered nebulized antimicrobial versus oral and intravenous therapy. Endoscopic aspiration samples of visible purulence were sent for culture, sensitivity, and fungal isolation. These cultures and sensitivity along with patient drug reactions, determined antimicrobial selection. All patients completed standardized outcome measures before and after treatment and underwent pretreatment and posttreatment endoscopy. Demographic data and chart reviews were performed. Patients with immunosuppression and cystic fibrosis (CF) were excluded. Results: 46 patients were offered this therapy for an acute infection; 3 patients were excluded due to CF; i patient had not had surgery. The average age was 45.2 years with 66.6% females. The most common side effects were sore throat (9.5%), cough (7.1%), and tinnitus (2.4%). All were temporary. Microbiology and endoscopy data before and after nebulized treatments showed a longer infection-free period after treatment (average, 11 weeks) compared with prior treatment history (average, 6 weeks). This was reconfirmed with patient outcome measures, which showed improvements in posterior nasal discharge, thick nasal debris, facial pain/pressure, and emotional consequences related to their illness. Conclusion: Nebulized antimicrobial therapy was safe and effective for acute infections in this sample of postsurgical chronic sinusitis patients, Patients, who were offered this treatment option more than once, preferred it to oral or intravenous treatment. Endoscopy and outcomes measure changes showed consistent improvements. Further studies are needed with larger samples at multiple institutions.

OtolaryngologyHead and Neck Surgery Volume 125 Number 2

9:38 AM

Itraconazole Use in Noninvasive Fungal Rhinosinusitis B Manrin Rains III MD; Corey William Mineck MD (presenter) Cordova TN; Memphis TN

Objectives: Many protocols describing high dose corticosteroid, immunotherapy, and surgical debridement in the treatment of noninvasive fungal rhinosinusitis, particularly allergic fungal sinusitis, have been described. However, very little data have been published on the use of high dose oral antifungal medications in managing these patients. In this retrospective study, the management of noninvasive fungal rhinosinusitis using high dose oral itraconazole, surgical debridement, and short burst low dose oral corticosteroid is described. Methods: A 12-year retrospective chart review of 225 patients with noninvasive fungus identified from a sinonasal source was performed. Patients were classified as having allergic fungal sinusitis (AFS) or non-AFS fungal rhinosinusitis (non-AFS). Demographic information, duration of therapy, need for repeated surgical procedure, and recurrence rates were extracted and analyzed using appropriate statistical methods. Results: Significant (P < 0.05) differences between patient populations were noted including average recurrence rate (46% of AFS patients recurred with an average of 2.2 recurrences per patient compared to 8% of non-AFS patients recurring an average of 1.8 times) and requirement of antifungal therapy (3.4 mon'ths non-AFS, 8.4 months AFS). Additional differences were noted in need for repeat surgical intervention as 44/161 (27%) of AFS and 11/64 (17%) of non-AFS patients required re-operation. No serious adverse effects attributable to itraconazole during the 1521 months of oral antifungal therapy were noted. Conclusion: Itraconazole appears to be a safe and effective component in the management of noninvasive fungal rhinosinusitis when used in conjunction with low dose short burst oral corticosteroids and surgical debridement. Our experience suggests recurring non-invasive fungal rhinosinusitis may be managed medically with oral itraconazole, thereby avoiding repeat operations and reducing the need for high dose corticosteroids. A prospective clinical trial is under development. 9:46 AM

Submucosal Radiofrequency Inferior Turbinate Reduction Arthur Cortland Taliaferro MD (presenter) Saint Augustine FL Objectives: To evaluate the safety and efficacy of an inexpensive, office-based technique of submucosal radiofrequency inferior turbinate reduction with outfraeture for the treatment of chronic nasal congestion and related symptoms. Methods: Retrospective analysis by questionnaire and visual analogue scales of 51 patients treated by the described technique of submucosal radiofrequency inferior turbinate reduction with outfracture. All patients included in the study

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presented with chronic nasal congestion relieved with topical decongestion of the inferior turbinates, including patients with significant septal deviations. Results: Mean reduction in nasal congestion by a visual analogue scale of 0 to 10 was from 8.3 to 3.4. 81% had improvement in postnasal drip, 58% had improvement in sinus headaches, and 76% had minimal-to-no pain associated with the procedure. No complications were noted, and 80% of the patients were satisfied with the procedure. Conchtsion: The described technique of submucosal radiofrequency inferior turbinate reduction with outfracture is an effective, safe, well-tolerated, and inexpensive office-based procedure for the treatment of chronic nasal congestion in selected patients. Many patients also had significant improvement in the associated nasal symptoms of postnasal drip and sinus headaches. Inferior turbinate reduction was also shown to be an effective treatment for nasal congestion in many patients with significant septal deviation. 10:00 AM

Effects of Three Nasal Topical Steroids In the Intraocular Pressure Compartment Daniel Bross-Soriano MD (presenter); Jose R Arrieta-Gomez MD; Jose Schimelmitz-ldi MD; Rene Guzman-Urrufia MD

Mexico City Mexico; Mexico City Mexico," Mexico City Mexico; San Salvador El Salvador

Objectives: The objective of the study was to determine if the use of topical fluticasone propionate, mometasone furoate, or beclomethasone propionate for the treatment of rhinitis provokes an elevation of the intraocular pressure. Methods: The design of the study was comparative, double-blind, experimental, prospective, longitudinal, and included 120 patients divided in 4 groups of 30 patients each. The interventions done were to measure the intrancular pressure of the patients at the third week, sixth week, third month, sixth month and first year with a Goldman Tonometer. Results: There were some slight modifications in the intraocular pressure in the patients using the nasal topical steroids, without exceeding the normal parameters. Conclusion: Fluticasone propionate, mometasone furoate, and beclomethasone propionate are safe and do not cause a pathological increment in the intraocular pressure. 10:08 AM Dual-Action Oral Appliance: Effective In Obstructive Sleep

Apnea Marc Bernard Blumen MD (presenter); Isabelle Buchet; P.lerre Meullen; Bernard Fleury MD; Frederic Chabolle MD

Suresnes France; Suresnes France; SuresnesFrance

Objectives: To evaluate a new type of oral appliance, a tongue retaining appliance associated with a mandibular advancement device, in a prospective study, in terms of effi-

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cacy on obstructive sleep apnea (OSA), tolerance, and compliance. Methods: OSA patients who refused continuous positive airway pressure or surgery were given the opportunity to be treated with an oral appliance. This custom-made monobloc appliance was conceived to combine retaining of the tongue and mandibular advancement. 34 patients were included in this prospective study. A follow-up sleep study was performed after 1 month of use. The patients were asked to answer a questionnaire to evaluate compliance to the treatment and tolerance. Evaluation criteria of efficacy were snoring, sleepiness, number of abnormal respiratory events, and minimal oxygen saturation. Daily/weekly use and abandon were assessed. Pain, discomfort, salivation, and bleeding were evaluated. Criteria of success was a reduction of the respiratory disturbance index (RDI) < 20 with a 50% reduction of the baseline RDI. Cure was defined as an RDI < 10. Results: 22 patients had a follow-up sleep study. Mean age and BMI were respectively 57 +_-10 and 26.6 - 3.5. Oral appliance improved significantly snoring levels and RDI. RDI decreased significantly from 44.9 to 13.2. Even for more severe patients (RDI > 30), RDI decreased significantly from 64.2 to 17.8. Success rate was 77%. Cure rate was 50%. Salivation was the most common side effect. Pain was found in 21% of the cases. 33% of the patients abandoned the appliance, 28% within the first month, mainly because of salivation and report of inefficacy on snoring. For the patients who continued the treatment, 90% used it throughout the night. Conclusion: The dual action oral appliance was effective on OSA, of all degrees of severity. Combining the 2 actions enables less protrusion of the mandibular; therefore side effects may be lesser than for a mandibular advancement device alone, especially in the long run. Nevertheless, the high level of treatment disruption implies that these patients should be seen for follow-up, mainly within the first month of

age, 39 years), from across the country, had the above procedures performed at Charing Cross Hospital, London, UK between Jan 1992 and Oct 2000. They were sent postal questionnaires to evaluate patient satisfaction with regard to the scar, cosmetic appearance of the laryngeal prominence, pitch of the voice, whether they had speech therapy, and which they found more beneficial, the surgery or speech therapy. The overall satisfaction with the operations was also determined. The patients were also contacted by telephone prior to despatching the questionnaires to ensure the contact details were accurate and to encourage participation in the survey. Results: One patient had died and 8 had moved from the address in the hospital records. Patient responses to the questionnaires showed that 85% had had both procedures performed, 10% had cricothyroid approximation only, and 5% hadthyroid chondroplasty only. 84% were pleased with the scar and 70% felt their laryngeal profile had improved. 74% thought their voice had improved, 18% thought their voice had remained the same, and 8% reported a deterioration. 94% of patients had received speech therapy before or after surgery or both. Of the patients who reported an improvement in voice, 42% felt the surgery had contributed more to pitch elevation, 38% felt it was the speech therapy that was more beneficial, and the remainder were unsure. 8% required revision surgery. Overall 76% were satisfied with the results of the surgery. Conclusion: The procedures of cricothyroid approximation and thyroid chondroplasty are successful in elevating pitch and improving the cosmetic appearance of the larynx in male to female transsexuals. This is accompanied by a high patient satisfaction rate. [The survey is due to be completed in early April 2001, ie, 6 months after the date of the last procedure included in the study.)

use.

Cervical Lesions with Medlastinal Extensions: Is Stetnotomy Mandatory?

10:16 AM

Paclflca Simo.n MD MS DLO PhD; Vldyasagar Ramakrishnan MBBSMS (presenter) Madras India; Madurai India

Crlcothyrold Approximation and Thyroid Chondroplasty: A Patient Survey Vandana Matal MD FRCS (presenter); Peter Clarke MD; Anthony D Cheeseman MD FRCS London United Kingdom; London United Kingdom; London United Kingdom

Objectives: Cricothyroid approximation is an operation performed in male to female transsexuals to raise the pitch of the voice. It is usually accompanied by a reduction of the thyroid cartilage in our department to decrease the prominence of the larynx, described as a thyroid chondroplasty. The survey was conducted to ascertain patient satisfaction with the 2 procedures. Methods: 53 patients, aged between 20 and 55 years (mean

10:24 AM

Objectives: It is not uncommon in our practice to find patients with cervical lesions with superior mediastinal extension, and one would always weigh an option to treat with either median sternotomy with cervical approach or cervical approach alone. Our main objectives were (1) criteria to select patients for cervical approach alone, and (2) methods to avoid median sternotomy without compromising the safety of the patient. Methods: A retrospective study of 8 cases of lower cervical and upper thoracic tracheal stenosis and 2 cases of cystic hygroma with mediastinal extensions were done. For all these patients, CT scans of the neck and thorax showed the lesion

OtolaryngologyHead and Neck Surgery Volume 125 Number 2

extending into the superior mediastinum for various lengths. Of these I0 patients, only 2 required median sternotomy in addition to a cervical approach. Median sternotomy was avoided in other cases by (1) hyperextension of the neck, (2) suprahyoid release/laryngeal drop, and (3) mobilization of distal thoracic trachea by finger dissection to anastamosis without tension. In cases of cystic hygroma with superior mediastinal extension, hyperextension of the neck and gentle upward traction of the mass were sufficient to excise the mass in taro by cervical approach alone. Results: Of the 10 patients, 2 required additional median sternotomy as the stenotic segment of the lower cervical trachea was more than 3.5 cm and demanded intrathoracic release. The other 6 patients of tracheal stenosis who were well managed by cervical approach alone had less than 3.5 cm of stenotic segment of lower cervical trachea; 2 patients with cystic hygroma had less than 4 cm of superior mediastinal extension and were successfully removed in toto by cervical approach alone. Conclusion: Not more than 3.5 cm of lower cervical tracheal stenosis can be approached by cervical approach alone with (1) hyperextension of neck, (2) suprahyoid release/laryngeal drop, and (3) mobilization of distal thoracic trachea by finger dissection. In cases of soft benign lesions of the neck, up to 4 cm of mediastinal extension can be delivered by cervical approach alone by meticulous dissection and upward traction of the mass in a hyperextended neck. however, we should be prepared to proceed with sternotomy in case of difficulties. 9 : 3 0 AM tO 1 0 : 3 0 AM

CCC Room A209 •

Scientific Session: Head a n d Neck Surgery James Boyd MD; Lawrence Burgess MD

9:30 AM

Oncologic and Functional Results of Near-total Laryngectomy Ricardo Millan Bernaldez MD (presenter); Marta GarclaPallaresMD; LuisLassalettaMD; Javler Gavilan-BouzasMD

Madrid Spain; Madrid Spain; Madrid Spain; Madrid Spain Objectives: To investigate the oncologic and functional results of patients undergoing near-total laryngectomy (NTL) and to determine those perioperative factors that are associated with success. Methods: A retrospective analysis of 87 patients has been carded out from 1991 through 1998. We classified 10 patients as initial stage and 77 patients as advanced stage. Seventy patients had neck dissection. Chi-squared was used to assess the statistical significance of association of different parameters. Survival was analyzed using the Kaplan-Meier method.

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Results: The 5-year overall survival, cause-specific survival, and relapse-free survival were 52%, 70%, and 67%. Univariate analysis revealed prognosis significance for location, stage, and pathologic lymph status. Six percent of the patients developed local recurrence, 16% neck node recurrence, and 10% distant metastases. Pharyngocutaneous fistula was the most frequent complication (48%). Seventy-seven percent of cases achieved voice preservation. Symptomatic aspiration was noticed in I 1% of cases. Conclusion: NTL produces good oncologic and functional results that are reproducible in different institutions. It is an alternative to total laryngectomy in patients with laryngeal or hypopharyngeal tumors who meet selected criteria. 9:38 AM

Predicting Functional Outcomes FollowingChemoradiatton for Larynx SCCA Jonathan Staton MD (presenter); K Thomas Robbins MD; Merry E SebelikMD; LisaNewman ScD

Memphis TN; Gainesville FL" Memphis TN; Memphis TN Objectives: To determine whether pretreatment parameters can be used to predict poor outcomes related to laryngeal function among survivors after organ preservation therapy for advanced laryngeal cancer. Methods: Among the 69 patients receiving concomitant intra-arterial cisplatin and radiation therapy for stage III and IV laryngeal cancer between 1993 and 1999, we identified 45 who were available for follow-up and were disease-free 6 months after completion of therapy. A nominal logistic regression analysis was performed to study the effect of age, gender, COPD, T and N classification, vocal cord fixation, massive cartilage destruction, and neck dissection on the likelihood of requiring a PEG for feeding and/or a tracheatomy for breathing at 6 months following completion of therapy. Results: Regression analysis of all pretreatment factors indicated vocal cord fixation as being the strongest predictor of a poor functional outcome (defined as the persistent need for a feeding tube and/or tracheostomy at 6 months posttherapy). Among the 27 patients in this subset, 15 (56%) had a poor functional outcome. In contrast, only 1 of 18 patients without vocal cord fixation had poor laryngeal function. Although the history of pulmonary disease was not a significant parameter by itself, when combined with vocal cord fixation, 6 of 8 patients had a poor functional outcome. Conclusion: Pretreatment parameters may be used to predict a poor functional outcome after chemoradiation. Beeanse of the high likelihood of suffering from poor function, laryngeal cancer patients seeking organ preservation therapy with chemoradiation should be cautioned if they present with a fixed vocal cord or bulky T4 disease. This subset of patients should also be observed closely for laryngeal dysfunction in order to prevent possible pulmonary complications.

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9:46 AM

Changes of Esophageal Motility after Total Laryngectomy Se-Heon Kim MD (presenter); Won Pyo Hang MD; Hang Shik Choi MD; Hyun Chul Yoon MD Seoul South Korea," Seoul South Korea; Seoul South Korea; Seoul North Korea

Objectives: Total laryngectomy completely interrupts the continuity of the proximal digestive tract and may lead to derangement in esophageal motility. The purpose of this investigation is to find out how total laryngectomy changes the resting and the maximum contracting pressures of the upper esophageal sphincter muscle, in addition to studying the coordination of the contraction and the relaxation between the pharynx and the upper esophageal sphincter muscles. If changes in the function of the upper esophageal sphincter muscle should occur, this study will also demonstrate how it affects the motility of the esophageal body and the lower esophageal sphincter muscle. Methods: In an attempt to explain postoperative motility changes, the stational pull-through method of manometric evaluation was used to quantify the alteration in esophageal motility. For the manometric evaluation of the esophagus, a polyethylene catheter with 8 internal tubes was used. The study was performed on a group of 15 patients with total laryngectomy and 15 people without esophageal disease or symptoms as the control group. Results: There was a statistically significant difference between the laryngectomy group and the control group for both the resting and contraction pressures as well as for coordination and relaxation of the upper esophageal sphincter (P < 0.05). In the laryngectomy group, 3 patients who complained of postoperative dysphasia showed more severe functional changes. The proximal esophageal body wave pressure and peristaltic waves were significantly decreased in the laryngectomy group. No significantdifference between the laryngectomy group and the control group was noted in terms of the lower esophageal resting sphincter pressure and the postdeglutition pressure. There was also no significant difference between the 2 groups in the degree of lower esophageal sphincter coordination and relaxation. Conclusion: From these results, it may be concluded that interruption of the cricopharyngeal muscle and pharyngeal plexus after laryngectomy may not only produce local derangement of upper esophageal sphincter function but may also produce abnormalities in peristalsis of the proximal esophageal .body. But the function of the lower esophageal sphincter did not show any significant difference between the laryngectomy group and the control group.

drome. The objective of this study is to evaluate the efficacy of an inexpensive gelatin barrier technique that would dissolve over a period of time. A barrier material should not subject the facial nerve bed to inflammation or fibrosis, which could make future surgery more difficult by risking facial nerve injury. Methods: Gelfilm (Upjohn Company, Kalamazoo, MI), a sterile gelatin implant approximately 0.075 mm in thickness, was selected for its prolonged absorption time of 2 to 5 months. It was initially implanted in the parotid beds of 5 experimental animals (adult goat) and evaluated over 10 months to observe changes in the nerve and perineural tissues. Subsequently 24 human subjects had Gelfilm placed in parotid beds following superficial parotidectomy. Three individuals had bilateral surgery with unilateral implants; 2 patients received implants to treat a chief complaint of severe Frey's syndrome. Results: Histopathologic evaluation of the parotid bed and facial nerve at 2-month intervals in the animal protocol showed no evidence of neural or perineural inflammation or fibrosis. The Gelfilm was present in the 6-month specimens before completely dissolving by 8 months. The human subjects were followed from 24 to 48 months after implant placement. All subjects including those who were their own controis demonstrated substantial and complete inhibition of auriculotemporal innervation of the cut/meous sweat glands on the side with the implant. Those with only 1 implant demonstrated less of an effect than those with more than 1 implant. Postimplant sialoma was identified in 3 patients and resolved without treatment. Scopolamine patch trial for postparotidectomy sialoma appears ineffective. Conclusion: Frey's syndrome can be prevented and treated effectively with a simple, safe, and inexpensive gelatin film implant. This study showed that Gelfilm could be placed safely over the facial nerve in the postparotidectomy patient without concern for fibrosis and scarring over the facial nerve. Should reoperation be required, this operative bed could be easily reassessed without significant concerns of facial nerve injury. It appears that the 6-month period the barrier is in place is an adequate time period to prevent cholinergic innervation of the cutaneous facial sweat glands. This implant requires no donor site morbidity for fascia or muscle interposition grafting. There was a 10% incidence of sialoma; this appears to be of little consequence and may enhance the final esthetic facial contour. ] 0:08 AM

] 0:00 AM Gelfllm Barrier for Prevention and Treatment of Frey's Syndrome Vincent D Eustermon DDS MD (presenter) Olympia WA

Objectives: A variety of natural and artificial barrier techniques have been described to prevent and treat Frey's syn-

Valency of the Cervical Plexus for Shoulder Pain after Neck Dissection Parwis Agha-Mir-Sallm MD (presenter); Uta Funk; Christine Lautenschlager; Alexander Berghaus MD Halle/Saale Germany; Halle/Saale Germany; Halle/Saale Brazil; Halle Germany

Objectives: Painful functional disorders after neck dissec-

OtolaryngologyHead and Neck Surgery Volume 125 Number 2

tion (ND) could be observed in 30% to 70% of the cases. A spinal accessory nerve palsy is considered to be the reason for this complication. The role of sensible parts of the cervical plexus for the development of neuropathic pain is not yet clear. Our study investigated the correlation between shoulder pain and cervical plexus damage after different types of ND. Methods: Forty patients were prospectively investigated preoperatively and 2 weeks and 3 and 6 months postoperatively in the years 1997 to 1999. In 8 cases, a radical ND was performed, in 8 cases a modified radical type 1, and in 24 cases a modified radical ND type 3 was performed. The sensibility for warm/cold and peak/blunt was tested in the dermatomes of C2, C3, C4, and the minor occipital nerve. Shoulder pain was measured semiquantitatively by a rating scale. Results: Six months after resection of the cervical plexus, 74% of the patients had a sensibility loss for all testet qualities and dermatomes. After preservation of this structure, an impairment was developed in 36% of the cases for peak/blunt and 43.3% for warm/cold after 6 months. For the minor occipital nerve, this effect could only be demonstrated in 3 (13.3%). Pain occurred postoperatively in 7% of the plexus preserved patients and increased to 44% after 6 months. After plexus resection, painful disorders were found in 10% and increased to 78% after 6 months. The results for the sensibility tests were statistically significant. Conclusion: Painful shoulder disorders have multifactorial reasons. Our investigations showed that the superficial cervical plexus function is assessable by cutaneous sensibility tests. Less pain symptoms in cases with preserved cervical plexus could be demonstrated. The minor occipital nerve seems to be less affected after ND. We can conclude that preservation of the sensible cervical plexus plays a major role in diminishing postoperative neuropathic shoulder pain symptoms. 10:16 AM

Predictive Value of Surgical Margins of Pleomorphic Salivary Adenomas Sudip Ghosh MD (presenter); Alessandro Panarese MD; John Lee MD MRCPath; Peter Bull MD FRCS

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

Objectives: The risk of recurrence of pleomorphic adenomas (PSAs) of the parotid after surgery is thought to be related to the adequacy of tumor clearance. Adequacy is often thought to be related to the presence of a satisfactory cuff of healthy tissue around the tumor, although it is by no means certain how much of a margin is adequate. With the lack of such objectivity, many cases of surgical excisions are reported by histopathologists as incomplete implying probable future recurrence. This study assesses the actual recurrence rates of PSAs reported as incomplete on histologic grounds and tries to assess the predictive value of the distance of surgical margins from tumors for future recurrence.

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Methods: We studied the histopathology reports of all the 274 cases of PSAs excised at our hospital between 1980 and 1995; 114 of these (41.6%) were reported as incomplete with a possibility of recurrence. Complete follow-up data until the present could be obtained in only 82 of these cases (71.0%), and cases treated with radiotherapy were excluded. We studied the nearest distance of tumor from the surgical margin in millimeters utilizing a margin scoring system and also whether this closeness was focal (<10% of surgical margin) or widespread (>10%). The Fisher exact test was used to compare the recurrence rates between the major subgroups. Results: The 2 major subgroups in our study were (1) tumor present at margin widely, 17 cases with 3 (17.6%) recurrences, and (2) tumor >0 mm but <1 mm from surgical margins widely, 56 cases with 1 recurrence (1.8%). The Fisher exact test revealed a high degree of correlation of the increased risk of recurrence with tumor present at the surgical excision margin (P = 0.0372). The surgical techniques utilized for excision (superficial parotidectomy or extracapsular dissection) showed poor correlation with the tumor status at margins. Conclusion: In the majority (56/82, 68.3%) of reported histologically incomplete excisions of PSAs, where tumor is not present at the surgical excision margin but within 1 mm of it, the recurrence rate is low (1.8%). In only a minority (17/82, 20.7%), the tumor is actually present at the margin with a statistically significant higher rate of recurrence (17.6%). Even a minimal amount of a cuff of surrounding healthy tissue (<1 mm) is adequate to prevent recurrence in cases of excision of PSAs. Objective criteria for adequacy of surgical excision based on surgical margins could be utilized for risk prediction in clinical practice.

9:30 AM to 10:30 AM CCC Room A109 •

Scientific Session: O t o l o g y l N e u r o t o l o g y Patrick A n t o n e l l i MD; William Slattery MD

9:30 AM

Tympanosclerosls Surgery: Long-Term Hearing Results Karen Borne Teufert MD (presenter); Antonio De la Cruz MD

Los Angeles CA; Los Angeles CA

Objectives: To analyze long-term hearing results and factors likely to affect outcome in patients with tympanosclerotic stapes fixation who underwent stapes mobilization or stapedectomy. Methods: Retrospective chart review of the last 10 years. The short-term and long-term (up to 9Y2 years) heating results of first stage and second stage operations for middle ear tympanosclerosis in 213 consecutive patients, performed in a tertiary referral otologic private practice, are presented. There were 169 tympanoplasties, 38 tympanoplasties with mas-

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toidectomy, and 6 tympanoplasties with mastoid obliteration, with ossicular fixation secondary to tympanosclerosis in 146 cases. Of these, 38% were primary cases, with the majority being planned second stages or revision procedures. Results: The average preoperative air-bone gap (ABG) was 31.4 dB. The average 3-month postoperative ABG was 17.2 dB with closure of the ABG within 20 dB in 66.2%. The success rate (ABG <20 dB) was 67.1% for patients with ossicular fixation. Partial sensorineural hearing loss occurred in 1.5% of the cases, and none suffered profound sensorineural hearing loss (dead ears). There was no statistically significant change from 3 months to last follow-up in either ABG or air PTA, with mean differences of only 0.2 dB and 1.1 dB, respectively. Mean time to last follow-up was 2.0 years. Further analyses will determine if there is any ABG variation according to which ossicle was fixed. Conclusion: After 40 years of performing ossicular reconstruction in individuals with tympanosclerosis at The House Ear Clinic, Inc, we continue to obtain reliable lasting hearing results with a low incidence of dead ears.

jects. Functional images of the auditory cortex activation were obtained in 6 subjects. Images of one subject were discarded due to motion artifacts. All subjects showed bilateral activation in superior temporal and transverse temporal gyri. The amount of auditory cortex activation as measured by the number of pixels ranged between 17-41 on the right side and 1531 on the left. Conclusion: Functional images of auditory cortex activation in response to pure-tone stimuli are obtained using a silent fMRI technique. The results are consistent with the previous studies of auditory cortex using conventional fMRI technique. Silent fMRI technique has the potential to investigate the auditory cortex activation without the confounding effect of background scanner noise.

9:38 AM

Objectives: Stapes surgery in the elderly is still controversial. Although some otologists reported poorer results and more frequent complications after stapes surgery in the elderly, others regard it as safe and effective surgery that should be offered to both elderly and younger patients with otosclerosis. The aim of this study is to analyze the results of stapedectomy in elderly patients with an age >65 years, trying to spotlight this controversy. Methods: Between 1987 and 1997, 65 patients >65 years underwent stapes procedures. There were 30 males and 35 females. The mean age at operation was 68.5 years with a range from 65 to 77 years. The follow-up periods ranged from I to 10 years. Pure-tone audiometry (AC and BC thresholds at frequencies of 500 to 4000 Hz) and speech reception threshold (SRT) were reviewed preoperatively, postoperatively (1 month, 3 months, 6 months, and 1 year), and at the last available follow-up. Results: The results were based on the preoperative and postoperative air conduction and bone conduction thresholds (500-4000 Hz). Our results showed that the mean postoperative air-bone gap, calculated as the difference between the postoperative air and bone conduction thresholds as figured at 500-4000 Hz, was 10.2 dB. Closure of the air-bone gap to within 10 dB was achieved in 55% (36 patients), whereas closure to within 20 dB was achieved in 95.3.1% (62 patients). The average hearing gain (500-4000 Hz) was 27.7 dB. The cochlear function after stapes surgery was stable with a mean improvement of bone conduction threshold of 5.2 dB. Conclusion: According to our results, we conclude that stapes surgery in elderly patients is satisfactory, and the results are comparable to the other published results in younger patients.

Evaluation of Auditory Cortex Activation Using Silent Functional Magnetic Resonance Imaging Zerrin F Yetkin MD; Peter S Roland MD (presenter) Dallas TX,"Dallas TX

Objectives: Auditory cortex activation evoked by puretone stimuli has been investigated using functional magnetic resonance imaging (fMRI). In previous fMRI studies, puretone stimuli have been delivered at high sound intensities to overcome the noise generated by the MRI scanner. A new fMRI technique has been proposed to acquire functional images of the brain in the absence of scanner noise. The aim of this study is to determine the feasibility of the new fMRI technique to obtain auditory cortex activation without the interference of MRI scanner noise. Methods: Healthy volunteers with normal hearing were studied. Hearing threshold for pure-tone presented at 1000 Hz was determined at the MRI scanner prior to scanning. Subjects were instructed to lie still and listen to the pure-tone stimuli presented monaurally through the headphones. Puretone stimuli were presented in the absence of the scanner noise and functional images of auditory cortex activation was acquired 3 seconds after the onset of stimulus with an interstimulus time of 12 seconds to avoid the confounding effect of background scanner noise. Functional image processing was performed using cross-correlation analysis and pixels exceedhag a threshold of P < 0.1 were accepted as activation. Auditory cortex activation was quantified by the number of pixels. Results: Seven subjects with normal hearing, aged 27 to 65 years, were studied. Hearing threshold of pure-tone stimulus at 1000 Hz ranged from 30-35 dB as measured in the MRI scanner. Pure-tone stimuli were presented at 70 dB in all sub-

9:46 AM

Stapes Surgery in Elderly Patients Mohamed Rashad Ghonim MD PhD (presenter); Yousef Kamel Shabana MD; Brahe C Pedersen MD; Ahmad A EI-Degwi MD Mansoura DK Egypt; El Mansoura DK Egypt; El Mansoura Egypt; Mansoura India

OtolaryngologyHead and Neck Surgery Volume 125 Number 2

10:00 AM Efficacy of Surgical Treatment of Chronic Otitis Media Oswaldo Laercto Mendonca Cruz MD; Fernando D Leonhardt MD (presenter); Cristlane Kasse MD Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil

Objectives: To evaluate long-term results of the surgical treatment for chronic otitis media with or without cholesteatoma. Methods: Data from 78 patients (84 ears) were available for clinical and audiometric studies, with a minimum followup of 18 months. Forty-one cases with the diagnosis of chronic otitis media without cholesteatoma (48.80%) underwent mastoidectomy with tympanoplasty (intact canal wall). Fortythree cases (51.20%) presenting chronic otitis media with cholesteatoma were managed according to the extension of the disease. Mastoidectomy with tympanoplasty was indicated in 19 cases (44.18%, 19/43) of cholesteatoma restricted to the tympanic cavity and additus. A canal wall down technique with reconstruction of the conductive system was performed in 24 cases (55.82%, 24/43) of eholesteatoma extending to the mastoid antrum, associated extensive granulation tissue, or eustachian tube insufficiency. Results: In the group of patients diagnosed as having chronic otitis media without cholesteatoma (N = 41), closure of the tympanic membrane was obtained in 87.80% (36). Regarding functional heating results, 90.24% (37) of patients showed improvement in their SRT results (mean of 12 dB). In the chronic otitis media with cholesteatoma group (N = 43), the recurrence rate of cholesteatoma was 5.26% (1/19) for the intact canal wall procedure and 4.16% (1/24) for the canal wall down. A safe, dry middie ear was achieved in 78.94% (15/19) of intact canal wall procedure and in 79.16% (19/24) of canal wall down procedure. The functional hearing results showed no difference between the 2 different techniques for cholesteatoma, with maintenance of the previous SRT results in the postoperative period. Conclusion: For patients with noncholesteatomatous chronic otitis media, the intact canal wall mastoidectomy associated to tympanoplasty remains a safe and rewarding procedure. For patients with cholesteatomatous chronic otitis media either intact canal wall mastoidectomy with tympanoplasty or canal wall down showed good results regarding the control of disease as far as one observes strict criteria indications for each technique. Even a satisfactory functional result should be expected if a functional surgical reconstruction is performed after a careful exanteration of the cholesteatoma, granulation tissue, and hypertrophic mucous membrane. 10:08 AM

Otitis Media and Its Correlation to Craniofaclal Morphology Renata DiFrancesco MD (presenter); Perboyre L Sampaio MD SP; Rlcardo Ferrelra Bento MD PhD Sao Paulo Brazil; Sao Paulo Brazil; Sao Paulo Brazil

Objectives: There are a thousand types of faces. Individual

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faces result from the combination of different kinds of maxillas, mandibles, and orbits. The face proportions, in children, are distinct from adult ones. The auditory tube has a more horizontal position in children than in adults; therefore otitis media is more frequent in this age group. The lower frequency of otitis media in adults relates to the development of craniofacial growth and auditory tube. Cranial base development and the displacement of the maxilla during craniofacial growth can influence it. So, there should be a correlation between craniofacial morphology and otitis media. The aims of this study are to correlate facial types and cephalometric measurement morphology to otitis media and suggest which measurements can be used to predict its evolution. Methods: Sixty-six patients, 18 to 40 years old, were selected from the Outpatient Center of the Department of Otolaryngology of the University of Spo Paulo Medical School. They were divided into 2 groups: 32 with otitis media and 34 controls. We excluded patients with personal or familiar history of cleft palate, previous buccal, maxilar, pharyngeal, facial, or nasal surgery, orthodontic treatment, or obstructive process of the auditory tube ostia. All subjects underwent complete ENT physical examination, videotoscopy, fibemasalendoscopy, and lateral cephalograms. Several measures of the cephalograms were analyzed such as: anterior and medial cranial bases and the angle between them; projection of the maxilla; cranial base deflection; and size and angles of the mandible. Facial type was determined using Ricketts' index (VERT index). Results: There was no predominance of any facial type. Lengths of anterior and medial cranial bases and the angle between them were significantly shorter in patients with otitis media. They also showed a smaller projection of the maxilla and a smaller facial height. Conclusion: We can conclude cephalometry is a useful method to analyze craniofacial morphology as a prediction of the evolution of otitis media. We suggest a cephalometric analysis with the following measures: NS (anterior cranial base), NSBa (angle between anterior and medial cranial base), Pmax (projection of the maxilla), NMe (total facial height), and N-APS (superior facial height). 10:16 AM Ventilation Tube Removal in the Operating Room: Do We Need to Do More? Kara M Schwartz MD; Laura J Orvldas MD (presenter); Amy L Weaver Rochester MN; Rochester MN; Rochester MN

Objectives: To determine whether treatment of the tympanic membrane at the time of ventilation tube (VT) removal affects closure of the perforation. Methods: Chart review and phone fuUow-up when indicated in 136 patients (206 ears) who underwent VT removal in the operating room at our institution between January 1995 and December 1998.

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Resuhs: Based on 123 patients (185 ears; 57% male; mean age, 6.9 years), 45% had a previous set of tubes, and the majority (50%) had tubes removed from both ears. The majority (61%) were T-tubes and most often removed (88%) secondary to prolonged retention (average, 2.6 years). Perforation treatment after tube removal was frequent (151 ears, 82%) with the most common (52%) 25% tricholoracetic acid (TCA) was applied to the edges of the perforation. At last follow-up, 170 (92%) of the ears had healed without additional treatment, 7 succumbed to tympanoplasty, and 7 had not yet healed. Treatment failures occurred more frequently in ears not initially treated with TCA (4% failure with TCA, 10% with other treatment, 15% with no treatment) and in ears with tubes removed due to otorrhea (19%). Conclusion: The vast majority (92%) of perforations after VT removal healed regardless of treatment. Our results suggest that the use of TCA at the time of tube removal may prom o t e closure. A large randomized clinical trial is needed to eliminate physician bias. 9:30 AM tO 12:00 PM

CCC BR 2/3 •

Residents Assembly and Forum Medico-legal Issues: How To Avoid Getting Sued As a Resident Wilbur McCoy Otto JD; Geoffrey Fieger JD; K J Lee MD; William Shockley MD; Paul L Leong MD

This year's forum will address the medico-legal challenges that otolaryngologists in training and in community and academic practice face. The forum will give otolaryngologists in training a better understanding before starting their practices. The program will present the legal pitfalls otolaryngologists need to be aware of and how best to react if a legal issue arises.

10:30 AM to 12:00 PM CCC Room A207 •

OtolaryngologyHead and Neck Surgery August 2001

Scientific Sessions--Tuesday

Scientific Session: General Otolaryngology Stilianos Kountankis MD PhD; Sege Martinez MD

10:30 AM UPPP versus LAUP for the Treatment of Sleep-Disordered Breathing ~loochim T Maurer MD (presenter); KrlstlneHirth MD; Nodine Fronke; KarlH Hormonn MD Mannhelm Germany; Monnhelm Germany; Mannheim Germany; Mannhelm Germany

Objectives: This study was designed to objectively evaluate the clinical effectiveness of surgery for sleep-disordered breathing and to compare the results of conventional uvu-

lopalatopharyngoplasty (UPPP) and laser-assisted uvulopalatoplasty (LAUP) in patients without kissing tonsils. Methods: 77 consecutive patients with different degrees of sleep-disordered breathing and confirmed palatal obstruction without kissing tonsils were treated with either UPPP or LAUP. Techniques preserving the palatal muscles were used in all cases. Polysomnography was performed before and 3 to 6 months after surgery. The 20 patients receiving LAUP were matched with 20 UPPP-patients according to age, body mass index (BMI), preoperative respiratory disturbance index (RDI), tonsillar size, and number of tonsillectomies. The surgical response rate was defined as a >50% reduction in the RDI and a postoperative RDI <10/h. Results: There was no statistical difference according to age (UPPP 49 years vs LAUP 47 years), BMI (UPPP 27.8 kg/m" vs LAUP 27.7 kg/m"), preoperative RDI (UPPP 16/h vs LAUP 16.5/h), tonsillar size (UPPP 11 hyperplastic vs LAUP 10 hyperplastic, no kissing tonsils in either group), and number of tonsillectomies (UPPP 15 vs LAUP 14). The response rate was 35% in both groups. Patients receiving LAUP had an even lower postoperative RDI (11.8/h) than UPPP patients (14.5/h) even though this was not statistically significant. 4 UPPP patients and 3 LAUP patients showed an increase in the RDI of more than 100%. UPPP was less effective in patients with a regular alcohol consumption of >15 g/day and a BMI >26 kg/m °. The response rate in LAUP patients was negatively influenced by an elevated alcohol consumption only. Conclusion: In patients with sleep-disordered breathing and palatal obstruction but without kissing tonsils, UPPP does not show any advantage compared with LAUP as the response rates are similar. LAUP should be preferred especially in patients with previously performed tonsillectomy. The overall lower response rates in both procedures may be due to the exclusion of patients with kissing tonsils. Response rates worsen in cases of moderate but regular alcohol consumption.

10:38 AM Prognostic Indicators for Successful Uvulopalatopharyngoplasty Michael Friedman MD (presenter); Lee Boss;HaniZ Ibrohim MD Chicago IL' Chicago IL' Chicago IL

Objectives: Uvulopalatopharyngoplasty (UPPP) remains the most common surgical procedure performed for sleepdisordered breathing. Although reported success rates vary considerably, meta-analysis of the data indicates a success rate of only 40%. Most surgical treatments with a 60% failure rate would be considered unacceptable for benign disease• The purpose of this study is to identify prognostic indicators that would lead to stratification of patients likely to have successful surgery versus those destined to fail. Methods: We retrospectively reviewed 130 patients to cor-

OtolaryngologyHead and Neck Surgery Volume 125 Number 2

relate palate position and tonsil size to the success of the UPPP as based on postoperative polysomnography results. Similar to our previously published data on the Friedman score as a predictor of the presence and severity of obstructive sleep apnea, the palate position was determined on physical examination of the oral cavity. Based on a modification of the Mallampati classification used by anesthesiologists to predict a difficult airway, and combined with tonsil size, a staging system (I through IV) is proposed. Results: The Mallampati grade was inversely related to the likelihood of successful surgery, as opposed to the tonsil size, which correlated directly with successful surgery. Stage I patients (Mallampati grade I and II with tonsil size 3 and 4) resulted in successful surgery 80% of the time. Stage IV patients (Mallampati IV and tonsil size less than 2) were most likely to fail after the UPPP. Conclusion: Mallampati classification and tonsil size should be incorporated in surgical planning for obstructive sleep apnea. 10:46 AM

Endoscopic Treatment of Zenker's Diverticulum Using CO 2 Laser Yosef P Krespi MD (presenter); Marc J Remacle MD PhD New York NY; Yvoir Belgium

Objectives: The objectives of the present study are to review the technique of endoscopic laser-assisted esophagodiverticulostomy (ELAED) for the treatment of Zenker's diverticulum and to describe our 9-year experience with ELAED. We will also discuss the advantages of ELAED over previously described open surgical and endoscopic procedures. Methods: We retrospectively reviewed 83 cases of ELAED performed for the treatment of Zenker's diverticuli during the last decade. Patient data were analyzed for age, sex, size of diverticuli, duration of symptoms, length of hospital stay, initiation of oral intake, and other complications. Results: ELAED-treated patients were able to start an oral diet significantly earlier than all other surgical procedures for the treatment of Zenker's diverticuli. Hospital length-of-stay was also much shorter for ELAED than other endoscopic procedures performed for Zenker's diverticulum. Approximately 2% of our patients developed small fistulae, all of which closed spontaneously. Another 2% of our patients required conversion to an open Zenker's diverticulectomy due to inadequate endoscopic exposure. 5% of our patients required a revision endoscopic procedure for persistent symptoms. Conclusion: Our series of 83 patients treated over the last decade with an average follow-up of 4 years, from 2 large academic centers in 2 continents, confirms the experience of other reported similar series. ELAED is a safe and effective procedure for the management of Zenker's diverticulum.

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11:00 AM

Reserve Vocal Capabilities of Normal versus Pathological Voice Ahmad AbdeI-Aziz Orabi MD MSc FRCS (presenter); Andrew J Sims PhD; M Nasser Kotby MB ChB

Birmingham United Kingdom; Newcastle u Tyne United Kingdom; Cairo Egypt

Objectives: Assessment of voice capabilities beyond those used in speech activities (ie, voice reserves) is important for better understanding of the physiology, dynamics, and limitation of normal and pathologic voice. By concomitant examination of speaking and musical (overall) VRP, this can be achieved. Few previous studies stated that the differences between speech requirements and the maximum and minimum boundaries of the VRP pointed to voice reserves, no further steps have been taken to objectively assess and measure them. The aim of this study is to examine and further analyze the voice reserves in the normal and the pathologic voice and to see whether this might be useful in vocal assessment. Methods: 166 subjects were involved in this study. Musical and speaking VRP recordings (Kay's VRP model 4326 connected to CSL [Computerised Speech Lab] model 4300) were taken from 45 adult normal subjects and 121 adult dysphonic patients of various aetiologies (organic, MAPLs minimally associated pathological lesions, functional and mixed). A standardized protocol was used. The plots were analyzed using a specially developed computer program to enable precise calculations of different quantitative parameters, particularly the voice areas. This paper concentrates on new data concerning voice reserves assessment that are total reserve area, low frequency reserve, high frequency reserve, soft intensity reserve, loud intensity reserve, and different ratios between corresponding parameters in musical and speaking profiles. Results: This preliminary study showed that both our normal and pathological subjects used a small proportion (10% to 11%) of their overall vocal capabilities, about a quarter of the frequency capabilities, and a half of their dynamic capabilities during common life speech activities. Interestingly, percent value differences between normal and pathologic voice subjects were only significant in the dynamic domain. There were highly significant differences between normal and pathologic voices in the following parameters: total reserve area and high and low frequency reserves. This suggested that the speaking pathological voice was not merely collapsed, but also re-allocated within the total vocal capabilities. These results and their significance will be discussed in detail. Conclusion: For the first time in literature, objective and highly precise assessment and analysis of voice reserves have been performed. Calculation of reserve area, frequency, and dynamics is a new and clinically useful concept. It gives an idea about to what extent the subject is approaching his/her own limits during common life speech activities. The re-allocation

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OtolaryngologyHead and Neck Surgery August 2001

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while preserving the overall proportion of speaking in relationship to music in pathological voice is interesting. We will examine in the future different vocal subgroups using this concept. 11:08 AM

Laryngopharyngeal Reflux: Risk for Laryngeal Cancer Jan S Lewin PhD (presenter); Ann Gillenwater MD; David L Callender MD MBA; Jeffrey N Myers MD PhD Houston 1-)(;Houston TX; Houston TX; Houston TX

Objectives: Laryngopharyngeal reflux disease (LPRD) may be an important risk factor for the development of laryngeal carcinoma in both smoking and nonsmoking patients. The purpose of this study was to identify and evaluate the incidence and severity of LPRD in a group of patients with dysplasia or early cancer of the larynx using an ambulatory pH probe and computerized diary. Methods: Historical and 24-hour pH probe data were acquired on 40 previously untreated adult patients with dysplasia and T1 and T2 lesions of the larynx. Patients recorded meal times, foods, and other information during the 24-hour monitoring period. Results: Twenty-six patients had premalignant lesions, and 14 had laryngeal carcinoma. Fourteen patients were nonsmokers, and 26 were smokers. Six of the 40 (15%) had no evidence of LPRD, 12 (30%) had some or moderate evidence, and 22 (55%) had significant evidence based on total number of reflux episodes and overall reflux area index. Eighty-one percent of patients with premalignant lesions had LPRD compared with 93% of patients with malignant lesions of the larynx. Although 68% of patients with significant evidence of reflux were symptomatic, only 33% of patients with moderate evidence reported symptoms associated with reflux. Although smokers had slightly higher evidence of LPRD than nonsmokers, 79% of nonsmokers had moderate (29%) or significant (50%) LPRD. Conclusion: This study finds the majority of patients with premalignant and early tumors of the larynx have LPRD based on pH probe analysis. Many remain asymptomatic until the reflux is significant. Matched-case control studies are needed to substantiate a pathogenic role for LPRD in the carcinogenesis of laryngeal tumors. However, the results of the present study support early identification and treatment of LPRD to potentially prevent laryngeal carcinoma in selected patients. 11:16AM

The Effect of H Pylorl Eradication on Laryngeal Reflux Brian Gardner Kerr MD (presenter); Peter L Rigby MD; Paul Louis Friedlander MD; Ingrld C lwanow MD; George D Lyons MD Kenner LA; New Orleans LA,.New Orleans LA; New Orleans LA; New Orleans LA

Objectives: Helicobacter pylori infection is an essential

factor in the pathogenesis of chronic gastritis and may be associated with gastroesophageal reflux. The incidence of laryngeal reflux in patients afflicted with Helicobacter pylori gastritis is unknown. This study is designed to determine this incidence and to see if there is improvement in laryngeal reflux after eradication therapy. Methods: Fifteen patients with symptomatic H pylori gastritis were identified prior to undergoing medical therapy. Patients received a questionnaire concerning symptomatology and underwent videostroboscopy to determine the signs of laryngeal reflux. Patients completed a 2-week course of Prevpac, and the questionnaire and examination were repeated. Analysis of signs of laryngeal reflux was performed with a Student t test. Results: Thirteen patients (87%) completed the study. A large number of patients were found to have laryngeal signs (77%) and laryngeal symptoms (46%) of reflux before treatment. Eight patients (62%) were seen to have improvement of interarytenoid edema (P = 0.I0); whereas 6 patients (46%) were seen to have improvement of laryngeal edema (P = 0.19). Marked improvement of esophageal symptoms and minimal improvement of pharyngeal and laryngeal symptoms were seen in this population. Conclusion: A high incidence of signs and symptoms of laryngeal reflux is seen in patients with H pylori gastritis. A modest improvement of both signs and symptoms were seen after eradication therapy. More studies are needed to further define the role of Hpylori infection in laryngeal reflux, and to determine if treatment would be beneficial to this group of patients. 11:30

AM

Affect of HPV Expression on Clinical Course of Laryngeal Papilloma Se-Heon Kim MD; Kwang-Moon Kim MD (presenter); Nora Hoon Cho MD; Hyun Chul Yoon MD Seoul South Korea; Seoul South Korea; Seoul South Korea; Seoul North Korea

Objectives: Laryngeal papilloma is the most common benign laryngeal tumor. Although pathogenesis of laryngeal papilloma has been much understood until now, its high recurrence rate and unpredictable nature is still a problem to solve. Human papilloma virus (HPV) is assumed to be the main causative agent of this disease. In this study, we investigated the expression of whole genotypes of HPV through cases of laryngeal papilloma and correlated their expression with the clinical course of disease. Methods: Seventy cases of laryngeal papillomas were evaluated for the HPV genome presence by the technique of in situ hybridization using wide spectrum HPV DNA probe; 50 cases of laryngeal polyps were also tested as the control group. Etiologic associations were analyzed between the 2 groups. According to the expression of HPV genome, cases

OtolaryngologyHead and Neck Surgery Volume 125 Number 2

were subdivided and specific types of HPV infection were determined by DNA in situ hybridization using type-specific HPV DNA probe (HPV6, 11, 16, 18, 31, 33). Separate analyses were conducted comparing viral types, average number of procedures, and duration of the disease-free period. Results: We detected HPV DNA in 40 of the 70 laryngeal papilloma cases (57%). There were significant associations between HPV and laryngeal papilloma (P < 0.01). Among the HPV positive cases, major specific types were HPV 6/11 (97%). Significant associations were noted between viral expression and clinical course also. (Disease-free duration, HPV [+] group: HPV [-] group = 4.9 months: 11.3 months [P < 0.05]; recurrences per 3 year; HPV [+] group: HPV [-] group = 5.3 times : 2.3 times [P < 0.05].) Conclusion: Our observations suggest that HPV 6/11 were the main causative agents of laryngeal papilloma and that detection of active HPV DNA expression may be helpful in identifying patients with aggressive recurrent laryngeal papillomas. In addition, it may confer the rationale of combined antiviral therapy for aggressive laryngeal papilloma. 11:38 AM

Office-Based Treatment of Laryngeal Papillomatosls with Cldofovir Dinesh K Chhetri MD (presenter); Joel Blumin MD; Gerald S Berke MD

Los Angeles CA; Los Angeles CA," Los Angeles CA

Objectives: Currently the standard treatment for recurrent laryngeal papillomatosis is direct laryngoscopy and carbondioxide laser ablation under general anesthesia. Intralesional injections of the antiviral drug cidofovir have been effective in the treatment of juvenile recurrent respiratory papillomatosis. We explored the potential of office-based treatment of laryngeal papillomatosis in adults with cidofovir using a percutaneous injection technique. Methods: Adult patients with recurrent laryngeal papillomatosis limited to the vocal cords and anterior commissure were selected for office-based treatment. Cidofovir was injected into the involved areas using a previously described pointtouch technique. Clinical improvement or remission of the papillomatosis was noted. Results: Five patients received office treatment of laryngeal papillomatosis with cidofovir. The patients On average needed direct laryngoscopy and CO2 laser ablation every 3 months before initiating office treatments. There were no complications related to the percutaneous injection technique. No patients required return to the operating room for papilloma removal although minor Tecurrences occurred (follow-up period ranged from 9 months to 18 months). Remission of papillomatosis was achieved in 2 patients and significant improvement was achieved in 3 patients.

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Conclusion: Office-based treatment of adult patients with anterior laryngeal papillomatosis using percutaneous injection of cidofovir is effective and appears to reduce or obviate the need for repeated direct laryngoscopy and laser ablation under general anesthesia. 11:46 AM

Speech Therapy for the Treatment of Paradoxlcal Vocal Cord Dysfunction Boris Karanfilov MD (presenter); David M Powell MD; Michael D Trudeau PhD; L Arick Forrest MD; Paul J Krumrnen BS

Columbus OH; Columbus OH; Columbus OH; Dublin OH. Columbus OH

Objectives: Paradoxical vocal cord dysfunction (PVCD) is a laryngeal disorder characterized by paroxysms of inspiratory and/or expiratory stridor secondary to improper vocal fold adduction during respiration. Patients are often misdiagnosed as having an acute asthma exacerbation and seek urgent medical attention in the form of emergency room treatment or clinic visits. Speech therapy is recognized as the most efficacious treatment for PVCD, however, results of treatment have been reported inconsistently. The goals of this study were (1) to report the efficacy of speech therapy with regard to frequency and duration of attacks, (2) to demonstrate the impact of speech therapy on emergent medical treatment, and (3) to compare the cost savings of speech therapy over acute medical treatments. Methods: A retrospective review of all patients diagnosed with PVCD at a tertiary care voice center was conducted to select those patients who completed a course of stahdardized speech therapy protocol. The laryngeal control program focuses on respiratory retraining, increasing laryngeal awareness, relaxation training, and eliminating vocal abuse. A phone interview followed completion of therapy and data were collected with an emphasis on frequency of attacks after speech therapy and utilization of emergency resources for acute exacerbations. Results: Between May 1997 and June 2000, 35 adult patients diagnosed with PVCD were enrolled in the laryngeal control program. A significant reduction in paroxysmal attacks was demonstrated after an average of 3.8 therapy sessions. Acute care visits decreased from an average of 2.8 per month before therapy to less than 1 per 6 months after therapy completion. An average course of therapy is approximately $300, while a single emergency room visit incurs costs nearly 3 times this figure. The overall cost savings is several thousand dollars based on patterns of treatment before and after speech therapy. Conclusion: A significant reduction in the number of attacks and utilization of emergency resources was demonstrated in patients completing speech therapy. Speech therapy is a highly efficacious and cost-effective strategy for the treatment of PVCD.

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10:30 AM to 12:00 PM C C C R o o m s C207-209 •

OtolaryngologyHead and Neck Surgery August 2001

ScientificSession: H e a d a n d N e c k Surgery Lawrence Burgess MD; Eduardo Diaz M D

10:30 AM

Skull Base Surgery for Primary Recurrence of Nasopharyngeal Carcinoma Sheng-Po Hao MD (presenter); Ngan-Ming Tsang MD DSc; Chen-Nen Chang MD

Taipei Taiwan (Republic of China); Taoyuan Taiwan (Republic of China)," Taoyuan Taiwan (Republic of China)

Objectives: To evaluate the efficacy of salvage skull base surgery for patients with primary recurrences of nasopharyngeal carcinoma (NPC). Methods: Twenty-four consecutive NPC patients with primary recurrences underwent salvage skull base surgery between July 1993 and July 2000. The operations were carried out via a facial translocation approach, and 6 patients needed combined neurosurgical resection. Only 3 of 24 patients had microresidual disease during resection. Eight patients further underwent a second course of radiotherapy postoperatively. Results: To date, 5 patients died of disease, including 2 with local disease, l with disseminated brain disease, l with neck metastasis, and 1 with distant metastasis. Nineteen patients are currently alive, including 1 patient alive with axillary node metastasis. The actuarial 3-year survival rate was 76.5% and the local control rate was 76.5% with a median follow-up time of 17.4 months. There was no surgical mortality, and the morbidity was only 12.5%. Conclusion: Skull base surgery offers reasonable survival and local control of primary recurrence of NPC and should be a better option than reirradiation. Intracranial invasion is no longer a surgical contraindication. Long-term survival can be achieved after skull base surgery, even in cases with intracranial invasion. 10:38 AM

Results and Pitfalls in Intraoperative Sentinel Node Biopsy in HNSCC Anja A Duenne (presenter): Burkard M Lippert; Desiree Brandt MD; Jochen Alfred Werner MD

Marburg Germany; Marburg Germany,"Marburg HessGermany; Marburg Germany

Objectives: There are only a few communications about the value of sentinel node (SN) biopsy in head and neck squamous cell carcinoma (HNSCC) despite promising announcements concerning breast cancer as well as other tumor entities like malignant melanoma and vulvar and penile carcinoma. Currently no final verdict can be judged about the status of SN

biopsy in HNSCC. We investigated the predictiveness and pitfalls of intraoperative SN biopsy in 53 patients with HNSCC. Methods: A total of 53 previously untreated patients with clinically N0-neck in 36 cases and N+-neck in the remaining 17 cases with HNSCC were staged by intraoperative SN biopsy. After intraoperative identification of the SN, all patients were treated by neck dissection (ND) depending on the primary tumor side. The histologic results of the SN and the ND specimens were compared postoperatively. Results: In 30 patients, the tumor-free SN reflected the regional lymph node status. In 5 patients, an isolated tumor metastasis (pNl) was found in the identified SNI. In 1 patient, an isolated metastasis was proven in the SN2 located in a neighboring basin. In 3 cases, the intraoperative identified SN was tumor-free, since several lymph nodes contained tumor metastases. These were characterized by extra capsule lymphogenic spread. In 5 further cases, no intranodal accumulation of the tracer by any lymph node could be found. In these cases, extra capsule spread could also be identified histologically. In the remaining 9 patients, the SN reflected the cervical lymph node status (pN+). Conclusion: Intraoperative SN biopsy seems to be predictive of clinically occult lymph node metastases in HNSCC. Based on the tight lymph node system several tracer accumulating lymph nodes (SN1, SN2, SN3) have to be investigated in cases of clinically suspected N0-neck to prevent false-negative results. The nature of the investigation is bound tightly to the quality of the injection and thus to the experience of the investigator. An intraoperative injection technique may therefore lead to considerably superior results, due to a better exposure and less interference by the patient. Furthermore, in cases of advanced lymphogenic metastatic spread including capsule rupture SN biopsy should be avoided. 10:46 AM

IntraDose Injectable Gel Provides Palliative Benefit in HNSCC Barry Wenig MD MPH (presenter); Jochen Alfred Werner MD; Dan J Castro MD PhD; Kasi S Sridhar MD; Harinder S Garewal MD PhD; Olaf Arndt MD; Wolfgang Kehrl MD; Anna Pluzanska MD

Evanston IL' Marburg Germany; Los Angeles CA; Miami FL" Tucson AZ" Regensburg Germany," Hamburg D Germany; Lodz Poland

Objectives: The most clinically important feature of HNSCC is recurrent or refractory local/regional disease, which is often highly symptomatic and degrades the quality of life (QOL). When cure is no longer possible and conventional modalities are no longer feasible, local disease control for symptom palliation or prevention remains a significant medical need. We evaluated IntraDose (cisplatin/epinephrine [CDDP/epi]) Injectable Gel, a novel drug system designed for

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Volume 125 Number 2

targeted antitumor therapy, in 2 identical phase III trials. Study objectives were relief of symptoms of troublesome lesions and local tumor control in patients with advanced disease. Methods." Patients with histologically confirmed HNSCC (tumor volume >0.5 to 20 cm 3, who had limited or no therapeutic options and poor prognosis were enrolled and randomized 2:1 to receive CDDP/epi gel or placebo gel by direct injection into lesions. Up to 6 weekly treatments were administered. Dose was 0.25 mL active or placebo per cm 3, tumor, up to I0 mL total. A new validated QOL instrument (Treatment Goals Questionnaire) was used to assess patient benefit (PB) resulting from local control of symptomatic target lesions. 178 patients (307 lesions) were evaluable. Median time from initial diagnosis to study entry was 19 months (range, 2 to 386). 89% of patients had previously been treated with 2 or 3 modalities; most lesions (89%) were in previously irradiated fields. Results: Combined results of 2 studies confirmed objective responses (CR + PR) of target lesions: 29% (35/119) for CDDP/epi gel versus 2% (1/59) for placebo (P < 0.001). Responses occurred after a median of 21 days and endured a median of 78 days (30 to 554+). Median survival in these patients was 133 days (95% CI, 116 to 201), thus they were afforded meaningful clinical benefit for a portion of their remaining life. The most frequently selected patient treatment goals were improved pain control, wound care, and relief of obstructive symptoms. Tumor response and PB were significantly correlated (P = 0.006); 46% of patients with target lesion responses benefited from treatment versus 15% of nonresponders. Side effects included local cytotoxic effects at the injection site (eg, necrosis and pain). Renal and hematologic toxicities were infrequent. Conclusion: CDDP/epi injectable gel significantly reduces tumor burden, ameliorates tumor symptoms, and provides a new therapeutic option for palliative treatment of patients with advanced HNSCC.

11:00 AM Nodal Size of Metastatic Squamous Cell Carcinoma Michael Katz MD (presenter); John E Gooey MD; Gerard F Domanowski MD Needham MA; Brookline MA,"Rochester NY

Objectives: To determine the relative incidence of squamous cell carcinoma nodal metastases in relation to the size of the lymph node in neck dissection specimens. Methods: Neck dissection specimens from all patients with primary upper aerodigestive tract squamous cell carcinoma treated at the Boston Veteran Affairs Medical Center from 1993-1997 were examined and their charts reviewed. Lymph nodes with and without pathologic evidence of metastases were measured. Incidence of nodal metastases in rela-

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tion to nodal size was calculated. Data were statistically analyzed and plotted on a receiver operator characteristic (ROC) curve to determine the optimal cutoff size for nodal metastases. Results: A total of 2373 lymph nodes were examined in 55 patients. There was a statistically significant difference in the mean size of positive (9.57 mm) and negative (3.76 mm] lymph nodes (P < 0.0001). The average size of a lymph node with evidence of extracapsular spread was 10.57 mm. Lymph node metastases were found in lymph nodes ranging in size from 1 to 40 mm. A cutoff value of 5 mm provides a 81.3% sensitivity and 70.1% specificity for detecting nodal metastases. There were no specimens that had isolated nodal metastases under 5 mm without at least another nodal metastasis greater than 5 mm. Conclusion: Lymph node metastases from squamous cell carcinoma of the upper aerodigestive tract can occur in lymph nodes as small as 1 mm. The probability of nodal metastases increases with increasing size of the lymph node. While there can be metastases in lymph nodes as small as 1 mm, there was no evidence of isolated metastases less than 5 mm without concurrent metastases greater than 5 mm. In the setting of a known squamous cell carcinoma of the upper aerodigestive tract, consideration should be given to treatment of cervical lymph nodes greater than 5 mm. 11:08 AM

Site Specific Quality of Life in Surgically Treated Head and Neck Cancer Guy J Petruzzelli MD PhD (presenter); Fanchon Knight RN BSN Maywood IL" Maywood IL

Objectives: Quality of Life (QOL), in addition to oncologic outcomes, has become an important consideration in cancer therapy. Head and neck cancer treatment uniquely affects critical social functions such as speech, deglutition, and appearance making QOL assessment in these patients critical. This study was undertaken to assess the differential responses in various QOL domains across the 4 most common sites of head and neck cancer and following unilateral or bilateral neck dissections.

Methods: Prospective analysis of QOL data at 1 year in 152 previously untreated patients with head and neck cancer treated with primary surgery with or without adjuvant radiotherapy at the Loyola University Medical Center. The University of Washington head and neck cancer QOL instrument was used to collect QOL data. The Z 2 and Kruskall-Wallis tests were used to determine statistical significance. Patients were screened by clinical social worker to rule out concurrent depression.

Results: There were no statistical differences in overall QOL indexes across treatment groups (P > 0.05). Significant differences between subsites were identified in the domains of

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recreation, swallowing, and shoulder function (P < 0.05). Patient with oral cavity tumors had better scores overall. Patients with oropharyngeal tumors reported the poorest swallowing, and those with hypopharyngeal tumors the worst shoulder function. Comparison of the data with regard to neck dissection showed a similar pattern with statistical differences in the shoulder function and swallowing domains but also in the pain domain (P < 0.05), with patients with bilateral procedures having worse QOL scores. Conclusion: QOL should be included as an endpoint in reporting treatment for head and neck cancer. Overall composite QOL indexes are not sufficiently sensitive to detect differences between patient groups due to the heterogeneity of the disease regarding subsites and treatment of the neck. Analysis of specific QOL domains can demonstrate where specific interventions (ie, speech or physical therapy, rehabilitation medicine) can be used in an efficient and cost-effective fashion. 11:16AM

AntI-VEGF Receptor Antibody Inhibits Squamous Cell Carcinoma Growth Theodoros N Teknos MD (presenter); Claudell Cox MD; Douglas Chepeha MD; Thomas E Carey PhD; Peter Bohlen PhD Ann Arbor MI; Ann Arbor MI; Ann Arbor MI,"Ann Arbor MI; New York NY

Objectives: At the conclusion of this presentation, the audience will appreciate the efficacy of a monoclonal antibody (DC101) in suppressing the growth of squamous cell carcinoma in an orthotopic murine model. Methods: Seventy 8-week-old C3H/HEJ mice were randomly assigned to a DCI01 treatment group (n = 30), a positive control group (n = 10), and a placebo group (n = 30). On day 0, the DC101 and placebo groups received floor of mouth injections with 1.5 x 10^5 murine SCVII/SF cells in 200 mL of RPMI media. The positive control group received an injection of 1.5 x 10^5 A673 rhabdomyosarcoma cells into the hind limb. Treatments were initiated 10 days after tumor implantation. The DC101 and positive control groups received a single intraperitoneal dose of 50, 100, or 200 mg of DC 101 antibody in 200 mL phosphate-buffered saline solution (PBS). The placebo group received intraperitoneal injections of 200 mL PBS only. All mice were sacrificed at the conclusion of the experiment, and immunohistochemicalstaining of their tumors with Factor VIII antibody was performed. Results: Single-dose treatment with 50, 100, and 200 mg DC101 successfully suppressed tumor growth by 50%, 63%, and 38%, respectively. All doses suppressed growth to a statistically significant degree (P = 0.004, P < 0.0001, and P = 0.0014 for 50, 100, and 200 mg doses, respectively). Blood vessel density was dramatically reduced in all anti-VEGFR-2 groups compared with the controls.

Conclusion: VEGFR-2 antagonist (DCI01) is capable of dramatically reducing the tumor burden in a very aggressive form of murine squamous cell carcinoma. This antibody also decreases the level of angiogenesis these tumors exhibit. These encouraging results have resulted in ongoing studies investigating the efficacy of this antibody in human tumors. 11:30 AM

Nodal Yield in Neck Dissection and the Likelihood of Metastasis David Reiter MD DMD; Mark T Agrama MD (presenter); Allan Topham; Mary Cunane MD Philadelphia PA: Havertown PA; Philadelphia PA; Philadelphia PA

Objectives: To quantify the minimum lymph node yield from radical neck dissection necessary for determination that no regional lymphatic metastasis exists in head and neck cancer with 95% probability. Methods: National Cancer Institute SEER data are used for statistical evaluation of the percent of positive nodes found in over 1000 radical neck dissections. Statistical methodology previously validated for colorectal and prostate cancer is applied to find the minimum nodal yield which, if negative for metastasis, gives a 95% probability of freedom from cervical lymphatic spread of head and neck cancer. Results: The wide variation in nodal yield among the approximately 1500 radical neck specimens in the SEER database and the relatively low percentage of positive nodes in specimens with large numbers suggests that the 95% confidence interval begins at approximately 20 nodes, or 1 SD below the mean. Conclusion: This preliminary study suggests that one must remove at least 15 and probably 20 or more nodes to rule out regional lymphatic spread of head and neck cancer with 95% certainty. However, extensive node dissections into areas remote from the primary tumor may not increase the likelihood of identifying regional lymphatic spread in head and neck cancer, as the incidence of nodal metastasis is not significantly greater in specimens yielding 40 or more nodes than it is in those yielding 20 nodes. We must correlate tumor control with nodal yield to better understand the role of neck dissection in disease management (a study currently in progress). 11:38 AM

Lymphoscintigraphy and Sentinel Node Sampling for Head and Neck Melanoma David H Chi MD (presenter); David B Dorofi MD; Ellen Desper RN BSN; Paul A Levine MD Charlottesville VA; Norfolk VA; Charlottesville VA; Charlottesville VA

Objectives: (1) To describe a protocol for the evaluation

OtolaryngologyHead and Neck Surgery Volume 125 Number 2

and management of head and neck malignant melanoma with clinically negative lymph nodes. (2) To examine the early outcomes of patients who were initially managed with sentinel lymph node (SLN) biopsy. Methods: All patients with head and neck melanoma with clinical stage I through II disease were enrolled in the study. Same day preoperative technetium Tc 99m lymphoscintigraphy was performed to map the SLN and mark the overlying skin. Intraoperative gamma probe localized the SLN. The SLN was excised often in conjunction with the wide local excision of the primary lesion. Patients with histologically positive SLN underwent a subsequent therapeutic lymphadenectomy. Patients with negative SLN were observed clinically. The measured outcomes include the demographics, staging, histologic characteristics, SLN results, and potential predictive factors for SLN positivity and recurrence. Results: Nineteen patients from November 1997 to December 2000 were enrolled. The mean Breslow depth was 2.7 mm (0.55 to 8.3 mm). An average of 2.2 SLN was detected by Tc 99m scan. 100% of sentinel lymph nodes were identified intraoperatively. A total of 3 patients had positive SLN and underwent completion neck dissection. The positive SLN biopsy patients had lesions with mean Breslow depth of 4.6 mm and staging of at least T3. No lesion less than T2 had a positive biopsy result. No further pathologic lymphadenopathy was detected after completion neck dissection. All 3 patients are disease-free with a mean follow-up of 23.3 months. Two (10.5%) patients with initially negative SLN developed subsequent.cervical metastases detected during follow-up. Conclusion: Lymphoscintigraphy has been reported by other surgical specialties to identify the SLN. The technique of lymphoscintigraphy is simple and reproducible. The SLN was obtained in 100% of cases. A false-negative rate of 10.5% is present in this series. The 3 patients with positive SLN biopsy results and subsequent neck dissections have been disease-free for 23.3 months. However, the head and neck melanoma data regarding the diagnostic accuracy and the survival rate will become more significant as the number of patients and follow-up time increase.

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11:46 AM

E-cadherin and l~-Catenln Expressions in Hypopharyngeal Cancer, Meijin Nakayama MD (presenter); Hiro-omi Takahashi MD; Makito Okamoto MD; Yu-ichi Sato PhD; Tomhiro Makoshi MD; Kazuo Yao MD

KanagawaJapan; SagamiharaJapan; Kanagawa-KenJapan; Sagamihara Japan; SagamiharaJapan; SagamiharaJapan Objectives: To find the histologic factors related to the invasiveness of squamous cell carcinoma in hypopharynx. The cell adhesion molecules, E-cadherin and ]3-catenin, were immunohistochemically stained and the results compared with the histologic findings of the hematoxylin-eosin (H-E) stained whole-organ serial sections. Results from both studies were ultimately correlated with the prognosis of each case. Methods: A total of 20 surgical specimens, obtained from 17 total and 3 partial pharyngolaryngectomies between 1994 and 1999, were processed. We developed H-E stained wholeorgan serial sections and examined them using the prognostic factors, such as pattern of cancer invasion, degree of cartilage destruction, and presence of vascular infiltration. Among all sections, the most representative ones were selected and stained with E-cadherin and I~-catenin; the stainability and their localization were assessed. Results: In the H-E stained whole-organ sections, cancer with infiltrating pattern, cartilage destruction, and vascular infiltration was observed in 70%, 45%, and 60% of the cases; these cases tended to metastasize and therefore demonstrate poor prognosis. Reduced expression of E-cadherin and ~-catenin was shown particularly at the invasive front (16 of 20 cases) and at the edge of cartilage destruction (all 9 cases with cartilage destruction); these cases also manifested poor prognosis. Conclusion: Reduced E-cadherin and ~-catenin expressions at the invasive front and at the edge of cartilage destruction imply the increased invasiveness at these particular sites. This is the first report to confirm the possible relationship between the down-regulation of cell adhesion molecules and the invasiveness of hypopharyngeal cancer. Cell adhesion molecules became much useful if combined with the prognostic factors elicited from H-E stained whole-organ serial sections.

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OtolaryngologyHead and Neck Surgery August 2001

10:30 AM to 12:00 PM C C C BR 4 •

Miniseminar: A d v a n c e s in Meniere's Disease a n d Autoimmune Ear Disorders

(with Spanish translation) Aristides Sismanis MD FACS (moderator); M o h a m e d A Hamid PhD; Michael E Hoffer MD; Herbert Silverstein MD FACS; Edwin M Monsell PhD

Richmond VA; Beachwood OH; San Diego CA; Sarasota FL" Detroit MI

Educational Objectives: (1) Presentation of the latest developments in the management of Meniere's disease and autoimmune ear disorders; (2) presentation of intratympanic pharmacotherapy with gentamicin and steroids as well as systemic treatment with steroids, methotrexate, and other immunosuppressants; (3) discussion of the indications for surgery. Description of Symposium: The introduction of new treatment modalities has changed the management of Meniere's

disease and autoimmune ear disorders. These treatments include intratympanic gentamicin (peffusion and micro delivery methods), oral and intratympanic steroids, and systemic administration of methotrexate and other immunosuppressants. Each panelist will make a 6-minute presentation on his experience in managing Meniere's disease and autoimmune ear disorders. Following this, the moderator will present representative cases for discussion. Conclusions and guidelines will be presented. Time will be allowed for questions.

Have You Tried COG*ENT--Our Acclaimed Patient Outcomes Software? Stop by our A A O - H N S F R e s o u r c e Center (Booth 1017) for showings o f our unique C O G * E N T software. Enjoy a hands-on demonstration o f this groundb r e a k i n g s o f t w a r e for t r a c k i n g p a t i e n t o u t c o m e s in otitis m e d i a and rhinosinusitis. C O G * E N T is y o u r key for generat~o~-,~, ing data that can show the quality o f your patient c a r e - - a n d i m p r o v e y o u r performance. L o o k in Meeting Daily newspaper for times o f demonstrations.

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10:30 A M to 12:00 PM

C C C R o o m A205 •

Miniseminar: Evidence-Based Medicine: W h a t Otolaryngologists Should K n o w Michael G Stewart M D M P H (moderator); Bevan Yueh MD; David L WitsellMD; Andrew N Goldberg M D Houston TX,"Seattle WA; Durham NC; San Francisco CA

Educational Objectives: Attendees will learn to define and describe evidence-based medicine [EBM) and how to apply its methods to otolaryngology. Furthermore, attendees will learn how literature searches are performed, how the available evidence is "ranked," and how surgical research is performed. In addition, attendees will see specific examples of EBM from Dr Rosenfeld, who has written a textbook on the subject. Finally, we will receive an update on important Academy activities using EBM from Dr Archer, who is chairman of the Academy's Quality Improvement Committee. Description of Symposium: "Evidence-based medicine" is an important concept that is rapidly gaining in momentum and significance in contemporary medicine. EBM has been defined as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." There are 3 key components of EBM that clinicians should use: individual clinical expertise, the best available research evidence, and patient preference. Although

not all clinical questions can be answered using data from randomized clinical trials, a thorough and unbiased review of the available clinical research evidence can offer significant assistance in many cases. Ideally, EBM offers significant advantages over "practice guidelines" or other formal external benchmarking because it offers the opportunity to use clinical experience and available evidence to formulate an individual treatment plan. Furthermore, EBM will allow us to strengthen and potentially expand current clinical indications for otolaryngologic treatment and surgery. In this miniseminar, several otolaryngologists with interest and training in EBM and clinical research will give presentations on different aspects of EBM, including specific examples of its use in otolaryngology. We will allay some of the fears, myths, and misinformation on the subject, along with demonstrating how it can assist in clinical practice and how the Academy is using EBM to help the specialty. Finally, we will allow time at the end to take questions from the audience.

View Our Slide Lectures, CD-Roms, and Videos Stop by our AAO-HNSF Resource Center (Booth 1017) to try out our continuing education products. View for yourself our latest slide lecture series, including the best-selling "Rhinosinusitis," and the new "Diseases of the Larynx," and "The Aging Face." Then test-drive our videos, including our highly rated endoscopic sinus surgery series.

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Scientific Sesslons--Tuesday

OtolaryngologyHead and Neck Surgery August 2001

10:30 AM to 12:00 PM C C C R o o m A209 •

Alternative Medicine Committee: Spirituality and Healing: The Role of Faith and Belief in Medicine Jack J Wazen M D (moderator); Benjamin F Asher MD; Carol R Gerson MD; Joan Borysenko PhD New York NY," Berlin Vl~; Chicago IL" Boulder CO

The root of the word medicine means right inner balance. In a modern world in which stress-related disorders account fol' two thirds or more of visits to family practice physicians, how can we find that balance? The word healing has its roots in the Anglo-Saxon word haelen, to make whole. Healing is the emerging process of reestablishing right relationship among the fragmented parts of our lives; the relationship with self, others, the environment, and Spirit as we understand it. Two thirds of all patients believe .that spirituality is an integral part of medical care, and nearly half want their physicians to pray with them, yet this scared dimension of medi-

cine has been largely disowned. Through research data, teaching stories, anecdotes, poetry, and a guided imagery experience, we will reclaim the sacred in the healing art of medicine. Objectives: Upon completion of this program the participants should: (1) know some of the research data concerning faith and illness recovery, illness prevention, and cost containment, (2) be able to articulate a model of healing based on the emergence of fight relationship; (3) understand the difference between spirituality and religion; (4) use patients' faith to help in the healing process.

10:30 AM to 12:00 PM

CCC •

R o o m s C201/205

Rhinology and Paranasal Sinus Committee: Image-Guided SinusSurgery: Applications and Limitations (Interactive) Ralph B Metson MD (moderator); Donald A Leopold MD; David W Kennedy MD; Ralph B Metson MD; Michael S Benninger MD Boston MA; O m a h a NE. Philadelphia PA; Boston MA." Detroit MI

Dr Leopold will present a comparison of image-guided systems. Dr Kennedy will discuss patient selection for image-guided sinus surgery. Dr Metson will discuss pitfalls of image-guideel sinus surgery. Dr Benninger will discuss economic and legal

implications of image-guided surgery. Clinical cases will then be presented to illustrate both the applications and limitations of image-guided surgery for chronic sinusitis. There will be a period for questions and discussion.

OtolaryngologyHead and Neck Surgery Volume 125 Number 2

Research Forum--Tuesday

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8 : 0 0 AM t o 8 : 5 5 AM

8:10 AM

•

A Practical Assessment Algorithm for Diagnosis of Dizziness Steven D Rauch MD (presenter); Erna Kentala MD Boston MA; Boston MA

SESSION A: Vestibular System

A111 Marian Girardi MA (moderator) 8:00 AM

Molecular Geno-phenotypic Analysis of Vestibular Schwannoma Atta Mohyuddin FRCS (presenter); Gareth DGR Evans MRCP; Richard T Ramsden FRCS (ORL); Andrew Wallace PhD; Andrew Read PhD Manchester United Kingdom," Manchester United Kingdom; Manchester United Kingdom; Manchester United Kingdom; Manchester United Kingdom

Problem: To identify the causative NF2 mutation in 14 unilateral vestibular schwannomas and correlate genotype with the clinical characteristics. Our hypothesis is that the correlation with milder phenotype with nontruncating mutations will be strengthened. Further a relative proportion of these cases will represent mosaic forms of the disease, with important implications for reproduction and mutational identification. We believe it will be possible to tailor advice and management in some individuals and families for specific mutations. We further hypothesize that a proportion of these cases will be due to somatic mutation and a further proportion due to mosaicism. Methods: We extracted the DNA product from 14 pairs of blood and tumor. All of the exon 17 of the NF2 gene were amplified by standard polymerase chain reaction methods. The DNA products were analyzed by single strand conformational polymorphism (SSCP) and heteroduplex methods via polyacrylamide gel electrophoresis; and visualized by silver staining technique. The mutant SSCP and heteroduplex products were sequenced. Subsequently the loss of heterozygosity was assessed by PCR and polyacrylamide gel. Results: To date 75% of samples reveal mutations in the tumor and some mosaics. Clinical research is ongoing. Conclusion: Clinical research is ongoing. Clinical Significance: The clinical significance is to observe the mutations of the unilateral vestibular schwannomas and to correlate the genotype with the phenotype. The clinical parameters to monitor the rate of growth of the tumor is the length of the history, and the tumor size on radiological examination and at operation. The tumors are also looked at for the tumor marker Ki-67 (histologically) in an attempt to predict their invasive ability. By predicting the type of mutation and correlating it to a milder or more severe phenotype, one can tailor the management of such patients and genetic counseling. Support: This research is part of an MD thesis. It is partly funded by Professor R T Ramsden, Consultant Otolaryngologist at Manchester Royal Infirmary Hospital, Manchester, UK.

Problem: Over the last decade, one of us (SDR) has developed a practical assessment algorithm for dizzy patients. The approach is based on 2 parameters: the type of dizziness and the temporal characteristics of the dizziness. This algorithm has been applied informally in the clinical setting for several years. The present study was undertaken to test the validity of using these 2 dizziness parameters, type and timing, as the basis for a diagnostic classification scheme. Methods: A prospective blinded methodology was used. Consecutive newly referred dizzy patients were asked to complete a dizziness questionnaire in which they self-report the type and timing of symptoms based on brief definitions contained in the questionnaire text. The questionnaire gives 4 choices for type of dizziness and 4 choices for duration of dizziness; when applicable, more than 1 type and timing could be selected. Questionnaires were completed before seeing the otologist. Clinical diagnoses for each patient were extracted from the office records and compared tO the self-report questionnaire results. MatLab statistical software was used for the data analysis. Results: A total of 102 patients (57 women, 45 men) with a mean age of 55 years (range, 23 to 89) completed questionnaires. Forty patients reported a single type of dizTiness,46 had 2 types, 11 had 3 types, and 5 reported all 4 types. All 4 duration choices (short episodes, moderate episodes, long episodes, and persistent dizziness) were seen in association with each of the 4 types of dizziness. Statistical tests of association were performed to determine if common vestibulopathies (BPPV, vestibular neuritis, labyrinthitis,Meniere's disease, cervicogenic dizziness, migraineassociated dizziness, and dysequilibrium of aging) were associated with predicted patterns of di7~inesstype and timing. Conclusion: A simple classification of dizziness by type and timing can be self-reported by patients using a brief questionnaire. Even complex combinations of different dizzy patterns can be sorted out. The type and timing of dizzy symptoms provides the basis for a diagnostic classification scheme. Clinical Significance: The classification scheme reported here is based on history alone. It is simple and effective. It permits rapid and accurate triage of dizzy patients into diagnostic groups for further work-up and management. 8:20 AM

Vestibular-Evoked Myogenic Potentials In the Diagnosis of Menlere's Disease Sven-Olrik Streubel MD (presenter); John P Carey MD; Uoyd B Minor MD Baltimore MD; Baltimore MD; Baltimore MD

Problem: Although cochlear impairment is routinely estab-

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lished in patients with Meniere's disease, vestibular dysfunction has been more difficult to assess. Caloric and rotatory tests are the tests widely used in the assessment of the vestibular deficits. These studies evaluate only horizontal canal function. More recently, vestibular evoked myogenic potentials (VEMPs) have been applied to the diagnosis of vestibular deficits in patients with Meniere's disease. VEMP responses appear to arise from activation of the sacculus. The goal of this study is to assess the role of VEMPs in the evaluation of vestibular function in patients with Meniere's disease. Methods: VEMP responses were tested in 32 patients (22 women and 10 men; ages, 38 to 80 years) with established Meniere's disease. The stimulus parameters were as follows: duration = 0.1 ms, stimulation rate = I0 Hz, loudness = 60 103 dB NHL. Patients elevated their head to activate the sternocleidomastoid muscles during the recordings. The EMG signal was recorded from surface electrodes overlying the sternocleidomastoid muscle. The analysis time was 80 ms. The signal was bandpass filtered from 20 Hz to 2 kHz. A total of 128 sweeps were averaged. The delivery of the sound stimulus and the analysis of the responses were performed with a Nicolet Spirit evoked potential system. Results: A VEMP response was obtained in 19 of the 32 patients (59%). Low-frequency as well as high-frequency hearing loss of the affected ear was greater in patients who did not show an ipsilateral VEMP response than in patients who had a VEMP response. The 15 patients without a VEMP after stimulation of the affected ear had a mean low-frequency threshold of 61 _ 17 dB, whereas the low-frequency threshold was 48 _ 23 dB in the 17 patients who had a normal VEMP response (P = 0.07). The mean high frequency hearing loss for patients with a VEMP was 47 dB _ 22 dB, for patients without a VEMP the high-frequency threshold was 69 -+ 17 dB (P = 0.0O4). Conclusion: The measurement of VEMP responses is useful in the evaluation of vestibular dysfunction. Our findings suggest that there is a relationship between cochlear damage and the vestibular deficits that leads to altered VEMP responses. A similar conclusion for low-frequency hearing loss was reached by De Waele et al (Am J Otol 1999;20:223-32). We also found that high-frequency (2 to 8 kHz) hearing loss is correlated with the loss of VEMP responses in patients with Meniere's disease. Clinical Significance: VEMP responses may be absent in patients with Meniere's disease in the setting of more severe hearing loss. The loss of the VEMP response may be an early indicator of vestibular dysfunction in these patients. The test may also be useful in following symptoms as well as in predicting control of vertigo. Support: AAO-HNS Foundation Resident Research Grant, National Institute on Deafness and Other Communication Disorders Grants RO1 DC-02390 and T32 DC-00027.

8:30 AM Sidelying as an Alternative to the Dix-Hallpike Maneuver to Test Posterior Canal Helen S Cohen EdD (presenter); Elizabeth Elizalde BS; Melody A Fregia BA; Emily K Murphy BA REEGT Houston 1)(; Houston TX; Houston TX; Houston TX

Problem: The standard test for benign paroxysmal positional vertigo of the posterior semicircular canal is the DixHallpike maneuver (Dix and Hallpike, 1952). In a person with normal neck and trunk range of motion, the maneuver is easily performed. To do the test properly, the patient must have approximately 45 degrees of yaw rotation to either side, and 20 degrees of upward pitch rotation (hyperextension) of the neck. In patients with cervical arthritis or other health conditions causing limitations in passive or active neck or trunk ranges, or conditions causing decreased motor control, the test is difficult, and sometimes impossible, to administer. Therefore, an alternative test is needed. Methods: Subjects were patients referred for diagnostic testing and suspected of having benign paroxysmal positional vertigo by history. Eye movements were recorded with electronystagmography, with eyes closed for 1 minute. Then the patient was assisted to sit up, keeping eyes closed. To do the Dix-Hallpike maneuver, a technician tilted the subject backward rapidly with the head rotated 45 degrees toward the ear being tested. To do side lying one technician applied force through the shoulders to lie the subject on one side, as another technician held the head turned 45 degrees away from the side being tested, so that in the test position the head was positioned roughly nose upward. Results: The dependent measure was velocity of nystagmus. Using a within-groups design, we compared the responses from each test for each ear when the Dix-Hallpike maneuver elicited a complaint of vertigo or the patient gave a history of vertigo when lying on one side. Preliminary analyses, using Wilcoxon matched pairs signed ranks tests, showed no significant difference between the 2 tests. Both tests elicited measurable nystagmus and the velocities did not differ. At the time of this writing we are in the process of collecting a larger sample. Conclusion: These data suggest that sidelying is a valid test of posterior canal function and that it is at least as useful at detecting an impairment in the posterior canal as the DixHallpike maneuver. Clinical Significance: This test expands the battery of tests available for examining the vestibular system, particularly for the common disorder of posterior canal benign paroxysmal positional vertigo. A disadvantage of this maneuver is that a petite staff member is unable to give the test alone. Because patients often turn their heads during testing 2 staff members are needed, 1 to hold the head in position and 1 to hold the shoulders. The advantage, however, is that patients with decreased range of motion and motor control deficits can be

OtolaryngologyHead and Neck Surgery Volume 125 Number 2

accommodated while still keeping the head in the appropriate stimulus position. Support: Supported by NIDCD grant DC03602. 8:40 AM

Magnetic Resonance Imaging: Diagnostic Tool for Central Dysequilibrium George T Moynihan MD (presenter); Sam J Morzo MD; John P Leonetti MD

Chicago IL; Lemont Ib Maywood IL

Pioblem: The objective of this study is to determine the incidence of significant radiological findings on a contrasted MRI of the brain and the usefulness of this data in the definitive work-up of patients with the diagnosis of central vertigo/dysequilibrium. Methods: This study was conducted as a retrospective chart review on all patients presenting to the LUMC Balance Center from July 1999 to November 2000. A total of 116 patients, who had the diagnosis of central dysequilibrium/vertigo and a contrasted MRI of the brain within the last 6 months, were selected for this study. The following data were reviewed and analyzed: age, gender, electronystagmography, and contrasted M R / o f the brain. Results: Of the 116 patients, 74 were female, 42 male; the mean age was 64 year old. Seventy-six percent of the patients were more than 50 years of age. ENG data were available for 69% of the patients. The contrasted MRI results revealed significant findings on 63% of the patients. In those patients older than 50 years of age, 74% had significant MRI findings. In patients less than 50 years of age, 71% had normal MRI findings. Eighty percent of the abnormal findings on MR/were the result of both acute and chronic ischemic cerebral vascular disease. Conclusion: There is no definitive test that is useful in determining the cause of the majority of central dysequilibrium/vertigo. With the knowledge that the cortex contributes a large part to the maintenance of the balance center/vestibular system, the findings of this study support the theory that ischemic cerebral vascular changes could cause a large majority of central dysequilibrium, especially in those older than 50 years of age. Clinical Significance: The use of the M R / i n determining the cause of the majority of central dysequilibrium diagnoses should prove to be cost-effective with the conclusion of an often elaborate and costly work-up for the complaint of dizziness. Support: Department of Otolaryngology, Loyola University Medical Center.

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evaluate vestibular function. This test is considered positive if the patient generates a detectable saccade toward the target after a sudden head impulse. However, there is some testretest variability in the results, and sometimes the test is clinically negative when a vestibular loss is expected. Variability in the clinical results of the Sudden Head Thrust (Halmagyi) test can be explained by detailed analysis of the dynamics of the eye and head during head thrusts. Methods: The Halmagyi test was performed in several vestibular-deficient patients, and the dynamics of the eye and head movements as measured by scleral search coil recordings were carefully analyzed for the presence of posthead thrust saccades, VOR gain, and other compensatory eye movements. Results: The presence and amplitude of the posthead thrust saccade are not reliable measures of the intrahead thrust VOR gain. Many patients make compensatory saccades during the head thrust that mask the true deficiency in VOR gain. These would not be clinically detectable, but explain the variability in results and the sometimes unexpected negative results. This finding has not been previously reported. Conclusion: The posthead thrust saccade is not a good measure of the true VOR gain during this test. Variability in test results may be explained by some patients' ability to generate a clinically undetectable intrahead thrust saccade. Clinical Significance: This study examines the electrical recordings while performing the Halmagyi head thrust and explains why it may not be a sensitive clinical sign for abnormalities in the VOR. 9:00 AM

Discussion 9:05 AM

Poster Session (See pages P109 to P148.) 8 : 0 0 AM t o 9 : 0 0 AM

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SESSION B: H e a l t h S e r v i c e s R e s e a r c h R o o m A I 12 TBA ( m o d e r a t o r )

8:00 AM 8;50 AM

Is the Sudden Head ThrustTest Reliable? Manohar L Bance MD (presenter); Daniel M Kaplan MD; Sukhmlnderjlt S Hehar MBBChir FRCS; David Tomlinson PhD

Halifax Canada; Toronto Canada; Nottingham United Kingdom," Toronto Canada

Problem: The Halmagyi test is commonly used to clinically

Quality of Life for Children wlth Persistent Slnonasal Symptoms David J Kay MD (presenter); Richard M Rosenfeld MD MPH Brooklyn NY; Brooklyn NY Problem: This prospective study validates the SN-6 survey as a measure of change in health-related quality of life (HRQoL) for children with persistent sinonasal symptoms.

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The SN-6 is a parent-completed HRQoL measure of how sinonasal symptoms affect a child's physical, social, and emotional well-being regardless of the symptom cause (eg, infection, obstruction, or allergies). Parents answer 6 domainspecific questions using a 7-point ordinal scale and provide a direct measure of global sinonasal health status using a 10point visual-analog scale. Methods: Parents of children aged 2 to 12 years with persistent sinonasal symptoms for 1 month or longer complete the SN-6 survey at baseline and again after 5 to 7 days to assess test-retest reliability. Additional HRQoL measures are also completed, including the PedsQL survey and an abbreviated rhinoconjunctivitis questionnaire. Other external measures used to assess construct validity include medication usage history and selected physical examination findings. The SN-6, PedsQL, and a change assessment form are again completed at least 4 weeks after initial management, in order to calculate change scores and responsiveness of the SN-6 to clinical changes. Results: Preliminary data of the first 37 patients show a wide range of responses, with the SN-6 summary score of all domains ranging from 1.8 to 5.3 (higher scores indicating more of a perceived problem) with a mean of 3.9 (SD 0.8). The direct global rating of sinonasal QoL (visual-analog scale) showed a mean response of 6.1 (SD 2.0) with a range of I-I0 (higher scores indicating a better QoL). The SN-6 summary score had a modest correlation with the visualanalog scale (r = ---0.33). Calculations of internal consistency, construct validity, and responsiveness to clinical change will be performed after the entire data set for the first 85 patients has been accumulated. Conclusion: The SN-6 survey is easy to use, quick to complete, and shows a wide range of distribution for all domains measured, making it useful for data collection in children with persistent sinonasal symptoms. Clinical Significance: Future validation of the SN-6 as an evaluative survey will provide clinicians, researchers, and administrators with a simple and powerful tool for evaluating HRQoL changes in children with sinonasal symptoms. Support: American Academy of Otolaryngology-Head and Neck Surgery Foundation 2000 Outcomes Research Small Project Award.

8:]0 AM Cost-utility Analysis for Endoscopic Sinus Surgery Pa-Chun Wang MD MSc (presenter); Chia-Chen Chu MSc:

August 2001

(CUR) can be calculated. Cost-effectiveness data provide scientific evidences for outcomes management on common surgical procedures such as endoscopic sinus surgery (ESS). Aims of this study were to evaluate the CUR for ESS, and to analyze the cost-effectiveness of different severity groups. Methods: A total of 202 patients with chronic sinusitis answered a validated chronic sinusitis survey (CSS) before and 1 year after ESS; all patients were evaluated with sinus CAT scan before surgery. Direct health care cost generated by the ESS procedure during the first year after surgery were retrieved from the hospital claim database. The utility gain was defined as change in CSS total score. The cost-utility ratio was defined as cost per utility gain. Patients were stratified by disease severity (stage I through IV) using the Harvard Staging System based on the CAT scan findings. Results: The average total direct cost attributable to ESS in the 1-year period after surgery was $1351.25, with the majority of that cost stemming from the operation fee (43.8%). The after-care expenses during the first year after ESS comprised 29.3% of the total cost. Treating pansinusitis with diffuse polyposis was most costly owing to longer length of stay in hospital, more postoperative medical resource consumption, and higher risk of recurrence. The average utility gain, expressed by the change of CSS total score, was 21.2. The average cost-utility ratio was 2036.1. The cost-utility ratio of 6163.1 for pansinusitis cases was extremely high, partly due to the limited utility gain. Conclusion: The total direct costs in the first year after ESS were not much different among the 4 severity groups. Surgery for recurrent disease and intensive postoperative follow-up incurred a considerable part of the health care expenses. Treating mild and moderate chronic sinusitis was most cost-effective because of their favorable utility gain and relatively low cost. However, there was no linear relationship between the disease severity and their cost-utility ratio. Clinical Significance: Chronic sinusitis is one of the most common surgical disease entities; surgery for its relief consumes a considerable part of global health care expenditures annually. The cost-utility data on ESS generated from this study provided scientific evidences for the prioritization of health care resource allocation. Severity index and outcomes data are the key information needed for a cost-effective approach to endoscopic sinus surgery. Support: Department of Health, DOH89-TD-1101, Taiwan, Republic of China.

Shu-Cheng Uang MSc; Chlh-Jaan Tai MD MSc

Taipei Taiwan (Republic of China); Talpei Talwan (Republic of China); Talpel Talwan (Republic of China); Talchung Toiwan (Republlc of China) Problem: Cost-utility analysis is a widely used method to

8:20 AM

Long-term Outcome of LAUP in Treatment of Simple Snoring Maged M F Abdelkader FRCS (presenter); Dale G Carrlck

a s s e s s the cost-effectiveness of medical interventions. The

FRCS

cost, o u t c o m e s , and clinical process are incorporated into a

Glasgow United Kingdom; Great Western Rd United Kingdom

decision-analytical model and the expected cost-utility ratio

Problem: Simple snoring is a common problem. Laser

OtolaryngologyHead and Neck Surgery Volume 125 Number 2

surgery of the palate is a well-known treatment modality. Long-term outcomes after laser-assisted uvulopalatopharyngoplasty (LAUP) are to be evaluated. Methods: 145 patients who snore were reviewed 1 year after LAUP. They underwent surgery for distressing simple snoring. The technique was the same in all of them. Complications and patient satisfaction are recorded. Results: 110 patients were happy I year postoperatively. Maximum improvement of snoring was observed 8 weeks postoperatively and declined gradually over time. Mean pain score peaks in the 4th week postoperatively and then declines. 70% of patients considered this surgery as severely painful. Other complications are discussed as well. Conclusion: LAUP is a useful tool in palatal surgery of snoring. Complications and most important long-term outcome must be discussed in depth with the patient. Clinical Significance: Short-term improvement after LAUP is not indicative of the long-term outcome.

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easily applied and shows that lateral rhinotomy and medial maxillectomy is effective in treating advanced stage inverted papilloma. Clinical Significance: Review of the literature clearly shows that severity of disease is not comparable among patients treated with open and endoscopic surgery. Adoption of a staging system for inverted papilloma to allow evaluation of surgical techniques is now required. We support the further evaluation of the Krouse staging system to meet this need and reiterate the claim that medial maxillectomy remains the gold standard in treatment for advanced stage inverted papilloma. 8:40 AM

Quality of Life after Systemic Amlnoglycoslde Vestibulotoxicity Sukhminderjit S Hehar MBBChir FRCS (presenter); Marc Alexander Thorp MD; Daniel M Kaplan MD; John A Rutka MD FRCS

8:30 AM

Nottingham United Kingdom; Cornerbrook Canada; Toronto Canada; Toronto Canada

Staging of Inverted Papilloma Related to Outcomes Grant G Grant MB ChB BSc (presenter); Akhtar Hussoin FRCS Aberdeen United Kingdom; Aberdeen United Kingdom Problem: En-bloc resection with lateral rhinotomy and medial maxillectomy is regarded as the current gold standard treatment for inverted papilloma. More recently an endoscopic approach has been advocated but controversy exists over the limitations of this technique. Interest has arisen in developing a staging system for inverted papilloma to allow evaluation of surgical techniques objectively based on severity of disease. The system presented by Krouse segregates patients into categories based on extent and location of disease. The aim of this study is to apply this classification to patients who underwent operative treatment for inverted papilloma and to correlate this with clinical outcomes. Methods: We performed a retrospective analysis of patients treated by the corresponding author for inverted papilloma between 1995 and 2000. All patients were preoperatively assessed with CT imaging and endoscopic evaluation. Patients were restaged according to the Krouse system and data collected on surgical outcomes and tumor recurrence. Only cases with a minimum follow-up of 12 months were included in the analysis. Results: Nine patients with inverted papilloma were identified, 6 males and 3 females. Their ages ranged from 39 to 75 (mean, 61) years. The duration of follow-up ranged from 12 to 60 months with a mean of 35 months. All of the patients were treated with lateral rhinotomy and medial maxillectomy. Three patients had sphenodotomy, and 6 patients underwent sphenoethmoidectomy. None of the 9 patients had any tumor recurrence. All 9 patients were staged retrospectively as T3 according to the Krouse system. Conclusion: The staging system presented by Krouse is

Problem: To measure the quality of life of patients who have vestibulotoxicity from systemic aminoglycoside administration. Methods: Study Design: Patient self-assessment using the short form 36 (SF-36) multidimensionalquality of life health questionnaire, and the dizziness handicap inventory (DHI). Setting: Tertiary referral neurotology unit. Results: SF-36 mean values for our patients and Canadian normative data, in brackets, are physical functioning 21 (85.8), role functioning 18.3 (82.1), bodily pain 56.6 (75.6), general health 41.4 (77), vitality 41.3 (65.8), social functioning 48.3 (86.2), role emotional 71.1 (84), and mental health 60.7 (77.5). Scores on the DHI gave a mean of 54.5 (standard error 7.4). A score of 0 suggests no handicap, and a score of 100 indicates significant self-perceived handicap. The mean score for our patients is actually greater than that for patients experiencing continuous dizziness previously reported. Conclusion: These results indicate the very considerable handicap and reduced quality of life perceived by patients who have suffered from vestibulotoxicity following systemically administered aminoglycosides. This is, however, a snapshot and further interval testing would be of value to follow the patients' rehabilitation. Clinical Significance: These results are important as they help to emphasize the magnitude of the problem such patients face. It is imperative that the message should get out to practicing physicians and surgeons that these antibiotics should only be used when there is no alternative in a seriously ill patient. There are also medicolegal and long-term care implications from the results of this study, since normal balance function may not be regained for years, if at all. Support: Dr Hehar was partly funded by the Thomas Wickham Jones Foundation Fellowship.

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August 2001

8:50 AM

8;00 AM

Evldence-Based Medicine in Otolaryngology Journals

Orbital Blowout Fracture: Experimental Evidence for the Pure Hydraulic Theory

Boris L BentsianovMD (presenter); Brooklyn NY

Problem: To assess, within the context of evidence-based medicine (EBM), the levels of supporting evidence for therapeutic recommendations made in leading otolaryngology journals. Methods: Cross-sectional survey of clinical research articles published in 1999 in 4 high circulation otolaryngology journals. Outcome Measures: Study design methodology and level of evidence for clinical research articles with therapeutic recommendations. Outcomes were stratified by type of recommendation (positive vs negative) and by study focus (medical vs surgical therapy). Results: Of the 1019 articles identified, 737 (72%) were clinical research and 268 (36%) made therapeutic recommendations. Median sample size was modest (27 subjects), with only 38% of studies reflecting planned research and 22% including an internal control or comparison group. Positive studies were 20 times more prevalent than negative ones, but were 69% less likely to have an internal control group (P = 0.042) and 93% less likely to include confidence intervals (P = 0.020). Moreover, the level of evidence for positive studies was lower than for negative studies (P = 0.037), with twice as many negative recommendations supported by analytic research. Similarly, the level of evidence for surgery was lower than for medical therapy (P < 0.001), with 3 times as many medical recommendations supported by analytic research. Conclusion: Most therapeutic recommendations in otolaryngology journals are based on descriptive case series (80%) and least often on randomized controlled trials (7%). A dual standard appears to exist for negative vs positive studies and for medical vs surgical recommendations. Greater scrutiny of the breadth and quality of evidence levels supporting therapeutic recommendations is likely to occur as the popularity of, and demand for, EBM increases. Clinical Significance: Each day otolaryngologists use published material in accepted peer review journals to guide clinical decisions for their patients. We evaluate the quality of the evidence being used during each patient encounter in hopes of improving physicians clinical application of its conclusions. 9:00 AM

Discussion 8 : 0 0 AM t o 8 : 5 5 AM

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SESSION C: Plastic a n d Resconstructive Surgery Room A 2 0 9 TBA ( m o d e r a t o r )

John Kilde MD (presenter); John Rhee MD; FrankA Pintar PhD; Narayan Yoganandan PhD New Berlin WI; Milwaukee WI; Milwaukee WI; Milwaukee WI

Problem: The mechanism of injury and the underlying biomechanics of orbital blowout fractures remain controversial. The hydraulic theory proposes that a generalized increased orbital content pressure results in direct compression and fracturing of the thin orbital bone. The objective of this study was to examine the pure hydraulic mechanism of injury by eliminating the factor of globe-to-wall contact and its possible contribution to fracture thresholds and patterns. Methods: Six fresh human cadaver specimens were used for the study. In each cadaver head, 1 orbit was prepared to mimic normal physiologic conditions. The second orbit served as a hydraulic control, whereby the globe and orbital contents were exenterated and replaced by a saline-filled balloon at physiologic intraocular pressure. A 1 kg pendulum was used to strike the cadaver heads. Drop heights ranged from 0.2 to 1.1 m (1960 mJ to 10,780 mJ energy). Direct visualization, high-speed video, and CT scans were used to determine injury patterns at various heights between the 2 orbits. Results: A fracture threshold was found at a drop height of 0.3 m (2940 mJ). Fracture severity and displacement increased with incremental increases in drop height (energy). Fracture displacement, with herniation of orbital contents, was obtained at heights above 0.5 m (4900 mJ). Isolated orbital floor fractures were obtained at lower heights, with medial wall fractures occurring in conjunction with floor fractures at higher energies (> 6860 mJ). The globe intact side and balloon (hydraulic control) side showed nearly identical fracture patterns and levels of displacement at each drop height. Conclusion: This study provides support for the hydraulic theory and evidence against the role of direct globe-to-wall contact in the pathogenesis of orbital blowout fractures. In addition, the orbital floor was found to have a lower threshold for fracture than the medial wail. Preliminary threshold values for fracture occurrence and soft tissue displacement were obtained. Clinical Significance: Modeling of orbital blowout fractures has been proposed to provide a basis for quantifying and qualifying fracture patterns and the necessary forces and energy to produce these fractures. Research on identifying factors that correlate to injury patterns may improve the ability to prevent, minimize, or more effectively treat this type of injury. 8:10 AM

Tissue Engineering of Cartilage: Differential Site Specific Chondrocyte Behavior Nimesh N Patel FRCS(presenter); Christopher L Murphy PhD; Lee DK Buttery PhD; Julia M Polak MD DSc FRCPath; Nell Samuel TolleyMD FRCS

OtolaryngologyHead and Neck Surgery Volume 125 Number 2

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

Problem: Tissue engineering offers an alternative to using artificial implants or organ transplantation. To successfully create tissue-engineered cartilage for facial, head, and neck reconstruction, understanding cell source cell biology is essential. We may thus determine the ideal cell source for the development of constructs. It is unclear whether differences in the donor site of cell sources have a significant impact on the characteristics of engineered constructs. We investigated the specific conditions influencingthe growth and differentiation of chondrocytes from different sites with reference to cartilage tissue engineering. Methods: Chondrocytes were isolated from human cartilage harvests from different anatomic sites using enzymatic degradation and cultured as monolayers. Samples were analyzed to assess rate of achieving confluence and optimum seeding densities. Cell harvest rates and viability was assessed by trypan blue dye exclusion and hemocytometry. Cell phenotype was assessed by photomicroscopy and analysis of matrix molecules produced in culture, using histological staining (Alcian blue, elastic van Geison) and immunohistochemistry (immunoperoxidase technique to detect expression of collagens, proteoglycans, and glycosoaminoglycans). Results: In vitro chondrocyte cell behavior was analyzed from human nasal septal, tracheal, articular, and conchal cartilage sources. There were differences in the cell harvest rates for the different tissues. There was no significant difference in cell proliferation rates. In monolayer culture chondrocytes from different types of cartilage expressed matrix molecules with different profiles. This was, as might be expected, most marked where chondrocytes were sourced from different histological types of cartilage. Conclusion: Proliferation characteristics of chondrocytes from different cartilage sources are not significantly different. However, their differentiation and phenotypic expression does vary. Clinical Significance: These findings may have significance in identifying the appropriate source of cells to engineer specific tissues for reconstruction in facial plastic and head and neck surgery. 8:20 AM

Tissue Engineering of Autologous Cartilage Grafts in Reconstructive Surgery H H Naumann, MD (presenter); Andreas Naumann MD; James M Coticchla MD; James Dennis PhD; J Aigner MD; James E Arnold MD; Ernst Kastenbauer MD Munich Germany; Munich Germany; Rocky River OH; Cleveland OH; Cleveland OH; Cleveland OH; Munich Germany

Problem: In reconstructive surgery there is an increasing demand for replacements to fill defects, especially cartilage defects of the nose and auricle. Tissue engineering of autolo-

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gous cartilage grafts in reconstructive surgery is mainly based on the use of bioresorbable and preshaped scaffolds in the form of fiber structures as cell carriers for a 3-dimensional culture of chondrocytes before in vivo implantation. We investigated the behavior of human auricular chondrocytes cultured on bioresorbable scaffolds in form of nonwoven fleece structure by using morphologic, histochemical, and immunohistochemical methods. Methods: Auricular chondrocytes, harvested from a tiny biopsy from patients during otologic surgery were enzymatically isolated, multiplied under conventional culture conditions and expanded for 4 weeks before the cells were loaded onto bioresorbable scaffolds based on polylactic/polyglycolic copolymer. The cell-material constructs were subcutaneously implanted in athymic nude mice for 6 weeks to generate cartilage tissue in vivo. Scanning electron microscopy revealed that the chondrocyes attach well on the fleece fibers, additionally colonizing the interfibrillar spaces as a result of the proliferative activity of the cells during culture. Results: Reconstruction of the 3-dimensional cell culture on the bioresorbable material with confocal laser scanning microscopy demonstrated about 90% viability of homogenously distributed cells in the bioresorbable material. Immunohistochemical data on cryostat sections indicated the expression of cartilage specific collagen type II as well as proteoglycans. Conclusion: The results reveal the excellent properties of bioresorbable materials for culturing human auricular chondrocytes. The advantage of this cell carder is the attachment of the cells without any adhesion factors. This experience with human chondrocytes cultured on nonwoven bioresorbable material as a cell carrier opens promising possibilities of cartilage tissue engineering for reconstruction of cartilage defects in the future. Clinical Significance: The availability of tissue-engineered cartilage of similar morphologic and physical properties would be beneficial in reconstruction of auricular defects, microtia repair, repair of septal defects, and could also be used as augmentation ==rafts in rhinoplasty. The advantage of this tissue-engineered cartilage over autologous grafts would include eliminating the need and morbidity of donor site harvest. This technique would provide cartilage grafts of the same morphologic properties of the tissue being reconstructed, and could be fashioned in any preformed geometrical shape as dictated by the bioresorbable scaffold. Support: Fidia biotechnologies provide the scaffolds for tissue seeding. 8:30 AM

Smad3 Deletion Decreases Skin Reaction and Improves Healing in Irradiated Skin Alidad Arabshflhi MD (presenter); Anita Roberts PhD; James B Mitchell PhD: Angelo Russo MD PhD; Christopher Major PhD

¢.O LU I=--

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Research ForumMTuesday

Baltimore MD; Bethesda MD; Bethesda MD; Bethesda MD; Bethesda MD

Problem: Surgery on irradiated tissue is associated with significant postoperative morbidity, including impaired healing, tissue breakdown, and fistula formation. Loss of Smad3, an intracellular mediator of transforming growth factor [3 (TGF-~), has recently been shown to improve wound healing in nonirradiated models. It is hypothesized that deletion of Smad3 will also alter response of skin to radiation and improve wound healing in an irradiated model. Methods: Radiation was presented in 2 doses, 30 and 45 Gy, to flank skin of 3 types of mice: Smad3 null (KO), obtained by targeted disruption of the Smad3 gene via homologous recombination, heterozygote (HT) for Smad3, and wild type (WT) with both genes present. Skin reaction was grossly evaluated from days 0 to 40 postirradiation. On day 40 the mice received a 1 cm incisional wound to their flanks. The skin was harvested 3 to 4 days later for histologic examination and assessment of the healing process. Results: KO mice demonstrated a decrease in epithelial layer thickness as compared with WT and HT groups at both radiation doses. Tissue reaction to radiation in the KO mice was less severe, more delayed, and more rapidly resolved. In addition, wound healing in KO mice was characterized by a more rapid rate of epithelial migration and wound coverage and a decrease in cellular chemotaxis; fewer inflammatory and fibroblast cells were noted. Conclusion: As demonstrated by the decrease in epithelial hypertrophy, Smad3 deletion provides a degree of radio-resistance to skin during the acute phase of radiation response. Smad3 deletion also improves wound closure by accelerating epithelial coverage of wounds and by decreasing inflammatory cell migration to wounds. This leads to the release of fewer cytokines, which translates to less fibrosis and scarring in healed wounds. Clinical Significance: Because deletion of Smad3 in animals improves wound healing in radiation-impaired skin, it can be suggested that inhibiting Smad3 in nonaltered skin may lead to less radiation reaction and an enhancement in the healing process. Application of such an inhibitor to human skin could potentially help decrease postoperative morbidity in radiated head and neck patients.

Support: Department of Radiation Biology, National Cancer Institute, NIH Laboratory for Cell Regulation and Carcinogenesis, National Cancer Institute, NIH Department of Otolaryngology Head and Neck Surgery, University of Maryland Medical Center. 8:40 AM

Psychosoclal Aspects of Plastic Surgery Hamed Kabiri MD (presenter) Tehran Iran

Problem: The close link between the disciplines of plastic surgery and psychiatry necessitates recognition of psychosocial problems of patients cared for by plastic surgeons. Methods: The study was carried out to analyze the psychosocial problems of patients requiring plastic surgery referred to the clinics of Tehran University of Medical Sciences. One hundred patients were randomly chosen from those referred during the summer of 1999. Data were collected using standard tests for studying patients' adjustment to illness and the impact of various social factors, and used standard instruments to study health and quality of life. Standardized tests were performed to detect depression and DSM IV (Diagnostic and Statistical Manual of Mental Disorders) criteria were used for diagnosing posttraumatic stress disorder. Results: The results not surprisingly showed that the majority of these patients had serious psychosocial problems. Of various statistically valid results, the prevalence of posttraumatic psychologic problems (94%), feelings of embarrassment, and aversion to publicity (61%) were of great significance. The results show that Iranian plastic surgical patients have unique concerns. For example, the effect of their appearance on arranging a desirable marriage proved of great importance. Conclusion: The study stresses the significance of recognizing psychosocial aspects of treatment and the incorporation of specialists in social sciences within the medical team responsible for every plastic surgical patient. Clinical Significance: Previous studies of psychosocial issues in plastic surgical patients derive primarily from northern European and US patients. This report is based on a population of plastic surgery patients not previously studied. Support: Department of Plastic Surgery Tehran University of Medical Sciences.