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What’s new in otolaryngology-head and neck surgery
What’s New in Otolaryngology–Head and Neck Surgery Paul R Lambert, MD, FACS “What’s New in Surgery” evolves from the contributions of leaders in each of the fields of surgery. In every instance the author has been designated by the appropriate Council from the American College of Surgeons’ Advisory Councils for the Surgical Specialties. This feature is now presented in issues of the Journal throughout the year.
A number of important advances occurred in otolaryngology–head and neck surgery last year. Clinical and basic research efforts throughout the specialty continue to be robust, resulting in a variety of new strategies for patient care. Some of the major developments within each of the subspecialty areas—head and neck oncology, otology-neurotology, rhinology and sinus surgery, facial plastic and reconstructive surgery, and general otolaryngology—will be highlighted.
therapy.3,4 Ongoing trials should help elucidate the optimal dosage and delivery protocol, and provide additional patient accrual to document efficacy. Most clinicians rely primarily on the patient’s history for diagnosing Meniere’s disease, eg, episodic vertigo, hearing loss, tinnitus, and aural fullness. Corroborative studies include an abnormal audiogram (typically a unilateral and predominately low-frequency sensorineural hearing loss), decreased vestibular function by electronystagmography, and abnormal electrocochleography (increased summating to action potential ratio). A definitive test for defining the histologic correlate of this disease, increased endolymphatic fluid, termed endolymphatic hydrops, has been elusive. Recently, Niyazov and colleagues5 demonstrated endolymphatic hydrops in a guinea pig by MRI scanning.5 They used a standard approach of inducing hydrops by surgically obliterating the endolymphatic sac in the experimental animals. Various doses of gadolinium were administered and repeat scanning using a 1.5-T field strength was performed at intervals over an 8-hour period to define optimal inner ear resolution. The investigators found that gadolinium was preferentially taken up by the perilymph, and that the greatest differentiation between perilymphatic and endolymphatic fluid spaces occurred 4 hours after administration of the contrast agent. They were able to obtain good-quality images showing endolymphatic hydrops, and histologic examination confirmed the MRI findings. The ability to objectively and nonevasively diagnose Meniere’s disease has great clinical applicability. Progress continues to be made in developing vaccines against the principal bacterial pathogens causing acute otitis media: Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis.6 Prevnar, a heptavent pneumoccal vaccine became available
Otology-neurotology
Treatment of various inner ear pathologies with pharmaceutical agents delivered by direct, rather than systemic, pathways continues to be an area of active investigation. Round window membrane permeability is the link between the middle ear space and the cochlear fluids, permitting these new treatment paradigms. A number of studies have documented the efficacy of intratympanic gentamicin for Meniere’s disease.1 The focus is now shifting toward middle ear steroid infusion for sudden sensorineural hearing loss, a condition traditionally treated with high-dose oral steroids for 1 or 2 weeks. Intratympanic administration is attractive because side effects from systemic absorption are essentially eliminated. In addition, animal studies have consistently shown perilymph steroid concentrations higher after intratympanic injection versus intravenous administration.2,3 The initial clinical studies have been promising. In cases of sudden sensorineural hearing loss, hearing recovery appears at least as great as it is after oral steroid Received March 21, 2002; Accepted March 21, 2002. From the Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC. Correspondence address: Paul R Lambert, MD, FACS, Medical University of South Carolina, Department of Otol/HNS, 150 Ashley Ave, Charleston, SC 29425.
© 2002 by the American College of Surgeons Published by Elsevier Science Inc.
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Abbreviations
CSF HNSCC ICP
cerebrospinal fluid head and neck squamous cell carcinoma intracranial pressure
in mid 2000 and is being widely used in children less than 2 years of age. Early studies have shown a 6% to 7% overall decrease in the incidence of otitis media, and a one-third to two-thirds reduction in cases caused by S. pneumoniae.7,8 Vaccines directed at nontypeable H. influenza and M. catarrhalis are currently being studied in animal models. Preliminary results show that the vaccines under investigation induced a strong immune response and good bactericidal activity.9,10 Given the fact that acute otitis media is the most common reason children receive antibiotics, continued success in this area will have a profound effect on middle ear infections and their sequelae.6 The majority of patients with sensorineural loss do not seek amplification or have not been successful hearing aid users. Frequent complaints include disruptive feedback (“squeal”), poor sound quality in background noise, and discomfort from ear canal occlusion. Digital circuitry is very effective in reducing background noise and improving listening comfort. A microcomputer in the hearing aid is programmed to distinguish unwanted background noise from speech. When the background noise is a steady-state type such as road noise or machinery, the hearing aid is very adept in turning down amplification in those frequencies while maintaining amplification in the other frequency bands where speech is dominant. Background noise can also be minimized by directional microphones, which are designed to be less sensitive to receiving sound from behind the listener.11 Recent microphone and digital technologies have resulted in the development of an active directional microphone. With this technology the microcomputer continually assesses the azimuth of the highest source of noise in the rear, and then automatically configures the microphone to be least sensitive at that general location. As the noise source moves, the microphone tuning changes. Another approach to amplification has been the development of semiimplantable hearing aids. In the last 18 months, two partially implanted hearing aid systems
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have completed clinical trials in the United States and have been FDA approved. Both the SOUNDTEC (Soundtec, Inc) and the Vibrant Soundbridge (Symphonix Devices, Inc) provide amplification by electromagnetic transmission of sound.12, 13 With the Soundtec device, a neodymium–iron–boron magnet is implanted at the incudostapesial joint and driven by an electromagnetic coil placed within an ear canal mold. With the Vibrant Soundbridge, an electromagnetic coil is attached to the incus and hard wired to a receiver implanted on the mastoid bone. Both devices use a sound processor, amplifier, and electromagnetic transmitter coil to vibrate the implanted magnet, and the ossicular chain. Both semiimplantable devices provide an average 10-dB improved functional gain across frequencies 250 to 6,000 Hz compared with an optimally fitted traditional hearing aid.13,14 Although standardized testing has not demonstrated significantly improved speech perception in quiet or in noise, most recipients have reported greater ease in daily communication. Roland and associates,14 for example, report that the Soundtec patients note a higher fidelity of sound, and greater than 95% prefer the device over their traditional hearing aid. Head and neck oncology Head and neck reconstruction
Haughey and coworkers15 reviewed their series of 241 head and neck free flap reconstructions over a 10-year period. This analysis further confirms the reliability and usefulness of free tissue transfer for head and neck defects and provides valuable new information related to variables important to length of stay, flap survival, and major medical complications. Multivariate analysis revealed that cigarette smoking and volume of crystalloid greater than 7 L intraoperatively correlated with overall flap complications. In this series, the fibula free flap was used in 46 of the 241 patients (19%); the radial forearm was the used in 96 (40%). The radial forearm flap has received more recent comparison to the ulnar forearm flap in a study of 75 patients undergoing 51 ulnar and 24 radial flaps.16 Flap survival and recipient site healing were not different, but the ulnar flaps had a lower donor site complication rate, shorter pedicle, were less hairy, and had thinner subcutaneous tissue. Controversy remains in the preoperative evaluation for vascular patency of the lower extremity vessels before fibula free flap harvest. Lorenz and Esclamado17 re-
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ported on 29 patients evaluated by magnetic resonance angiography rather than conventional angiography. This evaluation resulted in changing the side of harvest in four patients (12.5%) and excluding that site of flap harvest in three (9%). Correlation with palpable distant pulses and proximal patent arteries was not reliable in this series. Futran and associates18 have reported on the successful transfer of a fibula osteocutaneous free tissue reconstruction of the midface in 26 of 27 patients, with all achieving oral intake and intelligible speech. Secondary osseointegrated implant placement remains a significant advantage of the fibula flap over other flaps in this region and was further confirmed in this study. Expanding use of the acellular dermal graft (AlloDerm; Lifecell Corp, Branchburg, NJ) has been evaluated in the donor site for radial forearm free flaps by Sinha and colleagues.19 Of 52 consecutive patients using the thick (800 to 900 m) graft material without split thickness skin graft, there were no tendon exposures, and the only wound complications were 5 cases of seroma formation. Refinement continues in techniques of frontal sinus obliteration. Parhiscar and Har-E120 reported the use of a vascularized pericranial flap in 10 patients. Only one patient had a persistent headache (1 month) and there was one asymptomatic recurrence of a neofrontal sinus with median 3-year followup. A novel technique of frontal sinus obliteration using hydroxyapatite cement combined with a pericranial flap separation of frontal and ethmoid sinuses was reported by Petruzzelli and Stankiewiecz.21 In three patients with traumatic frontal sinus fractures and eight with recurrent frontal sinusitis, the technique was successful in all but one, with a mean followup of 27 months. Six of the eight with recurrent frontal sinusitis had previously failed the classic osteoplastic flap obliteration technique. Diagnostics
The use of sentinel node biopsy in head and neck melanoma has not yet met with universal acceptance because of exposure and access to areas of the head and neck, potential for nerve injury, proximity of the primary lesion to lymph nodes, and variable lymphatic drainage. A recent report by Jansen and coworkers22 looked at 30 patients undergoing lymphoscintigraphy and sentinel node biopsy for cutaneous melanoma of the head and neck. A sentinel node was identified in 27 of
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30 patients but was positive in only 8 patients. Of the 19 patients with negative sentinel node biopsies, 4 developed recurrences, with 2 having involved nodes at that time. The authors suggest further investigation before this procedure can become the standard of care in managing head and neck melanoma. The use of lymphoscintigraphy and sentinel node biopsy in head and neck squamous cell carcinoma remains an unproved technique, although clinical trials are being developed to analyze its use.23,24 Taylor and associates25 evaluated nine previously untreated patients with oral and oropharyngeal squamous cell carcinoma with sentinel node biopsy followed by neck dissection. All had sentinel nodes identified; only four were positive and represented the only involved lymph nodes at the time of neck dissection. In a study of 1,444 patients treated from 1970 to 1998 with malignant melanoma of the head and neck, Fisher26 identified a 12% recurrence rate in the regional lymph nodes as the initial site of recurrence. In addition, occult disease was found in 11% of patients who underwent elective neck dissection. Patients in this series had an improved survival when delayed (recurrence in the neck at least 3 months after diagnosis at the primary site in previously undissected neck) lymph node dissection was performed over elective or therapeutic neck dissection. Surgical techniques
Continued improvements in quality of life in head and neck cancer patients necessitates improvement in postsurgical and radiation morbidity, including xerostomia. Agents such as Ethyol (Medimmune Oncology, Gaithersburg, MD) have provided benefit in the postoperative radiation patient, but surgical techniques such as submandibular gland transfer to a nonirradiated region by microvascular techniques may also offer significant benefit. This technique was evaluated in a rabbit model and technical details were modified to result in a successful transfer and retransplantation with histologic confirmation of survival.27 Transoral techniques continue to be used successfully for submandibular disease, especially in centers outside the United States. Zenk and associates28 report on 231 patients with submandibular lithiasis who underwent a transoral approach with preservation of the submandibular gland, resulting in stone clearance and resolution of symptoms in 91%.
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Endoscopic repair of a Zenker’s diverticulum continues to involve new techniques with the potential for lower morbidity and less invasive procedures. Thaler and coworkers29 report on their experience with endoscopic staple-assisted esophagodiverticulostomy in 23 patients. The factor limiting success of the procedure appears to be inadequate exposure endoscopically, resulting in conversion to an open approach in seven patients (23%). Two other patients treated endoscopically had persistent dysphagia postoperatively, with confirmed residual diverticulum. One of these underwent successful repeat endoscopic repair. No complications were noted in any of the patients. Smith and associates30 compared the endoscopic stapling technique with the open procedure in a random sample of eight patients in each group and found that the endoscopic procedure resulted in a statistically significant reduction in operative time, hospital stay, and time to resume oral feedings.30 Treatment
The events of 2001 have heightened our awareness of such diseases as anthrax, and Wirtschafter and colleagues31 presented a timely reminder on the ENT manifestations of oropharyngeal anthrax. This site of potential involvement may present with signs and symptoms similar to other pharyngitis-related problems, with symptoms including fever, dysphagia, neck pain, hoarsness, cough, globus, dyspnea, and neck swelling. Examination might reveal reddish-purple lesions or pseudomembrane formation that might progress to ulceration and necrosis. Increasing emphasis has been placed on the potential viral etiologies of oral and oropharyngeal squamous cell carcinoma, particularly the role of human papilloma virus as an etiologic factor. In addition to its role in the pathogenesis of these cancers, a study by Schwartz and associates32 reveals that the presence of HPV-16 type DNA can be associated with a favorable prognosis when evaluated in 254 patients with primary oral cancer.32 With the recent human genome project’s completion, development continues in the areas of gene therapy for head and neck squamous cell carcinoma (HNSCC). Clinical trials have been completed in viral mediated gene therapy for head and neck cancer. Li and associates33 report on a novel nonviral gene delivery system using lipid formulated mIL-2 and polymer-formulated mIL-12 in an HNSCC murine model.33 This gene
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transfer was successful in generating potent antitumor responses in this model. Recent interest in molecular targets involved in HNSCC includes studies evaluating vascular endothelial growth factors that have been found to interact with cyclooxygenase-derived prostaglandins in angiogenesis. Cycolooxygenase-2 (COX-2) is an enzyme that can be induced by inflammation, growth factors, and oncogenes. Jaeckel and colleagues34 identified a potential role of COX-2 in HNSCC both in primary tumors and metastatic tumors compared with normal tissue in human subjects. Pediatric otolaryngology
Tonsillectomy is one of the most common procedures performed in pediatric otolaryngology. Of the multiple techniques available, blunt dissection and electrodissection (bovie) tonsillectomy are most commonly performed. Decreased operative time and blood loss has made the electrodissection tonsillectomy popular. Postoperative pain remains the major disadvantage of the electrodissection technique. Although less painful, operative blood loss and increased operative time continue to be problems for the blunt dissection technique. A new technique, the ultrasonographic dissection coagulator (harmonic scalpel) combines hemostasis and speed of the electrodissection technique with a reduction in postoperative pain that is superior to both other techniques. This is possibly because of the low secondary heat (⬍100°C) and minimal lateral thermal damage (1.2 mm) created by the vibratory motion of the harmonic scalpel blade. Prospective studies have confirmed decreased postoperative pain and earlier return to normal activity without any increase in perioperative bleeding.35,36 Both studies conclude that the harmonic scalpel offers advantages over the other popular tonsillectomy technique. Accurate assessment of congenital and acquired laryngotracheal anomalies continues to challenge pediatric otolaryngologists. Although laryngoscopy and bronchoscopy remain the definitive diagnostic techniques, their accuracy is limited when the luminal diameter of the airway is too narrow to admit the smallest of telescopes. The surgeon is left unable to definitively plan reconstructive airway surgery. MRI technology initially held promise in the area of airway imaging, but has been limited by its susceptibility to motion artifact and the need for patient sedation. The advent of spiral CT has
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improved the two-dimensional and three-dimensional reconstruction of the airway. The accuracy of the technique continues to be improved by virtual endoscopy software and by mathematical modeling techniques of tubular cavities. Triglia and coworkers37 have used the new mathematical modeling programs to create antegrade and retrograde endoscopic views of the airway and a three-dimensional reconstruction of the airway. This technique accurately predicted the length of nine stenoses too narrow to be completely assessed endoscopically. Earlier reports of virtual endoscopy software demonstrated an approximate 10% discrepancy in stenosis-tolumen ratio compared with endoscopy.38 Continued development of this technology should allow for accurate, unsedated evaluation of many critical pediatric airways. Facial plastic and reconstructive surgery
Esthetic facial procedures continue to evolve at an astounding rate. With the burgeoning demand among younger patients, there has been less tolerance for “down time.” So procedures that require minimal recovery but that ultimately achieve similar results are gaining popularity. For example, with regard to the aging face, the focus has been on elevation of the sagging malar fat pad for midfacial rejuvenation. The gold standard in the past 5 to 10 years has been the deep plane facelift, but the typical recovery is at least 7 to 10 days away from moderate activity. The use of tissue adhesives in facelifting can provide for avoidance of drains, lessened edema, decreased risk of hematoma formation, faster healing, and earlier return to work.39 A minimally invasive percutaneous technique to directly address the sagging of the ptotic malar fat pad was recently described, with excellent results.40 The authors used a subcutaneous polytef (Gore-Tex; WL Gore and Assoc, Flagstaff, AZ) patch to suspend the midface and efface the melolabial fold, obviating the need for facelift incisions and extensive dissection, minimizing recovery time. Adjunctive aging face procedures, originally used to augment and enhance the results from face lifting, have undergone recent refinements. Nonablative methods of treating photodamaged skin have become increasingly popular. Using specially designed lasers or other modalities, attempts are made at epidermal preservation by concentrating the laser energy in a zone approximately 100 to 400 m from the skin surface, which contains most of the solar elastosis in photodamaged skin.41 The search for nonablative methods of facial resurfacing has
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been fueled by the desire to avoid postoperative erythema and pain, expected sequelae of traditional laser resurfacing.42 The chemical peel, the oldest method of resurfacing, has come full circle. Refinements in technique yield a more predictable depth of penetration, with faster healing times, less pain, and at significantly less cost compared with ablative or nonablative treatments. Botulinum toxin type A (BTX-A) has been used for several years for off-label cosmetic use in facial wrinkles. It is especially useful in areas of the face where other surgical procedures might be less successful, such as crow’s feet, glabellar frown lines, horizontal forehead lines, and mentalis muscle strain. Especially useful in patients who have developed antibodies to botulinum toxin type A, another subtype of botulinum toxin, type B, has recently become available. The FDA is reportedly near granting approval to botulinum toxin type A for limited cosmetic indications. Two notable developments in head and neck reconstructive surgery deserve mention. The use of free tissue transfer in complex three-dimensional reconstruction of head and neck cancer ablative defects is gaining acceptance as standard of care, supported by prospective outcomes studies.43 There is increased recognition of the benefits of early establishment of integrity of the traumatized facial skeleton, rather than allowing secondary intention healing to occur before definitive reconstruction. Emphasis on the principle of early establishment of skeletal support through rigid fixation and attention to meticulous soft tissue suspension in facial trauma should improve functional and cosmetic outcomes. Laryngology
Normal voice production results from complex modifications to the sound produced at the level of the vocal folds through dynamic shaping of the vocal tract. Characteristic vocal tract anatomy, together with modification and shaping of the source sound, give the speaker a unique vocal resonance. This resonance, together with other attributes of voice production (ie, voice quality, pitch, and prosody) contributes to the individuality and character of the patient’s preoperative voice. Surgical disruption to the vocal chamber that accompanies oropharyngeal cavity resections often results in aberrant modifications in vocal resonance, contributing to the perceived abnormality of the postoperative voice. Historically, evaluation of voice and speech produc-
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tion after operations on the head and neck has focused on perceptual judgments of specific features of voice and speech such as voice quality, resonance, and speech intelligibility. Measures with greater degree of objectivity have been more recently developed. These include measurements of acoustic and airflow features of voicing using signal digitization and analysis with increasingly computer-friendly applications. Dynamic imaging and recordings of the vocal folds and vocal tract, using either flexible or rigid fiberoptic technology, have also contributed greatly to the armamentarium of clinical tools used for examination and interpretation of voice abnormality. Normative data and behavioral patterns have been quantified and described from testing and observing healthy subjects across the age continuum, and clinicians attempt to compare their patient data and observations with published norms.44–46 Despite these advances in voice evaluation, controversy exists regarding the reliability and representative clinical value of some of these commonly used measures. Better understanding of the dynamic configuration of a patient’s vocal tract, and its influence on preoperative voice and speech production, should aid clinicians in developing and applying surgical closure methods, reconstructive techniques, and compensatory voice and speech strategies that result in closer approximation to the preoperative vocal chamber and unique attributes of the preoperative voice. Recently, computer modeling has been used to study the contribution of the continuous movements and configuration of the vocal tract to voice and speech production.47,48 This work involves three-dimensional imaging of the vocal tract configurations during the production of vowels and consonants in normal speakers and trained singers using MRI and CT. The three-dimensional images, combined with multitrack recordings of acoustic and aerodynamic information, are being used to generate computer models that simulate the biomechanical and acoustic properties of voice and speech. This type of research is in its infancy stages, yet the potential for clinical application is clear and promising. In view of evolving conservative operations and functional reconstructive techniques that can result in improved articulation and speech intelligibility, surgeons continue to be challenged by the reality that these procedures have not been shown to optimize or maintain preoperative resonance voice characteristics. Attempts to preserve the resonance characteristics of the vocal cham-
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ber will undoubtedly improve with a detailed understanding of the shape and influence of the preoperative functional anatomy on the overall sound and uniqueness of the patient’s voice. Finally, the impact of voice and speech rehabilitative techniques on vocal tract shape and the perceived sound of the patient’s voice could be studied and optimized using such computer modeling methods. Rhinology and sinus surgery
One of the most interesting developments in the field of rhinology and sinus surgery has been the clarification and redefining of the pathophysiology of spontaneous cerebrospinal fluid (CSF) leaks. Historically, a variety of nontraumatic, congenital, and otherwise idiopathic causes for CSF leaks have been combined into the spontaneous category and termed “normal pressure leaks.”49,50 Recent work has shown that patients with idiopathic, truly spontaneous CSF leaks actually suffer from elevated intracranial pressure (ICP) that leads to formation of the leaks and encephaloceles.51 Demographically, approximately 80% of patients presenting with spontaneous CSF leaks are obese, middle-aged women.51 This is similar to the population that presents with benign intracranial hypertension, also known as pseudotumor cerebri. Many of the spontaneous CSF leak patients also present with symptoms that can be attributed to elevated ICPs, such as pressure-type headaches, pulsatile tinnitus, balance problems, and visual disturbances. Radiographically, nearly all spontaneous CSF leak patients present with empty or partially empty sellas.51 Up to 94% of patients with documented benign intracranial hypertension have empty sellas.52 This is thought to be from impaired absorption of CSF at the arachnoid villi, leading to elevated ICPs and herniation of the sellar diaphragm and meninges into the sella turcica.53 Meningeal herniation and filling of the sella with CSF compresses the pituitary gland and gives the radiographic appearance of an empty sella. Some studies have actually shown that an empty sella may be reversible with correction of elevated ICPs52 and can serve as a radiographic indicator of CSF pressure. Direct evidence of these elevated ICPs has been measured using both CT cisternograms and pressure measurements through lumbar drains during the immediate postoperative period.51 Elevated CSF pressure directly impacts both perioperative and postoperative manage-
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ment. It is likely that these patients may need more structurally sound repairs using underlay bone grafts. In most cases, these repairs can be done endoscopically without the morbidity associated with traditional intracranial repairs. Aggressive postoperative reduction of ICP is probably warranted to prevent recurrent or multiple skull base defects. The current standard of care for spontaneous CSF leak and encephalocele patients consists of repair of the skull base defect and fails to consider the potential need to treat the elevated ICP as the underlying cause in the pathophysiology of the development of the leak. Adjunctive treatments can include longterm treatment with acetazolamide or shunts to maximize the chances for longterm success at CSF leak prevention. This will also target the primary pathology and can improve patient symptoms that could be attributable to intracranial hypertension. Acknowledgment: I thank J Madison Clark, MD, Terry A Day, MD, Lucinda A Halstead, MD, Alan J Klein, PhD, Bonnie Martin-Harris, PhD, and Rodney J Schlosser, MD, for assistance in compiling this article.
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11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
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30. Smith S, Genden M, Urken M. Endoscopic stapling technique for the treatment of Zenker diverticulum vs. standard open-neck technique. Arch Otolaryngol Head Neck Surg 2002;128:141– 144. 31. Wirtschafter A, Cherukuri S, Benninger M. Anthrax: ENT manifestations and current concepts. Otolaryngol Head Neck Surg 2002;126:8–13. 32. Schwartz S, Yueh B, McDougall J, et al. Human papillomavirus infection and survival in oral squamous cell cancer: A population based study. Otolaryngol Head Neck Surg 2002;125:1–9. 33. Li D, Shugert E, Gue M, et al. Combination nonviral interleukin 2 and interleukin 12 gene therapy for head and neck squamous cell carcinoma. Arch Otolaryngol Head Neck Surg 2001; 127:1319–1324. 34. Jaeckel E, Raja S, Tan J, et al. Correlation of expression of cyclooxygenase-2, vascular endothelial growth factor, and peroxisome and neck squamous cell carcinoma. Arch Otolaryngol Head Neck Surg 2001;127:1253–1259. 35. Sood S, Corbridge R. Powles J, et al. Effectiveness of the ultrasonic harmonic scalpel for tonsillectomy. Ear Nose Throat J 2001;80:5:14–518. 36. Walker RA, Syed ZA. Harmonic scalpel tonsillectomy versus electrocautery tonsillectomy: a comparative pilot study. Otolaryngol Head Neck Surg 2001;125:449–455. 37. Triglia JM, Nazarian B, Sudre-Levillain I, et al. Virtual laryngotracheal endoscopy based on geometric surface modeling using spiral computed tomography data. Ann Otol Rhinol Laryngol 2002;111:36–43. 38. Burke AJ, Vining DJ, McGuirt WF Jr, et al. Evaluation of airway obstruction using virtual endoscopy. Laryngoscope 2000;110: 23–29. 39. Oliver DW, Hamilton SA, Figle AA, et al. A prospective, randomized, double-blind trial of the use of fibrin sealant for face lifts. Plast Reconst Surg 2001;108:2101–2104. 40. Keller, GS, Namazie A, Blackwell K, et al. Elevation of the malar fat pad with a percutaneous technique. Arch Facial Plast Surg 2002;4:20–25.
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41. Kelly KM, Majoron B, Nelson S. Nonablative laser of light rejuvenation: the newest approach to photodamaged skin. Arch Facial Plast Surg 2001;3:230–235. 42. Alster TS, Lupton JR. Prevention and treatment of side effects and complications of cutaneous laser resurfacing. Plast Reconst Surg 2002;109:308–316. 43. Schliehake A, Jamil MU. Impact of intraoral soft-tissue reconstruction on the development of quality of life after ablative surgery in patients with oral cancer. Plast Reconst Surg 2002; 109:421–430. 44. Baken RJ, Orlikoff RF. Clinical measurement of speech and voice. San Diego: Singular Publishing Group Inc; 2000. 45. Hirano M, Bless DM. Videostroboscopic examination of the larynx. San Diego: Singular Publishing Group Inc; 1993. 46. Colton RH, Casper JK. Understanding voice problem: A physiological perspective for diagnosis and treatment. 2nd ed. Baltimore: Williams & Wilkins; 1996. 47. Story BH, Titze IR. Parameterization of vocal tract area functions by empirical orthogonal modes. Phonet 1998;26:223– 260. 48. Story BH. A distinctive region model (DRM) based on empirical vocal tract area functions. Acoustic Soc Amer 2001;110 pt.2, 40SC7:2761. 49. Hubbard JL, McDonal TJ, Pearson BW, Laws ER Jr. Spontaneous cerebrospinal fluid rhinorrhea: Evolving concepts in diagnosis and surgical management based on May Clinic experience from 1970 through 1981. Neurosurgery 1985;16:314–321. 50. Ommaya AK, Di Chiro G, Baldwin M, Pennybacker JB. Nontraumatic cerebrospinal fluid rhinorrhea. J Neurol Neurosurg Psychiat 1968;31:214–225. 51. Schlosser RJ, Bolger WE. Management of multiple spontaneous nasal meningoencephaloceles. Laryngoscope (in press). 52. Zagardo MT, Cail WS, Kelman SE, Rothman MI. Reversible empty sella in idiopathic intracranial hypertension: An indicator of successful therapy? AJNR 1996;17:1953–1956. 53. Maira G, Anile C, De Marinis L, et al. Cerebrospinal fluid pressure and prolactin in empty sella syndrome. Can J Neurol Sci 1990;17:92–94.
A number of important advances occurred in otolaryngology–head and neck surgery last year. Clinical and basic research efforts throughout the specialty continue to be robust, resulting in a variety of new strategies for patient care. Some of the major developments within each of the subspecialty areas—head and neck oncology, otology-neurotology, rhinology and sinus surgery, facial plastic and reconstructive surgery, and general otolaryngology—will be highlighted.
therapy.3,4 Ongoing trials should help elucidate the optimal dosage and delivery protocol, and provide additional patient accrual to document efficacy. Most clinicians rely primarily on the patient’s history for diagnosing Meniere’s disease, eg, episodic vertigo, hearing loss, tinnitus, and aural fullness. Corroborative studies include an abnormal audiogram (typically a unilateral and predominately low-frequency sensorineural hearing loss), decreased vestibular function by electronystagmography, and abnormal electrocochleography (increased summating to action potential ratio). A definitive test for defining the histologic correlate of this disease, increased endolymphatic fluid, termed endolymphatic hydrops, has been elusive. Recently, Niyazov and colleagues5 demonstrated endolymphatic hydrops in a guinea pig by MRI scanning.5 They used a standard approach of inducing hydrops by surgically obliterating the endolymphatic sac in the experimental animals. Various doses of gadolinium were administered and repeat scanning using a 1.5-T field strength was performed at intervals over an 8-hour period to define optimal inner ear resolution. The investigators found that gadolinium was preferentially taken up by the perilymph, and that the greatest differentiation between perilymphatic and endolymphatic fluid spaces occurred 4 hours after administration of the contrast agent. They were able to obtain good-quality images showing endolymphatic hydrops, and histologic examination confirmed the MRI findings. The ability to objectively and nonevasively diagnose Meniere’s disease has great clinical applicability. Progress continues to be made in developing vaccines against the principal bacterial pathogens causing acute otitis media: Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis.6 Prevnar, a heptavent pneumoccal vaccine became available
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Treatment of various inner ear pathologies with pharmaceutical agents delivered by direct, rather than systemic, pathways continues to be an area of active investigation. Round window membrane permeability is the link between the middle ear space and the cochlear fluids, permitting these new treatment paradigms. A number of studies have documented the efficacy of intratympanic gentamicin for Meniere’s disease.1 The focus is now shifting toward middle ear steroid infusion for sudden sensorineural hearing loss, a condition traditionally treated with high-dose oral steroids for 1 or 2 weeks. Intratympanic administration is attractive because side effects from systemic absorption are essentially eliminated. In addition, animal studies have consistently shown perilymph steroid concentrations higher after intratympanic injection versus intravenous administration.2,3 The initial clinical studies have been promising. In cases of sudden sensorineural hearing loss, hearing recovery appears at least as great as it is after oral steroid Received March 21, 2002; Accepted March 21, 2002. From the Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC. Correspondence address: Paul R Lambert, MD, FACS, Medical University of South Carolina, Department of Otol/HNS, 150 Ashley Ave, Charleston, SC 29425.
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Abbreviations
CSF HNSCC ICP
cerebrospinal fluid head and neck squamous cell carcinoma intracranial pressure
in mid 2000 and is being widely used in children less than 2 years of age. Early studies have shown a 6% to 7% overall decrease in the incidence of otitis media, and a one-third to two-thirds reduction in cases caused by S. pneumoniae.7,8 Vaccines directed at nontypeable H. influenza and M. catarrhalis are currently being studied in animal models. Preliminary results show that the vaccines under investigation induced a strong immune response and good bactericidal activity.9,10 Given the fact that acute otitis media is the most common reason children receive antibiotics, continued success in this area will have a profound effect on middle ear infections and their sequelae.6 The majority of patients with sensorineural loss do not seek amplification or have not been successful hearing aid users. Frequent complaints include disruptive feedback (“squeal”), poor sound quality in background noise, and discomfort from ear canal occlusion. Digital circuitry is very effective in reducing background noise and improving listening comfort. A microcomputer in the hearing aid is programmed to distinguish unwanted background noise from speech. When the background noise is a steady-state type such as road noise or machinery, the hearing aid is very adept in turning down amplification in those frequencies while maintaining amplification in the other frequency bands where speech is dominant. Background noise can also be minimized by directional microphones, which are designed to be less sensitive to receiving sound from behind the listener.11 Recent microphone and digital technologies have resulted in the development of an active directional microphone. With this technology the microcomputer continually assesses the azimuth of the highest source of noise in the rear, and then automatically configures the microphone to be least sensitive at that general location. As the noise source moves, the microphone tuning changes. Another approach to amplification has been the development of semiimplantable hearing aids. In the last 18 months, two partially implanted hearing aid systems
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have completed clinical trials in the United States and have been FDA approved. Both the SOUNDTEC (Soundtec, Inc) and the Vibrant Soundbridge (Symphonix Devices, Inc) provide amplification by electromagnetic transmission of sound.12, 13 With the Soundtec device, a neodymium–iron–boron magnet is implanted at the incudostapesial joint and driven by an electromagnetic coil placed within an ear canal mold. With the Vibrant Soundbridge, an electromagnetic coil is attached to the incus and hard wired to a receiver implanted on the mastoid bone. Both devices use a sound processor, amplifier, and electromagnetic transmitter coil to vibrate the implanted magnet, and the ossicular chain. Both semiimplantable devices provide an average 10-dB improved functional gain across frequencies 250 to 6,000 Hz compared with an optimally fitted traditional hearing aid.13,14 Although standardized testing has not demonstrated significantly improved speech perception in quiet or in noise, most recipients have reported greater ease in daily communication. Roland and associates,14 for example, report that the Soundtec patients note a higher fidelity of sound, and greater than 95% prefer the device over their traditional hearing aid. Head and neck oncology Head and neck reconstruction
Haughey and coworkers15 reviewed their series of 241 head and neck free flap reconstructions over a 10-year period. This analysis further confirms the reliability and usefulness of free tissue transfer for head and neck defects and provides valuable new information related to variables important to length of stay, flap survival, and major medical complications. Multivariate analysis revealed that cigarette smoking and volume of crystalloid greater than 7 L intraoperatively correlated with overall flap complications. In this series, the fibula free flap was used in 46 of the 241 patients (19%); the radial forearm was the used in 96 (40%). The radial forearm flap has received more recent comparison to the ulnar forearm flap in a study of 75 patients undergoing 51 ulnar and 24 radial flaps.16 Flap survival and recipient site healing were not different, but the ulnar flaps had a lower donor site complication rate, shorter pedicle, were less hairy, and had thinner subcutaneous tissue. Controversy remains in the preoperative evaluation for vascular patency of the lower extremity vessels before fibula free flap harvest. Lorenz and Esclamado17 re-
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ported on 29 patients evaluated by magnetic resonance angiography rather than conventional angiography. This evaluation resulted in changing the side of harvest in four patients (12.5%) and excluding that site of flap harvest in three (9%). Correlation with palpable distant pulses and proximal patent arteries was not reliable in this series. Futran and associates18 have reported on the successful transfer of a fibula osteocutaneous free tissue reconstruction of the midface in 26 of 27 patients, with all achieving oral intake and intelligible speech. Secondary osseointegrated implant placement remains a significant advantage of the fibula flap over other flaps in this region and was further confirmed in this study. Expanding use of the acellular dermal graft (AlloDerm; Lifecell Corp, Branchburg, NJ) has been evaluated in the donor site for radial forearm free flaps by Sinha and colleagues.19 Of 52 consecutive patients using the thick (800 to 900 m) graft material without split thickness skin graft, there were no tendon exposures, and the only wound complications were 5 cases of seroma formation. Refinement continues in techniques of frontal sinus obliteration. Parhiscar and Har-E120 reported the use of a vascularized pericranial flap in 10 patients. Only one patient had a persistent headache (1 month) and there was one asymptomatic recurrence of a neofrontal sinus with median 3-year followup. A novel technique of frontal sinus obliteration using hydroxyapatite cement combined with a pericranial flap separation of frontal and ethmoid sinuses was reported by Petruzzelli and Stankiewiecz.21 In three patients with traumatic frontal sinus fractures and eight with recurrent frontal sinusitis, the technique was successful in all but one, with a mean followup of 27 months. Six of the eight with recurrent frontal sinusitis had previously failed the classic osteoplastic flap obliteration technique. Diagnostics
The use of sentinel node biopsy in head and neck melanoma has not yet met with universal acceptance because of exposure and access to areas of the head and neck, potential for nerve injury, proximity of the primary lesion to lymph nodes, and variable lymphatic drainage. A recent report by Jansen and coworkers22 looked at 30 patients undergoing lymphoscintigraphy and sentinel node biopsy for cutaneous melanoma of the head and neck. A sentinel node was identified in 27 of
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30 patients but was positive in only 8 patients. Of the 19 patients with negative sentinel node biopsies, 4 developed recurrences, with 2 having involved nodes at that time. The authors suggest further investigation before this procedure can become the standard of care in managing head and neck melanoma. The use of lymphoscintigraphy and sentinel node biopsy in head and neck squamous cell carcinoma remains an unproved technique, although clinical trials are being developed to analyze its use.23,24 Taylor and associates25 evaluated nine previously untreated patients with oral and oropharyngeal squamous cell carcinoma with sentinel node biopsy followed by neck dissection. All had sentinel nodes identified; only four were positive and represented the only involved lymph nodes at the time of neck dissection. In a study of 1,444 patients treated from 1970 to 1998 with malignant melanoma of the head and neck, Fisher26 identified a 12% recurrence rate in the regional lymph nodes as the initial site of recurrence. In addition, occult disease was found in 11% of patients who underwent elective neck dissection. Patients in this series had an improved survival when delayed (recurrence in the neck at least 3 months after diagnosis at the primary site in previously undissected neck) lymph node dissection was performed over elective or therapeutic neck dissection. Surgical techniques
Continued improvements in quality of life in head and neck cancer patients necessitates improvement in postsurgical and radiation morbidity, including xerostomia. Agents such as Ethyol (Medimmune Oncology, Gaithersburg, MD) have provided benefit in the postoperative radiation patient, but surgical techniques such as submandibular gland transfer to a nonirradiated region by microvascular techniques may also offer significant benefit. This technique was evaluated in a rabbit model and technical details were modified to result in a successful transfer and retransplantation with histologic confirmation of survival.27 Transoral techniques continue to be used successfully for submandibular disease, especially in centers outside the United States. Zenk and associates28 report on 231 patients with submandibular lithiasis who underwent a transoral approach with preservation of the submandibular gland, resulting in stone clearance and resolution of symptoms in 91%.
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Endoscopic repair of a Zenker’s diverticulum continues to involve new techniques with the potential for lower morbidity and less invasive procedures. Thaler and coworkers29 report on their experience with endoscopic staple-assisted esophagodiverticulostomy in 23 patients. The factor limiting success of the procedure appears to be inadequate exposure endoscopically, resulting in conversion to an open approach in seven patients (23%). Two other patients treated endoscopically had persistent dysphagia postoperatively, with confirmed residual diverticulum. One of these underwent successful repeat endoscopic repair. No complications were noted in any of the patients. Smith and associates30 compared the endoscopic stapling technique with the open procedure in a random sample of eight patients in each group and found that the endoscopic procedure resulted in a statistically significant reduction in operative time, hospital stay, and time to resume oral feedings.30 Treatment
The events of 2001 have heightened our awareness of such diseases as anthrax, and Wirtschafter and colleagues31 presented a timely reminder on the ENT manifestations of oropharyngeal anthrax. This site of potential involvement may present with signs and symptoms similar to other pharyngitis-related problems, with symptoms including fever, dysphagia, neck pain, hoarsness, cough, globus, dyspnea, and neck swelling. Examination might reveal reddish-purple lesions or pseudomembrane formation that might progress to ulceration and necrosis. Increasing emphasis has been placed on the potential viral etiologies of oral and oropharyngeal squamous cell carcinoma, particularly the role of human papilloma virus as an etiologic factor. In addition to its role in the pathogenesis of these cancers, a study by Schwartz and associates32 reveals that the presence of HPV-16 type DNA can be associated with a favorable prognosis when evaluated in 254 patients with primary oral cancer.32 With the recent human genome project’s completion, development continues in the areas of gene therapy for head and neck squamous cell carcinoma (HNSCC). Clinical trials have been completed in viral mediated gene therapy for head and neck cancer. Li and associates33 report on a novel nonviral gene delivery system using lipid formulated mIL-2 and polymer-formulated mIL-12 in an HNSCC murine model.33 This gene
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transfer was successful in generating potent antitumor responses in this model. Recent interest in molecular targets involved in HNSCC includes studies evaluating vascular endothelial growth factors that have been found to interact with cyclooxygenase-derived prostaglandins in angiogenesis. Cycolooxygenase-2 (COX-2) is an enzyme that can be induced by inflammation, growth factors, and oncogenes. Jaeckel and colleagues34 identified a potential role of COX-2 in HNSCC both in primary tumors and metastatic tumors compared with normal tissue in human subjects. Pediatric otolaryngology
Tonsillectomy is one of the most common procedures performed in pediatric otolaryngology. Of the multiple techniques available, blunt dissection and electrodissection (bovie) tonsillectomy are most commonly performed. Decreased operative time and blood loss has made the electrodissection tonsillectomy popular. Postoperative pain remains the major disadvantage of the electrodissection technique. Although less painful, operative blood loss and increased operative time continue to be problems for the blunt dissection technique. A new technique, the ultrasonographic dissection coagulator (harmonic scalpel) combines hemostasis and speed of the electrodissection technique with a reduction in postoperative pain that is superior to both other techniques. This is possibly because of the low secondary heat (⬍100°C) and minimal lateral thermal damage (1.2 mm) created by the vibratory motion of the harmonic scalpel blade. Prospective studies have confirmed decreased postoperative pain and earlier return to normal activity without any increase in perioperative bleeding.35,36 Both studies conclude that the harmonic scalpel offers advantages over the other popular tonsillectomy technique. Accurate assessment of congenital and acquired laryngotracheal anomalies continues to challenge pediatric otolaryngologists. Although laryngoscopy and bronchoscopy remain the definitive diagnostic techniques, their accuracy is limited when the luminal diameter of the airway is too narrow to admit the smallest of telescopes. The surgeon is left unable to definitively plan reconstructive airway surgery. MRI technology initially held promise in the area of airway imaging, but has been limited by its susceptibility to motion artifact and the need for patient sedation. The advent of spiral CT has
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improved the two-dimensional and three-dimensional reconstruction of the airway. The accuracy of the technique continues to be improved by virtual endoscopy software and by mathematical modeling techniques of tubular cavities. Triglia and coworkers37 have used the new mathematical modeling programs to create antegrade and retrograde endoscopic views of the airway and a three-dimensional reconstruction of the airway. This technique accurately predicted the length of nine stenoses too narrow to be completely assessed endoscopically. Earlier reports of virtual endoscopy software demonstrated an approximate 10% discrepancy in stenosis-tolumen ratio compared with endoscopy.38 Continued development of this technology should allow for accurate, unsedated evaluation of many critical pediatric airways. Facial plastic and reconstructive surgery
Esthetic facial procedures continue to evolve at an astounding rate. With the burgeoning demand among younger patients, there has been less tolerance for “down time.” So procedures that require minimal recovery but that ultimately achieve similar results are gaining popularity. For example, with regard to the aging face, the focus has been on elevation of the sagging malar fat pad for midfacial rejuvenation. The gold standard in the past 5 to 10 years has been the deep plane facelift, but the typical recovery is at least 7 to 10 days away from moderate activity. The use of tissue adhesives in facelifting can provide for avoidance of drains, lessened edema, decreased risk of hematoma formation, faster healing, and earlier return to work.39 A minimally invasive percutaneous technique to directly address the sagging of the ptotic malar fat pad was recently described, with excellent results.40 The authors used a subcutaneous polytef (Gore-Tex; WL Gore and Assoc, Flagstaff, AZ) patch to suspend the midface and efface the melolabial fold, obviating the need for facelift incisions and extensive dissection, minimizing recovery time. Adjunctive aging face procedures, originally used to augment and enhance the results from face lifting, have undergone recent refinements. Nonablative methods of treating photodamaged skin have become increasingly popular. Using specially designed lasers or other modalities, attempts are made at epidermal preservation by concentrating the laser energy in a zone approximately 100 to 400 m from the skin surface, which contains most of the solar elastosis in photodamaged skin.41 The search for nonablative methods of facial resurfacing has
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been fueled by the desire to avoid postoperative erythema and pain, expected sequelae of traditional laser resurfacing.42 The chemical peel, the oldest method of resurfacing, has come full circle. Refinements in technique yield a more predictable depth of penetration, with faster healing times, less pain, and at significantly less cost compared with ablative or nonablative treatments. Botulinum toxin type A (BTX-A) has been used for several years for off-label cosmetic use in facial wrinkles. It is especially useful in areas of the face where other surgical procedures might be less successful, such as crow’s feet, glabellar frown lines, horizontal forehead lines, and mentalis muscle strain. Especially useful in patients who have developed antibodies to botulinum toxin type A, another subtype of botulinum toxin, type B, has recently become available. The FDA is reportedly near granting approval to botulinum toxin type A for limited cosmetic indications. Two notable developments in head and neck reconstructive surgery deserve mention. The use of free tissue transfer in complex three-dimensional reconstruction of head and neck cancer ablative defects is gaining acceptance as standard of care, supported by prospective outcomes studies.43 There is increased recognition of the benefits of early establishment of integrity of the traumatized facial skeleton, rather than allowing secondary intention healing to occur before definitive reconstruction. Emphasis on the principle of early establishment of skeletal support through rigid fixation and attention to meticulous soft tissue suspension in facial trauma should improve functional and cosmetic outcomes. Laryngology
Normal voice production results from complex modifications to the sound produced at the level of the vocal folds through dynamic shaping of the vocal tract. Characteristic vocal tract anatomy, together with modification and shaping of the source sound, give the speaker a unique vocal resonance. This resonance, together with other attributes of voice production (ie, voice quality, pitch, and prosody) contributes to the individuality and character of the patient’s preoperative voice. Surgical disruption to the vocal chamber that accompanies oropharyngeal cavity resections often results in aberrant modifications in vocal resonance, contributing to the perceived abnormality of the postoperative voice. Historically, evaluation of voice and speech produc-
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tion after operations on the head and neck has focused on perceptual judgments of specific features of voice and speech such as voice quality, resonance, and speech intelligibility. Measures with greater degree of objectivity have been more recently developed. These include measurements of acoustic and airflow features of voicing using signal digitization and analysis with increasingly computer-friendly applications. Dynamic imaging and recordings of the vocal folds and vocal tract, using either flexible or rigid fiberoptic technology, have also contributed greatly to the armamentarium of clinical tools used for examination and interpretation of voice abnormality. Normative data and behavioral patterns have been quantified and described from testing and observing healthy subjects across the age continuum, and clinicians attempt to compare their patient data and observations with published norms.44–46 Despite these advances in voice evaluation, controversy exists regarding the reliability and representative clinical value of some of these commonly used measures. Better understanding of the dynamic configuration of a patient’s vocal tract, and its influence on preoperative voice and speech production, should aid clinicians in developing and applying surgical closure methods, reconstructive techniques, and compensatory voice and speech strategies that result in closer approximation to the preoperative vocal chamber and unique attributes of the preoperative voice. Recently, computer modeling has been used to study the contribution of the continuous movements and configuration of the vocal tract to voice and speech production.47,48 This work involves three-dimensional imaging of the vocal tract configurations during the production of vowels and consonants in normal speakers and trained singers using MRI and CT. The three-dimensional images, combined with multitrack recordings of acoustic and aerodynamic information, are being used to generate computer models that simulate the biomechanical and acoustic properties of voice and speech. This type of research is in its infancy stages, yet the potential for clinical application is clear and promising. In view of evolving conservative operations and functional reconstructive techniques that can result in improved articulation and speech intelligibility, surgeons continue to be challenged by the reality that these procedures have not been shown to optimize or maintain preoperative resonance voice characteristics. Attempts to preserve the resonance characteristics of the vocal cham-
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ber will undoubtedly improve with a detailed understanding of the shape and influence of the preoperative functional anatomy on the overall sound and uniqueness of the patient’s voice. Finally, the impact of voice and speech rehabilitative techniques on vocal tract shape and the perceived sound of the patient’s voice could be studied and optimized using such computer modeling methods. Rhinology and sinus surgery
One of the most interesting developments in the field of rhinology and sinus surgery has been the clarification and redefining of the pathophysiology of spontaneous cerebrospinal fluid (CSF) leaks. Historically, a variety of nontraumatic, congenital, and otherwise idiopathic causes for CSF leaks have been combined into the spontaneous category and termed “normal pressure leaks.”49,50 Recent work has shown that patients with idiopathic, truly spontaneous CSF leaks actually suffer from elevated intracranial pressure (ICP) that leads to formation of the leaks and encephaloceles.51 Demographically, approximately 80% of patients presenting with spontaneous CSF leaks are obese, middle-aged women.51 This is similar to the population that presents with benign intracranial hypertension, also known as pseudotumor cerebri. Many of the spontaneous CSF leak patients also present with symptoms that can be attributed to elevated ICPs, such as pressure-type headaches, pulsatile tinnitus, balance problems, and visual disturbances. Radiographically, nearly all spontaneous CSF leak patients present with empty or partially empty sellas.51 Up to 94% of patients with documented benign intracranial hypertension have empty sellas.52 This is thought to be from impaired absorption of CSF at the arachnoid villi, leading to elevated ICPs and herniation of the sellar diaphragm and meninges into the sella turcica.53 Meningeal herniation and filling of the sella with CSF compresses the pituitary gland and gives the radiographic appearance of an empty sella. Some studies have actually shown that an empty sella may be reversible with correction of elevated ICPs52 and can serve as a radiographic indicator of CSF pressure. Direct evidence of these elevated ICPs has been measured using both CT cisternograms and pressure measurements through lumbar drains during the immediate postoperative period.51 Elevated CSF pressure directly impacts both perioperative and postoperative manage-
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ment. It is likely that these patients may need more structurally sound repairs using underlay bone grafts. In most cases, these repairs can be done endoscopically without the morbidity associated with traditional intracranial repairs. Aggressive postoperative reduction of ICP is probably warranted to prevent recurrent or multiple skull base defects. The current standard of care for spontaneous CSF leak and encephalocele patients consists of repair of the skull base defect and fails to consider the potential need to treat the elevated ICP as the underlying cause in the pathophysiology of the development of the leak. Adjunctive treatments can include longterm treatment with acetazolamide or shunts to maximize the chances for longterm success at CSF leak prevention. This will also target the primary pathology and can improve patient symptoms that could be attributable to intracranial hypertension. Acknowledgment: I thank J Madison Clark, MD, Terry A Day, MD, Lucinda A Halstead, MD, Alan J Klein, PhD, Bonnie Martin-Harris, PhD, and Rodney J Schlosser, MD, for assistance in compiling this article.
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11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
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