Polydimethylsiloxane elastomer injection in the management of the patulous eustachian tube.

OBJECTIVE: To determine the effectiveness of augmentation surgery using polydimethylsiloxane elastomer injection for the management of patulous eustachian tube. METHOD: All patients were treated with eustachian tube injection augmentation performed via a combined transnasal-transoral endoscopic approach. Clinical presentation, volume of injection, complications and initial response were all prospectively recorded. Longer-term follow up was conducted through structured telephone interviews using previously described patient-reported outcome measures. RESULTS: Overall, 8 of 11 patients (73 per cent) derived complete or significant symptom improvement; 1 patient had significant improvements but was dissatisfied, and in 2 patients the symptoms were unchanged. The eight satisfied patients showed improvement in their quality-of-life scores. CONCLUSION: This study describes an effective treatment option for patulous eustachian tube. Unlike many prior published reports, previously described patient-reported outcome measures were utilised in order to allow more direct comparison.

Outcomes of canalplasty for chronic obliterative otitis externa.

INTRODUCTION: Chronic obliterative otitis externa is a rare cause of conductive hearing loss, characterised by stenosis of the deep ear canal secondary to chronic inflammation. A multitude of canalplasty techniques have been described, with variable success. METHOD: Fourteen patients undergoing canalplasty performed by the senior author for refractory obliterative otitis externa, over an 8-year period, were included in the study. All underwent split-skin grafting of the denuded canal and meticulous post-operative aural care. Outcome measures included the Glasgow Benefit Inventory and pure tone audiology. RESULTS: At 3 months post-operatively, the four-tone average threshold had improved by a mean of 13.9 dB (95 per cent confidence interval -9.9 to 37.8 dB; t < 0.001) in the operated ear. The mean Glasgow Benefit Inventory score was 20 (95 per cent confidence interval -2.3 to 42.1). CONCLUSION: Significant improvements in both hearing and quality of life are achievable in patients with end-stage obliterative otitis externa treated surgically. Highly trained and competent aural care practitioners are a prerequisite for the success of the procedure, and a substantial number of patients must be prepared to submit to long-term follow-up care.

Malignant peripheral nerve sheath tumours of the infraorbital nerve: case report and literature review.

OBJECTIVE: We report a case of malignant peripheral nerve sheath tumour seen in our department. METHOD: We present case reports and a review of the world literature concerning malignant peripheral nerve sheath tumour. RESULTS: A 38-year-old Caucasian woman was diagnosed with malignant peripheral nerve sheath tumour of the infraorbital nerve. She underwent a wide enbloc resection followed by a course of radiotherapy. A five-year post-operative magnetic resonance imaging scan revealed no evidence of recurrence. CONCLUSION: Malignant peripheral nerve sheath tumours are rare in the head and neck. An awareness of their occurrence is important for early diagnosis. Management involves: accurate histological diagnosis; radiological imaging to define tumour extent and plan resection; wide surgical excision with histologically negative margins; reconstruction of the tissue defect; and post-operative radiotherapy.

Traumatic facial nerve neuroma following mastoid surgery: a case report and literature review.

Traumatic facial nerve neuroma is rare. There are only 10 reported cases in the literature, caused either by physical trauma or chronic inflammation. Traumatic facial neuromata differ from true facial nerve neoplasms in radiological, macroscopic and microscopic appearance, but clinical presentation is less reliable in differentiating the two. Management depends on the pre-operative grade of facial palsy, as this is a benign condition and surgical management carries a risk of further affecting facial nerve function. We present a further case of traumatic facial nerve neuroma following surgery for cholesteatoma. We also review the literature and discuss the management of this condition.

Use of an ophthalmic knife for middle-ear microsurgery.

Traditionally, micro-scissors, hooks, sickle knives and needles are used in the ear for the dissection and release of fibrous adhesions. The major limitation of these instruments is that they are often bent or blunt, as they are reusable. We describe an ophthalmic knife that offers precision in middle-ear microsurgery.

Metastases from glomus jugulare tumours.

This review describes the features of glomus jugulare tumours with metastases. There were 100 sites of metastasis in the 53 cases previously reported. The sites of metastasis may be summarized as bone (33), lungs (23), lymph nodes (19), liver (nine) and other (16). Metastases presented up to 30 years after the initial treatment. The mean age of patients was 45 years and the sex ratio was approximately two females to one male, with no significant difference compared to non-metastatic tumours. There was a significantly higher incidence of pain and a significantly lower incidence of hearing loss at presentation compared to non-metastatic tumours. The commonest treatment was a combination of surgery and radiotherapy. The duration of symptoms before diagnosis was significantly shorter and the rates of persistent or recurrent local disease and death were significantly higher than for non-metastatic tumours. This review highlights the fact that glomus jugulare tumours are not always benign.

Glomus jugulare tumour with metastases to cervical lymph nodes.

Glomus jugulare tumours are classically described as benign tumours with a long time course often measured in decades. Although these tumours may be locally invasive, most cases are histologically benign and metastases are rare. The case of a malignant glomus jugulare tumour with a particularly aggressive pattern of spread is presented. At the time of surgery, which was within 12 months of the development of symptoms, intracranial spread and metastasis to cervical lymph nodes had already occurred, demonstrating that glomus jugulare tumours are not always benign.

A third decade's experience with the gastric pull-up operation for hypopharyngeal carcinoma: changing patterns of use.

Gastric transposition has been used extensively in this department since 1965 for reconstruction following pharyngolaryngoesophagectomy (PLO). A previous report by Harrison and Thompson in 1986 detailed our experience with 101 cases dating back to 1965. Here we review our experience between 1986-1996. Medical records of 41 cases were examined. The primary site and stage of tumour and associated lymph nodes, patient demographics, complications, in-patient mortality and survival as demonstrated by the Kaplan-Meier method were recorded. Gastric transposition is now used for more extensive tumours: 70 per cent T4 (83 per cent pathologically T4) compared to 21 per cent in the previous report. A high proportion of 'radiation failures' remains (54 per cent). The in-hospital mortality has fallen from 11 per cent to seven per cent. The five-year-survival calculated using the Kaplan-Meier method is 11 per cent. This procedure is increasingly being used as a palliative procedure aiming to restore swallowing in the relatively young patient who has very extensive hypopharyngeal carcinoma. Long-term survival rates specific to this operation have fallen. This is attributed to patient selection for the procedure with the vast majority having disease extending into bone, cartilage or soft tissues (T4). The defect created by the resection of less extensive tumours are now increasingly reconstructed with jejunal free flaps and musculocutaneous flaps.

Long-term follow-up of submandibular duct rerouting for the treatment of sialorrhea in the pediatric population.

OBJECTIVE: To determine the long-term control of sialorrhea in children who underwent submandibular duct rerouting (SMDR) and to identify potential preoperative predictors of outcome. DESIGN: Retrospective chart review of children who underwent SMDR; information updated by discussion with the permanent caregiver. SETTING: Tertiary care center. PATIENTS: Children who had significant sialorrhea resulting from a variety of neuromuscular disabilities between January 1980 and December 1995. OUTCOME: We report the outcome on 59 patients who underwent SMDR for the treatment of sialorrhea. Patients were ascribed a preoperative sialorrhea and global neurologic deficit score. Postoperative outcome was scored as marked, moderate, no improvement, or worse. Twenty-eight of 59 (47.4%), 28 of 59 (47.4%), and 3 of 59 (5.1%) of the patients had preoperative sialorrhea scores of 3 (profuse), 2 (moderate), and 1 (mild), respectively. Twenty of 59 (33.9%), 29 of 59 (49.2%), and 10 of 59 (16.9%) had preoperative scores of 3 (severe), 2 (moderate), and 1 (mild) neurologic impairment, respectively. Mean time to follow-up of the 59 patients was 5.46 years. Postoperative improvement scores were as follows: 50.8% had marked, 28.8% had moderate, and 20% had no to minimal improvement in their sialorrhea. Two patients were transiently worse. A complication rate of 11.3% (9 of 79) was demonstrated: 7 ranulae, 1 transient swelling of the floor of the mouth, and 1 submandibular gland infection. The preoperative global neurologic deficit score was found to be more predictive of surgical outcome than sialorrhea score.

Recent advances in the use of lasers in otolaryngology.

The laser (Light Amplification by Stimulated Emission of Radiation) has been used in Otolaryngology for over 20 years and is by now an accepted part of the armamentarium. A tremendous amount of work is being done in refining existing techniques and developing new ones, and this review discusses some of the recent advances.

Chondrosarcoma of the petrous apex. Dilemmas in diagnosis and treatment.

A case of chrondrosarcoma of the petrous temporal bone is presented. Chondrosarcomas rarely occur intracranially and typically present apex mass. The dilemmas faced in the diagnosis and treatment of petrous apex chondrosarcomas are discussed. This case also gives interesting insight into the natural history of this tumour.

Autofluorescence characteristics of oral mucosa.

BACKGROUND: The fluorescence characteristics of tissues depend upon their biochemical composition and histomorphological architecture, both of which undergo a change during malignant transformation. These changes are detectable as an alteration in the fluorescence spectral profile of the tissues. METHODS: Biopsy specimens from clinically suspicious lesions and normal-appearing oral mucosa were obtained from patients. Fluorescence spectroscopic measurements were obtained to study the differences between normal and dysplastic tissues and to determine the most appropriate excitation wavelength(s) for exploiting these differences. RESULTS: Fluorescence spectra from a total of 12 histologically normal (healthy mucosa or benign lesions) and ten abnormal (dysplastic or malignant) tissue samples were compared. Significant spectral differences were seen between the two groups. These differences were most marked at the excitation wavelength of 410 nm. Using this wavelength, fluorescence correctly diagnosed 20 of 22 samples studied. CONCLUSIONS: This technique accurately differentiates normal from abnormal tissues in vitro and has the potential applications for in vivo use as a noninvasive diagnostic tool.

Epithelial-myoepithelial carcinoma of the parotid gland. An unusual cause of ear canal stenosis.

Epithelial-myoepithelial carcinoma (EMC) accounts for approximately one per cent of salivary gland tumours. This tumour is gaining wider recognition following inclusion into the WHO histological classification of salivary gland tumours in 1990. Salivary gland tumours characteristically present with an enlarging mass. We describe an unusual presentation of a salivary gland tumour with stenosis of the external ear canal in the absence of a palpable mass. EMC usually arises from the salivary glands but isolated cases have been described arising primarily from the paranasal sinuses, trachea and lacrimal gland. The management of this tumour is still evolving with surgical excision being the main-stay of treatment. The efficacy of radiotherapy has not yet been established but high local recurrence rates despite apparently adequate excision and the possibility of a multicentric origin of the tumour may herald an increasing role for radiotherapy in the future. We stress the importance of awareness of adjacent structures when considering the cause of cartilaginous canal stenosis.

Endoscope-assisted ear surgery.

Endoscopes deliver the otologic surgeon's view into the temporal bone to provide rapid access to its intricate recesses. The attic, sinus tympani, facial recess, hypotympanum, internal auditory canal, and other recesses are immediately visualized with angled endoscopes, using minimal exposure without the time-consuming removal of overlying bone. This report presents results of 32 otologic and neurotologic operations, performed since 1993, that incorporated endoscope-guided dissection as a principal part of the procedure to reduce incision size, exposure width, and operative time, or to access areas otherwise inaccessible. Included are endoscopic excision of acquired cholesteatoma without mastoidectomy, second-look mastoid procedures, mastoidectomy for biopsy (performed entirely endoscopically), and acoustic neuroma dissection from the lateral internal auditory canal. Endoscopic ear surgery is a valuable adjunct to conventional surgical techniques that require wider exposures and are limited to the direct line of sight.

Comparison of endoscopic and surgical explorations for perilymphatic fistulas.

A history suggestive of perilymphatic fistula (PLF) often prompts repeated tympanostomies to establish a diagnosis and perform a repair. Two patients having multiple previous explorations for perilymphatic fistulas were reoperated, comparing endoscopic and open surgical methods. A third patient with a history consistent with PLF also underwent dual assessment. Endoscopic exploration of the middle ear was performed through a myringotomy and, immediately after, by elevation of a tympanotomy flap. The endoscopic examinations were thorough yet revealed no evidence of perilymphatic fistula; however, the surgical approaches revealed pooling in the oval windows consistent with perilymphatic fistula. These findings were video documented. Recurrent and primary fistulas may be the result of artifact, such as injected anesthetic agents and transudates introduced during surgical explorations, which may interfere with an accurate diagnosis of perilymphatic fistula. Endoscopy of the middle ear is recommended as one method to minimize errors in diagnosis.

Mesenchymal chondrosarcoma of the maxilla.

We report, to our knowledge, the 10th recorded case of mesenchymal chondrosarcoma (MC) occurring in the maxilla. Our case is the youngest person reported with a tumour in this location. The prognosis for cure is poor with a high incidence of local recurrence as well as metastases. Treatment is based on radical surgery. Radiotherapy and chemotherapy have a adjuvant role but additional experience with this tumour is required to define the most efficacious treatment.

Salivary gland choristoma of the middle ear.

A salivary gland choristoma is an extremely uncommon tumour in the middle ear space. It appears to be a developmental abnormality and may be associated with abnormalities of adjacent structures. It usually presents with unilateral conductive deafness which may be long-standing and the tumour often pursues a benign, slow growing course. It is usually possible to excise it, but problems may arise as there may be variable associated anatomical abnormalities of the middle ear. We present the nineteenth recorded case, review the literature and discuss the management of this condition.

Post-traumatic cholesteatoma.

Post-traumatic cholesteatoma often presents many years after the original injury. This case occurred 24 years after a head injury which represents the longest recorded interval. A further interesting feature was that the patient presented with an infected skull prosthesis that was inserted at the time of the original injury.