Nebulized surfactant for experimentally induced otitis media with effusion.

Eustachian tube dysfunction frequently results in clinical evidence of otitis media with effusion (OME). Surface active substances, surfactants, are hypothesized to play a role in normal eustachian tube function. Recent work in a rodent model has demonstrated improved eustachian tube function with topical application of surfactants to the middle ear. A novel, noninvasive, and clinically practical method of delivering surfactant to the eustachian tube was studied in a gerbil model of OME. Otitis media with effusion was experimentally induced in 20 gerbils by transtympanic inoculation of heat-killed Streptococcus pneumoniae. This represents a well established model for creating a serous effusion in the gerbil that significantly increases eustachian tube opening pressure. Effusion developed in 27 of 40 ears (67.5%) after inoculation. An inhaled nebulized surfactant was used to treat the animals with microscopically confirmed OME in one or both ears. The treatment period was 5 days. Eustachian tube opening studies were performed on both affected and nonaffected animals. Successful eustachian tube opening pressures were obtained in 30 of 36 ears (83.3%). The mean opening pressure for ears without effusion (healthy ears) was 42.8 mmHg. The mean opening pressure for ears with effusion in animals treated with nebulized surfactant was 41.4 mmHg. The difference between these mean values was not statistically significant (t = 0.32; p > 0.50). This pilot study suggests that inhaled nebulized surfactant may be efficacious in treating eustachian tube dysfunction when manifested in disorders such as OME.

Stridor in the neonate: laryngomalacia.

Stridor in the neonate is usually congenital in etiology, the most common cause being laryngomalacia. Emergency airway management is always the first priority. The history is highly suggestive of the diagnosis in the majority of cases, but endoscopy is required for confirmation. The possibility of synchronous lesions must not be overlooked. Laryngomalacia presents with stridor usually within the first few weeks of life. The stridor is inspiratory in nature and varies with position and activity level. Anatomic, histologic, and neurologic factors have been proposed as the cause of laryngomalacia. Patients typically have a benign form of the disease, which they outgrow by age two. A small percentage of patients will have a severe form of the disease requiring surgical intervention.

Pediatric maxillofacial fractures.

Maxillofacial trauma in the pediatric population is a relatively infrequent occurrence. Studies have demonstrated consistently that 5% of all facial fractures occur in children. The low percentage of facial fractures in this age group has been attributed, in part, to the lack of full pneumatization of the sinuses until later in childhood. Review of the literature indicates that boys are more commonly affected than girls and that the majority of pediatric facial fractures occur in children between 6 and 12 years of age. Motor vehicle accidents, falls, and blunt trauma are responsible for the largest number of pediatric facial fractures. The most common site of facial fracture is the nose and dentoalveolan complex, followed by the mandible, orbit, and midface in most pediatric cohorts. Management of the mandible is often conservative owing to the high percentage of isolated condylar fractures in children. Open reduction and internal fixation of pediatric facial fractures is indicated in complex mandible, midface, and orbital fractures. The effect of rigid fixation on facial skeleton growth is not completely understood.

Temporal bone fractures.

Temporal bone fractures are clinically interesting because of the rich anatomy across which they traverse. These fractures most often present after blunt head trauma and may present with a variety of symptoms including facial nerve paralysis, hearing loss, and vertigo. This paper will classify these fractures and discuss their associated clinical findings.

Hypopharyngeal carcinoma.

Hypopharyngeal carcinomas are considered indolent, silent tumors. These tumors dictate a high index of suspension. They can present with a myriad of symptoms and clinical complaints. The silent nature of these tumors unfortunately causes a high number of patients to present with advanced disease. A multimodality approach is often used. Although our approach to this disease has advanced, the overall mortality remains high at 5 years.

Passive smoking.

One in three adults in the United States smokes. Smokers inhale one quarter of the smoke from cigarettes. But 75% of cigarette smoke is released into the environment. Nonsmokers are exposed to this environmental tobacco smoke and are at risk for disease. A growing body of literature supports the association of passive, involuntary, or secondhand smoking with human pathology. This discussion examines the makeup of environmental tobacco smoke and its role in causing human disease with a review of the literature relating environmental tobacco smoke to head and neck pathology.

Hemangiomas of the head and neck.

The physician's ability to diagnose different types of vascular anomalies, predict their clinical course, and choose the correct mode of treatment has been hampered by the inconsistent, overlapping nomenclature found in the bulk of medical literature. This article discusses how to differentiate hemangiomas from other vascular anomalies. In addition, it reviews complications associated with hemangiomas and various treatment options for hemangiomas including observation, corticosteroids, interferon, surgical resection, laser surgery, and radiotherapy.

Carotid artery sacrifice testing: assessment in patients with advanced head and neck cancer.

The otolaryngologist seeking a cure of the patient with advanced cancer of the head and neck removes all neck metastases along with the primary tumor. Tumor involvement of the carotid artery presents a special dilemma to the otolaryngologist because a complete resection would mean removal of the affected carotid artery, a procedure which has, historically, carried high morbidity and mortality rates. Today, the otolaryngologist will offer tumor resection with carotid artery sacrifice only after a patient passes a preoperative assessment of collateral circulation to the brain. Numerous methods have been devised to determine a patient's preoperative risk of neurologic compromise. Several tests are detailed and their usefulness discussed.

The association of gastroesophageal reflux and otolaryngologic disorders.

The laryngeal manifestations of GER may present with a number of nonspecific signs or symptoms. Patients with hoarseness, dysphagia, globus sensation, laryngeal granulomas, and subglottic stenosis should be evaluated for GER. In addition, physicians should be aware of the possible association of GER with Zenker's diverticulum and laryngeal carcinoma. While pH manometry is the mainstay for diagnosis of GER, the sensitivity is lower for patients with head and neck manifestations of GER probably because of the intermittancy of the reflux. The use of a pharyngeal probe may improve the sensitivity of the test. Treatment of head and neck manifestations of GER is no different than reflux esophagitis and medical therapy is typically successful in resolving symptoms.

Cogan's syndrome manifesting as sudden bilateral deafness: diagnosis and management.

Cogan's syndrome is an uncommon entity of nonsyphilitic interstitial keratitis with vestibulo-auditory disturbances. Although it is unusual, Cogan's syndrome should be considered in the differential diagnosis of patients with sudden hearing loss, even when they lack ophthalmologic symptoms. Systemic manifestations are not uncommon and, along with serologic and hematologic abnormalities, may help in making the diagnosis, which requires a high index of suspicion. Treatment with steroids has largely been based on symptoms. We suggest using the C-reactive protein level as a monitor of subclinical disease activity; it is therefore beneficial in the adjustment of steroid therapy. We have described the case of a 41-year-old woman who sought treatment for an upper respiratory infection syndrome and severe vertigo. Evaluation included hematologic and serologic studies, lumbar puncture, and CT and MRI scans. Abnormal findings consisted of an elevated white blood cell count and an ESR of 112 mm/hr. Six days later, profound, bilateral sensorineural hearing loss developed suddenly. Intensive corticosteroid and vasodilator therapies were instituted, but there was no improvement in hearing levels. Ten days later eye pain and redness developed, and ophthalmologic evaluation revealed an interstitial keratitis consistent with Cogan's syndrome. Steroid eye drops and oral prednisone therapy promptly relieved the eye symptoms. Steroid tapering was associated with diffuse joint pain and swelling consistent with a systemic vasculitis. After rheumatologic consultation, steroid dosage was titrated to the CRP level and ESR, and vasculitic symptoms resolved. Hearing levels did not improve, and the patient had cochlear implantation. Thirteen cases of bilateral sudden deafness due to Cogan's syndrome have been reported previously. This is the first case in which there were no immediate eye symptoms.

Velopharyngeal insufficiency.

Velopharyngeal insufficiency (VPI) is a relatively uncommon diagnosis and requires an understanding not only by the otolaryngologist but also by primary care physicians who are often the first to recognize its presence. An appreciation of the speech pathology that occurs in VPI assists in the often challenging diagnosis. Although VPI is more commonly seen in the pediatric population, there are multiple causes for its presence in adults and children. We review the anatomy of the velopharynx and the etiology of VPI, as well as the evaluation and the management of these patients.

Zenker's diverticulum.

Dysphagia is a fairly common medical complaint. Zenker's diverticulum, although uncommon, is an easily diagnosed and treated cause of dysphagia. The clinical presentation, evaluation, pathophysiology, and therapeutic options will be discussed.

Intratumor administration of beta-interferon in recurrent malignant gliomas. A phase I clinical and laboratory study.

We administered doses of 5 to 180 x 10(6) IU of beta-serine-interferon (IFN-beta ser17) twice weekly to 20 patients with recurrent malignant gliomas in a Phase I study. Interferon was given through an Ommaya reservoir connected by a catheter to the tumor cavity. Side effects of interferon therapy occurred in only one patient and consisted of nausea, vomiting, fever, and chills after each treatment, presumably due to rapid diffusion of interferon into ventricular cerebrospinal fluid (CSF). Problems with the Ommaya reservoir (obstruction in two patients and infection in four patients) led to six patients being terminated from the study, and represent the major difficulty with this form of therapy. Although this was primarily a study of interferon toxicity, of 12 evaluable patients, 3 had stable disease for 148, 192, and 539 days; 9 had progressive disease. In addition, we tested the effect of IFN-beta ser17 on the growth of early passage in vitro cultures of malignant gliomas established from patients. Growth inhibition varied from 0% to more than 50%. In all cultures evaluated, the combination of recombinant gamma-interferon plus IFN-beta ser17 enhanced growth inhibition. Further clinical and laboratory study is necessary to better define the therapeutic efficacy of IFN-beta ser17 and the role of combinations of interferons in the treatment of malignant gliomas.