Combined supraciliary and endoscopic endonasal approach for resection of frontal sinus mucoceles: technical note.

OBJECTIVE: Mucoceles are progressive, slow-growing lesions of the paranasal sinuses that, left untreated, can erode into surrounding structures. Complete obliteration and exenteration of the frontal sinus via a bicoronal skin incision and frontal craniotomy is the standard neurosurgical approach to treat these lesions. TECHNIQUE: We describe two patients who underwent a combined supraciliary "keyhole" craniotomy and endonasal endoscopic resection of mucoceles with frontal sinus obliteration. The technique takes advantage of a smaller incision, while preserving adequate visualization and the ability for surgical instrumentation. Through the craniotomy, the frontal sinus mucosa is fully exenterated, the posterior table of the sinus is removed to establish communication with the intracranial space, and the nasal frontal ducts are packed with autologous tissue. The endoscopic endonasal route allows a minimally invasive access to the frontal nasal duct to ensure its blockage from the intracranial compartment. Additionally, the endoscope can be used from above through the supraciliary approach to allow for contralateral frontal sinus exposure and mucosal exenteration. CONCLUSION: The combined supraciliary-endoscopic endonasal approach provides a minimally invasive access for the treatment of sinonasal disease with frontal sinus mucoceles that invade the intracranial cavity.

Endoscopic treatment of Zenker's diverticulum using CO2 laser.

OBJECTIVES: The objective of the present study was to review the technique of endoscopic laser-assisted esophagodiverticulostomy (ELAED) for the treatment of Zenker's diverticulum. METHODS: We reviewed 83 cases of ELAED performed for the treatment of Zenker's diverticuli during the past decade. RESULTS: ELAED-treated patients had a reduced hospital stay and were able to start an oral diet earlier than were patients who underwent other surgical procedures. Two (2.4%) of our patients developed small fistulas, which closed spontaneously. An additional 2 (2.4%) of our patients required conversion to an open approach due to inadequate endoscopic exposure, and 5 (6%) required a revision endoscopic procedure for persistent symptoms. CONCLUSIONS: Our series of 83 patients treated at 2 large academic centers during the past decade with an average follow-up of 4 years demonstrates that ELAED is a safe and effective procedure for the management of Zenker's diverticulum.

Unilateral versus bilateral neck exploration in parathyroid surgery: an assessment of 55 cases.

We retrospectively evaluated the cases of 55 patients who had undergone surgery for primary hyperparathyroidism at our institution to determine whether their parathyroid glands were abnormal on both sides. Thirty-six of these patients had undergone a bilateral neck exploration, and 19 had had a unilateral investigation. Of the 36 bilaterally explored patients, 30 had a solitary adenoma and no parathyroid pathology on the opposite side, five patients had hyperplastic glands with more than one gland involved, and one patient had two adenomas. In the unilaterally explored group, all 19 patients had a solitary adenoma. There were no failures in the way of persistent hypercalcemia in either group. Based on our findings, we conclude that a unilateral neck exploration should be performed during surgery for primary hyperparathyroidism whenever a large parathyroid adenoma and a normal parathyroid gland are found on the same side. Bilateral exploration should be reserved for patients in whom pathology cannot be found on the initially explored side during surgery and for patients who have obvious parathyroid hyperplasia.

Congenital cystadenoma of the tongue in a neonate case report with review of literature.

We present a congenital cystadenoma of the tongue in a neonate, which presented at birth. Cystadenomas are uncommon tumors that form from salivary gland duct tissue and are more commonly seen in adults. This is the youngest case to be reported in the English literature. A review of literature with differential diagnosis and management is presented.

Results of the bone-anchored hearing aid in unilateral hearing loss.

OBJECTIVES: The advantages of binaural hearing are well established and universally accepted. However, a tendency remains to withhold the benefits of binaural hearing to adults and children with one normal ear. The purpose of this study is to demonstrate the benefit of the bone-anchored hearing aid (BAHA) in a group of patients with unilateral conductive or mixed hearing loss. STUDY DESIGN: This is a prospective study of nine patients (five males and four female patients) with conductive or mixed hearing loss who met the criteria for BAHA except for having normal hearing in the other ear. They had congenital aural atresia or mastoidectomies secondary to chronic ear infections with or without cholesteatoma or had a temporal bone tumor excised METHODS: Patients had evaluations before and after implantation, including audiological testing and responses to a standardized hearing handicap questionnaire. Statistical analyses of the data were made using the Wilcoxon signed rank test and the paired Student t test for repeated measures. RESULTS: All patients had tonal and spondee threshold improvement with BAHA when compared with thresholds before treatment. Speech recognition performance in BAHA-aided conditions was comparable to the patient's best score in unaided condition. Patients reported a significant improvement in their hearing handicap scores with the BAHA. CONCLUSIONS: The use of BAHA has significantly improved the hearing handicap scores in patients with unilateral conductive or mixed hearing loss. The proven safety and efficacy of the device promote its use in unilateral cases that traditionally had been left unaided.

Reinforcement of an end-to-end tracheal resection anastomosis with fibrin glue: a case report.

Tracheal resection and primary anastomosis is the treatment of choice for a short-segment stenosis. However, the procedure does carry the risk of two potentially fatal complications: anastomosis breakdown and leak. We describe the case of a 67-year-old man who was treated for a 3-cm tracheal stenosis secondary to a prolonged intubation and multiple tracheostomies. The patient underwent a tracheal resection and primary anastomosis. The anastomosis was reinforced with fibrin sealant, which created an airtight seal. The patient was extubated postoperatively, and he healed without complication. Fibrin sealant is a convenient, safe, and effective material for reinforcing anastomotic suture lines.

Use of potassium titanyl phosphate (KTP) laser in management of subglottic hemangiomas.

OBJECTIVE: to study the role of KTP laser in management of subglottic hemangioma. DESIGN: retrospective analysis of patients with subglottic hemangioma treated by the senior authors. SETTING: tertiary care teaching hospital. PATIENTS: twelve patients with subglottic hemangiomas. INTERVENTION: patients were treated with KTP laser (eight cases), CO(2) laser (two cases) or observation (two cases). MAIN OUTCOME MEASURE: resolution of symptoms, decrease in size of subglottic hemangioma or tracheotomy decannulation. RESULTS: All patients treated with KTP laser or CO(2) laser had resolution of symptoms and five tracheotomy-dependent children were decannulated. CONCLUSION: subglottic hemangioma is a potentially life-threatening disease seen in young children. Most authors recommend use of either CO(2) or open surgical excision. There is very little data available on the use of KTP lasers in the management of subglottic hemangiomas. The KTP laser beam is preferentially absorbed by hemoglobin making this laser system more applicable to the treatment of vascular tumors such as the hemangioma. KTP laser is a good tool for management of subglottic hemangioma with a low incidence of complications.

Transsphenoidal surgery utilizing computer-assisted stereotactic guidance.

Computer-assisted guidance technology represents the next step in the application of stereotactic techniques to skull base surgery. Use of this 3-D technique reduces operative time and complications as the technique allows a more direct approach with precise real-time anatomical guidance. We present seven cases of transsphenoidal parasellar surgery where this technique has been employed. The pathology included lesions of the sella turcica, parasellar region and the petrous apex.

Management of nasopharyngeal stenosis after uvulopalatoplasty.

OBJECTIVE: The objective of this study is to evaluate the management of nasopharyngeal stenosis (NPS) with the CO(2) laser and a customized nasopharyngeal obturator. STUDY DESIGN: An 8-year retrospective study based at a tertiary care teaching hospital consisting of 18 patients with NPS after uvulopalatoplasty treated over an 8-year period with the CO(2) laser and a nasopharyngeal obturator. Patients with grade I stenosis were treated in the office and did not require a nasopharyngeal obturator. More severe cases (grades II and III) were treated in the operating room and required a nasopharyngeal obturator. RESULTS: Eighteen patients with NPS, stages I to III, were treated with a CO(2) laser with or without a nasopharyngeal obturator with good results. CONCLUSION: The repair of NPS with a CO(2) laser and a nasopharyngeal obturator in severe cases helps in restoring nasopharyngeal patency. SIGNIFICANCE: This technique provided a reliable method of correcting postuvulopalatoplasty NPS.

Reduced-time-window sestamibi scanning for nonlocalized primary hyperparathyroidism.

BACKGROUND: Technetium Tc 99m sestamibi scan is the standard of care for localizing parathyroid adenomas. METHODS AND MATERIAL: We performed a retrospective, single-institution study of 111 consecutive patients with primary hyperparathyroidism who underwent standard sestamibi scan for localization of a parathyroid lesion. A revised protocol of reduced-time-window sestamibi scan was used in nonlocalized patients. The protocol was composed of single-view scans at 15, 30, 45, and 120 minutes and tomograms at 60 minutes. RESULTS: Thirty-five patients underwent surgery at our institution. Thirty-one had adenomas, and 4 had hyperplasia. Three of 31 patients did not show localization on the standard scan and underwent reduced-time-window scans, which localized 2 more adenomas. These were confirmed at the time of surgery. CONCLUSION: We suggest that all patients with a high degree of suspicion for a parathyroid adenoma, which is not visualized by a standard scan, undergo a reduced-time-window scan.

Effects of thyroplasty type I on vocal fold vibration.

OBJECTIVE: To ascertain effects of medialization thyroplasty on vocal fold vibration in glottic incompetence dysphonia. STUDY DESIGN: Quantitative videostroboscopic glottic measurements and vocal function study were perioperatively undertaken in 20 patients undergoing Isshiki's thyroplasty type I. METHODS: In digitized images, the glottal area, glottal width, posterior glottal width, and amplitude over an entire glottal cycle were measured and normalized by membranous vocal fold length. The ratio of closed phase to total phase of vibratory cycle was calculated from the data of the glottal area and the glottal width at the middle point of the membranous vocal fold. Well-accepted acoustic, aerodynamic, and perceptual measures analyzed vocal function. RESULTS: Glottal area and glottal width were reduced after surgery. While preoperative closure of glottal area was incomplete in all 20 patients, incomplete closure was obtained in 16 patients after surgery. In these 16 patients, closure of glottal width at the middle point of the membranous vocal fold was complete, whereas a posterior glottal gap remained in 14 patients. Closed phase over one cycle of glottal width waveform and amplitude of vocal fold vibration were increased after surgery. Glottal area, glottal width, posterior glottal width, and closed phase over one cycle of glottal width waveform correlated with vocal function measures. CONCLUSIONS: Thyroplasty type I reduces a glottal gap and increases closed phase over one cycle and amplitude of vocal fold vibration, although a posterior glottal gap remains. With the improved glottic vibration, thyroplasty type I provides more efficient phonation in patients with glottic incompetence dysphonia.

Tongue reduction in Beckwith-Weidemann syndrome.

OBJECTIVE: To review our experience with patients with macroglossia as a component of Beckwith-Weidemann Syndrome (BWS). DESIGN: Chart review of six patients treated with BWS. SETTING: Tertiary care teaching hospital. PATIENTS: Six patients diagnosed with BWS and macroglossia. INTERVENTIONS: Four patients underwent at least one surgical procedure to address their macroglossia. The surgical options and potential complications are discussed. RESULTS: Three patients who have undergone tongue reduction have a functioning tongue with normal mobility. Two patients have required tracheotomy as apart of their management and still have significant tongue enlargement. CONCLUSIONS: Macroglossia as a part of BWS may present a difficult management problem. Various methods of tongue reductions have been reported with mixed results.

Value of radiologic imaging and computer assisted surgery in surgical decisions of the anterior skull base lesions.

The role of radiologic imaging in surgical decision making of anterior skull base lesions has been found to be critical in the endoscopic surgical management of these lesions. The non-invasive radiologic imaging may include the use of CT scans, MRI scans, MRA scans and their subtraction technique. The imaging offers an understanding of the vascularity of the lesion, the relationship to the nearby neurovascular structures and the type of tissue density of these lesions. The addition of image guided applications offers one a sagittal reconstruction and a 3-D imaging capacity which has immensely improved the accuracy and precision in endoscopic surgical applications in these areas.

Large intraosseous arteriovenous malformation of the maxilla - a case report with review of literature.

Large intraosseous arteriovenous malformations (AVM) of the maxilla are rare lesions, which are probably hamartomas. We report a case of an 8-year-old child who presented with exsanguinating hemorrhage after an attempted dental biopsy. The management of dental intraosseous AVMs includes transarterial embolization and direct intralesional injection of liquid acrylic (NBCA). This approach avoids mutilating surgery and its sequelae in children. We present this case for its rarity and the intralesional use of acrylic glue in its management.

Solitary mastocytoma in an infant - case report with review of literature.

Solitary mastocytoma in infants is an uncommon disease which is characterized by mast cell hyperplasia and release of mast cell mediators. The most common presentation is pruritus. The treatment of solitary mastocytoma is symptomatic. Cutaneous mastocytoma tend to resolve by adulthood.

Need for tracheotomy is rare in patients with acute supraglottitis: findings of a retrospective study.

We retrospectively reviewed the cases of 23 adults and six children who had been given a presumed diagnosis of acute supraglottitis between 1987 and 1997. The most common symptoms in these patients were odynophagia, dysphagia, hoarseness, and fever. Stridor and drooling were also observed, primarily in the children. Fiberoptic laryngoscopy confirmed the presence of edema and erythema of the supraglottic structures in all patients. Blood cultures were positive for Hemophilus influenzae type b in three children and for Serratia marcescens in one adult. All other blood cultures were negative. All patients were treated with intravenous broad-spectrum antibiotics and humidified oxygen, and two-thirds received intravenous corticosteroids. Patients were monitored with pulse oximetry and serial fiberoptic laryngoscopy. Two patients required intubation; one had an epiglottic abscess, and the other had laryngeal edema so severe that vocal fold mobility could not be assessed. The length of stay in the intensive care unit ranged from 1 to 7 days (mean: 1.9). All patients recovered and were discharged free of symptoms after 2 to 11 days of overall hospitalization (mean: 4.4).

Choanal atresia, CHARGE association, and congenital nasal stenosis.

Congenital bilateral narrowing or obstruction of the nasal airway can result in significant respiratory distress in the neonate, requiring emergency intervention. Some of these children have associated congenital malformations that may also impact on the management of the nasal anomaly. The embryology, presentation, and management of this spectrum of disorders are discussed, and the major surgical controversies are reviewed.

Ectopic thymus presenting as a solid submandibular neck mass in an infant: case report and review of literature.

Solid ectopic cervical thymus is an extremely uncommon etiology of a neck mass in an infant. It occurs in the line of descent of the thymus from the angle of the mandible to the superior mediastinum. Nine cases of ectopic cervical thymus in infants have been reported in the literature. Only two of nine cases were solid, the remaining seven were thymic cysts. A preoperative diagnosis is seldom considered and is often misdiagnosed as a possible malignancy or a lymph node. We present a case of a 2-month-old infant with an asymptomatic enlarging right neck mass. Patient underwent complete excision of the mass.