Intratympanic steroid injections for intractable Ménière's disease.

OBJECTIVE: To examine whether intratympanic injection of dexamethasone is effective in controlling vertigo in patients with Ménière's disease who have persistent vertigo despite standard medical treatment, including a low-salt/no-caffeine diet and diuretics. STUDY DESIGN: A prospective study. METHODS: From August 1999 to November 2000, 21 patients with intractable Ménière's disease underwent intratympanic injections of 4 mg/mL dexamethasone over a period of 4 weeks as an office procedure. American Academy of Otolaryngology-Head and Neck Surgery guidelines for the definition and reporting of results in Ménière's disease were used. RESULTS: Complete relief of vertigo was maintained in 11 of the 21 patients (52%) at 3 months and in 9 of 21 patients (43%) at 6 months. Repeat injections in 5 patients who had initial control of vertigo, but later failed, yielded control in 3 (60%) patients. The complication rate was low: one patient had a 35-decibel pure tone average decrease in hearing during treatment and one patient had a persistent tympanic membrane perforation. CONCLUSIONS: Intratympanic injections of dexamethasone are a reasonable initial surgical treatment for persistent vertigo in Ménière's disease. The principal benefits are avoidance of systemic administration of steroids, lower cost than endolymphatic sac surgery, and ease of administration as an office procedure. The disadvantages are the need for repeated office visits for injections and the decreasing effectiveness over time.

Electrocautery versus carbon dioxide laser for uvulopalatoplasty in the treatment of snoring.

Laser-assisted uvulopalatoplasty is a popular method for reducing snoring. Drawbacks are the large initial expense of the laser unit and related equipment and required safety precautions. The equipment required for electrocautery for cautery-assisted uvulopalatoplasty is significantly less expensive to obtain and operate compared with the carbon dioxide laser. Ninety-eight patients were randomly assigned to one of two treatment groups to undergo uvulopalatoplasty: one performed with the carbon dioxide laser and the other with electrocautery. We compared postoperative pain, time off work, efficacy, and the number of treatments required to achieve a satisfactory result. We found no statistically significant difference in any of these parameters between the two treatment groups (P > 0.05). Our data show that the use of the carbon dioxide laser offers no advantage over electrocautery in performing uvulopalatoplasty to treat snoring.

Management of persistent chylothorax.

The aggressive management of persistent chylothorax is necessary for avoidance of significant morbidity and possible mortality. The failure of TPN and chest tubes to rapidly control a chylothorax should lead to consideration of thoracic duct ligation.

Brown tumor of the mandible.

Brown tumor is a focal lesion differentiated from other giant-cell tumors by the presence of hyperparathyroidism. Treatment of brown tumors must be initially directed towards correcting the hyperparathyroidism. Tumor regression may occur with resolution of the hyperparathyroidism. Persistent or large destructive tumors are treated with resection or curettage.

Use of intraoperative neuromonitoring to prevent orbital complications in ethmoid sinus surgery.

Orbital injury is one of the most serious complications in sinus surgery. Although these injuries are generally infrequent, there is a considerable increased risk for orbital complications during procedures in which anatomic landmarks are distorted because of the severity of disease or prior surgery. Currently there are no methods to detect early defects in the lamina papyracea or to prevent continued resection until orbital fat or periorbita is seen. Thirteen New Zealand white rabbits were studied by use of a nerve monitor to identify the periorbita and orbital fat in surgically created lamina defects. Evoked potentials were measured at the medial orbit when the lamina papyracea, periorbita, and orbital fat were stimulated at current intensities ranging from 0.25 to 1.00 mA. Stimulation of the lamina at 0.8 and 1.0 mA resulted in response amplitudes that were significantly lower compared with those of periorbita stimulation (means at 1 mA, 38.26 microV vs. 117.85 microV; p < 0.01). Stimulation of the orbital fat also resulted in higher potentials (mean, 59.47 microV) than those of the lamina papyracea (mean, 38.26 microV) but did not reach statistical significance. The statistically significant difference in response amplitudes between the lamina papyracea and the periorbita indicate that intraoperative monitoring may be useful in identifying early lamina defects, which could in turn reduce the risk of orbital injury during sinus surgery.

Haemophilus influenzae type B epiglottitis after immunization with HbOC conjugate vaccine.

INTRODUCTION: US Food and Drug Administration (USFDA) has licensed four Haemophilus influenzae type B (Hib) vaccines for use in children. Haemophilus influenzae type B is by far the most common pathogen in childhood epiglottitis and it is hoped that with the introduction of the Hib vaccine that a corresponding decrease in epiglottitis cases will be appreciated. MATERIALS AND METHODS: A retrospective study of all children admitted with the diagnosis of epiglottitis for the 11-year period of 1982 to 1992 was conducted in order to determine the incidence of epiglottitis and Hib vaccine failure. Fifty-nine cases were included in the study by documentation of an inflamed epiglottis. The case of Hib epiglottitis in a 4-year-old child immunized with HbOC conjugate vaccine at 18 months of age is detailed. RESULTS: A statistically significant decrease was found in the incidence of epiglottitis since introduction of the vaccines; however, the overall trend in decrease for the 11-year period was not statistically significant. Vaccination status was difficult to accurately document with only two cases of vaccine failure identified. CONCLUSION: The incidence of Haemophilus influenzae type B epiglottitis at our regional Children's hospital has decreased since the introduction of the Hib vaccine. Reasons for vaccine failure are postulated.