Bilateral, simultaneous cochlear implantation in children: surgical considerations.

PROBLEM: The advantages of bilateral, simultaneous cochlear implantation include: the possibility to pre-empt cochlear calcification following meningitis; reduction of the intervention to only one procedure, general anaesthetic and course of clinical care (with obvious benefits for the patient); and greater cost-effectiveness. The disadvantages of such a procedure include: doubling the risk of associated complications; placing the patient on the implanted side during contralateral implantation; the possibility of vestibular alteration simultaneously in both ears; the need for precise planning of symmetrical incisions and implant sites; and longer surgery time. METHODS: The study cohort included 10 children who underwent bilateral, simultaneous cochlear implantation using the suprameatal approach. RESULTS: The overall operation time, inclusive of anaesthesia, was approximately three hours in all cases. None of the children had any intra- or post-operative complications. CONCLUSIONS: From a surgical perspective, bilateral, simultaneous cochlear implantation is a safe procedure. The use of a non-mastoidectomy approach is recommended.

Efficacy of FIT produce wash and chlorine dioxide on pathogen control in fresh potatoes.

A commercial fresh pack potato operation was used as a model to evaluate FIT fruit and vegetable wash effectiveness in reducing levels of microorganisms on potatoes and in flume water. Fresh potatoes were washed in flume water with or without FIT, or treated with a spray bar utilizing either FIT, 9 ppm chlorine dioxide (CIO2), or a water control. Both flume treatments were also evaluated for APC and Gram-negatives. There were no significant differences in reduction of these microorganisms on treated or control potatoes. However, levels of Gram-negative bacteria in FIT-amended flume water were reduced by 5.95 log CFU/g, and the APC was reduced by 1.43 log CFU/g. To validate plant trial findings, this test was repeated using solutions of sterile potato flume water from the fresh pack operation, containing a typical level of dissolved and suspended solids. Treatment solutions prepared with flume water or deionized water containing FIT, 9 ppm CIO2, or a water control were inoculated with E. coli O157:H7, Salmonella Typhimurium, or Pectobacterium carotovorumssp. carotovorum. FIT and ClO2 prepared with deionized water reduced levels of microorganisms by >6.1 to 6.6 log CFU/g to below the detection limit. FIT prepared with flume water reduced levels of all organisms by >6.0 to 6.4 log CFU/g to below the detection limit, whereas ClO2 prepared from flume water reduced bacterial levels of all organisms by only 0.7 to 1.4 log CFU/g. Neither FIT nor ClO2 was particularly efficacious against E. coli O157:H7, S. Typhimurium, APC, yeasts, or molds on potato surfaces.

High resolution gamma ray tomography scanner for flow measurement and non-destructive testing applications.

We report on the development of a high resolution gamma ray tomography scanner that is operated with a Cs-137 isotopic source at 662 keV gamma photon energy and achieves a spatial image resolution of 0.2 line pairs/ mm at 10% modulation transfer function for noncollimated detectors. It is primarily intended for the scientific study of flow regimes and phase fraction distributions in fuel element assemblies, chemical reactors, pipelines, and hydrodynamic machines. Furthermore, it is applicable to nondestructive testing of larger radiologically dense objects. The radiation detector is based on advanced avalanche photodiode technology in conjunction with lutetium yttrium orthosilicate scintillation crystals. The detector arc comprises 320 single detector elements which are operated in pulse counting mode. For measurements at fixed vessels or plant components, we built a computed tomography scanner gantry that comprises rotational and translational stages, power supply via slip rings, and data communication to the measurement personal computer via wireless local area network.

Mediastinal dissection in head and neck cancer.

The superior mediastinum contains a considerable number of lymph nodes. Although occasionally involved in head and neck cancer, there are not many reports of mediastinal dissection in the practice of head and neck surgery. We present a group of seven patients with head and neck tumours that underwent mediastinal dissection in our department. Three patients are alive and free of disease six months to three years after the operation, two are alive with disease four and five years after the procedure, and two patients died peri-operatively. According to reviewed current literature, direct invasion of cancer of the head and neck to the mediastinum or mediastinal lymph node involvement is uncommon. Yet, mediastinal dissection provides the only chance for cure in selected cases.

[Intratympanic gentamicin treatment for intractable Menière's disease].

BACKGROUND: Intratympanic gentamicin is an accepted mode of treatment for patients with Meniere's disease who suffer from recurrent vertigo attacks in spite of conservative medical treatment. Recently, it gained popularity as the primary treatment for intractable Meniere's disease, prior to surgical procedures. However, administration methods and treatment protocols still differ from one medical center to another. OBJECTIVES: We aimed to present outcomes of gentamicin treatment for vertigo attacks and functional capacity, based on our experience with 23 patients over 3 years and review the literature on the subject. METHODS: Three specially prepared gentamicin injections, were administered once a month, according to the state of vertigo attacks, functional capacity, and hearing status. Clinical observation, frequent hearing examinations and caloric tests were used for follow-up. RESULTS: Following treatment, 20 (87%) patients no longer experienced vertigo attacks, while 16 of them (69.6%) reported full functional recovery. Two patients (8.7%) did not respond to treatment, and therefore, underwent surgical procedures. One patient (4.4%) did not complete therapy. Post treatment caloric tests showed significant deterioration (P < 0.02). Severe vestibular weakness (51-100%) was found in the treated ear in 11 of the 14 patients with unilateral disease (78.6%). The mean change in hearing examination was non-significant. However, two of the 21 patients suffered a change from moderate to severe hearing loss to complete deafness (9.5%). There was no case of post treatment infection or permanent tympanic perforation. CONCLUSIONS: Intratympanic gentamicin injection is a simple and safe procedure for intractable Meniere's patients, with a high success rate and low risk for hearing deterioration. It is recommended for patients with continuous functional disability prior to surgical treatment.

[Upper respiratory tract manifestations in yellow nail syndrome].

Yellow Nail Syndrome (YNS) is characterized by a triad of ankle edema, pleural effusion and yellow nails. A close association was also found between YNS and rhinitis and sinusitis ranging from 25% to 83%. Although usually other symptoms precede rhinosinusitis, we describe three cases in which the onset of the upper respiratory tract manifestations predated nail changes and other characteristics of YNS. Our aim is to emphasize the importance of upper respiratory tract diseases in this uncommon syndrome.

Pretreatment prevalence of hypothyroidism in patients with head and neck carcinoma.

BACKGROUND: Hypothyroidism in the normal population age > 60 years is encountered in the range of 0.5-5% clinically, and 5-20% have subclinical hypofunction. Hypothyroidism is recognized as a common complication of treatment in patients with head and neck carcinoma (HNC) and is reported in up to 75% of patients who receive combined treatment. Surprisingly, base-line pretreatment measurements of thyroid function in large series of patients have not been reported. METHODS: Serum thyroid-stimulating hormone, free T4, and total T3 levels were recorded in 110 patients with nonthyroid HNC prior to treatment in a prospective, controlled study. RESULTS: The mean patient age (+/- standard deviation) was 65 years +/- 13.8 years, and 82% of patients had squamous cell carcinoma. A diagnosis of hypothyroidism already was established in 4.5% of patients, and subclinical hypothyroidism was discovered in an additional 6.4% of patients. Sixteen patients had other equivocal anomalies in thyroid function and were referred for further endocrine evaluation. No patients with formerly unrecognized clinical hypothyroidism were found. CONCLUSIONS: Hypothyroidism in patients with head and neck carcinoma in Israel corresponds with the reported incidence in the general population. Hypothyroidism after treatment for head and neck carcinoma stems from the effects of treatment. The need for pretreatment evaluation of thyroid function should be considered.

Upper jugular lymph nodes (submuscular recess) in non-squamous-cell cancer of the head and neck: surgical considerations.

Cervical lymphadenectomy of level II encompasses lymph nodes associated with the upper internal jugular vein and the spinal accessory nerve (SAN). Removal of tissue superior to the SAN (submuscular recess-(SMR)) was recently shown to be unwarranted in selected cases of squamous-cell cancer. Thirty-five patients with non-squamous-cell cancer (SCC) of the head and neck treated with cervical lymphadenectomy were prospectively evaluated. Thirty-seven neck dissection specimens were histologically analysed for the number of lymph nodes involved with cancer. At the time of surgery, level II was separated into the supraspinal accessory nerve component (IIa) and the component anterior to the SAN (IIb). Neck dissections were most commonly performed for cancer of the thyroid gland (19) followed in frequency by the parotid gland (seven), skin: melanoma (five), basal-cell cancer (two), and other sites (four). Twenty-five neck dissections were modified-selective procedures and 12 were either radical or modified radical neck dissection. Twenty-nine necks were clinically N+ and eight N0. Histological staging was pathologically N+ in 32 neck dissection specimens. Level IIb contained an average of 12 nodes and the IIa component contained a mean of 5.0 nodes. Level II contained metastatic disease in 28 of 32 histologically node-positive specimens (87 per cent). Level IIa was involved with cancer in six cases (16 per cent), five of which were pre-operatively staged as clinically N+. All cases (100 per cent) with level IIa involvement had level IIb positive nodes. Three of the level IIa positive cases were cancer of the parotid gland comprising 43 per cent of this sub-group of patients. Incidence of involvement of SMR in non-SCC cases is not uncommon. The additional time required and morbidity associated with dissection of the supraspinal accessory nerve component of level II are probably justified when performing neck dissection in cancer of the thyroid gland. The SMR should be excised in cancer of the parotid gland. Large-scale prospective controlled studies with long-term follow-up periods are necessary to support resection of level IIb only.

Laryngotracheal anastomosis: primary and revised procedures.

OBJECTIVES: Acquired upper airway stenosis is usually associated with a complex of pathological conditions at the high tracheal and the subglottic levels. Reported reconstructive techniques include widening by incorporation of grafts, segmental resection, and anastomosis or combined procedures. The management of recurrent stenosis after reconstructive surgery is a major challenge and has rarely been discussed in the literature. The purposes of the present study are to compare the clinical course of primary versus revised reconstructive procedures and to analyze the effect of age, diabetes, chronic lung disease, grading of stenosis, extent of resection, and revised procedures on the operative rate of success. STUDY DESIGN: A cohort study in a tertiary referral medical center. METHODS: The clinical course of 23 consecutive patients undergoing laryngotracheal anastomosis was studied comparing a group of 13 primary with 10 revision procedures. Seventeen patients underwent cricotracheal and six patients thyrotracheal anastomoses. All patients but one were tracheotomized before the definitive reconstructive procedure. Suprahyoid release was routinely performed except for two cases, and only one patient required sternotomy. The Wilcoxon test was used to examine the relationship between preoperative clinical parameters and the postoperative success (i.e., airway patency). RESULTS: Twenty-two of 23 patients (95.6%) had successful decannulation. Four patients required a revision procedure because of repeat stenosis at the site of the anastomosis (2) or distal tracheal malacia (2). Residual airway stenosis of less than 50% was noted in six patients, although only three complained of dyspnea during daily-activity exertion. There was no associated mortality. Complications included subcutaneous emphysema (4), granulation tissue formation (3), pneumonia (2), cardiac arrhythmia (2), and one each of pneumomediastinum, neck hematoma, and urosepsis. Protracted aspirations were noted in one patient who had revision surgery. Age was the only parameter that correlated with postoperative airway patency (P <.07), whereas the presence of chronic obstructive lung disease and diabetes, grade of stenosis, type of surgery, and revision surgery were found to be insignificant. CONCLUSIONS: The clinical course of laryngotracheal anastomosis in primary and revised procedures was similar in our group of patients. The operation can be performed safely, with an expected high rate of success and acceptable morbidity.

Suprameatal approach: new surgical approach for cochlear implantation.

The conventional technique for cochlear implantation is via a mastoidectomy and posterior tympanotomy. An alternative approach for cochlear implantation is hereto described. The middle ear is entered through a suprameatal approach (SMA) bypassing the mastoid cavity. This surgical approach shortens the duration of the procedure to approximately one hour. The introduction of the cochlear implant electrode array involves drilling in the suprameatal region and the osseous portion of the external auditory canal at a safe distance from the anatomical position of the facial nerve. This prevents possible injury by direct trauma or drill overheating of the chorda tympani or facial nerves. We report 15 consecutive patients who were operated on using the SMA technique. No complications were encountered as a result of this surgical technique but further experience may be necessary.

Salivary flow dynamics after parotid surgery: a preliminary report.

BACKGROUND: Tumors in the parotid gland may affect salivary flow. The effects of tumor on glandular function and postoperative changes in both resected gland and contralateral gland were not formerly reported. We prospectively evaluated salivary flow rates and composition in patients undergoing parotidectomy preoperatively and postoperatively. METHOD: Stimulated parotid saliva from 17 patients undergoing parotidectomy was collected bilaterally preoperatively and postoperatively by using a parotid cup. Subjective complaints were recorded. Salivary flow rates, sodium, potassium, and amylase levels were evaluated. RESULTS: None of the patients complained of "dry mouth" before or after surgery. Analysis of the individual results revealed 3 patterns of preoperative and postoperative response, compatible with either a preoperative or postoperative compensatory mechanism in the contralateral gland. The postoperative decrease in flow rate corresponds with the amount of gland removed. Salivary electrolyte composition was unchanged. CONCLUSION: This study is the first to demonstrate the effects of parotid tumors and their surgery on salivary flow and a compensatory response and its different patterns in human parotid glands after their excision.

Acute mastoiditis--the antibiotic era: a multicenter study.

OBJECTIVES: To evaluate the clinical course and identify the causative organisms of acute mastoiditis in a community where most of the patients who develop acute otitis media are treated with antibiotics. METHODS: A multicenter retrospective review of a series of 223 consecutive cases of acute mastoiditis. SETTING: Nine secondary or tertiary academic or non-academic referral centers. RESULTS: Prior to the diagnosis of acute mastoiditis, 121 of the patients (54.3%) had been receiving oral antibiotic treatment for acute otitis media for periods ranging from 1 to 21 days (mean 5.3 days). Samples for bacterial culture were obtained from 152 patients. Cultures were negative in 60 patients. The organisms isolated in the 92 positive cultures were: Streptococcus pneumoniae (15 patients), Streptococcus pyogenes (14 patients), Staphylococcus aureus (13 patients), Staphylococcus coagulase negative (three patients), Pseudomonas aeruginosa (eight patients), Haemophilus influenzae (four patients), Proteus mirabilis (two patients), Escherichia coli (two patients), Klebsiella pneumoniae (one patient), Enterobacter (one patient), Acinetobacter (one patient), anaerobic gram-negative bacilli (one patient), and fungi (two patients). Ten patients had mixed flora. Sixteen patients presented with complications (cerebellar abscess, perisinus empyema, subdural abscess or empyema, extradural abscess, cavernous sinus thrombosis, lateral sinus thrombosis, bacterial meningitis, labyrinthitis, petrositis, or facial nerve palsy). CONCLUSIONS: Antibiotic treatment cannot be considered an absolute safeguard against the development of acute mastoiditis. Early myringotomy for acute otitis media seems to decrease the incidence of complications. The distribution of causative organisms in acute mastoiditis differs from that in acute otitis media. Intracranial complications in acute mastoiditis are not rare. Because of the diversity of causative organisms in acute mastoiditis and the growing resistance of bacteria to the various antibiotics, all means to obtain a sample for culture prior to antibiotic treatment, including general anesthesia.

Granular myringitis in children.

BACKGROUND: Granular myringitis (GM), described mainly in adults, is considered a rare infection of the tympanic membrane (TM) with possible involvement of the external ear canal. The study was aimed to evaluate the clinical characteristics of the disease in children. MATERIAL: A 2-year prospective study on all children with GM in a primary otolaryngology practice affiliated to a tertiary academic medical center. GM was defined by de-epithelization of the TM, granulation-tissue formation and discharge. Children with otitis media were excluded. Treatment included topical application of ear drops, caustic solution in unresponsive cases and mechanical removal of polypoidal granulations. RESULTS: Nine children, five boys and four girls, aged 3--16 (mean=11.5 years) were diagnosed as GM. Mainly plugged ear (6) and aural discharge (5) presented GM. Only a circumscribed area of the pars tensa was involved. GM was expressed either by a tiny shallow lesion (6) or by raised polypoidal masses (3). All children recovered within 2--11 weeks (mean 3.6). Recurrent infection was noted twice in one child. Small dry perforation of the TM was noted in two children. Histopathological studies revealed non specific acute and chronic inflammatory reaction. CONCLUSIONS: Granular myringitis must be recognized in children. GM has a benign course responding to topical treatment. It may be misidentified as persistent chronic suppurative otitis media with polyps protruding through the TM. Although perforation of the TM may develop in the course of the disease, the middle ear remained intact.

Steroids, carbogen or placebo for sudden hearing loss: a prospective double-blind study.

There is no consensus regarding treatment modalities for idiopathic sudden sensorineural hearing loss (SNHL). In order to evaluate the effectiveness of steroid or carbogen inhalation therapies, a prospective double-blind placebo controlled study was designed. All 41 patients enrolled in the study had unilateral SNHL with no prior history of SNHL, otological pathological history or otoscopic findings. Patients were assigned to four treatment groups: prednisone tablets, placebo tablets, carbogen inhalation or room air inhalation. All were treated for 5 days. The audiometric data at admission was compared to that at day 6 and to data collected at follow-up (average 33 days). Results revealed no significant difference between the groups for early or late audiometric outcome. Age, time from onset of symptoms to initiation of treatment, tinnitus, audiogram configuration, and the presence of vertigo at onset did not significantly affect the outcome. The discrimination scores that were poor in all patient groups on admission improved within days in all groups. These findings suggest that steroids or carbogen inhalation have no therapeutic advantage over placebo. Also, regardless of treatment modality, hearing continued to improve for at least a month after treatment was stopped.

Pain in the neck after neck dissection.

BACKGROUND: Reports of disability after neck dissection have been directed toward shoulder dysfunction and pain. We could find no report addressing the issue of pain localized to the actual operative site. We have conducted a combined prospective and retrospective study of pain in patients undergoing neck dissection. METHODS: Eighty-eight disease-free patients were evaluated in 3 groups for neck pain. One group was followed up prospectively for 1 to 8 months after surgery, and 2 retrospective groups were followed up for more than 2 years or for 6 months to 2 years. Pain was assessed by a body map and visual analog scale. RESULTS: None of 31 patients followed up for more than 2 years reported neck pain. Four of 27 patients followed up for 6 to 24 months had pain, with a mean visual analog scale score of 3.7. Seventy percent of the prospective group of 30 patients had pain during the first postoperative week, and only 1 patient had pain persisting for more than 2 months. Shoulder pain and disability after radical neck dissection were encountered in all groups, comparable with the incidence reported in the literature. No postoperative neuromas were found. CONCLUSIONS: Chronic pain localized to the operative site is an uncommon occurrence even after radical neck dissection. Chronic pain in the shoulder region may follow radical neck dissection, whereas modified neck dissection is usually a painless procedure.

Acquired tracheoesophageal fistula in critically ill patients.

Acquired benign tracheoesophageal fistula (TEF) is an infrequent complication of prolonged intubation and tracheostomy. Not infrequently, it is associated with severe circumferential malacia of the trachea and a need for concomitant correction of both. Controversy exists as to whether this should be performed in a single-stage or a 2-stage procedure. Four patients with acquired TEF underwent operation in a tertiary referral medical center between 1995 and 1997. The operations were performed through either an anterior (3) or a lateral (1) neck approach. Three patients underwent closure of the fistula with tracheal resection and anastomosis in a single stage and are doing well. One patient with complete subglottic stenosis underwent closure of the TEF and was planned for tracheal reconstruction in a second stage. This patient died in the early postoperative period. The complications included aspiration of blood leading to pneumonia (2), spontaneously resolving pneumomediastinum (1), subcutaneous emphysema (2), and cardiac arrhythmia ( 1). Residual fistula, noted in 1 patient, was treated conservatively and resolved spontaneously within several weeks. We conclude that acquired TEF is amenable to repair through a cervical approach. A single-stage correction of the TEF with reconstruction of the trachea is suitable and successful in most patients. Several stages seem justified when concurrent laryngotracheal reconstruction is needed.

Postsurgical prevertebral abscess of the cervical spine.

OBJECTIVES: Prevertebral abscess formation is an uncommon occurrence following cervical spine fusion surgery. Abscesses may present early or in a delayed fashion and require surgical drainage and long-term antibiotic treatment. The issues of osteomyelitis and the need for plate removal remain unresolved. STUDY DESIGN: A case series of six tetraplegic patients admitted for rehabilitation to the Chaim Sheba Medical Center (Tel Hashomer, Israel) is presented. METHODS: Five patients were trauma patients; one patient underwent repeated procedures and irradiation for tumor of the cervical spine. All patients developed prevertebral abscesses after a mean period of 30 days from their fusion surgery. Computed tomography scan was used in all patients to establish the diagnosis and define the extent of the infective process. All patients underwent one or more drainage procedures. The plate was removed in two patients at 1 and 4 months. RESULTS: Infection completely resolved in four patient and was refractory in one patient with malignant tumor, and a chronic small fistula remained in one case. Staphylococcus aureus was the main infective organism, but mixed infections were the rule. Even for a protracted course of infection, no significant osteomyelitis was encountered. CONCLUSIONS: Abscess formation after instrumentation of the neck may be more common than formerly recognized. Despite the prolonged course of disease and treatment, osteomyelitis is not a major concern. There is no automatic indication for plate removal to control infection, although plating may be safely removed after 10 to 12 weeks if the neck is explored and the cervical spine is stable. A high index of suspicion is warranted, and early recognition and diagnosis, prompt surgical drainage under general anesthesia, and long-term antibiotic treatment are key for eradication of the infective process. Prophylactic antibiotics may be of value. Meticulous antisepsis and surgical technique should be maintained to reduce the incidence of these severe complications.

Structural changes and protein expression in the mastoid bone adjacent to cholesteatoma.

OBJECTIVE: Cholesteatoma of the mastoid and middle ear causes erosion of nearby bone. In this study we examined the mastoid bone adjacent to cholesteatoma and compared it with normal mastoid bone. In particular, noncollagenous proteins, which have a special structural and functional role in bone, were addressed. STUDY DESIGN: Nine mastoid specimens with cholesteatoma and four normal specimens obtained at surgery were examined. METHODS: Histological and immunohistochemical methods were employed to evaluate the nature of structure and noncollagenous protein content changes in the mastoid bone affected by cholesteatoma. RESULTS: The bone associated with cholesteatoma had structural changes as a noncontinuous periosteum, empty lacunae, irregular cement lines, and, specifically, the appearance of eosinophilic vesicles at the interface between the bone and cholesteatoma Immunohistochemistry demonstrated that noncollagenous proteins were apparently absent in the affected mastoid bone. Bone remote from the cholesteatoma seemed normal. CONCLUSIONS: These findings demonstrate for the first time the changes in the noncollagenous protein content in the mastoid bone affected directly by cholesteatoma These changes could be a result of a direct influence of cholesteatoma-derived products on the osteoblast.

Salivary flow and its relation with oral symptoms in terminally ill patients.

BACKGROUND: Patients with terminal malignant disease commonly report hyposalivation or xerostomia. This leads to "dry mouth," fungal infection, and mucosal abnormalities. To the authors' knowledge oral symptomatology and findings have not been correlated previously with accurate salivary flow measurements. METHODS: Measurement of stimulated parotid salivary flow rate and clinical recording of oral symptoms within 24 hours from the time of hospital admission were obtained in 48 terminally ill cancer patients. Subjective reporting of symptoms by patients, parotid salivary flow rate, clinical recording of dental status, presence of candidiasis, angular cheilitis, and dryness of the floor of the mouth were obtained. RESULTS: A clinical diagnosis of oral candidiasis was made tentatively in 94% of patients, and 50% of the patients were found to have angular cheilitis. Thirty-one of 45 evaluable patients (68%) reported a sensation of oral dryness. Sixteen of the 48 patients (33%) had no saliva at the floor of the mouth. Analysis of individual salivary flow rates was stratified into 3 levels of secretion: 0, < 0.2, and > or= 0.2 mL/minute. Symptoms were found to correlate with salivary flow rates. CONCLUSIONS: In the current study, symptoms were found to be most severe in the patients with xerostomia followed by those patients with hyposalivation. Treatment should be directed individually to each group of patients using either salivary substitutes or stimulants. The rate of incidence of oral pathologic findings may be higher than formerly recognized.