Human papillomavirus-associated oropharyngeal cancer: review of current evidence and management.

Oropharyngeal cancer (opc) has become the leading site for human papillomavirus (hpv)-associated cancers in humans. It is an epidemic that remains relatively unfamiliar to most physicians, potentially delaying diagnosis and treatment. Traditionally, cancers involving the head and neck have occurred in smokers and in those with a significant alcohol history. Typically, hpv-positive opc presents in a younger, healthier population with a different set of risk factors and good prognosis for survival. However, many head-and-neck cancer patients, including those with hpv-positive disease, develop lifelong disabilities because of the morbid nature of their treatments, and those patients have the highest level of unmet needs in studies spanning cancer sites. Knowledge of this epidemic, a high index of suspicion, and an understanding of how the tumours present in clinical practice can help physicians to make an early diagnosis, thus sparing the patient significant morbidity from treatments associated with more advanced disease stages. Furthermore, recognizing that these patients have distinct psychosocial needs and implementing a collaborative team approach is critical to providing optimal care and improving quality of life in the survivorship period.

Clinical applications of a finite-element model of the human middle ear.

Computer-generated models are increasingly being used in otolaryngology for teaching purposes, preoperative planning, and clinical simulations, especially when dealing with small, complex areas such as the middle ear. One technique used to analyze the mechanics of complex models is the finite-element method, whereby the system of interest is divided into a large number of small, simple elements. The mechanical properties and applied forces are represented by functions defined over each element, and the mechanical response of the whole system can then be computed. We present a unique three-dimensional finite-element model of the human eardrum and middle ear. Our model takes advantage of phase-shift moiré shape measurements to precisely define the shape of the eardrum. The middle ear geometry is derived from histologic serial sections and from high-resolution magnetic resonance microscopy of the human ear. We discuss the importance of this model in terms of understanding and teaching the mechanics of the human middle ear, simulating various pathologic conditions, and designing ossicular prostheses.

Assessment of the caloric-induced tilt in the perceived visual vertical: preliminary report.

OBJECTIVE: The perceived visual vertical (PVV) has been shown to be abnormal in patients with acute vestibular lesions but reverts to normal in compensated patients. The objectives of this study are to ascertain whether the PVV can be modulated by caloric stimulation and whether this modulation diminishes in compensated patients with unilateral vestibular lesions. DESIGN: Prospective. SETTING: Tertiary care facility. METHOD: Sixty-eight patients referred for vestibular testing had an electronystagmography and a PVV. MAIN OUTCOME MEASURES: Tilt in PVV, in degrees after caloric stimulation. RESULTS: Cold caloric stimulation resulted in a mean tilt in the PVV toward the irrigated ear and warm irrigation had the reverse effect. The mean modulation (amplitude of the angular distance in degrees between cold and warm tilts) was 4.3 degrees. In a subgroup of patients with severe unilateral vestibular dysfunction, this modulation of the PVV with caloric stimulation was diminished on the side of the lesion (p = .0001). CONCLUSION: Further study is required to assess the potential of the caloric PVV as a test of otolith function.

Meningioma of the internal auditory canal.

Meningiomas are the second most common tumor to involve the cerebellopontine angle (CPA), but controversy exists as to whether they can arise within the internal auditory canal (IAC) or whether involvement of the IAC occurs secondarily by extension from the CPA. This paper reports on a patient with an enhancing IAC meningioma that then grew and on subsequent scans was found to involve the CPA. This case demonstrates that these tumors can arise within the IAC and can grow out to involve the CPA. These findings are discussed within the context of meningioma tumor genetics and the histologic evidence for precursor cells in the IAC. The radiologic findings useful in distinguishing an acoustic neuroma from a meningioma are reviewed in the light of this case. While an enhancing mass projecting into the IAC is most often an acoustic neuroma, this radiologic findings is not pathognomonic.

Prognostic significance of intraoperative facial nerve stimulus thresholds.

OBJECTIVE: Intraoperative facial nerve monitoring has reduced the incidence of facial nerve paralysis associated with acoustic neuroma surgery, but poor facial nerve outcomes continue to occur. Intraoperative prediction of facial nerve outcome would be advantageous in patient management and counseling. This study seeks to evaluate intraoperative facial nerve stimulus thresholds as a tool for predicting postoperative facial nerve outcome. STUDY DESIGN: This study is a prospective clinical study of the prognostic value of intraoperative stimulus thresholds. SETTING: The study was performed at a tertiary referral center. PATIENTS: There were 109 patients undergoing excision of acoustic neuromas included in this study. INTERVENTIONS: The minimum current required to stimulate the facial nerve at the brain stem was prospectively recorded after excision of the acoustic neuroma. MAIN OUTCOME MEASURES: Facial nerve outcome was evaluated by the House-Brackmann grade. RESULTS: A statistically significant relationship was found between poor initial facial nerve outcome and higher stimulus thresholds. Long-term impaired facial function was also more common in the higher stimulus group compared to that of the lower stimulus groups. CONCLUSIONS: Although these findings suggest that intraoperative stimulus thresholds have prognostic potential, other prognostic factors should also be considered and additional research is needed.

Severe complications of the anterior cricoid split operation and single-stage laryngotracheoplasty.

The management of congenital and acquired subglottic stenosis has been considerably facilitated with the introduction of the anterior cricoid split operation and, more recently, the single-stage laryngotracheoplasty. These procedures are followed by a 1- to 2-week period of sedation, during which the patient is paralyzed and completely dependent on mechanical ventilation. Although these procedures have proven very successful at achieving decannulation, the postoperative period can be the source of significant complications. This is illustrated with 4 cases of severe postoperative complications. The possible pathophysiologic causes are discussed, and the literature concerning the postoperative complications of these procedures is reviewed. The avoidance of neuromuscular blockade must be weighed against the possible increased need for narcotics and increased risk of self-extubation. An intensive care unit setting proficient in the care of these patients is necessary for a successful outcome.

Endoscopic repair of anterior skull base cerebrospinal fluid fistulas: an emphasis on postoperative nasal function maximization.

Endoscopic repair of cerebrospinal fluid (CSF) fistulas has been proposed as an alternative to the traditional intracranial and extracranial approaches. This study reports on four consecutive adult cases of anterior skull base CSF fistulas. The technique used for endoscopic repair, which was designed to maximize postoperative nasal function, is described in detail. The results and complications recorded, using this technique, are reported. Endoscopic repair appears to be a safe and successful approach in the surgical treatment of CSF fistulas while preserving nasal function.

Functional imaging of head and neck tumors using positron emission tomography.

Positron emission tomography (PET) is an imaging modality that generates in vivo maps of tissue radioactivity originating from a labelled substrate of glucose metabolism: 18-fluorine labelled deoxy-glucose (FDG). This study was undertaken to evaluate PET in the detection of head and neck malignancies, and to determine its effectiveness in diagnosing recurrent cancer in operated or irradiated fields. PET revealed that each biopsy-proven tumour is an area of increased radioactivity. Tumour radioactivity ranged from 130% to 300% above that of the cerebellum, and up to 650% above the contralateral, normal side. By basing the maps on tissue metabolic function, PET proved capable of distinguishing tumour (increased radioactivity) from scar tissue (reduced radioactivity). Its application may facilitate the diagnosis of recurrent tumours amid the fibrosis and distortion of normal architecture in operated, irradiated fields.

Tracheostomy: a retrospective review of 281 cases.

Although tracheostomy is an ancient technique, disagreement continues concerning the complication rate associated with the procedure. A retrospective review of 281 consecutive tracheostomies was undertaken to evaluate the current risks of tracheostomy in tertiary care teaching hospitals. In addition, we sought to identify factors associated with increased morbidity. The intraoperative and postoperative complications were analyzed regarding indication and comorbidity factors. The majority of cases (56%) were performed on ICU patients. The total complication rate was 24%. A statistically significant increased risk of complications was found both in emergency situations and in ICU patients. Delaying tracheostomy was associated with prolongation of ICU stay. Despite the relatively large number of patients studied, there were no deaths.

Cogan's syndrome: a review of otologic management and 10-year follow-up of a pediatric case.

Although first characterized over 45 years ago Cogan's syndrome still remains a rare disease, with a high incidence of poor outcome. Experience with a case of Cogan's syndrome over a 10-year period is presented. The fluctuating clinical evolution and laboratory findings over this period are depicted, starting from presentation at age 10. The response to treatment, as revealed by audiograms, is traced. The literature is reviewed with regard to treatments that have been proposed. In those cases where a sustained follow-up is available, the success of the therapy on the vestibuloauditory system is evaluated. Although some patients have a positive response to steroids, the prognosis for hearing remains poor. The ability of steroids to change the prognosis for hearing loss is not yet established, but warrants further clinical trial.