Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract: predictors of success.

INTRODUCTION: Cerebrospinal fluid (CSF) leaks may arise as a complication of endoscopic sinus surgery, trauma, or hydrocephalus, or they may occur spontaneously without any identifiable cause. Despite general agreement that CSF leaks should not be left untreated, their initial management, the surgical indications, and the technique of repair are controversial. OBJECTIVE: We undertook this study to ascertain whether a particular surgical technique or material was more successful for repair. Additionally, we tried to identify which specific characteristics of the patient, the CSF fistula, or the adjunctive treatment influenced the result of the repair. STUDY DESIGN: We completed a retrospective review of all patients undergoing endoscopic repair of a CSF leak at our academic hospitals. RESULTS: Forty-eight patients with 53 CSF fistulas were included in the study. Fifty sites were successfully repaired endoscopically on the first attempt. Three persistent leaks were repaired successfully on the second attempt. Location and size of the leak, cause, technique, and choice of material used for the repair did not significantly affect surgical outcome. However, the presence of hydrocephalus had a statistically significant negative influence on surgical outcome. All patients with increased intraventricular pressure required a ventricular shunt in addition to a second endoscopic repair. CONCLUSION: If the surgical technique is sound, endoscopic repair of CSF leaks is highly successful, independent of the choice of the material and technique used in the repair.

Liposarcoma of the orbit: a management challenge.

A previously healthy 35-year-old man experiencing slowly progressive, painless proptosis of the right eye. Visual function was normal, but supraduction was limited. Computed tomography revealed a superior, extraconal orbital mass. Subtotal excision was performed, and a diagnosis of liposarcoma was rendered only with expert analysis. Despite subsequent orbital exenteration and postoperative radiation, a local recurrence developed 5 years later. The clinical features that predict recurrence, and management options that may promote longevity, are discussed.

The posterior inferior orbitotomy.

Four patients with orbital apex tumors between the optic nerve and inferior rectus underwent a posterior inferior orbitotomy through the maxillary sinus. Three tumors were removed successfully and the fourth was not located, but the visual function improved after surgery, presumably owing to decompression of the posterior orbital floor. The technique was carried out through a standard Caldwell-Luc approach through the maxillary sinus. The posterior inferior orbital wall was removed and the inferior rectus was retracted either laterally or medially to gain access to the tumor, which was removed microsurgically. The authors believe this approach provides a reasonably safe alternative to remove small, well-circumscribed, inferior posterior orbital apical tumors. It also avoids dissection through the orbit from other directions with the inherent risks of damaging overlying vital structures.

Bacteriology of acute otitis media in adults.

OBJECTIVE: --The objective of this study was to determine the bacteriology of acute otitis media in adults. Although this has frequently been studied in children, no data have recently been reported from adults in the United States. Additionally, information on the prevalence of Haemophilus influenzae as a causative organism in acute otitis media in adults has not been available. DESIGN: --Middle-ear aspirates for cultures were obtained by myringotomy from adults meeting entry criteria. SETTING: --Emergency department, Eye and Ear Hospital of Pittsburgh, Pa. PATIENTS: --Thirty-four patients (volunteer sample) met the eligibility requirements. Exclusion criteria included history of chronic otitis media, recent antibiotic therapy, immunosuppressive illnesses, or prior otologic surgery. INTERVENTION: --Ten days of oral cefuroxime axetil (250 mg) was prescribed. MAIN OUTCOME MEASURES: --Patients were followed closely for at least 6 weeks. Aerobic and anaerobic cultures were incubated and evaluated per the scheduled protocol. RESULTS: --Haemophilus influenzae and Streptococcus pneumoniae were grown on culture of specimens from nine and seven patients (26% and 21%), respectively. Twenty-two percent (2/9) of the H influenzae isolates and the single isolate of Moraxella catarrhalis produced beta-lactamase (9% overall). CONCLUSIONS: --The present results suggest that, as in children, amoxicillin would be an appropriate first-line agent for empiric therapy of acute otitis media in adults. Antimicrobials inactive against H influenzae (eg, penicillin V, cephalexin, erythromycin, or tetracyclines) are not appropriate for initial therapy. Antimicrobials with efficacy against organisms producing beta-lactamase, such as cefuroxime axetil, which was used to treat the study patients, do not appear to be required for routine initial therapy in adults. However, they would be appropriate when an organism producing beta-lactamase is isolated from the middle ear or when a patient fails to improve rapidly on amoxicillin therapy.

The association of laryngoceles with squamous cell carcinoma of the larynx.

The clinical diagnosis of laryngoceles simultaneously occurring with squamous cell carcinoma of the larynx is infrequent; however, when specimens from patients with laryngeal cancer have been examined closely, the two entities have been associated in 4.9% to 28.8% of cases. Despite this apparent relationship, the literature has failed to address the potential impact of a concurrent laryngocele on surgical decision making. Also, the wide variation in the reported rates of simultaneous occurrence of these two entities is unexplained. We performed whole-organ histopathologic analysis on a laryngeal specimen with bilateral external laryngoceles associated with squamous cell carcinoma and correlated this to computed tomography findings. Based on this information and other reports concerning the pattern of spread of carcinoma within laryngoceles, it appears that supraglottic laryngectomy is oncologically sound in the presence of a laryngocele as long as the usual criteria for this procedure are met.

The skeletal anatomy of mandibulofacial dysostosis (Treacher Collins syndrome).

Three-dimensional osseous surface re-formation imaging from CT scans was used to examine the facial skeletons of 14 living patients with mandibulofacial dysostosis. Partial to complete aplasia of the zygomatic process of the temporal bone, mild hypoplasia to aplasia of the frontal process of the zygoma, antimongoloid slant of the transverse orbital axis, and hypoplasia of the medial pterygoid plates and muscles are common to all patients examined. Deformities of the zygoma, zygomatic process of the frontal bone, mandible, and lateral pterygoid plates and muscles vary from minimal to severe, including aplasia. The body of the zygoma is the least affected part of the bone. Right-left asymmetry characterizes these deformities in all patients. The most consistent skeletal aplasia (cleft) in mandibulofacial dysostosis involves the zygomatic process of the temporal bone rather than the zygoma itself.