Facial cutaneous necrosis associated with suspected levamisole toxicity from tainted cocaine abuse.

OBJECTIVE: This study aimed to illustrate the otorhinolaryngologic manifestations of levamisole toxicity and illuminate the features of this diagnosis. METHODS: We describe a case of a known cocaine abuser with suspected levamisole toxicity who developed cutaneous necrosis of the cheeks, earlobes, nose, upper and lower lip, and the midline hard palate. We also review the existing clinical literature about this emerging phenomenon. RESULTS: Levamisole is a common adulterant in cocaine distributed in the United States and has been reported to cause microvascular thrombosis and vasculitis with resultant skin necrosis in cocaine abusers. The distribution of skin findings characteristically involves the cheeks, earlobes, nose, lips, and hard palate and responds variably to cessation of cocaine use. In its most severe cases, immune suppression and/or surgical debridement may be required. CONCLUSION: Levamisole toxicity can frequently involve the ears, nose, and throat tissues. Otorhinolaryngologists should recognize these manifestations to expeditiously diagnose and manage this condition. Failure to do so promptly can lead to complications that may necessitate reconstructive or amputation surgery.

Transnasal esophagoscopy findings: interspecialty comparison.

INTRODUCTION: Otolaryngologists implement transnasal esophagoscopy (TNE) to assess esophageal pathology. Previous studies using TNE are largely retrospective and deal with select patient populations. The prevalence of esophageal pathology in patients presenting with throat symptoms to an otolaryngology voice center is presently unknown. OBJECTIVE: To assess the prevalence of esophageal pathology in this population and determine the interobserver variability of the findings reviewed by an otolaryngologist and a gastroenterologist. STUDY DESIGN: A prospective study. SETTING: This study was conducted in a laryngology/voice subspecialty clinic. SUBJECTS AND METHODS: Fifty patients with throat symptoms presenting to the voice center were asked prospectively to undergo TNE. The findings were videotaped and reviewed by an otolaryngologist and a gastroenterologist blinded to the patients' presenting complaint. RESULTS: Hoarseness was the most common presenting symptom (68%). According to the gastroenterologist, the prevalence of esophageal findings was: z-line irregularity suspicious for Barrett esophagus (12%), esophagitis (10%), hiatal hernia (32%), and esophageal stricture (10%). The percent agreement for a normal study was 72 percent. The percent agreement for various pathological findings were as follows: Barrett esophagus 86 percent, esophagitis 88 percent, hiatal hernia 76 percent, and esophageal stricture 96 percent. For an abnormal study, the percent agreement was 80 percent. CONCLUSION: Esophageal abnormalities are common in patients presenting to a voice subspecialty clinic.

Bone-anchored hearing aid abutment skin overgrowth reduction with clobetasol.

OBJECTIVES: The bone-anchored hearing aid (BAHA) osseointegrated cochlear stimulator can treat hearing loss in a variety of clinical situations. Occasionally skin/scar overgrowth may cover the abutment. This overgrowth interferes with affixing the BAHA to the abutment. Surgical scar revision/excision has been used to treat this problem. Clobetasol (0.05%), a steroid gel, can reduce skin overgrowth. Experience with skin overgrowth and the efficacy of clobetasol to treat this problem was reviewed. SUBJECTS AND METHODS: The authors conducted a retrospective analysis of patients who underwent BAHA abutment implantation from January 2003 through December 2006. RESULTS: Eighty-eight patients (2 patients received bilateral BAHAs) were reviewed. Twenty (22%) of 90 sites developed overgrowth. Thirteen of 20 sites were treated with clobetasol. The overgrowth resolved in 11 (85%) of 13 sites after treatment. Patients with incomplete skin graft survival were significantly more likely to develop skin overgrowth (P = 0.0017). CONCLUSION: Clobetasol is an effective treatment for abutment skin/scar overgrowth. Clobetasol allows patients to resume BAHA use and obviates the need for scar revision.

An alternate approach for surgical dressing of bone-anchored hearing aid abutment sites.

OBJECTIVE: To present an alternative surgical dressing for bone-anchored hearing aid (BAHA) abutment sites, comparing it with the manufacturer's recommended "healing cap" in terms of split thickness skin graft (STSG) survival. STUDY DESIGN AND SETTING: A retrospective review of 30 patients who underwent unilateral BAHA implantation at a tertiary referral center. Patients were divided into two groups on the basis of the surgical dressing for the BAHA abutment site. Group 1 had a "healing cap" dressing, and group 2 had a bolster dressing. STSG survival was evaluated. RESULTS: Between May 2002 and July 2006, 30 patients underwent BAHA implantation. Seven patients received the "healing cap" dressing, and 23 patients received the bolster dressing. There was 100% STSG survival in the bolster dressing group and 71% skin graft survival in the healing cap group (P = .048). CONCLUSION: A traditional bolster dressing had improved STSG survival as compared with the manufacturer's recommended "healing cap." Additional benefits of a bolster are that it is maintenance free, well suited for noncompliant patients, and inexpensive.

Hearing loss with stapedotomy in otitis media.

OBJECTIVE: Stapes fixation is often found in patients with either active or inactive otitis media (OM). Stapedotomy is generally not performed in ears with OM because of the potential risk of sensorineural hearing loss (SNHL). Recent studies have demonstrated that the inner ear may be fenestrated in the presence of OM without significantly increased risk of SNHL. The goal of this study was to determine if stapedotomy in the presence of OM significantly increases the incidence of postoperative SNHL. METHODS: Streptococcus pneumoniae or Pseudomonas aeruginosa was injected bilaterally into the middle ears of guinea pigs (n = 18 and 16, respectively). A control group (n = 14) was injected with saline solution. Two days postinjection, a unilateral stapedotomy was performed. Auditory thresholds were evaluated by electrocochleography before and after stapedotomy. RESULTS: Bacterial OM was induced in all ears injected with pneumococci and pseudomonas. Auditory thresholds increased in all ears treated with stapedotomy. Stapedotomy performed in the presence of pseudomonas OM resulted in significantly greater SNHL than in control or pneumococcal ears (P = 0.0055). Hearing thresholds were not significantly different between pneumococcal OM and control ears treated with stapedotomy. CONCLUSION: Stapedotomy in the presence of pseudomonas OM, but not pneumococcal OM, significantly increases the risk of SNHL in the guinea pig model. SIGNIFICANCE: Stapedotomy should be avoided in patients with active OM, particularly in the presence of pseudomonas.