Contemporary management of deep neck space infections.

Deep neck infections continue to be seen despite the wide use of antibiotics. These infections follow along fascial planes to create deep neck space abscesses. The clinical presentation often points to the space involved. Understanding the regional anatomy gives the surgeon the ability to treat these grave infections. The records of 24 patients with a diagnosis of deep neck space abscess admitted to Hermann Hospital between 1988 and 1993 were reviewed. Fifty percent of the patients had received antibiotics for an infection of the ear, nose, or throat before the development of a neck space abscess. Ten patients had parapharyngeal abscesses, seven had retropharyngeal abscesses, six had submandibular space abscesses, and one had parotid space abscess. Thirty-five organisms were isolated in 18 cases (1.9 isolates per patient). The most common organism cultured was Streptococcus (13 of 18), followed by Staphylococcus (6 of 18), Bacteroides (5 of 18), Micrococcus (2 of 18), and Neisseria (2 of 18). One case each of Candida, Enterobacter, Enterococcus, Peptostreptococcus, Proteus, Proprionobacter, and Pseudomonas was cultured. Six patients had no growth on culture but did have organisms found on Gram's stain. The operative techniques and antibiotics used are discussed. The main complications of jugular vein thrombosis, carotid artery rupture, and mediastinitis are described, as well as an unusual case of meningitis from a large retropharyngeal-parapharyngeal abscess.

The "Y" sign of lateral dislocation of the incus.

This report presents a new sign of ossicular dislocation utilizing high resolution computed tomography of the temporal bone. In the case of lateral dislocation of the incus, a "Y" shaped configuration (Y sign) of the malleoincudal complex is seen in the coronal views even though the axial views present a normal "ice cream cone" configurations.

Orbital blowout fractures as a cause of sinonasal obstructive disease.

Six cases of orbital blowout fracture with inferomedial herniation of orbital contents into the sinonasal ostiomeatal unit causing obstruction to maxillary sinus outflow are presented. Potential hazards during endoscopic sinus surgery in these cases are outlined.

Pediatric temporal bone fractures.

Twenty-seven temporal bone fractures in 25 pediatric patients were evaluated over a 6-year period. The diagnosis was confirmed with otoscopy and high-resolution computed tomography scans (HRCT). Three-dimensional reconstruction of high-resolution computed tomography scans were used to aid in the diagnosis. The most common fracture was an oblique fracture which is oriented in an axial or horizontal plane with the temporal bone. Facial nerve paralysis was found in 6 of our patients, which is less than the expected incidence when compared to adults. Hearing loss was found in 24 patients, the most common of which was conductive hearing loss, which had a higher incidence than expected when compared with adults.

Temporal bone fractures: longitudinal or oblique? The case for oblique temporal bone fractures.

Classical descriptions and illustrations of temporal bone fractures are misleading. Both oblique and longitudinal fractures produce a similar fracture line in the middle cranial fossa; however, externally, they are different. Oblique fractures cross the petrotympanic fissure while longitudinal fractures run within it. In a study of 150 temporal bone fractures, the majority were oblique. An array of fracture planes accounts for most of the fractures observed. Depending on the direction of trauma, fracture planes rotate around an anteroposterior axis. When they approach the horizontal (axial) plane, they result in oblique fractures. True longitudinal fractures are rare. They are vertical and perpendicular to the oblique planes.

Subcochlear approach for cholesterol granulomas of the inferior petrous apex.

Cholesterol granulomas of the petrous apex are drained through two major extralabyrinthine routes: one, along the posterosuperior chain of air cells, and two, along the anteroinferior chain. Procedures that use the posterosuperior chain approach the apex from the sinodural angle, the base of the zygomatic arch, the attic, or through the arch of the superior semicircular canal. Operations that use the anteroinferior chain reach the apex along the internal carotid canal (Ramadier's operation) or by a posterior infralabyrinthine approach between the descending facial nerve and jugular bulb. Inferior petrous apex cholesterol granulomas may be unreachable by any of these routes, and hence the subcochlear route is proposed as an alternative. The subcochlear approach starts in a triangle bounded superiorly by the cochlea, anteriorly by the internal carotid canal and posteriorly by the deep jugular vein. This operation requires lowering the inferior bony canal wall to the level of the "crutch." It provides access to an inferiorly situated cholesterol granuloma, yet preserves hearing. It allows enough room for the placement of a tube drain from the petrous apex to the mastoid. It is particularly useful when a high jugular bulb precludes the use of the posterior infralabyrinthine route.

[Fracture of the temporal bone. Evaluation of 123 cases]. / Fractures du rocher. Bilan de 123 cas.

Out of 2,888 blunt head injuries that were treated at the Hermann Hospital Trauma Center of the University of Texas at Houston, only 123 temporal bone fractures were diagnosed in 110 patients. The clinical diagnosis was confirmed with high resolution computerized tomography of the temporal bones. Three main categories of fractures were identified: oblique in 74%, longitudinal in 13% and transverse in 13%. The clinical manifestations included hemotympanum in 83%, cerebrospinal fluid otorrhea in 21% and Battle's sign in 10.6%. One third of the patients had conductive hearing loss, 1/2 had mixed hearing loss and the rest sensorineural loss. On exploration, the most frequent middle ear pathology was incudostapedial joint dislocation. Immediate facial paralysis was observed in 64 patients. Only 11 patients needed facial nerve exploration following signs of denervation, the rest recovered spontaneously. Thirteen patients who had delayed facial paralysis also recovered spontaneously. One third of the patients had persistent unsteadiness 6 weeks following the injury. Other unusual complications encountered include 6 cases of abducent paralysis, 2 cases of trigeminal paralysis and 2 cases of aseptic sigmoid sinus thrombosis.

[Fractures of the petrous bone. An evaluation of 123 cases]. / Fractures du rocher. Bilan de 123 cas.

Out of 2,888 blunt head injuries that were treated at the Hermann Hospital Trauma Center of the University of Texas at Houston, only 123 temporal bone fractures were diagnosed in 110 patients. The clinical diagnosis was confirmed with high resolution computerized tomography of the temporal bones. Three main categories of fractures were identified: oblique in 74%, longitudinal in 13% and transverse in 13%. The clinical manifestations included hemotympanum in 83%, cerebrospinal fluid otorrhea in 21% and Battle's sign in 10.6%. One third of the patients had conductive hearing loss, 1/2 had mixed hearing loss and the rest sensorineural loss. On exploration, the most frequent middle ear pathology was incudostapedial joint dislocation. Immediate facial paralysis was observed in 64 patients. Only 11 patients needed facial nerve exploration following signs of denervation, the rest recovered spontaneously. Thirteen patients who had delayed facial paralysis also recovered spontaneously. One third of the patients had persistent unsteadiness 6 weeks following the injury. Other unusual complications encountered include 6 cases of abducent paralysis, 2 cases of trigeminal paralysis and 2 cases of aseptic sigmoid sinus thrombosis.

Massive posterior epistaxis. A manifestation of internal carotid injury at the skull base.

Severe crushing head injuries can produce massive posterior epistaxis as a result of injury to the internal carotid artery at the skull base. We describe two such cases with traumatic pseudoaneurysm of the internal carotid therapy. They were managed with detachable balloon embolization. The anatomy of the internal carotid artery is reviewed. The diagnosis of pseudoaneurysms and their incidence, clinical presentation, and management are discussed.

Cicatricial velopharyngeal stenosis.

Cicatricial velopharyngeal stenosis is a complication of uvulopalatopharyngoplasty. Uvulopalatopharyngoplasty, posterior nasal packing, and instrumentation produced swelling and ulceration of the oropharyngeal mucosa. Prolonged intubation compounded the problem by pushing the freshly cut surface of the velum against a raw oropharyngeal wall, thus causing synechiae and, ultimately, stenosis. A surgical technique using a pharyngeal rotation flap and a free graft is proposed to treat this condition.

Unusual complications of temporal bone fractures.

Eighty-two temporal bone fractures were diagnosed in 75 patients with high-resolution computed tomographic scanning. Excluding six gunshot injuries, 55 (72%) of the fractures were oblique, 11 (15%) were longitudinal, and ten (13%) were transverse. Facial paresis or paralysis occurred in 45 patients (60%), hemotympanum occurred in 67 (89%), and cerebrospinal fluid otorrhea occurred in 19 (25%). Among 66 patients in whom audiometry was performed, 20 (30%) had conductive hearing loss, nine (14%) had sensorineural loss, and 36 (55%) had mixed hearing loss. Vestibular symptoms were present in 23 patients (30%). Other unusual complications of temporal bone fractures were observed: bilateral abducens paralysis, three patients (4%); unilateral abducens paralysis, two (2.67%); trigeminal paralysis, one (1.33%); and aseptic sigmoid sinus thrombosis, one (1.33%).

Tracheotomy in the morbidly obese patient.

Tracheotomy in the morbidly obese patient (weight more than 130 kg) is a difficult procedure. Because of the thickness of the anterior part of the neck and the redundant chin, most commercially available cannulas are inadequate. A custom-made tube is designed by splitting an endotracheal tube along its longitudinal axis and bending the split sides into a T shape. A modification of the available cannulas is proposed to make them suitable for the morbidly obese patient: they should be longer and straighter toward the external opening and an optional extension should be provided to bypass the double chin.

Sphenoidotomy.

Because of the complex anatomic relations of the sphenoid, the surgical approach to this sinus was only introduced 100 years ago. There are three approaches to the sphenoid sinus: transethmoidal, transseptal, and transpalatal. We present a case report, and discuss surgical anatomy, with attention to the important anatomic relationship of the cavernous sinus and its contents. A variant of the classical, sublabial, transseptal approach is described as follows: a window is created in the face of the sphenoid. This approach is particularly applicable to the surgery of mucoceles and allows easy postoperative inspection of the sphenoid sinus.

High resolution CT scan of temporal bone fractures: association of facial nerve paralysis with temporal bone fractures.

This radiologic study analyzed high resolution computed tomographic (CT) scans of 22 patients with temporal bone fractures. There were 19 males and three females. Fifteen of 22 had clinical evidence of facial nerve injury ranging from mild paresis to complete paralysis. The high resolution CT scan analysis identified a characteristic fracture of the temporal bone in every patient with facial nerve injury. A high percentage of these fractures (68%) could be classified as mixed and did not fall into a longitudinal or transverse fracture category. The characteristic fracture extends from the petrotympanic fissure at the glenoid fossa to the anterior inferior aspect of the medial bony external auditory canal. It resumes at the superior aspect of the external auditory canal (scutum) extending laterally along the external canal wall. If the vector force of the fracture is projected medially, it will cross the facial nerve in its horizontal portion. Often, the evaluation of trauma patients with routine CT scans for central nervous system (CNS) (brain) evaluation is inadequate for evaluation of temporal bone fractures. A high resolution CT scan should be performed when clinical criteria warrant its use. It is recognized that the incidence of facial nerve injury may be higher in this select population.

The use of dexamethasone in pediatric bronchoscopy.

The beneficial effect of intravenous corticosteroids in preventing traumatic laryngeal edema is controversial. Between 1968 and 1971, a controlled clinical study was conducted, at the American University of Beirut Medical Center, of 70 children who underwent bronchoscopy for removal of foreign bodies from the tracheobronchial tree. The patients were divided into two randomized groups; one group was given intravenous dexamethasone while the second was kept as a control. The length of hospitalization and the development of complications attributable to tracheobronchial edema were compared. Intravenous corticosteroids do not seem to reduce the incidence of post-bronchoscopy laryngeal edema.

Human incus long process depressions in the surface of the normal ossicle.

Depressions in the bone surface of the normal human incus long process are found with great frequency. This paper reviews the frequency and distribution of these depressions, discusses their histologic appearance, and speculates upon their significance. While their clinical significance is unclear, they may be related to several conditions encountered in otologic practice.

Otosclerotic inner ear syndrome.

Twenty-seven patients with clinical otosclerosis and vertigo underwent stapedectomies. Vertigo improved or completely disappeared in 23 patients, indicating that stapedectomy is probably helpful. Three case reports are also presented as well as photomicrographs of temporal bones showing the focus in contact with the pars superior.

Esthesioneuroblastoma: diagnosis and treatment.

Esthesioneuroblastoma is a nasal tumor which arises from cells of neural crest origin. It is a difficult tumor to diagnose clinically and histopathologically. First described in 1924, approximately 160 cases have been reported with over 125 of these in the last 15 years. This reflects an increased awareness of the tumor by physicians rather than an icreased incidence. In the past 17 years, 12 cases of esthesioneuroblastoma have been treated at the Department of Otolaryngology and Maxillofacial Surgery of the University of Virginia Medical Center. Reviewing these cases and the literature leads us to make the following recommendations for diagnosis and treatment: The diagnosis of esthesioneuroblastoma can be made by 1) the clinician who suspects it in any patient with a nasal mass causing unilateral obstruction; 2) the finding of plexiform intercellular fibrils by light microscopy (rosettes and pseudorosettes are not as common as reported); 3) the finding of secretory granules and neurites by electron microscopy of the highly undifferentiated tumors; and 4) formaldehyde-fume-induced fluorescence. Combined therapy with preoperative irradiation followed by craniofacial resection of the tumor to include the cribriform plate is recommended. This treatment should result in a five-year survival in excess of 50% of patients.