Mucosal melanoma of the middle ear cavity and Eustachian tube: a case report, literature review, and focus on surgical technique.

OBJECTIVE: To present a case of mucosal melanoma of the Eustachian tube with a focus on surgical technique and to review the literature on treatment of mucosal melanoma of the head and neck, and review cases involving the middle ear and/or Eustachian tube. PATIENT: A 67-year-old man was diagnosed with mucosal melanoma of the middle ear and Eustachian tube. INTERVENTION: The patient underwent primary surgical resection including transtemporal/transpetrosal approach, endoscopic nasopharyngectomy, infratemporal fossa dissection, temporomandibular joint resection, ipsilateral neck dissection (levels II-IV), and superficial parotidectomy. RESULTS: The patient was discharged on postoperative Day 7 with a very good functional status. He did have early dysphagia and dysarthria as a result of the VII to XII anastomosis for facial nerve reconstruction, which did require PEG tube placement. However, at 4 months after surgery, the patient was eating solid foods and returning to normal activities. He received radiation therapy postoperatively. There has been no evidence of tumor recurrence at 8 months after treatment. CONCLUSION: The standard treatment of head and neck mucosal melanoma is primarily surgical. Surgical removal of mucosal melanoma in the Eustachian tube/middle ear can present challenges in achieving microscopically negative margins. However, gross tumor resection with postoperative radiotherapy has been shown to improve locoregional control.

Telemedicine-assisted neurotology in post-Katrina Southeast Louisiana.

OBJECTIVE: This study evaluates technical requirements, privacy and legal constraints, reimbursement considerations, and overall feasibility of a new telemedicine neurotologic patient care delivery model in post-Katrina, Southeast Louisiana. METHODS: This study is a retrospective review of the first year of a telemedicine neurotology practice with limited on-site neurotology physician availability (3-days monthly) with a full-time on-site audiologist, a full-time specialty-trained nurse practitioner, full-time neurosurgery on-site availability, and full-time otolaryngology on-site availability. RESULTS: A combined "store-and-forward" and "real-time" telemedicine delivery model was implemented for a new neurotology practice. Technical requirements include secure data transfer, real-time video-streaming, high-quality video otoscopy and microscopy, infrared video eye movement visualization and recording, remote visualization of radiologic imaging studies, and formalized diagnostic algorithms for patient evaluation. Telemedicine patient evaluations occur with the patient in Baton Rouge, LA, while the examining neurotologist is linked through a secure, commercially available communication connection in Pittsburgh, PA. Specifically designed consent forms and bilocation licensing and liability insurance coverage were required. Third-party payers were consulted before implementation to assure adherence to local reimbursement requirements. During the first 12 months of operation, 450 patient encounters were accomplished purely through telemedicine, with an additional 800 on-site patient visits and 150 operative procedures, including 24 neurotologic skull base procedures. CONCLUSION: Telemedicine is a viable delivery model for neurotology care delivery. Planning and implementation of such a model requires systematic considerations of medical, nursing, information systems, legal, reimbursement, and management parameters. Although the authors' initial motivation for this model was the resource-restricted, post-Katrina health care environment in South Louisiana, this delivery model has wider applicability in otolaryngology, other medical specialties, humanitarian outreach, and medical education. Prospective assessment of clinical outcomes and patient satisfaction is ongoing for objective validation of this delivery model.