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Objective: To develop a reliable, user-friendly, intraoperative, electromyographic monitoring technique to decrease the incidence of injury to the recurrent and superior laryngeal nerves. Design: Prospective, nonrandomized, clinical trial of a nerve monitoring technique. Setting: Private tertiary care community hospital. Patients: A population-based sample of 31 patients scheduled to undergo thyroid surgery was enrolled consecutively. Included in the study were patients older than 18 years who were scheduled for surgery and who were able to provide informed consent. Exclusion criteria were pregnancy, implanted metallic devices, and history of laryngeal surgery, injury, paresis, hoarseness, or paralysis. Nopatients were excluded, and all completed the study and returned for follow-up visits. Interventions: Twenty-nine patients required total thyroidectomy, of which 10 involved malignancy, and the other 2 patients required lobectomy. Each patient completed the Voice Handicap Index and underwent a preoperative fiberoptic laryngeal examination. Continuous monitoring was performed using a widely available, commercial nerve integrity monitor and a paired electrode placed into the cricothyroid space under direct vision. Postoperatively, participants completed a follow-up Voice Handicap Index survey and underwent a laryngeal examination. Main Outcome Measures: The incidence of vocal paresis, or paralysis, and the preoperative and postoperative voice handicap score were recorded. The usefulness of the device based on the surgeon's subjective and immediate postoperative impressions was rated on a visual analog scale. Results: Sixty-two recurrent laryngeal nerves were identified with continuous electromyographic monitoring. Vocal cord paresis or paralysis was not observed. Postoperative Voice Handicap Index scores were unchanged from preoperative assessment. The technique was given a rating of 1 (most useful) on a 5-point scale in 70% of cases. Conclusions: The technique described is sensitive, easy to use, accurate, and associated with a high degree of surgeon satisfaction. This technique is not associated with additional risk to the patient and offers the potential to reduce injury. Monitoring provides assurance that the nerve is intact and functioning prior to extubation. [ABSTRACT FROM AUTHOR]

Objective: To analyze the distribution of 3 collagen types in healthy tympanic membranes, during healing of a perforation, and during infection. Design: Immunohistochemical study of collagen types I, II,andIII in the tympanic membranes of healthy rats as well as during healing of a perforation and in the presence of infection with Streptococcus pneumoniae at various time points. Setting: Laboratory research center at a university hospital. Results: Type II collagen was a main constituent of the lamina propria of the pars tensa, whereas type I collagen was found mainly in the pars flaccida. Collagen types I and III were found at the insertion to the malleus handle and in the loose connective tissue surrounding the main collagen layer of the pars tensa. After myringotomy, collagen types I and III were found at the perforation border and around dilated blood vessels early in the healing phase. During infection, the collagen layer was thickened and stained strongly for type II collagen. Collagen types I and III were found in the edematous connective tissue around the main collagen layer and around dilated blood vessels. Three months after perforation or infection, all 3 collagens were present in the lamina propria of the tympanic membrane. Extensive amounts of all 3 collagen types were present in the scar tissue in the tympanic membranes of rats that had undergone myringotomy during the presence of acute otitis media. Conclusions: The lamina propria of the pars tensa is mainly made up of type II collagen, whereas type I collagen is found in the pars flaccida. Thus the fibrous structure of the pars tensa and flaccida is composed of diverse collagen types, which reflects the different physiological properties of these tissues. Collagen types I and III are present in the acute healing phase after myringotomy and infection, and the collagen content of the tympanic membrane is modified during the inflammatory and healing process. [ABSTRACT FROM AUTHOR]

Objective: To report postoperative mortality, complications, and outcomes in a subset of patients with the histologic diagnosis of malignant melanoma extracted from an existing database of a large cohort of patients accumulated from multiple institutions. Design: Retrospective outcome analysis. Setting: Seventeen international tertiary referral centers performing craniofacial surgery for malignant skull base tumors. Patients: A total of 53 patients were identified from a database of 1307 patients who had craniofacial resection for malignant tumors at 17 institutions. The median age was 63 years. Of the 53 patients, 25 (47%) had had prior single modality or combined treatment, which included surgery in 22 (42%), radiation in 11 (21%), and chemotherapy in 2 (4%). The margins of resection were close or microscopically positive in 7 (13%). Adjuvant radiotherapy was given in 22 (42%), chemotherapy in 3 (6%), and vaccine or interferon therapy in 2 (4%). Complications were classified into overall, local, central nervous system, systemic, and orbital. Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were determined using the Kaplan-Meier method. Predictors of outcome were identified by multivariate analysis. Results: Postoperative mortalityoccurredin3patients(6%) and postoperative complications were reported in 14 patients (26%). Local wound complications occurred in 6 patients (11%), central nervous system in 7 (13%), systemicin3( 6%),and orbital in1(2%).With a median followupof10months( range,1-159months), the 3-yearOS,DSS, and RF Srates were 28.2%, 29.7%, and 25.5%, respectively. The extent of orbital involvement and adjuvant postoperative radiation therapy(PORT)were independent predictors of DSS and O Sonmultivariate analysis, whereas only PORT was an independent predictor of RFS. Patients treated with PORT had significantly better 3-yearOS(39%vs 18%; relative risk, 2.9; P=.007), DSS (41% vs 19%; relative risk, 3.0; P=.007), and RFS(39% vs 15%; relative risk, 4.2;P=.001). Conclusions: Craniofacial resection in patients with malignant melanoma of the skull base has mortality (6%) and complication rates (26%) comparable to other malignant tumors of the skull base. However, malignant melanoma is associated with a much poorer OS, DSS, and RFS. Adjuvant PORT correlated with improved 3-year OS, DSS, and RFS on multivariate analysis. These factors must be taken into account when considering craniofacial resection in a patient with malignant melanoma invading the skull base. [ABSTRACT FROM AUTHOR]

Objective To evaluate a symptom-focused vocal impairment instrument for the evaluation of patients with voice disorders. Design Prospective, nonrandomized study of patients with voice disorders undergoing treatment with validation of a new symptom index, the Glottal Function Index (GFI). Setting Voice disorders clinic at an academic tertiary care hospital. Patients Consecutive patients undergoing therapy for glottal insufficiency, adductor spasmodic dysphonia, nodules, and granuloma (40 patients in each group) and 40 control patients. Interventions The Pearson correlation coefficient was used to evaluate GFI reproducibility and to compare it with the Voice Handicap Index (VHI). The paired-samples t test was used to compare pretherapy and posttherapy GFI values. Main Outcome Measures Correlation of GFI with VHI; comparison of the GFI in normals, and in pretherapy and posttherapy GFI and VHI scores. Results The mean ± SD normative GFI score was 0.87 ± 1.32. The correlation coefficient for GFI between independent pretherapy measurements was 0.56 (P<.001). The correlation coefficient between total GFI and total VHI scores was 0.61 (P<.001). The mean posttherapy GFI scores improved among all groups as follows: glottal insufficiency: presenting GFI score, 12.7 ± 4.1; posttherapy GFI score, 6.8±5.4; nodules: presenting GFI score, 12.9 ± 4.2; posttherapy GFI score, 8.9 ± 4.6; adductor spasmodic dysphonia: presenting GFI score, 13.2 ± 4.1; posttherapy GFI score, 8.9 ± 4.9; and granuloma: presenting GFI score, 7.8 ± 4.6; posttherapy GFI score, 3.8 ± 2.1. Relative to controls, the GFI score at presentation was significantly elevated and demonstrated significant reduction following treatment across each of these entities (P<.05). Conclusions The GFI is a reliable, reproducible, 4-item, self-administered symptom index with excellent criterion-based and construct validity. Its advantages over existing indexes include brevity and ease of administration. The GFI is a useful adjunct in the evaluation and treatment of patients with glottal dysfunction. [ABSTRACT FROM AUTHOR]

Objective To identify risk factors for operation-specific outcomes of pediatric cricotracheal resection (CTR). Design We identified the first 100 consecutive children undergoing CTR at our institution from January 1, 1993, to December 31, 2004. Retrospective review of medical records provided data on demographics, operation dates, decannulation dates, and proposed risk factors, including age, stenosis grade, vocal cord function, Down syndrome, history of distal tracheal surgery, history of open laryngotracheal surgery, presence of tracheotomy at the time of operation, use of suprahyoid release, extended CTR, and use of chin-to-chest sutures. Complete data sets were available for 93 patients. We performed multivariable logistic regression analysis to identify significant independent risk factors. Setting A tertiary care children’s hospital. Patients All patients younger than 18 years who underwent CTR at our institution. Main Outcome Measures Operation-specific and overall decannulation rates. Results Results of the preoperative evaluation showed grade III or IV stenosis in 89 patients (96%). The overall decannulation rate included 87 patients (94%); the operation-specific decannulation rate, 66 patients (71%). The only significant risk factor for failure to decannulate after 1 operation was the presence of unilateral or bilateral vocal cord paralysis (P = .007). Conclusions Cricotraceal resection may be safely performed in patients with multiple airway lesions. Patients with a history of vocal cord paralysis who undergo CTR often require more than 1 open airway procedure for decannulation and should be counseled appropriately. This study represents the largest reported series of pediatric CTR. [ABSTRACT FROM AUTHOR]

Objective To analyze laryngeal aerodynamics in the same patient in 4 different circumstances: before the onset of unilateral vocal fold paralysis (UVFP), after the onset of UVFP, and after 2 types of surgical vocal fold medialization techniques to compare the results of surgery with the measurements made in that same patient when his larynx was healthy (before paralysis). Design Prospective self-paired study of 1 male patient. Measurements were taken before iatrogenic UVFP (of the patient’s healthy larynx), 1 week after the onset of iatrogenic UVFP (thoracic surgery), 3 days after vocal fold medialization with autologous fat, and 2 months after polytetrafluoroethylene thyroplasty. Setting University hospital. Main Outcome Measure Phonatory airflow and intraoral pressure. Results Airflow and intraoral pressure increased after the onset of UVFP. Airflow decreased to preparalytic values after both types of vocal fold medialization. Intraoral pressure decreased after fat injection but increased after thyroplasty, despite the favorable effects of this treatment on laryngeal resistance and vocal efficiency compared with preparalytic values. Conclusions Our study demonstrates the variability of intraoral pressure as an indirect measure of subglottal pressure after vocal fold medialization in UVFP, due to as yet unknown factors. Phonatory airflow, laryngeal resistance, and vocal efficiency seem to be more reliable indicators of aerodynamic results after vocal fold medialization. [ABSTRACT FROM AUTHOR]

Objective To compare our experience with the osteocutaneous radial forearm free flap (group 1) (n = 108) with other commonly used osteocutaneous free flaps (group 2) (n = 56) such as the fibula and scapula in single-stage oromandibular reconstruction. Design Retrospective case review. Setting Tertiary-care academic medical center. Patients One hundred sixty-three consecutive patients who underwent 164 mandibular reconstructions with osteocutaneous free flaps. Main Outcome Measures Assessment of preoperative and intraoperative variables for both groups. We compared recipient-site complication rate, intensive care unit stay, total hospital stay, and postoperative function. Results The most common donor site used was the radius (n = 108 [66%]), followed by the fibula (n = 36 [22%]) and scapula (n = 20 [12%]). Mean follow-up was 29 months (range, 1-116 months). Group 2 patients had larger soft tissue and/or bony defects. Surgical and medical complication rates and major donor site morbidity in group 1 were similar or better when compared with those in group 2. The lengths of the intensive care unit (4 vs 7 days; P = .009) and hospital stays (13 vs 15 days; P = .06) were shorter in group 1. Although the microvascular success rate was similar in both groups, the local wound complication rate was significantly better for group 1. The difference for the length of intensive care unit stay was statistically significant and potentially amounts to more than $6000 of savings. Functional outcomes, including the ability to tolerate oral diet, tracheostomy presence, and dental rehabilitation, were similar between the groups. Conclusions The primary site long-term morbidity, donor site morbidity, and postoperative function of osteocutaneous radial forearm free flaps are comparable to those of other commonly used osteocutaneous free flaps such as the fibula and scapula when used in single-stage oromandibular reconstruction. [ABSTRACT FROM AUTHOR]

Objective To determine if age alone is a prognostic indicator of surgical outcomes for major head and neck procedures. Design Retrospective cohort study over a 4-year period. Setting Academic referral center, institutional practice, hospitalized care. Patients Included in this study were patients who had undergone ablative, reconstructive, and other major surgical procedures of the head and neck, including neck dissection, laryngectomy, maxillectomy, thyroidectomy with lymphadenectomy, and composite resection of the oral cavity with reconstruction, for both malignant and benign disease. Main Outcome Measures Patient data and intraoperative and postoperative course factors were recorded. Comorbidity was graded using an Adult Comorbidity Evaluation 27 test, Charlson Comorbidity Index, and American Society of Anesthesiology score. Postoperative complications were dichotomized, and multiple logistic regression was used for data analysis. Results Medical chart review identified 157 cases. Analysis of data revealed that time under general anesthesia was the only factor consistently related to complications (P<.006), and it was the only factor consistently related to length of stay (P<.001). Analysis of major complications (6% incidence) as an outcome using univariate analysis resulted in a strong positive correlation with both comorbidity indexes: Adult Comorbidity Evaluation 27 (P = .002) and Charlson Comorbidity Index (P = .005). Multiple logistic regression showed no significant relationship between age 70 years or older (20% of patients) and either complications or hospital length of stay. Conclusions Patient’s age alone is not a prognostic indicator of surgical outcome for major head and neck procedures. However, comorbidity is an important predictive factor for postoperative complications in any age group. Time under general anesthesia showed a statistically significant relationship with complication rate and hospital length of stay in multivariate analyses. Consequently, prevention of complications should focus on optimizing preoperative comorbid conditions. [ABSTRACT FROM AUTHOR]

Objective To review cricotracheal resection (CTR) in children weighing less than 10 kg. Design and Setting Retrospective study of 17 patients (mean follow-up, 23 months) from 3 ear, nose, and throat pediatric centers. Patients Seventeen children (10 boys and 7 girls; mean age, 14.6 months; and mean weight, 7.6 kg) undergoing CTR from June 1995 to March 2003. Main Outcome Measures Decannulation rates and endoscopies. Results The cause was congenital subglottic stenosis in 2 children (12%) and acquired subglottic stenosis in 15 (88%). All but 1 had grade 3 or 4 stenosis. The mean hospitalization duration was 34 days. Single-stage CTR was performed in 11 children (65%), with peroperative decannulation in 7. Extubation of these patients occurred between days 3 and 9. Decannulation of the other 6 patients was performed after a median of 15 days. Sixteen (94%) of the 17 children were decannulated. Four patients required additional carbon dioxide laser treatment for subsequent glottic or subglottic edema or granulomas, but no reintubation was necessary. One child could not be decannulated because of bronchopulmonary disease, and subglottic stenosis recurred. Long-term tracheotomy was avoided in all other patients. Another child died of cardiac disease. All other patients remained free of significant subglottic stenosis at follow-up. Conclusions Cricotracheal resection in small children weighing less than 10 kg was a safe and effective procedure for severe subglottic stenosis. To our knowledge, this is the first reported attempt of CTR in this weight category, providing results comparable to those published in older children. [ABSTRACT FROM AUTHOR]

Objective To evaluate the usefulness of the LigaSure Precise instrument in superficial lobectomy of the parotid gland. Design Prospective study of the surgical procedures in the LigaSure Vessel Sealing System and comparison with a conventionally treated control group. Setting Secondary care academic referral center. Patients Thirty-five patients with a parotid gland benign tumor were randomly allocated to 2 superficial lobe parotidectomy groups: 17 using the LigaSure procedure (group A) and 18 using the conventional method (group B). Main Outcome Measures During the past few years, different methods of achieving hemostasis in parotid gland surgery have been tested as means of decreasing operative time and facial nerve injuries by controlling bleeding. With the whole LigaSure Vessel Sealing System, we experienced the usefulness of the LigaSure Precise instrument in superficial lobectomy of the parotid gland. Results No statistically significant differences were noted between the 2 groups in mean age, tumor diameter, length of hospital stay, time to return to work, or number of adverse events during or after surgery. Operative time was significantly shorter in group A than in group B (P < .001). Total operative time for conservative partial parotidectomy with traditional excision ranged from 115 to 235 minutes (mean, 155.8 minutes). Using the LigaSure system, the mean operative time was 136.4 minutes. Salivary fistulas were more common in group A (3 of 17 patients), with no cases in group B. Conclusions The LigaSure method is comparable with but not superior to the conventional method. The main advantages of the LigaSure system are its “sutureless technique” and operative time savings; however, the cost is considerably higher. [ABSTRACT FROM AUTHOR]

Objective To estimate the prevalence of “incidental” acoustic neuromas (ANs) in the population at large. Design An intracranial magnetic resonance imaging (MRI) database of 46 414 patients presenting to the University of California, San Francisco (UCSF), without known audiovestibular complaints was searched retrospectively from July 1995 to February 2003. Seventy percent of these MRIs included gadolinium, and none was specifically targeted through the internal auditory canal. A medical chart review of 688 patients with acoustic neuromas presenting to UCSF between 1980 and 1999 was searched for sex distribution. Setting Tertiary care university medical center. Results Eight patients with incidental AN were discovered. This figure suggests that undiagnosed ANs may be present in at least 0.02% of the population. Three patients were found to have audiovestibular symptoms on inquiry after diagnosis. Audiometry revealed asymmetry at 4 kHz in only 3 of 7 patients, with an otherwise symmetric audiogram in the remaining patients. Tumor size in this population ranged from 3 to 28 mm. Incidental ANs were more common in men, but ANs were more common in women overall. Conclusions The prevalence of incidental AN appears to be roughly 2 in 10 000 people. This figure indicates that AN may be less prevalent than suggested in previously reported temporal bone studies and more prevalent than suggested by epidemiologic studies. [ABSTRACT FROM AUTHOR]

Objective To study the relationship between performance on an endoscopic sinus surgery simulator (ES3) and fundamental perceptual, visuospatial, and psychomotor abilities. Design Validation study. Setting Tertiary care medical center. Participants Thirty-four medical students and 4 otolaryngology residents voluntarily enrolled. Interventions Subjects performed tasks on the ES3, minimally invasive surgical trainer virtual reality (MIST-VR), pictorial surface orientation (PicSOr), and 3 visuospatial tests (cube comparison, card rotation, and map planning). Main Outcome Measures The MIST-VR was scored for time, task error, economy of hand movement, economy of diathermy, and total score. Scores were generated for the PicSOr task and visuospatial tests. Scores were correlated with time, accuracy, and total subscore on navigation, injection, and dissection tasks, as well as hazard score and total trial score on the ES3. Results The PicSOr score was statistically significantly correlated with the hazard score on the ES3 (r = 0.50, P<.001). Cube comparison (r = 0.43, P<.01) and card rotation (r = 0.45, P<.01) scores correlated significantly with the ES3 trial score, as did the MIST-VR total score and the ES3 trial score (r = 0.57, P<.001). In a multiple regression model, the PicSOr, cube comparison, and MIST-VR total scores were statistically significant predictors of ES3 performance (r = 0.63, P<.01). Conclusions Scores on the ES3 correlate strongly with scores on previously validated measures of perceptual, visuospatial, and psychomotor performance. The ES3 provides a reliable assessment of factors that are important to the acquisition of minimally invasive surgical skills, demonstrating construct validity. [ABSTRACT FROM AUTHOR]

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Objectives: To build on work in laryngology and oral biology that suggests utility in the assay of secretions collected from wound sites as a predictive instrument to determine which infants will likely develop subglottic stenosis following endotracheal intubation and to document and describe the wound-healing process. Design: Prospective, randomized design. Intervention: Laser-induced subglottic injury was established in 3 rabbits. Secretions were collected from the subglottic region at 6 time points from days 4 to 21 following injury and from 4 uninjured control airways. The secretions were then subjected to enzyme-linked immunoassays for interleukin 1β and prostaglandin E2. Subjects: Three adult New Zealand white rabbits. Main Outcome Measures: Interleukin 1β and prostaglandin E2 levels. Results: Measurable amounts of both mediators were obtained. Furthermore, different temporal patterns of expression were observed with interleukin 1β, showing increased levels on days 4 to 18, and with prostaglandin E2, showing increased levels on days 7 to 18. These results concur with emerging data regarding the role of each mediator in the wound-healing process. Conclusion Although in its infancy, the analysis of secretions collected from the site of injury in the subglottis may have utility in the management of patients following intubation-related trauma. [ABSTRACT FROM AUTHOR]

The article presents a case of a 63 year old man presented with hoarseness and dysphagia. During his previous visits, for the same symptoms, examinations, including several imaging studies, had revealed no abnormalities. Because of the persistent symptoms and repeated negative endoscopic findings, as well as a mediastinal enlargement that had been seen on the last chest x-ray film, another computed tomographic (CT) scan of the patient's neck and chest was performed. The CT scan of the chest showed soft-density lesions in the sternum, lung apices, multiple ribs, and vertebral bodies.

Examines optimal techniques for skin rejuvenation. Hypothesis that nonablative laser therapy offers subtle improvements with an excellent risk-benefit ratio; Effectiveness of a process called coblation; Use of intense pulsed light to improve the appearance of photodamaged and photoaged skin.

Objective To compare disease response among children with recurrent respiratory papillomatosis (RRP) who underwent combined surgical debulking and intralesional cidofovir injections vs repeated surgical debulking only. Design Retrospective medical record review; follow-up range: 16 to 56 months. Setting Tertiary care children’s hospital. Patients Seven children with RRP, including 4 subjects treated with cidofovir and 3 controls matched for age and initial papilloma staging score. Interventions Subjects treated with cidofovir underwent combined surgical debulking and intralesional cidofovir injection every 2 months until disease remission. Control subjects underwent repeated surgical debulking at individually determined intervals. Main Outcome Measures Intraoperative endoscopic photographs were retrospectively assigned papilloma staging scores. Cidofovir and control group comparisons were made using nonparametric 2-sample Wilcoxon rank-sum (Mann-Whitney) testing, and comparisons of initial and final papilloma staging scores were made using nonparametric matched-pair Wilcoxon signed-rank testing. Results The final cidofovir group scores were significantly lower than the control group scores (P < .05). Within-group differences between initial and final scores were not significant (cidofovir group, P = .07; control group, P = .29). Conclusions Four children with RRP were safely and successfully treated with intralesional cidofovir injection. Consideration should be given to using cidofovir more widely for treatment of pediatric RRP. Larger numbers in the cidofovir and control groups are needed in future studies to determine the true impact of cidofovir on management of this disease. [ABSTRACT FROM AUTHOR]

Objective To determine the types and frequency of airway anomalies in patients with Pfeiffer syndrome. Design Retrospective case series. Setting Academic tertiary care pediatric hospital. Participants Eleven patients with Pfeiffer syndrome, 6 of whom were severely affected, were identified. All were included in the study. Main Outcome Measures Presence of tracheal anomalies, need for tracheotomy, and length of life. Results The 6 severely affected patients had mutations in genes that code for fibroblast growth factor receptor 2 (S351C [3 patients]; C342S [2 patients]; and W290C [1 patient]). Five of these patients were diagnosed during bronchoscopy or tracheotomy as having a congenital tracheal cartilaginous sleeve. In 1 patient, supportive care was withdrawn at 2 weeks of life, and the patient died. The remaining 5 patients required tracheotomy because of severe upper airway obstruction. Three of these patients died (at ages 9 months and 7 and 15 years). Two are still alive at ages 23 and 18 months. Conclusions Patients with Pfeiffer syndrome manifest significant airway pathologic conditions. Upper airway obstruction is related to midface hypoplasia and secondary nasal obstruction. Tracheal anomalies have been infrequently reported. [ABSTRACT FROM AUTHOR]

Objective The β2-transferrin assay is a specific method to identify cerebrospinal fluid (CSF). Hitherto, this test has not been widely used for the routine screening of patients with suspected CSF leakage. The purpose of this study was to investigate the clinical relevance of the identification of β2-transferrin by comparing the test results with other diagnostic measures and intraoperative findings. Design Case series. Patients Retrospective analysis of 182 patients tested once or multiple times for β2-transferrin. Main Outcome Measures Information was obtained regarding different diagnostic procedures applied to diagnose CSF leakage. The effectiveness of those diagnostic measures was compared. Results The main indication to test for β2-transferrin was posttraumatic rhinorrhea (25%), followed by spontaneous (22%) and postsurgical (22%) rhinorrhea. In 35 of 205 cases, β2-transferrin was detected in the tested specimens. Thirteen of these required surgical intervention for treatment of the CSF fistula, and the leakage site was identified in all of them. Taking all results into consideration, the highest correlation was observed between the β2-transferrin assay, intrathecal fluorescein application, and surgical exploration. Conclusions The β2-transferrin assay is a reliable method for confirming suspected CSF and should be used as a primary screening method in all patients with suspected CSF leakage. Although less invasive, the β2-transferrin assay almost matches the high sensitivity achieved by exploratory surgery and intrathecal application of fluorescein. However, the possibility of bias should be carefully considered, and in particular, negative results should be critically compared with clinical symptoms and with results from other diagnostic procedures. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effect of intravenous (IV) access in children undergoing bilateral myringotomy with pressure-equalizing tube placement. Design One hundred healthy children were enrolled in this randomized controlled study. One group received IV access; the other group did not. Anesthesia in both groups was induced through a mask and maintained with oxygen, nitrous oxide, and sevoflurane. Spontaneous ventilation was maintained. All children received fentanyl, 1 µg/kg intramuscularly. Children with IV access received 20 mL/kg of lactated Ringer's solution. Parents were telephoned the day after surgery to report on pain and vomiting, as well as their satisfaction with anesthesia. Setting Tertiary care children's hospital with all procedures performed by attending pediatric otolaryngologists and otolaryngology residents. Anesthesia was ad-ministered by a pediatric anesthesiologist and a trainee. Results The groups were similar in age, weight, and incidence of vomiting. Children with IV access spent more time than those without (mean ± SD minutes) in the operating room (21 ± 8 vs 17 ± 7; P = .02), in phase 2 recovery (75 ± 67 vs 51 ± 24; P = .02), and in the hospital (119 ± 67 vs 88 ± 30; P = .005). These children also required more pain medication (31% vs 2%; P<.001) and had a lower parental satisfaction rate (28% vs 95%; P<.001). Conclusions Intravenous access in otherwise healthy children undergoing myringotomy provided no added benefit. Children without IV access had reduced pain requirement and spent less time in the operating room, in phase 2 recovery, and in the hospital. Parental satisfaction, a clinically relevant outcome, was significantly greater for parents of children without IV access. [ABSTRACT FROM AUTHOR]

Objective To assess the efficacy and safety of a pollen blocker crème for prophylaxis of symptoms in patients with seasonal or perennial allergic rhinitis. Design Double-blind, randomized, placebo-controlled, crossover study conducted from November 2001 through September 2002 in 2 outpatient centers in Germany and 1 in Russia. Ninety-one patients aged 18 to 55 years with at least a 2-year history of seasonal or perennial allergic rhinitis confirmed by history and positive skin test results were randomly assigned to receive pollen blocker cream (n = 43) or carboxymethylcellulose in gel (placebo) (n = 48) applied sparingly to the lower internal nose region 4 times daily for a total of 9 days. The efficacy of treatment was assessed by means of nasal provocation testing. The investigators assessed the nasal symptom severity scores (range, 0-6), and the changes in nasal airflow after allergen application were measured by anterior rhinomanometry. Results The median score fell from 4 to 1 after application of the pollen blocker cream (P<.001) and from 4 to 3 in the placebo group (P<.05). The difference between the 2 groups after the second provocation was highly significant (P<.001). The increase in airflow in response to treatment was roughly 20% in the blocker group compared with only about 10% in the placebo group, relative to an airflow rate (299 mL/s) measured after provocation on day 1. Conclusions The blocker was significantly more effective than placebo and reduced the typical symptoms of allergic rhinitis in response to nasal challenge with allergen by nearly 60% (placebo reduced symptoms by 25%). The pollen blocker cream did not produce any adverse effects. Therefore, the efficacy of the investigational product can be rated as good. [ABSTRACT FROM AUTHOR]

Objective The anterolateral thigh flap has recently been rediscovered in Asia as a perforator flap. The objective of this study was to describe the reliability and donor morbidity of the anterolateral thigh flap for head and neck reconstruction without transmuscular perforator dissection. Design Consecutive case series by a single surgeon. Setting A regional tertiary-referral head, neck, and skull base surgical oncology center. Patients The first 34 consecutive patients. Intervention Microvascular reconstruction with an anterolateral thigh free flap. Main Outcome Measures Primary insufficiency, partial necrosis, complete necrosis, and donor morbidity rates. Results Two flaps necrosed partially (6%). No flaps demonstrated primary insufficiency, necrosed completely, or incurred significant donor morbidity. Conclusions The anterolateral thigh flap can be reliably harvested without transmuscular perforator dissection and without incurring serious donor morbidity. It possesses workhorse attributes (no repositioning, remote from defect, long pedicle) and is extremely versatile (one is able to independently tailor the skin and muscle), making it ideal for the heterogeneous group of extensive soft tissue head and neck defects. When a forearm flap will likely be too thin or too morbid, the anterolateral thigh flap can be considered its "big brother." [ABSTRACT FROM AUTHOR]

Objective To determine if patients undergoing microvascular reconstructive head and neck surgery (MRHNS) at a large integrated health maintenance organization can expect outcomes similar to some of the best or flagship centers in the United States. Design Outcomes (flap loss, mortality, length of stay), eligibility (recent consecutive US center experience), high-experience (100 cases), high-volume (26 cases per year), and flagship criteria were prospectively defined. A systematic MEDLINE search identified 17 eligible reports. Independent, blinded medical reviewers identified 5 centers (29%) as flagship centers. Patients The first 116 consecutive patients (average, 39 cases per year) who underwent MRHNS on this service. Results All 5 flagship centers are major academic health centers ranked in the top 18 "best head and neck hospitals" in the United States. Flap loss (1.7% vs 4.4% for flagship centers; range, 0.9%-8.8%) and mortality (2.6% vs 2.8% for flagship centers; range, 0.5%-6.3%) rates were not significantly different. Although lengths of stay in flagship centers were similar to each other and the literature (mean, 21.4 days; range, 20.1-22.5 days), our length of stay was significantly shorter (8.8 days, P<.001). Conclusion For high-experience and high-volume centers, patients undergoing MRHNS at a large integrated health maintenance organization can expect morbidity and mortality outcomes similar to flagship centers in the United States, with shorter hospitalizations. [ABSTRACT FROM AUTHOR]

Background The OM6 is a 6-item condition-specific handicap measure developed in the United States for children with recurrent acute otitis media and otitis media with effusion. Easy and quick to use, it has high test-retest repeatability and is sensitive to change after ventilation tube insertion. Objectives To explore aspects of the validity of OM6 in a United Kingdom population and to specifically address the instrument's ability to discriminate between children with different burdens of disease. Design The parents of 179 consecutive newly referred children with otitis media with effusion or recurrent acute otitis media completed the OM6 on their first visit to the hospital. The parents of 72 children with sore throats completed the OM6 for comparison. Scores were compared with markers of disease severity, demographic variables, and generic quality-of-life measures. Results Poorer scores were found in those with ear complaints than in those with sore throats. The OM6 scores were not associated with age, sex, socioeconomic class, or respondent (mother vs father). The OM6 scores did not correlate with frequency of otalgia, frequency of otorrhea, or time off school in the recurrent acute otitis media group. In the otitis media with effusion group, poorer scores were associated with bilateral B or C2 tympanometric findings but not with a better ear threshold of more than 20 dB. Correlation with a global 10-cm visual analog scale for quality of life and with the Health Utilities Index Mark III was good. Conclusions The OM6 scores correlate well with global quality-of-life measures and are free from many potential biases. However, OM6 does not adequately reflect disease severity, which may limit its usefulness as a discriminative measure. [ABSTRACT FROM AUTHOR]

Background Although the percentage of women in surgical subspecialties is increasing, little is known about the experiences of these women compared with their male counterparts. Objective To identify career and lifestyle factors that distinguish female otolaryngologists. Design, Setting, and Participants Otolaryngologists were asked to respond to a confidential 119-item questionnaire. The instrument was sent to all 502 female members of the American Academy of Otolaryngology–Head and Neck Surgery who had finished their residency training and were practicing medicine. For response comparison, the survey was mailed to 2 male otolaryngologists who were matched to each female survey recipient for years since completion of training, geographic region, and practice type. Results Of the 673 respondents (52.6% response rate), women were more likely to be divorced or separated (P = .001) and have fewer children (P <.001). In contrast to men, women reduced their work hours in conjunction with having more children (P <.001). Controlling for professional hours and hours spent in the operating room per week, type of practice, and years since completion of residency, women earned 15% to 20% less per year than men (P <.001). Men relied more on their spouse or partner for household responsibilities and child care (P <.001), and 34.3% of the women (compared with 7.1% of the men) spent 21 to 40 h/wk on household management (P <.001). Conclusion Although male and female otolaryngologists receive equal training opportunities, women earn less money for performing similar jobs and have increased family responsibilities, which may effect their career advancement. [ABSTRACT FROM AUTHOR]

Objective To compare the communication outcomes between children with aided residual hearing and children with cochlear implants. Design Measures of speech recognition and language were administered to pediatric hearing aid users and cochlear implant users followed up longitudinally as part of an ongoing investigation on cochlear implant outcomes. The speech recognition measures included the Lexical Neighborhood Test, Phonetically Balanced–Kindergarten Word Lists, and the Hearing in Noise Test for Children presented in quiet and noise (+5 dB signal-to-noise ratio). Language measures included the Peabody Picture Vocabulary Test: Third Edition (PPVT-III), the Reynell Developmental Language Scales, and the Clinical Evaluation of Language Fundamentals–Revised. Subjects The experimental group was composed of 39 pediatric hearing aid users with a mean unaided pure-tone average threshold of 78.2 dB HL (hearing level). The comparison group was composed of 117 pediatric cochlear implant users with a mean unaided pure-tone average threshold of 110.2 dB HL. On average, both groups lost their hearing at younger than 1 year and were fitted with their respective sensory aids at 2 to 2.6 years of age. Not every child was administered every test for a variety of reasons. Results Between-group performance was equivalent on most speech recognition and language measures. The primary difference found between groups was on the PPVT-III, in which the hearing aid group had a significantly higher receptive vocabulary language quotient than the cochlear implant group. Notably, the cochlear implant group was substantially younger than the hearing aid group and had less experience with their sensory devices on this measure. Conclusion Data obtained from children with aided residual hearing can be useful in determining cochlear implant candidacy. [ABSTRACT FROM AUTHOR]

To determine the effectiveness of auditory steady-state response (ASSR) as a measure of hearing sensitivity in young children suspect for significant hearing loss. Design Within-subject comparisons of click auditory brainstem response (ABR) thresholds and ASSR thresholds. Subjects The study population comprised 42 children suspect for hearing loss and subsequently referred for hearing assessment using electrophysiologic techniques. Main Outcome Measures Electrophysiologic threshold responses for click ABR and ASSR stimuli (0.5, 1, 2, and 4 kHz) for right and left ears. Results Based on ABR and ASSR thresholds, 50% of the subjects demonstrated significant hearing loss in the severe to profound range. In some subjects, ASSRs were present at higher stimulus levels when click ABRs were absent. Significant correlations (P <.05) were found between high-frequency ASSR and click ABR thresholds for this study sample. For some subjects, ASSR findings suggested differences between ears that were not observable from the no-response click ABR results. Conclusions Auditory steady-state response testing may provide additional information for children who demonstrate hearing levels in the severe to profound range. This information may be helpful when selecting the ear for cochlear implantation for a young hearing-impaired child. Multiple objective methods, such as ABR and ASSR testing, may be needed to determine accurate hearing sensitivity for young children being considered for sensory devices, and in particular, cochlear implants. [ABSTRACT FROM AUTHOR]

Much evidence suggests that, early in life, auditory input and communication are essential for the normal development of language, cognition, and behavior. Thus, deaf children, who experience significant disruptions in auditory input, are likely to show delays not only in the production of oral language but in other important aspects of development such as visual attention and behavioral control. Cochlear implants have shown tremendous promise in restoring auditory information to deaf children and concomitant improvements in speech recognition and production. However, little is known about how cochlear implants affect psychological variables. In this multisite trial, we assess the effects of cochlear implants on a range of developmental outcomes, including visual attention, problem-solving skills, symbolic play, and social adjustment. Measuring these constructs in young children, primarily younger than 2 years, has presented a number of unique challenges. In this article, we describe the methods used to assess these variables in young children and present preliminary findings comparing joint attention and symbolic play skills in a small sample of age-matched deaf and hearing children. As expected, deaf children performed more poorly than hearing children on measures of attention and symbolic play. As auditory input is restored via a cochlear implant, we predict that significant improvements in these variables will be observed. [ABSTRACT FROM AUTHOR]

Objective To measure the benefit (ie, sound localization and speech intelligibility in noise) of bilateral cochlear implants (CIs) in adults and in children. Design, Setting, and Patients Seventeen adults and 3 children underwent testing 3 months after activation of bilateral hearing. Adults received their devices in a simultaneous procedure and children in sequential procedures (3-8 years apart). Adults underwent testing of sound localization and speech intelligibility, with a single CI and bilaterally. Children underwent testing of sound localization, right/left discrimination, and speech intelligibility, with the first CI alone and bilaterally. We used computer games to attract the children's attention and engage them in the psychophysical tasks for long periods of time. Results Preliminary findings suggest that, for adults, bilateral hearing leads to better performance on the localization task, and on the speech task when the noise is near the poorer of the 2 ears. In children, localization and discrimination are slightly better under bilateral conditions, but not remarkably so. On the speech tasks, 1 child did not benefit from bilateral hearing. Two children showed consistent improvement with bilateral hearing when the noise was near the side that underwent implantation first. Conclusions Bilateral CIs may offer advantages to some listeners. The tasks described in this study might offer a powerful tool for measuring such advantages, especially in young children. The extent of the advantage, however, is difficult to ascertain after 3 months of bilateral listening experience, and might require a more prolonged period of adjustment and learning. Future work should be aimed at examining these issues. [ABSTRACT FROM AUTHOR]

Objective To examine changing parent and deaf community perspectives related to pediatric cochlear implantation. Design This research is based primarily on 2 nonrandom study designs. In the first study, conducted by the Gallaudet University Research Institute, Washington, DC, in the spring of 1999, a 12-page questionnaire was distributed to 1841 parents of children with cochlear implants; 439 questionnaires were returned. In the second study, we conducted 56 interviews with parents of 62 children with implants (and 1 without). Subjects Parents of children with cochlear implants; Gallaudet University faculty, staff, students, and alumni. Results While parents frequently receive conflicting information about educational and communication options for their child, they generally support signing before and after implantation. The parents of a child with an implant have a great interest in their child's spoken language development, and most would like to have had their child receive an implant earlier. Children with implants are educated in a variety of educational settings. Mainstreamed children with implants often continue to require classroom support services, and children with implants are frequently not isolated from both deaf and hearing peers. Parents have mixed experiences when getting information from persons in the deaf community. Comment Opposition to pediatric cochlear implantation within the deaf community is giving way to the perception that it is one of a continuum of possibilities for parents to consider. To ensure optimal use of the cochlear implant, parents need to remain involved in their child's social and educational development. [ABSTRACT FROM AUTHOR]

To examine whether age at cochlear implantation or duration of implant use is associated with speech, language, and reading skills exhibited at age 8 to 9 years in children who underwent implantation by age 5 years. Design Performance outcomes in speech perception, speech production, language, and reading were examined in terms of the age at which children first received a cochlear implant (2, 3, or 4 years), the age they received an updated (Spectra) processor, and the duration of use of an implant and an updated processor. Setting Data collection was conducted at summer research camps held over 4 consecutive years to maximize the number of children available at a specific age (8-9 years). Children were tested individually by experienced examiners, and their parents and therapists provided background and educational history information. Participants A total of 181 children from 33 different states and 5 Canadian provinces who received a cochlear implant by age 5 years were tested. A subsample of 133 children with performance IQ scores of 80 or greater and onset of deafness at birth were selected for the age-at-implantation analysis. Another subsample of 39 children with deafness acquired by age 3 years was also examined. Outcome Measures A battery of tests of speech perception, speech production, language, and reading was administered to each child and reduced to a single factor score for each skill. Results Correlation coefficients between age at implantation and duration of use did not reach significance for any of the outcome skills measured. Age at which the updated speech processor (Spectra) was fitted was significantly related to speech production outcome (earlier use of an updated processor was associated with greater speech intelligibility) but not to any other skill area. However, more of the children who underwent implantation at age 2 years (43%) achieved combined speech and language skills commensurate with their age-matched peers with normal hearing than did children who underwent implantation at age 4 years (16%). Furthermore, normal speech and language skills were documented in 80% of children who lost hearing after birth and who underwent implantation within a year of onset of deafness. Conclusions For children who receive a cochlear implant between the ages of 2 and 4 years, early cochlear implantation does not ensure better speech perception, speech production, language, or reading skills. However, greater speech and language proficiency may be expected from children who exhibit normal hearing for even a brief period after birth and receive a cochlear implant shortly after losing their hearing. Further research examining the benefits of cochlear implantation before age 2 years will help families and clinicians better understand the time-sensitive nature of the decision to conduct cochlear implant surgery. [ABSTRACT FROM AUTHOR]

Objective To test the feasibility of using the deaf white cat model of early-onset deafness. We studied the neuronal effects of prosthetic intervention with a clinical, "off-the-shelf" multichannel cochlear implant. Methods We placed cochlear implants in 5 deaf white kittens at age 12 and 24 weeks. The devices were activated and stimulated in the laboratory using a clinical speech processor programmed with a high-resolution continuous interleaved sampling (CIS) strategy for 8 to 24 weeks. Stimulus parameters were guided by electrically evoked brainstem responses and intracochlear-evoked potentials. Kittens were assessed with respect to their tolerance and general behavior in response to speech, music, and environmental sounds. Results Surgical complications were minimal, and kittens tolerated the experimental procedures well. Subjects were able to detect and respond to a specific sound played from a computer speaker. Electrophysiologic responses were reliably attainable and showed consistency with observed behavioral responses to sound. This experimental paradigm, using clinical devices, can be used in a practical research setting in cats. Conclusions Deafness and other variations in neural activity result in many distinct changes to the central auditory pathways. Animal models will facilitate assessment of the reversibility of deafness-associated changes at the level of the neuron and its connections. Our observations of the feasibility of using clinical devices in animal models will enable us to simulate clinical conditions in addressing questions about the effects of "replacement" activity on the structure and function within the central auditory pathways in deafness. [ABSTRACT FROM AUTHOR]

Objective To investigate the clinical usefulness of the dichotic single-frequency auditory steady-state response (ASSR) for estimation of behavioral thresholds in children with severe to profound congenital sensorineural hearing loss. Design A comparative experimental research design was selected to compare behavioral and ASSR thresholds for the sample. Behavioral pure-tone audiometry served as the criterion standard. Setting Hearing Clinic, Department of Communication Pathology, University of Pretoria, Pretoria, South Africa. Patients A referred sample of 10 patients (20 ears), 5 girls and 5 boys aged 10 to 15 years (mean age, 13 years 4 months), with severe to profound sensorineural hearing impairment. Main Outcome Measures The difference, and correlation, between 160 pure-tone behavioral and ASSR thresholds at 0.5, 1, 2, and 4 kHz. Results Mean differences between ASSR and behavioral thresholds were 6 dB for 0.5 kHz and 4 dB for 1, 2, and 4 kHz, with standard deviations varying between 8 and 12 dB. No significant differences (P <.05) were observed between ASSR and behavioral thresholds, except at 0.5 kHz, and Pearson correlation coefficients varied between 0.58 and 0.74 across the evaluated frequencies, with best correlation at 1 kHz and worst at 0.5 kHz. Conclusions The ASSR thresholds provided reliable estimations of behavioral thresholds for children with severe to profound hearing loss and indicated an increased sensitivity for more profound hearing loss. [ABSTRACT FROM AUTHOR]

Objectives To investigate the effect of age at cochlear implantation on the auditory development of children younger than 3 years and to compare these children's auditory development with that of peers with normal hearing. Design Using a repeated-measures paradigm, auditory skill development was evaluated before and 3, 6, and 12 months after implantation. Data were compared with previously published data from cohorts with normal hearing. Participants One hundred seven hearing-impaired children (age range, 12-36 months) who received a cochlear implant during clinical trials in North America. Main Outcome Measure Auditory skill development was assessed using the Infant-Toddler Meaningful Auditory Integration Scale, a tool that provides a quantitative measure in children as young as newborns. Results Infants and toddlers who receive implants show rapid improvement in auditory skills during the first year of device use regardless of age at implantation, although younger children achieve higher scores. Children who undergo implantation at a younger age acquire auditory skills nearer to those of their peers with normal hearing at a younger age. The mean rate of acquisition of auditory skills is similar to that of infants and toddlers with normal hearing regardless of age at implantation. Conclusion Performing implantation in children with profound hearing loss at the youngest age possible allows the best opportunity for them to acquire communication skills that approximate those of their peers with normal hearing. [ABSTRACT FROM AUTHOR]

Objective: To investigate the longitudinal effects of botulinum toxin type A (Botox) injections on voice-related quality of life (V-RQOL) for patients with adductory spasmodic dysphonia. Design: Prospective study. Setting: Academic tertiary care referral center. Participants: Forty-two patients who presented to our institution with dysphonia and were diagnosed as having adductory spasmodic dysphonia during a 38-month period. Intervention: Patients received Botox injections into both thyroarytenoid muscles via the cricothyroid membrane. The typical starting dose was 1.0 U per vocal fold. If necessary, the dosage was adjusted in subsequent injections to reduce adverse effects or to enhance duration of benefit. Main Outcome Measures: Patients filled out questionnaires, including the V-RQOL Measure and a self- assessed overall voice rating, before each injection. Postinjection questionnaires were completed 6 to 8 weeks after each treatment. Mean pretreatment and posttreatment scores were calculated for each treatment. Results: The number of treatments per patient ranged from 1 to 7. Statistically significant improvements in mean total and domain V-RQOL scores were calculated for every injection (P<.01) (no postinjection questionnaires were available for the seventh injections). The magnitude of the effect remained constant for later injections. Eighty-two percent of the population recorded at least 1 category of improvement in overall self-assessed voice rating with each injection. Conclusions: Botox has a significant beneficial effect on V-RQOL for at least 6 injection cycles. This study demonstrates the efficacy of Botox for treating patients with adductory spasmodic dysphonia and further illustrates the usefulness and validity of the V-RQOL Measure in evaluating patients with dysphonia. [ABSTRACT FROM AUTHOR]

Objective: To determine whether the use of mandibular distraction osteogenesis (DOG) can help to avoid tracheotomy or achieve decannulation in patients with mandibular hypoplasia and severe upper airway obstruction. Design: Retrospective medical record review (spanning a 27-month period). Setting: Tertiary care children's hospital. Subjects: Group A (n = 8) was composed of infants with Pierre Robin sequence and no tracheotomy (mean age, 2.5 months); group B (n = 6), older nontracheotomized micrognathic children with obstructive sleep apnea (OSA) (mean age, 69 months); and group C (n = 12), tracheotomized children with complex congenital syndromes (mean age, 33 months). Intervention: Bilateral mandibular DOG with endoscopic (n = 24) and/or radiographic (n = 17) airway evaluation (mean follow-up, 16 months [range, 2-42 months]). Outcome Measures: Group A, tracheotomy avoidance; group B, resolution of OSA (clinically or on polysomnography); and group C, decannulation. Results: Group A, 7 patients (88%) successfully avoided tracheotomy; group B, 5 patients (83%) had resolution of OSA; and group C, 2 patients (17%) underwent decannulation. Conclusions: Mandibular DOG (1) allows tracheotomy avoidance in infants with isolated Pierre Robin sequence and (2) relieves OSA in older micrognathic children without tracheotomy. However, mandibular DOG does not frequently lead to decannulation in tracheotomized patients with complex congenital syndromes. [ABSTRACT FROM AUTHOR]

Background: Health Insurance Portability and Accountability Act regulations, which took effect on April 14, 2003, placed new constraints on the use of protected health information for research purposes. Objective: To review practices of research subject privacy protection in otolaryngology in order to determine steps necessary to achieve compliance with Health Insurance Portability and Accountability Act regulations. Study Design: Literature review. Methods: Articles appearing in 2001 in 3 widely circulated otolaryngology journals were classified according to study design. The "Methods" section of each article was reviewed to determine whether the informed consent and institutional review board processes were clearly documented. Results: Descriptive studies involving case reports and case series were more common than observational studies that include a control group (66% vs 11%). Few case series documented the consent process (18%) and institutional review board process (19%). Observational designs demonstrated better documentation of the consent process (P<.001) and the institutional review board exemption and approval process (P<.001). Conclusions: Methods used to protect subject privacy are not commonly documented in case series in otolaryngology. More attention needs to be given to research subject privacy concerns in the otolaryngology literature in order to comply with Health Insurance Portability and Accountability Act regulations. [ABSTRACT FROM AUTHOR]

Objectives: To present the incidence of vestibular schwannoma (VS) in Denmark, compare the incidence with that of previous periods, and discuss the real incidence of VS. Design, Setting, and Patients: Prospective registration of all diagnosed VS in Denmark, with a population of 5.1 to 5.2 million, during the 6 years from January 1996 through December 2001. Incidence in this period was compared with that of 3 previous periods (July 1976 through June 1983 [first period], July 1983 through June 1990 [second period], and July 1990 through December 1995 [third period]). Results: In the 1996-2001 period, 542 cases of VS were diagnosed, representing a mean incidence of 17.4 VS/1 million inhabitants per year. Of these, 227 tumors underwent operation, 14 underwent irradiation, and 301 were allocated to observation (wait-and-scan policy). One hundred sixty-six tumors were intrameatal. Size of extrameatal tumors was small in 104; medium in 194; large in 68; and giant (>40 mm) in 10. Compared with incidences of 7.8 VS/1 million inhabitants per year in the first, 9.4 VS/1 million inhabitants in the second, and 12.4 VS/1 million inhabitants in the third periods, the incidence for the 1996-2001 period represents an increase to 17.4 VS/1 million inhabitants per year. The mean incidence for the entire 25.5-year period was 11.5 VS/1 million inhabitants per year. Conclusions: An estimate of a realistic mean incidence of VS depends on the observation period. Our 25.5-year registration of an entire population showed a mean incidence of 11.5 VS/1 million inhabitants per year. However, the latest period registered represents an incidence of 17.4 VS/1 million inhabitants per year, which, combined with a probable further increase of diagnosed tumors in forthcoming years, suggests a realistic incidence of approximately 13 VS/1 million inhabitants per year. [ABSTRACT FROM AUTHOR]

Background: With the increasing amount and complexity of medical information, medical schools are challenged with incorporating surgical subspecialty education, such as otolaryngology (OTO), into a time-limited curriculum. Objectives: To understand the state of OTO education in US medical schools and to generate a discussion of the role of surgical subspecialty education in the medical school curriculum. Design: Mail survey and follow-up letter and telephone survey conducted in 2000 to 2001. Participants: Academic faculty at each of the 125 US medical schools. Results: Responses were obtained from all 122 OTO programs associated with the 125 US medical schools with Liaison Committee on Medical Education–accredited programs. One third (33.6%) of the schools have a required rotation in OTO in the clinical years, with others offering elective rotations; only 5.2% offered no exposure in the third year of medical school. Most schools offer some OTO in the first 2 years; 71.1% and 87.2% taught OTO in the first and second years, respectively, mostly in anatomy and physical diagnosis. In the fourth year, almost 68.9% of schools reported student participation in an OTO elective. Conclusion: Most medical schools in the United States offer some teaching and clinical exposure to OTO, with considerable variability in the type of experience. [ABSTRACT FROM AUTHOR]

Objective: To establish normative values for voice-related quality of life across a broad pediatric otolaryngology population using the Pediatric Voice Outcome Survey (PVOS). Design: Longitudinal study. Setting: Multiphysician outpatient pediatric otolaryngology practice. Methods: The PVOS was completed by 385 parents of children and adolescents aged 2 to 18 years. Of the 385 parents, 75 were readministered the instrument 2 weeks after no intervention had been provided. Data were collected regarding the patients' age, main diagnosis, and operative intervention. Results: The PVOS demonstrated robust internal consistency with an overall Cronbach α value of .70. Test-retest reliability demonstrated a weighted κ value of 0.89 (95% confidence interval, 0.84-0.95) The mean ± SD converted score (based on a 0-100 scale) for the overall population was 80.5 ± 19.9. Converted PVOS scores are provided for each subpopulation according to main diagnosis. The PVOS scores varied significantly according to age (P<.05) and preoperative and postoperative status following adenoidectomy (P<.05). Conclusion: The PVOS represents a valid and reliable instrument to measure voice-related quality of life in a broad pediatric otolaryngology population. [ABSTRACT FROM AUTHOR]

Objective: To characterize the time demands and practice patterns of pediatric otolaryngologists. Design: Prospective survey of members from the American Society of Pediatric Otolaryngology. Results: The survey response rate was 54% (n = 136) of practicing members of the American Society of Pediatric Otolaryngology. Respondents described being actively engaged in clinical otolaryngology (99%), hospital or practice administration (71%), private enterprise (17%), research (71%), and teaching (89%) on a weekly basis. Sixty percent considered their time demands to be "too busy"; however, few anticipated changing their activities in 5 years. Among the responding physicians, 90% believed that nonotolaryngology peers within their institutions viewed pediatric otolaryngology favorably whereas only 50% thought that other otolaryngologists held the same opinion. Conclusions: Pediatric otolaryngologists participate in many activities beyond clinical medicine. While most considered their time demands to be too busy, few anticipated a change in their activities. This may be reflective of a high level of job satisfaction, financial constraints, or the relative youth of the subspecialty. [ABSTRACT FROM AUTHOR]

Objectives: To determine the performance of different tear and salivary tests applied in Sjögren's syndrome (SS) and to disclose how these tests relate to common serologic tests in SS. Design: In addition to the routine ocular and oral tests for diagnosing SS (Schirmer test, rose bengal score, unstimulated whole saliva flow, and parotid sialography), tear breakup time and flow rate of glandular saliva (parotid and submandibular-sublingual [SM/SL]) were evaluated in patients referred for diagnosis of SS. Patients were categorized into primary SS, secondary SS, and non-SS groups according to the revised European classification criteria for SS. Setting: Referral center. Patients: Referred sample of 80 consecutive patients. Main Outcome Measure: Correlation between ocular and salivary measures. Results: Breakup time performed insufficiently in diagnosing SS, as opposed to the rose bengal score. In patients with primary and secondary SS, a clear correlation was noted between tear and saliva quality and secretion rate, and between the rose bengal score and parotid sialography. Increased rose bengal scores also correlated significantly with hyperglobulinemia and presence of SS-B antibodies in serum, with duration of subjective eye dryness, and with decreased tear-gland function. With regard to the oral tests, whole, parotid, and SM/SL salivary flow decreased significantly with increasing duration of oral complaints, with the stimulated SM/SL flow rate showing the strongest decrease and being more specific in diagnosing SS. Also, parotid sialography was more specific in excluding patients without SS than the commonly applied diagnostic criterion of secretion of unstimulated whole saliva. Conclusions: The rose bengal score remains the eye test of choice, as it has the highest specificity for SS. Hyperglobulinemia and especially positive serologic findings for SS-B may warrant close monitoring of the eyes, since these serum findings appear to relate to the severity of ocular surface damage. Parotid sialography and stimulated secretion of SM/SL saliva are more specific in diagnosing SS than unstimulated secretion of whole saliva. [ABSTRACT FROM AUTHOR]

Background: Laser-assisted tympanic membrane fenestration (LTMF) provides intermediate-duration middle ear ventilation, which benefits selected children with acute otitis media (AOM) and otitis media with effusion (OME). Objective: To evaluate clinical and technical factors that may affect duration of LTMF patency. Design: Prospective clinical cohort effectiveness trial. Setting: Four tertiary care children's hospitals. Patients: Volunteer sample of 251 children (430 ears) followed up at 1, 2, 3, 4, 8, and 12 weeks; time to fenestration closure was evaluable in 201 ears, and assessment of cure at study conclusion was evaluable in 128 ears. Interventions: Laser-assisted tympanic membrane fenestration for prospectively defined AOM or OME. The surgeon determined spot size, wattage, and concurrent adenoidectomy based on clinical judgment. Main Outcome Measures: Cure of AOM/OME with effusion at 90 days and duration of LTMF patency relative to spot size (1.8-2.8 mm), fenestration location on tympanic membrane, power (7-22 W), concurrent adenoidectomy, age, diagnosis (AOM vs OME), type of effusion, and preoperative tympanogram characteristics. Results are based on the number of ears that could be evaluated at each data collection interval. Results: Fenestrations remained patent for 2 to 4 weeks (mean = 2.52, median = 2.0, SD = 1.4, n = 201); 97.4% were closed at 6-week follow-up. Spot sizes of 2.4 and 2.6 mm had a higher rate of patency than 2.0-mm spot size at 3 weeks following LTMF. Cure at 90 days was related to duration of patency for all patients combined and for patients treated for AOM and OME, but not for those undergoing adjunctive adenoidectomy. Cure at 90 days was related to larger spot size for all patients combined and those treated for AOM. Other investigated factors did not achieve statistical significance. Conclusions: Spot size of 2.4 mm or greater results in improved duration of LTMF patency, persisting for up to 3 weeks after LTMF, especially for treatment of AOM. Increased duration of LTMF patency correlates with greater incidence of cure of middle ear effusion at 90 days. Additional investigation is indicated to determine optimum spot size and optimum duration of patency for disease- severity-adjusted populations. [ABSTRACT FROM AUTHOR]

Objective:To assess the prognostic value of different variables on the outcome of pediatric type I tympanoplasty. Design: Retrospective review of medical records. Setting: An otolaryngology department in a large urban tertiary care medical center. Patients: We reviewed 72 ears in 60 patients who had undergone a type I tympanoplasty from 1987 to 2000. Patient ages ranged from 3 to 18 years. Interventions: Type I tympanoplasty. Main Outcome Measures: We identified the following 3 criteria for success: (1) healing of the neotym-panic graft; (2) healing of the graft with a postoperative air-bone gap of no greater than 20 dB; and (3) healing of the graft with aeration of the middle ear space. Results: Healing occurred in 59 (82%) of the 72 neo-tympanic grafts; 39 (83%) of the 47 healed ears for which a postoperative audiogram was available had an air-bone gap of no greater than 20 dB; and 49 (83%) of the 59 healed ears had a normally aerated middle ear space. A statistically significant difference in the rate of graft healing was identified for large perforations (76%), as well as for creation of an aerated middle ear space, when there was evidence of ongoing contralateral eusta-chian tube dysfunction (ie, otitis media with effusion or negative middle ear pressure, but not a perforation). Conclusions: Pediatric type I tympanoplasty can offer reasonably good chances for postoperative graft healing, serviceable hearing, and creation of an air-containing middle ear space if performed in carefully selected patients. Caution should be exercised in performing tympanoplasty in children with evidence of ongoing eu-stachian tube dysfunction, as evidenced by otitis media with effusion and negative middle ear pressure, but not perforations, in the contralateral ear. [ABSTRACT FROM AUTHOR]

Objective: To compare off-the-shelf digital imaging equipment with a standard single lens reflex 35-mm endoscopic camera in a busy pediatric ears, nose, and throat setting. Design: Two digital cameras with an endoscope adapter and a step-down ring were evaluated to obtain optimal settings for digital endoscopic photography. The equipment was used in various clinical and surgical settings to include otoscopy, sinonasal endoscopy, laryngoscopy, and bronchoscopy. The overall quality, color, brightness, and diagnostic quality of the endoscopic digital photographs were compared with those of the single-lens reflex 35-mm flash-generated photographs by experienced endoscopists. Cost analysis and ease of use were also compared. Subjects: Initial digital endoscopic settings were formulated from cadaveric tests. These settings were then studied in multiple patients during endoscopy. Results: Endoscopic digital photography resulted in high-quality images in all settings. Digital images were comparable to 35-mm images. The digital system was easier to use and less expensive than the 35-mm system. Conclusions: We introduce a simple, inexpensive, and easily available endoscopic digital photography system. Digital photography offers numerous advantages over analog photography in a clinical practice. Digital imaging and archiving is more durable and easier to incorporate into patient records and clinical presentations. As the demand for high-quality digital imaging increases, easy-to-use inexpensive digital endoscopic photography will soon replace 35-mm camera technology. [ABSTRACT FROM AUTHOR]

Background: Electrocochleography (ECochG) is useful in supporting the diagnosis of Meniere disease (MD). Possible MD (early disease as defined by the 1995 American Academy of Otolaryngology–Head and Neck Surgery Committee on Hearing and Equilibrium) is a readily treatable form of MD. Objectives: To identify whether ECochG summating potential/action potential (SP/AP) area curve measures are more sensitive than conventional SP/AP amplitude ratios in detecting possible MD. Patients and Methods: A retrospective chart review of a 3-year period (1997-2000) was conducted. All charts of patients diagnosed as having MD who had undergone tympanic ECochG were examined to identify those with possible MD. Exclusion criteria were incomplete workup, ECochG performed using a prior system, cochlear microphonic spike obscuring ratio measurements, and prior otologic surgery. A control group of patients with normal SP/AP ratios and ECochG data were identified. SP/AP amplitude and area curve ratios for both groups were measured. Results: Of 138 patients with MD reviewed, 20 (14%) had possible MD, and 8 passed exclusion criteria. An audiologist blinded to patients' diagnoses performed all measurements. The upper limit of normal for SP/AP amplitude and area curve ratios from the control group of ears (n = 13) (α = .05) were similar to previously published results. Of the 8 patients with possible MD, 4 had an abnormal SP/AP amplitude ratio, and 7 had an abnormal SP/AP area curve ratio; the difference between groups was statistically significant (P = .03, χ[sup 2]). Conclusions: The SP/AP area curve ratio significantly improves ECochG diagnostic sensitivity in possible MD. This ECochG refinement will allow earlier intervention to preserve inner ear function in MD. [ABSTRACT FROM AUTHOR]

Objective: To assess the subjective and objective short- and medium- to long-term results of laser-assisted uvulopalatoplasty (LAUP) for snoring and obstructive sleep apnea. Design: A nonrandomized, prospective, before-after trial. Patients and Interventions: Twenty-five patients underwent a modified procedure of LAUP termed one-stage LAUP, and a matched control group of 24 patients underwent uvulopalatopharyngoplasty. Main Outcome Measures: Subjective analysis of LAUP included a preoperative and 2 postoperative evaluations of the state of snoring (4 weeks and after a mean ± SD of 12.2 ± 9.9 months). A score on 5 other sleep-related symptoms was recorded before and after completion of LAUP. The objective polysomnographic outcomes were compared with a control group undergoing uvulopalatopharyngoplasty. Results: In 25 patients, improvement in the state of snoring significantly declined from 76% (n = 19) to 32% (n = 8), and worsening increased from 12% (n = 3) to 32% (n = 8) (P<.001). Evaluation of 5 other sleep-related symptoms showed that 52% of patients (n = 13) improved and 20% (n = 5) worsened. Polysomnography of LAUP patients showed that the mean postoperative respiratory disturbance index worsened significantly (33.1 ± 23.1) compared with the preoperative one (25.3 ± 14.3) (P = .05); also, 20% of the procedures were successful and 36% revealed marked worsening. The respiratory disturbance index of uvulopalatopharyngoplasty patients changed from 26.0 ± 18.0 to 18.7 ± 21.3, yet improvement did not reach statistical significance (P = .09). Furthermore, 58% (n = 14) of the surgical procedures were successful and only 8% (n = 2) revealed marked worsening. Conclusions: The favorable, subjective, short-term results of modified LAUP deteriorated over time. The procedure might also lead to aggravation of existing apnea. These findings are probably related to progressive palatal fibrosis and velopharyngeal narrowing originated by the... [ABSTRACT FROM AUTHOR]

Objective: To characterize the clinical behavior of non–squamous cell cancer of the maxillary sinus. Methods: Cases of non–squamous cell maxillary sinus malignancy during 1988 through 1998 were extracted from the Surveillance, Epidemiology, and End Results database. Data for histologic type of tumor, tumor stage, and survival were analyzed using the Kaplan-Meier method to determine mean, median, and 5-year survival statistics for the overall cohort and for individual histologic types of tumor. The effect of tumor stage on overall survival was assessed. To determine relative survival, the non–squamous cell group was compared with a second group of patients with squamous cell carcinoma, matched according to age at diagnosis, year of diagnosis, and T stage. Results: One hundred eighty-eight cases of non–squamous cell malignancy were identified. The mean patient age was 57.8 years, and 143 patients (76%) presented with T3 or T4 tumors. There were 31 adenocarcinomas, 64 adenoid cystic carcinomas, 15 mucoepidermoid carcinomas, 22 melanomas, 45 sarcomas, and 11 undifferentiated carcinomas. The overall mean survival was 63.4 months, and 5-year survival was 45.6%. Adenoid cystic carcinoma exhibited the best mean survival (79 months), whereas melanoma and undifferentiated carcinoma exhibited poor mean survivals (30.3 and 12.8 months, respectively). T stage did not statistically affect overall survival (P = .86). Survival for patients with non–squamous cell cancer was substantially better than survival for the matched group with squamous cell carcinomas (mean survival, 41.5 months; 5-year survival, 27.4%). Conclusions: Patients with non–squamous cell carcinoma of the maxillary sinus typically present with advanced T stage but have significantly better survival than patients with similar-stage squamous cell carcinoma of the maxillary sinus. T stage has less effect than histologic type of tumor on prognosis in non–squamous... [ABSTRACT FROM AUTHOR]

Reports on the diagnosis of allergic fungal sinusitis (AFS) with bacterial superinfection of frontal ethmoid mucoceles caused by AFS. Basis for the diagnosis of AFS; Tomographic scans of the sinuses; Compatibility of radiographic findings with fungal manifestations.

Background: Fanconi anemia (FA) is a rare autosomai recessive disorder characterized by a high degree of genomic instability and predisposition to cancer development. Recent evidence suggests that the incidence of head and neck squamous cell carcinoma (HNSCC) may be increased in patients with FA. Objective: To determine the cumulative incidence, tumor distribution, and outcome of HNSCC in patients with FA. Design and Setting: We analyzed data from 754 subjects from the International Fanconi Anemia Registry, a prospectively collected database of patients with FA. Main Outcome Measures: Cumulative incidence of HNSCC and 2-year overall, relapse-free and diseasespecific survival. Results: Of the 754 patients in the International Fanconi Anemia Registry, 19 (3%) had HNSCC. This is a significantly higher incidence of HNSCC compared with that observed in the general population (standardized incidence ratio, 500; 95% confidence interval, 300-781) (P<.001). The patients' age ranged from 15 to 49 years (median, 31 years), and there was a 2:1 female predominance. Surgical treatment was well tolerated (n = 17); however, radiation therapy and chemotherapy were associated with significant morbidity and mortality. Of the 19 patients, 10 (53%) developed locoregional recurrences within a median of 16 months from diagnosis. The median follow-up was 29 months. The 2-year diseasespecific, overall, and relapse-free survival rates were 49%, 49%, and 42%, respectively. The cumulative incidence of relapse by the age of 40 years was 50%. Conclusions: In patients with FA, there is a high incidence of aggressive HNSCC at a young age. Surgery remains the mainstay of treatment because patients with FA tolerate radiation therapy and chemotherapy poorly, with significant morbidity. An increased understanding of FA-associated malignancies is not only important in the clinical management of patients with FA but can also elucidate the role of chromosomal instability in the development of... [ABSTRACT FROM AUTHOR]