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Introduction: Osteoradionecrosis is one of many potentially severe complications of radiotherapy for nasopharyngeal carcinoma. Osteoradionecrosis of the skull base is life-threatening due to the critical proximity of the pathological process to vital structures, for example, the intracranial cavity, the upper spine, and major blood vessels. Reconstructive options following surgical debridement of the anterior skull base and upper spine osteonecrosis have been scarcely described in the literature., Case Presentation and Management: We present a rare case of osteoradionecrosis of the clivus and cervical vertebrae C1-C2 in a patient previously treated with chemoradiotherapy for nasopharyngeal carcinoma, presenting as severe soft tissue infection of the neck. Aggressive surgical debridement and reconstruction with a two-paddle free anterolateral thigh flap was performed using a combination of transcervical and transnasal endoscopic approaches. A novel endoscopic procedure in the sphenoid sinus enabled flap anchoring in this complex area., Discussion: Surgical modalities for osteoradionecrosis of the skull base and upper spine are discussed and review of the literature is presented., Conclusion: Reconstruction of the anterior skull base with a well-vascularized free flap following ablative surgery should be considered in management of life-threatening osteoradionecrosis of the area. Endoscopic opening of the sphenoid sinus and creating a funnel-shaped stem is a newly described technique that guarantees precise placement of the flap and is a valuable adjunct to the reconstructive armamentarium.

Objects: Dizziness makes up a diagnostic and treatment challenge. The diagnostic accuracy of the medical history and vestibular physical examination in cases of vestibular symptoms is not clear. The aim of this study is to determine the association between vestibular physical examination, vestibular questionnaires, and electronystagmography (ENG) test in patients with vestibular symptoms., Methods: This is a prospective study of 135 adults with vestibular symptoms. The subjects underwent targeted physical examination and filled vestibular questionnaires, including the Dizziness Handicap Inventory (DHI), before ENG testing. The results of the physical examination and questionnaires were compared with the final ENG findings., Results: Of patients who had normal ENG results, 32.1% (17/52) showed abnormal physical examination, and 48.8% (40/82) of the patient who had normal physical examination showed abnormal ENG results ( P = .46). Among patients with severe disability by DHI, 46.4% (13/28) had an abnormal ENG, and 42.9% (12/28) had a normal ENG ( P = .39)., Conclusions: This study did not demonstrate association between vestibular physical examination, vestibular questionnaires, and ENG results. Although history (augmented by questionnaires) and physical examination are the initial steps in the evaluation of vertigo, the current study suggests that they should be complemented by objective testing for evaluation of inner ear origin of vertigo.

Objectives: The purpose of this study was to define the clinicopathologic features and outcome of the oncocytic variant of papillary thyroid carcinoma (OVPTC) with a review of the literature., Methods: Twenty-three patients with OVPTC over a 10-year period were studied. Demographic, clinical, and histopathologic features and outcome data were analyzed retrospectively., Results: Seventeen women and 6 men, ages ranging from 20 to 76 years (95% confidence interval, 43.0 to 54.48), were studied. Cervical lymph node involvement was found in 43.4% of the patients. Most of the recurrences were associated with thyroid masses greater than 2 cm in diameter. Evaluation of the overall survival data by the Kaplan-Meier method revealed that most recurrences took place earlier than 30 months, and the majority of patients (74%) were well, with no evidence of disease, up to 78 months after the last treatment. All of the OVPTC cases presented as nonencapsulated tumors, and 78.2% demonstrated extrathyroid stromal invasion., Conclusions: OVPTC is a unique variant of papillary thyroid carcinoma that has distinctive clinicopathologic features. Since OVPTC is often associated with local invasion and may involve cervical lymph nodes, it may require more extensive surgery than classic papillary thyroid carcinoma.

Objectives: Halofuginone is a low-molecular weight quinazolinone alkaloid coccidiostat that inhibits collagen type I synthesis, extracellular matrix deposition, and angiogenesis. This study was conducted to assess its potential in preventing subglottic stenosis (SGS)., Methods: We induced SGS in 10 dogs randomly divided into 2 groups. Each group received treatment between 3 days before and 21 days after the induction of SGS. One group received oral halofuginone 40 microg/kg, and the other was given placebo. The area of the subglottic lumen was measured at baseline and 3 months later. In addition, human tracheal fibroblasts were cultured. The inhibitory effect of halofuginone was compared to the effect of mitomycin., Results: All dogs survived throughout the study with no side effects. Three months after the operation, no halofuginone-treated dog had SGS, in contrast to a 66% to 80% stenosis rate (mean, 72%) in controls (p < .008). Thick fibrotic tissue was found in the placebo-treated larynges, whereas an almost normal architecture was observed in halofuginone-treated larynges. Halofuginone inhibited the growth of human tracheal fibroblasts by 75%, in comparison with 60% inhibition by mitomycin (no statistically significant difference)., Conclusions: This preliminary study shows that halofuginone is effective in preventing SGS caused by an acute injury. Halofuginone has a potential therapeutic role in preventing SGS in humans.

Objectives: Our intent was to review the clinical signs, computed tomography (CT) scans, treatment, and outcome of parapharyngeal space infections (PPIs), and to define 2 types of infections of the parapharyngeal space (PPS) according to the location of the infectious process., Methods: We performed a retrospective analysis of patients hospitalized in a tertiary university hospital with a diagnosis of PPI, abscess, or deep neck abscess between 1988 and 2004. Files and CT scans were reviewed after classification into 2 groups: 1) infection located in the posterior part of the PPS (PostPPI); and 2) infection located in the anterior part of the PPS (AntPPI)., Results: Twenty-two patients had a PostPPI; their ages ranged from 10 months to 24 years. Five patients underwent surgical drainage, and 17 others were treated solely with intravenous antibiotic therapy. No pus was found during surgery in 2 patients. The average time of hospitalization was 10 days. Only 1 complication (aspiration pneumonia) was observed. Seven patients had an AntPPI; their ages ranged from 1.5 years to 65 years. All patients underwent surgical drainage, and pus was detected in all cases. The average time of hospitalization was 35 days. Complications (septic shock, respiratory arrest, mediastinitis, pleural empyema, pericarditis) were observed in 4 patients., Conclusions: The term "parapharyngeal abscess" was assigned long before the CT scan era, and was based on physical examination and plain film radiology. In essence, the entity PPS "abscess" or "infection" is composed of 2 different disorders. Infection located in the posterior part of the PPS with no invasion into the parapharyngeal fat and with no extension into other cervical spaces except the adjacent retropharyngeal space may be termed posterior parapharyngeal infection or parapharyngeal lymphadenitis. This is a relatively benign condition, and nonsurgical treatment should be considered. Infection involving the parapharyngeal fat may be termed parapharyngeal abscess or deep neck abscess. Diffusion into the mediastinum and other severe complications are frequent. Urgent surgical drainage is therefore mandatory.

This manuscript reports on our experience with purulent chondritis of the laryngeal cartilages (PCLC), an entity that has not yet been described. Three patients had a diagnosis of PCLC. The probable causes were relapsing polychondritis, a previous prolonged intubation, and an idiopathic cause. The patients suffered from hoarseness and inspiratory stridor for 1 to 3 months before diagnosis. None complained of pain in the neck. Laryngoscopy showed supraglottic edema. A computed tomography scan revealed abscess formation between the intact inner and outer perichondria of the thyroid cartilage. The treatment included rigid endoscopy, external incision and drainage, and prolonged medical therapy. The culture results were Staphylococcus aureus in the first 2 cases and Aspergillus fumigatus in the third. The second patient (in whom the cricoid cartilage was also affected) required emergency tracheotomy. The other 2 patients did not require airway intervention. The rarity of PCLC and the relatively mild symptoms require a high index of suspicion for its diagnosis.

The objective of this study was to test the feasibility of a new kind of implantable hearing device based on a cerebrospinal fluid hydroacoustic pathway by which sound waves are conducted from the dura mater to the inner ear by cerebrospinal fluid. In this prospective animal study, a piezoelectric bimorph was implanted into 2 guinea pigs and 1 dog between the skull bone and the dura at the parietal area. The bimorph was connected transdermally by wires to a click generator. The auditory brain stem response was recorded after stimulation of the piezoelectric device by the click generator. In the 3 animals, the auditory brain stem response could be recorded in response to a stimulus intensity of 135 dB peak equivalent (pe) sound pressure level (SPL; instrument setting), corresponding to 3.8 V activating the device. The auditory brain stem response disappeared during white noise masking, proving that the origin of the response was in the inner ear. The threshold was 125 and 115 dB pe SPL in the 2 guinea pigs and 135 dB pe SPL in the dog (instrument setting). We conclude that transmission of sound waves by a cerebrospinal fluid hydroacoustic pathway to the inner ear is possible. Such a device would have advantages over more traditional implantable hearing devices: it would not be necessary to couple it to the ossicular chain, and it could be used in patients with infected middle ears.

Tympanometry is well established as a means of assessing the presence of fluid in the middle ear. The type B tympanogram is usually considered a unique entity. However, its shape may vary from a rounded type B with a "pseudopeak" to a completely flat response. The aim of this study was to compare the characteristics of the B curve (maximum admittance, tympanometric peak pressure, and area under the curve) to the viscosity of the middle ear fluid and to the air-bone gap (ABG). In 67 children (93 ears) who underwent ventilation tube insertion, no correlation was found between the viscosity of the middle ear fluid and the characteristics of the B curve. However, these characteristics were able to differentiate between a low ABG (0 to 20 dB) and a high ABG (>20 dB). A statistical difference was also found for the three parameters (maximum admittance, p < .0025; pressure, p < .025; and area under the curve, p < .0005). Tympanometry may be used as an objective measure to estimate the extent of conductive hearing loss, especially in young children.

We performed a prospective masked animal study to determine whether virtual bronchoscopy, a noninvasive computed tomography technique, can accurately measure upper airway stenosis. Virtual bronchoscopy creates a 3-dimensional endoscopic image from spiral computed tomography data. Laryngotracheal stenosis was endoscopically induced in 18 dogs. The excised larynges were examined by endoscopy, virtual bronchoscopy, and macrodissection. Measurements were made of the anteroposterior (A-P) diameter, the left-right (L-R) diameter, the full length of stenosis in the sagittal plane, and the length of the tightest stenotic segment. Each measurement method was performed independently. All investigators were unaware of measurements made by others. The measurements obtained through virtual bronchoscopy and actual endoscopy were compared to those made at dissection by interclass correlation coefficients (ICCs). Endoscopy was better than virtual bronchoscopy in measuring the A-P diameter (ICC = .79, p < .0001; ICC = .42, p = .01). Both were equally effective in measuring the L-R diameter (ICC = .53, p = .0062; ICC = .52, p = .0064). The endoscopes could not assess the full length of the stenosis, whereas virtual bronchoscopy measured it fairly accurately (ICC = .72, p = .0001). Virtual bronchoscopy relatively accurately measured the length of the tightest stenotic segment (ICC = .68, p = .0002), whereas endoscopy produced measurements in only 11 of 18 larynges, and the measurements were less accurate (ICC = .45, p = .0068). Virtual bronchoscopy can provide good measurements of stenotic lesions in the airway. It is more accurate than actual endoscopy in determining the length of stenosis. It may therefore be useful as an adjunct imaging method in preoperative planning for reconstructive surgery.

Measuring sinus wall thickness on computed tomography may be important for distinguishing between acute and chronic inflammation of the paranasal sinuses or in cases of a suspected neoplasm. The objective of this study was to investigate the effects of opacified and aerated sinuses on the appearance of sinus wall thickness. A phantom model consisting of a skull half-immersed in water was scanned, and various slice thicknesses and different windows were used. The sinus walls of the water-immersed side appeared to be thicker than those of the aerated side. Bone windows did not completely eliminate this partial volume effect. It was concluded that comparison between a fluid- or tissue-filled sinus and an air-filled counterpart is not accurate enough for evaluating sinus wall thickness. Bone windows do not completely eliminate the artifactual thickening of the bony wall of a filled sinus.

A patient with acute vertigo, and normal findings on neurologic examination, was found to have vertebral artery dissection (VAD). This case shows that the clinical picture of VAD can mimic vertigo of labyrinthine (i.e, peripheral) origin.

A prospective study was performed on 45 patients for an assessment of the use of computed tomography (CT) in the management of a suspected esophageal fish bone or chicken bone. All patients had negative findings on laryngoscopy; therefore, pharyngeal and hypopharyngeal foreign bodies were excluded from further consideration. The patients underwent radiographic examination with plain films and a cervical CT scan without contrast material. Patients with positive findings were taken to the operating room, where they underwent rigid esophagoscopy under general anesthesia, while those with negative findings remained for observation for 24 hours. Thirty CT scans were positive for an esophageal foreign body, and in all cases but 1, a foreign body was found during the operation. Fourteen of 15 patients with normal CT scan findings managed well with no further intervention. One patient with persistent complaints underwent esophagoscopy, but no foreign body was found. Our conclusion is therefore that CT is a simple and reliable method for diagnosing esophageal bone impaction and may reduce the rate of unnecessary esophagoscopies.