Faculty Bibliography

Hematomas, pseudocysts, and seromas are all part of the differential diagnosis of auricular swellings. Seromas are benign collections of serous fluid that have a tendency to recur. The fluid accumulates in the space between the dermis and perichondrium of the ear. We describe what we believe is the first case of spontaneous bilateral auricular seromas to be reported in the literature. One of the seromas resolved in 4 weeks without treatment, and the other resolved with incision and drainage. It is important for physicians to be aware of auricular seromas when considering the differential diagnosis of an auricular swelling, and to understand the various treatment options

A significant proportion of the population has nasal septal deviation of varying degrees. Recent reports of such deviation occurring at younger ages suggest a congenital etiology. To the best of our knowledge, no previous clinical studies have compared the septal deviation of adult and pediatric populations with a uniform measure that focuses on the degree of deviation. We retrospectively analyzed computed tomography (CT) and magnetic resonance imaging (MRI) scans obtained from 81 patients who had undergone head and neck imaging for a variety of reasons. These subjects were divided into four age groups: younger than 4 months; 4 months to less than 5 years; 5 to 15 years; and more than 15 years. We used a measure of tortuosity to examine and compare nasal septal deviation among the different age groups. The tortuosity of the septum was measured at four precise points along the length of the septum on thin-section sinus CT and MRI. Tortuosity was defined as the ratio of the 'actual' length of the septum to the 'ideal' length of the septum, which was defined as the length of a straight line drawn from the superior to the inferior aspect of the septum. We found that subjects younger than 5 years of age exhibited significantly less tortuosity (p </= 0.017459) than did the older children and the adults. Therefore, we conclude that nasal septal deviation occurs at a higher frequency in older children and in adults when calculations of tortuosity are used as a measure. Our data may suggest that a noncongenital etiology is responsible for nasal septal deviation. However, given that the growth of the septum continues throughout childhood, our results do not preclude the possibility of a genetic predisposition to the later development of a deviated nasal septum

Objective:This study aimed to investigate the utility of three-dimensional reconstructions of paranasal sinus computed tomography data in depicting the anatomy of the frontal sinus drainage pathway.Methods:Twenty-nine patients underwent imaging of the sinuses for various clinical indications. Variations in frontal sinus recess anatomy were determined from 0.75-mm thick coronal, axial and sagittal computed tomography images. Three-dimensional, reformatted images were generated from manually segmented volumes of interest. Observations were made on the variation and usefulness of these reconstructions.Results:Three-dimensional, reformatted images of segmented volumes aided delineation of the spatial relationships of the frontal sinus, frontal sinus drainage pathway, infundibular and meatal direction of drainage, agger nasi cells, ethmoid bulla cells, supraorbital cells, and suprabullar cells.Conclusion:Three-dimensional, reformatted images of frontonasal anatomy enable improved understanding of the frontal sinus drainage pathway anatomy and of the spatial relationships between ethmoid air cells in this region. Such images may provide a useful adjunct to surgical planning and education

Studies of hand manipulation neurons in posterior parietal cortex of monkeys suggest that their spike trains represent objects by the hand postures needed for grasping or by the underlying patterns of muscle activation. To analyze the role of hand kinematics and object properties in a trained prehension task, we correlated the firing rates of neurons in anterior area 5 with hand behaviors as monkeys grasped and lifted knobs of different shapes and locations in the workspace. Trials were divided into four classes depending on the approach trajectory: forward, lateral, and local approaches, and regrasps. The task factors controlled by the animal-how and when he used the hand-appeared to play the principal roles in modulating firing rates of area 5 neurons. In all, 77% of neurons studied (58/75) showed significant effects of approach style on firing rates; 80% of the population responded at higher rates and for longer durations on forward or lateral approaches that included reaching, wrist rotation, and hand preshaping prior to contact, but only 13% distinguished the direction of reach. The higher firing rates in reach trials reflected not only the arm movements needed to direct the hand to the target before contact, but persisted through the contact, grasp, and lift stages. Moreover, the approach style exerted a stronger effect on firing rates than object features, such as shape and location, which were distinguished by half of the population. Forty-three percent of the neurons signaled both the object properties and the hand actions used to acquire them. However, the spread in firing rates evoked by each knob on reach and no-reach trials was greater than distinctions between different objects grasped with the same approach style. Our data provide clear evidence for synergies between reaching and grasping that may facilitate smooth, coordinated actions of the arm and hand

OBJECTIVE: We report a case of allergic fungal sinusitis causing bone erosion and diplopia. CASE REPORT: A 43-year-old man presented with a four-month history of increased nasal congestion and progressive diplopia. Clinical examination revealed bilateral nasal polyposis and a right lateral gaze deficit, consistent with a VIth cranial nerve palsy. Computed tomography of the paranasal sinuses demonstrated a large sellar mass with extensive bony erosion and both supra- and infra-sellar extension. An endoscopic approach to the sphenoid sinus, clivus and posterior cranial fossa with image guidance was performed, enabling surgical treatment involving nasal polypectomy, wide marsupialisation of the sphenoid sinus and removal of the extensive allergic fungal mucin. The patient awoke from anaesthesia with complete resolution of his diplopia. CONCLUSION: Otolaryngologists should be aware that approximately 20 per cent of patients with allergic fungal sinusitis demonstrate paranasal sinus expansion and bone erosion involving surrounding anatomical structures. Such patients may have clinical findings involving the orbit and cranial vault

BACKGROUND: Given its rarity, varied histological presentation and often pseudosarcomatous appearance, nodular fasciitis is frequently misdiagnosed on pre-operative, intra-operative and final analyses. METHODS: Four cases of nodular fasciitis are reviewed. RESULTS: Physical and radiological findings were consistent with a parapharyngeal tumour, probably neurogenic, a level four neck mass suspicious for lymphoma; a sternoclavicular mass in a patient with a history of breast cancer suspicious for metastasis; and a cheek mass consistent with an accessory parotid tumour. Fine needle aspiration results were consistent with a neurogenic tumour in two patients and an undifferentiated malignancy in two patients. Frozen section examination most commonly included masses with spindle-type cells. The final diagnosis of nodular fasciitis was made only after permanent section and immunohistological analysis. CONCLUSIONS: In a patient with nonspecific results following investigation of a head or neck mass, nodular fasciitis should be considered. Use of appropriate immunohistochemical markers will aid in the final diagnosis

Ideal surgery for congenital microtia-atresia would offer excellent cosmetic and hearing rehabilitation, with minimal morbidity. Classic approaches require multiple procedures, including rib cartilage harvest and aural atresia repair. Our facial plastic and otologic team approach incorporates a high-density porous polyethylene (Medpor, Porex Surgical, Newnan, GA) auricular framework, followed by single-stage bone-anchored hearing aid (BAHA) implantation. We evaluated the efficacy, safety, and morbidity of this 2-stage dual system approach. A prospective database of microtia patients was used to identify patients undergoing combined Medpor/BAHA auricular reconstruction and hearing rehabilitation between 2003 and 2006. The first stage involves placement of a Medpor framework beneath a temporoparietal fascia flap, followed by a second-stage procedure for lobule transposition and BAHA implantation. Twenty-five patients (28 ears) were evaluated. Aesthetic quality of the implants was excellent, with a high degree of framework detail visible, and a postauricular crease created in all patients. All patients were satisfied with the cosmetic result. There were no major Medpor complications such as infection, extrusion, loss of implant, or flap necrosis, and a 10.7% incidence of minor complications requiring operative revision. BAHA significantly improved hearing in all patients, with a complication rate of 31.8%, mainly skin overgrowth and cellulitis. The Medpor/BAHA dual plastic-otologic approach to microtia-atresia has produced excellent cosmetic results and hearing outcomes, which compare favorably to traditional microtia-atresia repair. This is a 2-stage aesthetic and functional protocol with an acceptably low rate of complications, which safely and efficiently achieves both aesthetic and functional goals

OBJECTIVE: To determine the reliability of the House-Brackmann facial nerve grading scale in the setting of differential function across its branches. STUDY DESIGN: Prospective. SUBJECTS AND METHODS: Eleven physicians with different levels of clinical experience and three upper-level medical students were provided with digital video clips of 11 patients with differential facial nerve functioning, and asked to report facial nerve function as a traditional global score and as a regional score on the basis of the House-Brackmann scale for the forehead, eye, nose, and mouth. Agreements between the traditional global score and the regional scores, as well as inter-rater agreement, were analyzed. RESULTS: In patients with variable facial weakness, a single House-Brackmann score did not fully communicate facial function. The single House-Brackmann score most strongly correlated with the regional scoring of the nose/midface (59%), followed by the mouth (51%), eye (48%), and forehead (35%). Overall inter-reader reliability was relatively strong for the midface (kappa = 0.503) and global scores (kappa = 0.541), followed by the mouth (k = 0.419), the forehead (k = 0.330), and the eye (k = 0.302). There was a marked tendency for reader agreement to increase among those with more clinical experience. CONCLUSION: Regional assessment using the House-Brackmann grading scale more fully communicates facial function and increases in reliability with experience

OBJECTIVE: To characterize the background and outcomes of tonsillectomy malpractice claims. METHODS: Review of 69 New York State insurance claims (Part I) and 87 national court trials (Part II) alleging injury after tonsillectomy. RESULTS: Part I. New York State insurance cases were most commonly discontinued (44%) or settled (42%) before trial. Compensations with a settlement or verdict were made in 48 percent of cases. Part II. Death or major injury occurred in 52 percent of insurance cases, with a mean award of $403,656 being made to plaintiffs. Of cases reaching trial, 60 percent of plaintiffs were compensated. Awards against anesthesiologists were more frequent and higher than against surgeons ($5 million vs $839,650). Death or major injury occurred in 52 percent of court cases, resulting in mean indemnity of $3.8 million. Most cases of death or major injury were attributable to airway complications. CONCLUSIONS: Approximately half of both New York state claims and court cases involved death or devastating morbidity, mostly related to airway complications, resulting in large awards. Tonsillectomy is a source of uncommon but potentially high-dollar-value litigation exposure to the surgeon, often attributable to non-surgical complications

The complex architecture of the auricle makes it one of the most challenging structures for the reconstructive surgeon to re-create. Overlying the ear's unique cartilage framework are layers of varied soft tissues forming a three-dimensional organ, which is distinctively positioned on the head. Arguably, the most challenging auricle to reconstruct is third-degree microtia due to a near-total absence of native tissue and a need for lifelong durability of the reconstruction. Many methods of reconstruction have been studied; autogenous costal cartilage reconstruction has been one of the more traditional methods, with favorable long-term results reported by several surgeons. However, this technique requires tremendous artistic and technical skill on the part of the surgeon-sculptor to construct a realistic-appearing ear. High-density porous polyethylene (Medpor) is a stable, alloplastic implant that can integrate with host tissues, is resistant to infection, and has been successfully applied to reconstruction of the head and neck. For auricular reconstruction, Medpor--enveloped in a temporoparietal fascial flap with full-thickness skin graft coverage--is a durable and aesthetically gratifying alternative in microtic patients. This alternative surgical technique reduces surgical time and morbidity, standardizes results among surgeons, and facilitates an aesthetic, natural-appearing reconstruction of the auricle