Faculty Bibliography

OBJECTIVE: To determine cochlear implant electrode stability in the young patient. Electrode migration due to future skull growth was a concern that led to prohibiting implantation in children less than 2 years of age. Recently, the high level of performance achieved by young implantees has led to a re-evaluation of this lower age limit, requiring an assessment of the effects of skull growth over time. STUDY DESIGN: Prospective radiographic analysis of electrode position of cochlear implants in young children. METHODS: Twenty-seven children implanted with the Nucleus (Cochlear Corp., Denver, CO) or Clarion (Advanced Bionics Inc., Sylmar, CA) multi-channel cochlear prostheses were subjects for this study. Follow-up radiographic studies were obtained for a period of 1 month to 5 years after implantation. The age at time of implantation ranged from 14 months to 5 years. An intraoperative modified Stenver's view plain radiograph was obtained as a baseline. After implantation, on a yearly basis transorbital Stenver's and base views were obtained for comparative purposes. Additional radiographs were obtained whenever a change in performance or electrode map caused suspicion for extrusion. Electrode position was determined using a computer graphics enhancement technique whereby image contrast filters enhanced the visibility of the electrode array and surrounding bony structures. RESULTS: An analysis of the data revealed no migration of the electrode array over time. CONCLUSIONS: The confirmation of the stability of the electrode array alleviates the concern of the effects of skull growth on cochlear implantation in young children

OBJECTIVES: To present cases of renal cell carcinoma presenting with only head and neck metastases, to review theories of physiology and anatomy describing this phenomenon, and to discuss the role of the otolaryngologist in the treatment of these lesions. STUDY DESIGN: Retrospective review of the records of three patients who presented with renal cell carcinoma with head and neck metastases over the 3-year period from 1992 to 1995. METHODS: Retrospective review of the records of three patients who presented with renal cell carcinoma with head and neck metastases. In addition, English-language literature was reviewed with special focus on the anatomic and physiologic pathways possible to allow for such a phenomenon. CONCLUSIONS: Renal cell carcinoma has an occasional presentation as a head and neck mass without evidence of disease elsewhere. Various routes of spread have been postulated. Batson's venous plexus, as postulated by Nahum and Bailey, is an anatomic route through which emboli could navigate to the head and neck and avoid pulmonary vascular filtration. Interactions on the cellular level may also be responsible for the seemingly paradoxical spread. We recommend local excision of head and neck metastases of renal cell carcinoma without sacrifice of vital structures as a sound treatment regimen

BACKGROUND: Comorbid conditions have a significant impact on the actuarial survival of patients with head and neck cancer. However, no studies have evaluated the impact of comorbidity on tumor- and treatment-specific outcomes. This study was performed to evaluate the impact of comorbidity, graded by the Kaplan-Feinstein comorbidity index (KFI) on the incidence and severity of complications, disease-free interval, and tumor-specific survival in patients undergoing curative treatment for head and neck cancer. METHODS: A multi-institutional, retrospective cohort of 70 patients 45 years of age and under with head and neck squamous cell carcinoma (SCC) presenting over an 11-year period was studied. RESULTS: Advanced comorbidity (KFI grade 2 or 3) was present in 21 patients (30%). Patients with advanced comorbidity did not differ from patients with low-level comorbidity (KFI grades 0 or 1) in sex distribution, race, presence of human immunodeficiency virus (HIV) infection, tobacco use, location of primary lesion, stage at presentation, pathologic differentiation of the tumor, or type of initial treatment. The overall incidence of treatment-associated complications was similar between the groups (57% versus 49%; p > 0.05), but a higher proportion of patients with advanced comorbidity developed high-grade complications (24% versus 6%; p = .04). The median disease-free interval (11.1 months versus 21.6 months; p = .045) and tumor-specific survival (13.7 months versus 57.6 months; p = .03) was poorer for patients with advanced comorbidity. The effects of comorbidity on survival remained significant even after adjusting for the confounding effects of HIV status and tumor stage (p = .05). CONCLUSIONS: The presence of comorbid conditions has a significant impact on tumor- and treatment-specific outcomes. Although the presence of advanced comorbid conditions is not associated with an increase in the rate of treatment-associated complications, complications tend to be more severe in this population. More importantly, advanced comorbidity has a detrimental effect on the disease-free interval and tumor-specific survival in patients with head and neck cancer, independent of other factors. This suggests that comorbidity may impact on tumor behavior, presumably by altering the host's response to cancer. Accordingly, to be more predictive and reliable, the current staging system for head and neck cancer should include a description of the patient's comorbidity

OBJECTIVE: This study aimed to evaluate the change in performance when the Speak processing strategy replaced the Mpeak strategy. SUBJECTS: Twenty-one veterans who participated in the original Department of Veterans Affairs Multicenter Cochlear Implant Study, received the Nucleus F0F1F2 processor (Cochlear Corp., Englewood, CO, U.S.A.) (WSP) and were subsequently upgraded to the Mpeak (MSP) processing strategy. METHODS: Closed- and open-set speech recognition in quiet and in noise in auditory only conditions at the phoneme, word, and sentence levels were evaluated. RESULTS: Changes in audiologic parameters were evaluated using a paired t-test for related samples. Statistically significant improvements in mean scores were found for all tests and were greatest for the speech-in-noise conditions. An examination of individual data revealed that 61% of the subjects improved for tests administered in quiet, whereas up to 69% of the subjects had improved performance in noise. Subjects with no open set speech discrimination using the Mpeak strategy showed no improvement with the Speak strategy. CONCLUSIONS: Cochlear implants can provide improved performance using modifications to external speech processor hardware and software without changing the internal implant

OBJECTIVE: To assess and document the development of open-set speech recognition in congenitally deaf children implanted with the Nucleus multichannel cochlear prosthesis at < 5 years of age. STUDY DESIGN: The study group consisted of 38 consecutively chosen children in whom the decision to proceed with implantation had already been made. PATIENTS AND SETTING: Congenitally profoundly deaf children were implanted with the Nucleus multichannel cochlear implant at < 5 years of age and followed at NYU Medical Center for a period of 1-5 years. MAIN OUTCOME MEASURES: Open-set speech perception was evaluated preoperatively and postoperatively using the following: the Glendonald Auditory Screening Procedure (GASP) word subset, the GASP sentence subtest, Phonetically Balanced Kindergarten monosyllabic word lists, Common Phrases test, Multisyllabic Lexical Neighborhood test, and Lexical Neighborhood test. RESULTS: Correlation coefficients were calculated between scores at each interval and age at implantation; one-way analyses of variance were performed independently. Results showed that all subjects had significant open-set speech recognition at the time of the last postoperative evaluation. Thirty-seven of the children use oral language as their sole means of communication. CONCLUSIONS: Multichannel cochlear implants provide significant and usable open-set speech perception in congenitally deaf children given implants at < 5 years of age

Comorbid conditions are medical illnesses that accompany cancer. The impact of these conditions on the outcome of patients with head and neck cancer is well established. However, all of the comorbidity studies in patients with head and neck cancer reported in the literature have been performed using the Kaplan-Feinstein index (KFI), which may be too complicated for routine use. This study was performed to introduce and validate the use of the Charlson comorbidity index (CI) in patients with head and neck cancer and to compare it with the Kaplan-Feinstein comorbidity index for accuracy and ease of use. Study design was a retrospective cohort study. The study population was drawn for three academic tertiary care centers and included 88 patients 45 years of age and under who underwent curative treatment for head and neck cancer. All patients were staged by the KFI and the CI for comorbidity and divided into two groups based on the comorbidity severity staging. Group 1 included patients with advanced comorbidity (stages 2 or 3), and group 2 included those with low-level comorbidity (stages 0 or 1). Outcomes were compared based on these divisions. The KFI was successfully applied to 80% of this study population, and the CI was successfully applied in all cases (P < 0.0001). In addition, the KFI was found to be more difficult to use than the CI (P < 0.0001). However, both indices independently predicted the tumor-specific survival (P = 0.007), even after adjusting for the confounding effects of TNM stage by multivariate analysis. Overall, the CI was found to be a valid prognostic indicator in patients with head and neck cancer. In addition, because comorbidity staging by the CI independently predicted survival, was easier to use, and more readily applied, it may be better suited for use for retrospective comorbidity studies

Two sisters presented to our medical center with nontraumatic cerebrospinal fluid (CSF) fistulas from left sphenoid sinocranial junction defects. One sister had recurrent meningitis over a 20-year period that prompted a skull base evaluation. Four years later, her younger sister presented with profuse CSF rhinorrhea. Transethmoid sphenoidotomy with sinus obliteration and lumbar-subarachnoid temporary CSF diversion successfully treated one sister, while the other required reoperation and permanent lumbar-peritoneal shunting. In both cases the skull base defect was identically located in the posterolateral left sphenoid sinus. Embryological considerations, evaluation and management are presented

A retrospective analysis was performed on 174 patients operated on from 1992 to 1995 to evaluate the safety and efficacy of continuous lumbar cerebrospinal fluid drainage (CLCFD) in the management of cerebrospinal fluid (CSF) leaks following acoustic neuroma surgery. There was a 17% incidence of CSF leak. CLCFD stopped the leak in 87% of cases. There were no cases of meningitis associated with CLCFD. One deep vein thrombosis was treated without sequelae. It is concluded that CLCFD is safe and efficacious. The authors recommend that CLCFD be implemented immediately when indicated, foregoing a trial of conservative therapy. Indications and precautions are discussed

While both prophylactic antibiotics and tympanostomy tube insertion have a role in the treatment of recurrent acute otitis media (AOM) and otitis media with effusion (OME) in children previous work has shown that patients in our urban clinic are not compliant with prophylactic antibiotics. Concerned about the potential for decreased compliance in a non-compliant population, we performed a retrospective review to assess the incidence of complications from the insertion of tympanostomy tubes in the same pediatric clinic population. A total of 391 tubes were placed in 165 patients. Follow-up ranged from 0-49.4 months with a mean of 21.3 months. Three ears (1.14%) had persistent perforations. Tympanosclerosis was found in 30 ears (11.1%). No ear showed a chronic retraction or cholesteatoma. Six ears (1.70%) developed postoperative otorrhea. Thirty-five patients had at least one episode of otorrhea outside of the perioperative period, and a total of 60 episodes (19.6% of ears) occurred during the study period. The mean pure tone average prior to tube placement was 25.0 dB, with tubes in place was 2.44 dB and after the last set of tubes had extruded was 6.97 dB. Our study shows that the incidence of complications of tympanostomy tubes was minimal in our inner city clinic population