Faculty Bibliography

Recent investigations of children with specific language impairment (SLI) have found deviant anatomical asymmetry of the perisylvian cortex. These studies argue that this deviant anatomical asymmetry is linked to the language disorders of SLI children. To date no studies have examined whether deviant functional asymmetry underlies the processing of spoken language in these children. In the current study, brain-electrical activity was recorded from 31 scalp sites while children with SLI listened to auditorally presented stories and two different nonsense contexts. Electrical activity was time-locked to the grammatical word "the" in these contexts. The SLI children showed reversed asymmetry compared to control children from 200 ms to 400 ms in processing "the" in all contexts. More specifically, they showed depressed processing at the left temporal scalp site (T7) and enhanced processing at the right temporal site (T8). The second spatial derivative (the Laplacian) of the voltage activity was calculated to remove constant voltage potential and uniform changes in voltage potential across the scalp. The Laplacian analysis indicated that the sources of the positive electrical activity seen at the temporal electrode sites T7 and T8 are the lateral surfaces of the temporal cortices. A comparison of the scalp topography of the voltage potentials and Laplacian also suggests that children with SLI lack some contribution from a deep neural generator, possibly in the hippocampus or basal ganglia. This investigation is the first to demonstrate a direct link between deviant neurophysiological asymmetry and the processing of spoken language in children with SLI.

Ofloxacin otic is as effective in curing otitis externa in children (<12 years of age) as is the preparation combining polymyxin/neomycin plus hydrocortisone and as ciprofloxacin otic. Furthermore ofloxacin otic, as it requires less frequent dosing, is likely to encourage greater patient adherence and consequently to achieve a better cure rate than both of these treatment options. Because a number of cases of otitis externa are complicated by an undiagnosed tympanic membrane perforation, the lack of ototoxicity associated with ofloxacin otic makes it a particularly safe option for use in these patients.

DepoCyte is a slow-release formulation of cytarabine designed for intrathecal administration. The goal of this multi-centre cohort study was to determine the safety and efficacy of DepoCyte for the intrathecal treatment of neoplastic meningitis due to breast cancer. DepoCyte 50 mg was injected once every 2 weeks for one month of induction therapy; responding patients were treated with an additional 3 months of consolidation therapy. All patients had metastatic breast cancer and a positive CSF cytology or neurologic findings characteristic of neoplastic meningitis. The median number of DepoCyte doses was 3, and 85% of patients completed the planned 1 month induction. Median follow up is currently 19 months. The primary endpoint was response, defined as conversion of the CSF cytology from positive to negative at all sites known to be positive, and the absence of neurologic progression at the time the cytologic conversion was documented. The response rate among the 43 evaluable patients was 28% (CI 95%: 14-41%); the intent-to-treat response rate was 21% (CI 95%: 12-34%). Median time to neurologic progression was 49 days (range 1-515(+)); median survival was 88 days (range 1-515(+)), and 1 year survival is projected to be 19%. The major adverse events were headache and arachnoiditis. When drug-related, these were largely of low grade, transient and reversible. Headache occurred on 11% of cycles; 90% were grade 1 or 2. Arachnoiditis occurred on 19% of cycles; 88% were grade 1 or 2. DepoCyte demonstrated activity in neoplastic meningitis due to breast cancer that is comparable to results reported with conventional intrathecal agents. However, this activity was achieved with one fourth as many intrathecal injections as typically required in conventional therapy. The every 2 week dose schedule is a major advantage for both patients and physicians.

Malignant lymphoepithelial lesions are rare tumors of the major salivary glands. They most often occur in Asians and Greenland Eskimos and are strongly associated with Epstein-Barr virus infection. We report a case of a malignant lymphoepithelial lesion of the parotid gland that developed in an Italian-American woman whose serology was positive for Epstein-Barr virus antibody. The patient underwent a left total parotidectomy and upper neck dissection, followed by radiation therapy. At the 2-year follow-up, she remained free of disease.

OBJECTIVE: Factors that play a role in the selection of surgical approach for acoustic neuromas include patient health and age, size of tumor, hearing status, and location of tumor in the internal auditory canal (IAC) and the cerebellopontine angle. Deep extension into the IAC makes hearing preservation extremely difficult when a retrosigmoid craniotomy is used, and the best approach is a middle fossa subtemporal route. Modern gadolinium-enhanced magnetic resonance imaging (MRI) can be inaccurate in identifying the presence of tumor laterally in the IAC. This may affect the selection of a surgical approach. STUDY DESIGN: This study was a retrospective case review. SETTING: Patients were accrued from a tertiary referral otologic practice. PATIENTS: From 1997 through 2000, the authors identified six patients who had undergone acoustic neuroma surgery, had adequate imaging and intraoperative data, and demonstrated a lack of correlation between MRI and intraoperative findings of the lateral IAC. INTERVENTION: The interventions were preoperative MRI of the IAC and surgical resection of an acoustic neuroma. MAIN OUTCOME MEASURE: Comparison of MRI and intraoperative findings of the lateral IAC were the main outcome measures. RESULTS: Six patients demonstrated a lack of correlation between MRI and intraoperative findings of the lateral IAC. CONCLUSIONS: Gadolinium-enhanced T1-weighted MRI findings of the depth of penetration into the lateral aspect of the IAC do not always correlate with intraoperative findings and thus may have implications in the selection of surgical approaches to acoustic neuromas.

The field of skull base surgery has expanded dramatically the surgical horizons in the treatment of skull base neoplasms, which, previously, were considered inoperable because of their locations and relation to vital structures. This article aims to offer improved understanding of surgical indications and appreciation for some of the details of surgical techniques involved.

OBJECTIVE: The outcomes of surgery for acoustic neuromas have improved dramatically since the development of modern surgical techniques, the operating microscope, magnetic resonance imaging (MRI), and cranial nerve monitoring. The goals of acoustic neuroma surgery are now preservation of facial nerve function and, when feasible, hearing preservation. Many large series do not report standardized hearing and facial function grading, and they include patients who did not benefit from the most modern techniques. The purpose of this study was to present the results of acoustic neuroma surgery using the most modern techniques and equipment, using standardized grading systems. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: 97 patients who underwent surgical removal of acoustic neuromas from 1992 to 1998. INTERVENTION: All patients underwent acoustic neuroma surgery and had preoperative audiograms and MRI with contrast. In addition, all patients had preoperative and postoperative facial function graded by the House-Brackmann scale and intraoperative facial nerve monitoring. Hearing preservation was attempted in patients with tumors of any size who had preoperative function of grade A or B according to the Committee on Hearing and Equilibrium guidelines for reporting results of acoustic neuroma surgery. MAIN OUTCOME MEASURES: Hearing preservation was considered successful if the patient retained serviceable hearing grade A or B. House-Brackmann grade 1 or 2 was considered excellent facial function. Complications were recorded. RESULTS: Facial nerve integrity was preserved in 96 of 97 patients (99%). Eight of 8 (100%) patients with intracanalicular tumors had excellent facial nerve function (HB 1-2). Fifty-two of 55 (95%) of patients with small tumors had excellent facial nerve function, and 15 of 24 (63%) with medium tumors had HB grade 1-2. Hearing was preserved in 29% of patients with tumors under 2 cm. The overall complication rate was 20%; cerebrospinal fluid leak was the most common. CONCLUSION: These results show that with modern imaging and surgical techniques, acoustic neuroma surgery is extremely safe and outcomes are very good. Surgery remains the treatment of choice for most tumors until alternative therapies, such as gamma knife, use uniform grading scales and show long-term facial and hearing results.

As a term, the "petrosal approach" to the petroclival region has a variety of meanings. The authors define a common nomenclature based on historical contributions and add new terminology to describe a technique of hearing preservation that allows for greater exposure of the petroclival region. The degree of temporal bone dissection defines five stages of operation. The authors used the second or "transcrusal" stage, in which the posterior and superior semicircular canals are sacrificed while preserving hearing, in six consecutive cases. Use of a common terminology ensures better understanding among surgeons. In the authors' hands, hearing has been successfully preserved in six patients after partial labyrinthectomy.

Rejuvenation of the midface is a challenge in facial plastic surgery. To this end, several techniques have been developed to address the changes seen in the midface with aging. Specifically, ptosis of the malar fat pad and deepening of the nasolabial fold contribute to the aesthetic changes that characterize midfacial aging. The history of modern facelifts and deep-plane facelift techniques to correct the nasolabial fold are presented

Congenital nasal pyriform aperture stenosis is a rare cause of airway obstruction in the newborn. Immediate recognition and therapy are essential for this potentially life-threatening condition. After initial management, which includes establishment of an oral airway, surgical repair of the stenotic bony inlet has been traditionally considered. We present a long-term follow-up of two patients with congenital pyriform aperture stenosis, who were managed expectantly. Pertinent embryology, clinical presentation, and general treatment strategies for these patients are also discussed