Faculty Bibliography

Reconstructive techniques for the stenotic pediatric airway have greatly enhanced the otolaryngologists ability to decannulate the tracheotomy-dependent child. Stents have played an important role in this process by both maintaining the reconstructed lumen and acting as a scaffold. However, decannulation is often not achieved after the first surgical intervention with some patients requiring two, three or more procedures. In an effort to improve upon the design of today's stents, an open stented tracheotomy tube was evaluated at our institution. This stent is designed to provide advantages of immediate postoperative voice and nutrition, and ease of evaluation, as well as to provide for safe and adequate healing. Four patients underwent laryngotracheal reconstruction with this stent over a 10-month period. All patients could vocalize and eat immediately postoperatively but recalcitrant granulation tissue and restenosis has prevented decannulation in three of the cases. The experience with this stent exemplifies the persistent difficulties of stent use in pediatric airway reconstruction. It also points out that progress is still needed in current reconstructive techniques as well as in the development of new techniques.

Untreated congenital syphilis is a known cause of hearing loss. In order to ascertain if infants are at risk of hearing loss at birth, 75 neonates with serologic evidence of syphilis and APGAR scores greater than 9 at 5 min were examined by auditory brainstem response (ABR) audiometry. All of the infants had normal ABRs. Ophthalmologic examination revealed no evidence of interstitial keratitis. Lumbar puncture was attempted on all the neonates. Cerebrospinal fluid (CSF) was successfully obtained from 41 infants and revealed no abnormalities. This study demonstrates that asymptomatic infants with serologic evidence of syphilis do not require audiologic evaluation in the neonatal period.

The electrical acoustic reflex threshold (EART) has been shown to be a reliable estimate of behavioral comfort levels in both child and adult cochlear implant patients. The purpose of this study was to investigate the potential for using EARTs for programming the Nucleus cochlear implant. EARTs and behavioral comfort levels were obtained from 7 adult implant patients. Two programs or "maps" were made for each patient, one based on behavioral comfort levels and one based on EARTs. Performance on open set tests of speech recognition was measured with each map. Mean data suggest that speech perception is similar with both maps. Analysis of individual data revealed that, whereas 2 subjects performed better with the C-level maps, the remaining 5 subjects tended to perform either better with the EART map or equally well with both maps. These results suggest that EARTs may be an adequate substitute for comfort levels when programming the implant for patients who are unable to make reliable psychophysical judgments.

The accuracy with which behavioral comfort levels could be predicted by the electrically elicited acoustic reflex threshold (EART) was examined in 35 Nucleus Cochlear Implant patients (16 adults and 19 children). EARTs were obtained by stimulating bipolar pairs of electrodes through the Nucleus Diagnostic Programming System and monitoring the change in middle ear admittance in the ear contralateral to the implanted ear. EARTs were successfully elicited in 24 patients. EARTs differed from behavioral comfort levels by a mean of 19.4 stimulus level units for adults and 9.6 stimulus level units for children. While EARTs were found to be acceptably close to behavioral comfort levels in four adults and eight children, EARTs significantly overestimated or underestimated comfort levels in the rest. The results of this study suggested that while the EART does not accurately predict comfort levels in all cases, it may provide valuable information regarding levels which should not be exceeded when programming the cochlear implant. Cautious use of information available from the EART may prove useful for programming the cochlear implant in children or adults who are unable to make reliable psychophysical judgments.

The evaluation and treatment of patients with unilateral vocal fold paralysis have evolved as improvements in objective measurements of phonatory function and new modalities for treatment have developed. A thorough history, physical examination, subjective voice evaluation, objective voice analysis, and electromyography are used to make a diagnosis, determine the cause, and plan treatment. The goal of treatment of the patient with a unilateral vocal fold paralysis is to restore normal phonatory function without aspiration. Multiple modalities have developed to allow for restoration of nearly normal phonatory function, and these include voice therapy alone or in combination with injection medialization, laryngoplastic phonosurgery, or laryngeal reinnervation. Otolaryngologists should be familiar with the incidence, cause, evaluation, and state-of-the-art treatment of unilateral vocal fold paralysis of optimize patient care and avoid suboptimal results often seen with antiquated or inappropriate treatment.

The emergence of magnetic resonance imaging with gadolinium has dramatically enhanced our ability to accurately detect the presence of acoustic tumors as small as 2 mm in diameter. Early diagnosis and improved surgical techniques continue to reduce the morbidity associated with surgical removal of these lesions. There exists, however, a select group of patients in whom no treatment may be the most appropriate management. Since 1979, a total of 51 patients with radiographic evidence of an acoustic neuroma have been prospectively followed for tumor growth and progression of symptoms. Patients were chosen for this conservative approach on the basis of age, medical condition, tumor size, audiometric data, and patient preference. This study reveals that a significant number of patients with acoustic tumors can be safely followed with regular imaging studies and may never require treatment. Discussed are tumor growth rates, epidemiology, and the impact of these factors on patient management.

Facial nerve tumors can present as masses in the internal auditory canal or cerebellopontine angle and may mimic an acoustic neuroma. These tumors can occur in any segment of the nerve from the brain stem to the neuromuscular junction. Prior to the advent of computed tomography and magnetic resonance imaging with gadolinium, facial nerve tumors were often difficult to diagnose. Even with these modalities it may be difficult to distinguish preoperatively between an acoustic neuroma and a facial schwannoma. Particular signs and symptoms associated with facial nerve tumors (in the spasms, and a facial tic. These symptoms, combined with modem radiologic studies, should allow for more accurate diagnosis, patient counseling, and treatment. This report presents a series of 32 facial nerve tumors diagnosed and treated at The Otology Group from 1975 to 1992. Of these lesions, 12 (38%) were thought to be acoustic neuromas. Eighteen tumors were correctly identified preoperatively as facial nerve tumors. Two facial nerve tumors were found incidentally.