Faculty Bibliography

Two cases of pediatric isolated cervical emphysema caused by foreign bodies are presented. This report emphasizes the need for roentgenograms, flexible nasolaryngoscopy, and situational barium swallows to identify the exact location of a tear and to determine whether the situation requires direct laryngoscopy and esophagoscopy to remove a foreign body, or an open surgical repair of a mucosal disruption. The treatment of this self-limited condition usually requires only antibiotics, fasting, intravenous fluid, and most importantly, close observation for signs of perforation

Endoscopic instruments have revolutionized surgical diagnosis and treatment. Recently, a high resolution microfiberoptic endoscope has been developed that has vast potential for otologic use. This microfiberoptic endoscope was used in cadaver and human studies to visualize the middle ear cavity. The technique used involved placing a 1.0-mm or smaller microfiberoptic scope into the middle ear via a tympanic membrane perforation, through a myringotomy tube or up the eustachian tube. Using the scope, the mesotympanum and hypotympanum can be well visualized. Similarly, the round window, oval window, ossicular chain, and related structures can be clearly demonstrated and recorded photographically. This technique has great potential to enhance diagnosis without open surgery

Cavernous malformations are congenital abnormalities of the cerebral vessels that affect 0.5% to 0.7% of the population. They occur in two forms: a sporadic form characterized by isolated lesions, and a familial form characterized by multiple lesions with an autosomal dominant mode of inheritance. The management of patients with cavernous malformations, particularly those with the familial form of the disease, remains a challenge because little is known regarding the natural history. The authors report the results of an ongoing study in which six families afflicted by familial cavernous malformations have been prospectively followed with serial interviews, physical examinations, and magnetic resonance (MR) imaging at 6- to 12-month intervals. A total of 59 members of these six families were screened for protocol enrollment; 31 (53%) had MR evidence of familial cavernous malformations. Nineteen (61%) of these 31 patients were symptomatic, with seizures in 12 (39%), recurrent headaches in 16 (52%), focal sensory/motor deficits in three (10%), and visual field deficits in two (6%). Twenty-one of these 31 patients underwent at least two serial clinical and MR imaging examinations. A total of 128 individual cavernous malformations (mean 6.5 +/- 3.8 lesions/patient) were identified and followed radiographically. During a mean follow-up period of 2.2 years (range 1 to 5.5 years), serial MR images demonstrated 17 new lesions in six (29%) of the 21 patients; 13 lesions (10%) showed changes in signal characteristics, and five lesions (3.9%) changed significantly in size. The incidence of symptomatic hemorrhage was 1.1% per lesion per year. The results of this study demonstrate that the familial form of cavernous malformations is a dynamic disease; serial MR images revealed changes in the number, size, and imaging characteristics of lesions consistent with acute or resolving hemorrhage. It is believed that the de novo development of new lesions in this disease has not been previously reported. These findings suggest that patients with familial cavernous malformations require careful follow-up monitoring, and that significant changes in neurological symptoms warrant repeat MR imaging. Surgery should be considered only for lesions that produce repetitive or progressive symptoms. Prophylactic resection of asymptomatic lesions does not appear to be indicated

The potential influence of auditory information in the production of /s/ and /integral of/ was explored for postlingually deafened adults with four-channel Ineraid cochlear implants. Analyses of the spectra of the sibilant sounds were compared for speech obtained prior to implant activation, after early implant use and after 6 months of use. In addition, the output of the Ineraid device (measured at each of the four electrodes) was analyzed with pre- and postactivation speech samples to explore whether the speech production changes were potentially audible to the cochlear-implant user. Results indicated that subjects who showed abnormally low or incorrect contrast between /s/ and /integral of/ preactivation, and who received significant auditory benefit from their implants were able to increase the distinctiveness of their productions of the two speech sounds

METHODS. Vertebral artery injury is a rarely described complication of anterior cervical decompression. The authors performed a retrospective review of their operative database for the purposes of defining the optimal management of this complication and its avoidance. RESULTS. Four of 1,215 (0.3%) patients undergoing anterior cervical operation sustained arterial injuries. In three cases, primary repair of the artery was successful; in one case, the artery was exposed and ligated. There were no postoperative ischemic complications. Artery laceration occurred during decompression (n = 2), screw tapping (n = 1), and during soft tissue retraction (n = 1). CONCLUSIONS. Injury to the vertebral artery during anterior approaches can be avoided by preoperative identification of anomalous arteries and by intraoperative attention to the midline. When the artery is injured, primary repair may be the optimal management strategy

Contemporary head and neck hard tissue reconstruction incorporates bone transfers in the treatment of osseous discontinuity defects subsequent to congenital malformation, traumatic injury, ablative oncologic surgery, and failures of physiologic osteosynthesis. Bone grafts may also be applied in contour augmentation and in strengthening and stabilization roles in congenital and acquired aesthetic as well as posttraumatic deformities. The osseous healing process is dynamic and unique. An understanding of the physiology of these processes allows the reconstructive surgeon to choose techniques and donor sites appropriate to specific requirements, to maximize transplanted bone volume, to achieve consistent and reliable results, and to modulate the osseous healing process in a favorable direction

Using a sample of 267 deaf adults, members of a stigmatized collective, this study tested three notions: (a) The ecological context in which group members live affects identification with their group; (b) group identification has a positive effect on members' self-esteem; and (c) several psychological mechanisms mediate between group identification and self-esteem. The first two notions received support. Family and school deafness were associated with group identification, which, in turn, had a positive effect on self-esteem both directly and through its moderating effect on the negative relationships between several variables and self-esteem. Data did not provide support, however, for the proposal that several variables mediate between group identification and self-esteem. Results highlight the importance of considering both the personal ecology of participants and their social-political context, as well as suggest revisions in theories on group identification and self-esteem

The principle of distraction osteogenesis, well-established in the enchondral bones of the axial skeleton, has recently been applied to the membranous bones (mandible, cranium) of the craniofacial skeleton in the experimental animal and in the human. In the craniofacial skeleton, however, the technique has been used only to lengthen bone in a direction along its major axis, i.e., unidimensional distraction. A canine model is presented to demonstrate the feasibility of distracting membranous bone away from its dominant axis, i.e., multidimensional distraction. Four mongrel dogs, 5 months of age, were the subjects of this study. Two osteotomies were made in the zygomatic arch, and the bone-lengthening device was fixed to the zygoma. After 7 days of external fixation, the osteotomized segment was lengthened 1 mm/day away from the long axis of the bone for 15 days. External fixation was then maintained for a minimum of 4 weeks, after which the dogs were sacrificed. Craniofacial CT with three-dimensional reconstruction documented multidimensional bone lengthening, and histologic analysis of the specimen confirmed the presence of new cortical bone in the expanded areas. Refinement in technique and miniaturization and internalization of the bone-lengthening device may allow for more precise changes in the amount and direction of lengthening, thus making distraction osteogenesis more widely applicable for use in the human craniofacial skeleton