Faculty Bibliography

PURPOSE: Until recently, the accepted management of life-threatening complications of unresectable cervicofacial arteriovenous malformations (AVMs) has been ligation of the major feeding vessels, usually the branches or the main trunk of the external carotid artery. Rapid enlargement of collateral vessels around the ligature is usually associated with an early return of symptoms. Percutaneous transcatheter embolization of the nidus of the arteriovenous malformation is now the preferred treatment for symptomatic AVMs that cannot be excised. Previous ligation of the main feeding vessels prevents catheter access and embolization therapy of the lesion. The purpose of this report is to describe our experience with the treatment of patients with symptomatic unresectable cervicofacial AVMs and previous external carotid artery ligation. METHODS: Six patients with symptoms from cervicofacial arteriovenous malformations required surgical reconstruction of their previously ligated external carotid artery with the anticipation of catheter embolization therapy to the branch vessels feeding the malformation. Saphenous vein was used in five reconstructions; a polytetrafluoroethylene graft was used in one. RESULTS: After successful arterial reconstruction, massive swelling of the tongue and perioral tissue developed in two patients, which necessitated tracheostomy in one patient; and embolization therapy before extubation could be safely performed in the other patient. In all, four patients underwent successful embolization therapy. One refused subsequent treatment. In one patient with severe epistaxis, external carotid artery revascularization led to the healing of the nasal ulcers without need for embolization therapy. CONCLUSIONS: For patients with previous ligations of the external carotid artery and symptomatic AVMs, revascularization of the external carotid artery is an important step in treatment. The surgery must be carefully coordinated with the interventional radiologist for possible emergency postoperative embolization therapy. External carotid artery ligation only complicates the treatment of patients with cervicofacial AVMs, and should no longer be used in the treatment of these individuals

The efficacy and safety of cefixime, the first oral third-generation cephalosporin, were evaluated in a multicenter clinical trial involving 118 adult patients with acute sinusitis or acute exacerbations of chronic sinusitis. Patients received a single daily dose of 400 mg of cefixime for a mean duration of 10 days; 106 patients completed a course of therapy. Clinical cure and improvement were achieved in 90% of these patients (61% cured and 29% improved). Among the patients evaluated again 2 weeks after therapy, 91% had a sustained clinical cure or improvement. Sinus exudate specimens were obtained from all patients by transantral puncture before therapy. Pathogens were isolated from 76 patients (66%), the most common pathogens being Haemophilus influenzae, alpha-hemolytic streptococci, and Streptococcus pneumoniae. Eighty-six percent of pathogens were presumed eradicated. Three patients discontinued therapy because of side effects. The most frequently reported adverse effects were gastrointestinal, with 20% of patients reporting diarrhea. Cefixime was effective in the treatment of bacterial sinus infections in adults and was well tolerated

PURPOSE: To define the normal CT anatomy of the levator scapulae muscle and to report on a series of five patients who presented with a palpable mass in the posterior triangle due to asymmetry of the levator scapulae muscles. PATIENTS AND METHODS: The contrast-enhanced CT examinations of the neck in 25 patients without palpable masses were reviewed to establish the normal CT appearance of the levator scapulae muscle. We retrospectively reviewed the contrast-enhanced CT examinations of the neck in five patients who presented with a palpable mass secondary to asymmetric levator scapulae muscles. RESULTS: In three patients who had undergone unilateral radical neck dissection, hypertrophy of the ipsilateral levator scapulae muscle was found. In one patient, the normal levator scapulae muscle produced a factitious 'mass' due to atrophy of the contralateral levator scapulae muscle. One patient had an intramuscular neoplasm of the levator scapulae. CONCLUSION: Asymmetry of the levator scapulae muscles, an unusual cause of a posterior triangle mass, can be diagnosed using CT

BACKGROUND. Cochlear implants restore some degree of hearing in patients with severe hearing impairment, but the efficacy of different implants has not been compared. We conducted a prospective trial to compare several cochlear implants. METHODS. We studied 82 patients who were randomly assigned to receive one of three cochlear implants: the Ineraid multichannel implant (implant 1), the Nucleus multichannel implant (implant 2), and the 3M/Vienna single-channel implant (implant 3). All the patients had profound deafness, and none had derived benefit from hearing aids. The assigned device was successfully implanted in 80 patients. Twenty-four hearing tests were used to assess the patients' performance before implantation and 12 and 24 months after implantation. The tests were grouped into five categories according to their content, and a weighted composite index was developed to provide a single numerical indicator of the overall auditory response. RESULTS. All the patients were able to hear with their implants. Nineteen of the 30 patients (63 percent) who received implant 2, 18 of the 30 patients (60 percent) who received implant 1, and 1 of the 20 patients (5 percent) who received implant 3 were able to distinguish some words and sentences. The scores for the composite index were similar in the patients who received implant 1 and those who received implant 2, and were higher in both these groups than in the patients who received implant 3 (P = 0.02). When 24 patients with implant 2 were given an improved speech processor, their composite index increased significantly within 3 months (P < 0.001); their score at that time was also significantly higher (P = 0.04) than the score of the patients with implant 1 at 24 months. Age at implantation, lip-reading ability, and IQ were prognostic indicators of the patients' performance with a cochlear implant. CONCLUSIONS. Multichannel cochlear implants are superior to single-channel implants, especially for understanding speech. Changes in speech processing can improve patients' performance

This meta-analysis of 42 empirical studies assessed the effect of six constructs on self-esteem: hearing status, parents' hearing status, type of school attended, communication mode used at home and in school, and group identification. Differences in self-esteem between deaf and hearing people varied based on (a) the self-esteem measure and (b) its format, and (c) the communication mode in which tests were administered. People whose parents were deaf compared favorably to those whose parents were hearing, as did people whose parents used sign language at home compared to those who used oral communication. School setting and classroom communication were unrelated to self-esteem. Finally, group identification was positively related to self-esteem. Results inform recommendations for guiding hearing parents in fostering self-esteem in their deaf children

A new technique is described which is suitable for long-term recording of the activity of neurones in the brain of an awake, unrestrained cat. By using telescopic electrodes, neurones up to 39 mm from the cranial surface can be reached with a miniature micromanipulator which is small enough to be left in place between recording sessions. The most stable recordings have been obtained with electrodes made from microwire, with which units have been held for up to 8 h

Eosinophilic granuloma is a localized form of histiocytosis X, or Langerhans' cell histiocytosis, a benign lesion of proliferating Langerhans' cells. It is the least severe of the histiocytosis syndromes, and is characterized by lytic lesions of one or more bones. Temporal bone lesions usually occur in association with multifocal disease; however, isolated lesions may occur in either the mastoid bone alone, or in the entire temporal bone, without disease elsewhere in the body. We present the first case (to our knowledge) of eosinophilic granuloma, or unifocal Langerhans' cell histiocytosis, limited to the petrous apex. The patient, an 8-year-old girl, presented with facial nerve paralysis. Because of delay in definitive diagnosis, the disease extended beyond its original boundaries and resulted in complete destruction of the temporal bone. We will also review Langerhans' cell histiocytosis, with attention to its involvement of the temporal bone

The efficacy and safety of a once-a-day antibiotic in the treatment of sinusitis was studied. Two randomly assigned groups were treated with either once-a-day cefixime, a third generation cephalosporin, or amoxicillin three times a day. One hundred and fourteen patients were evaluated with antral punctures, microbiologic evaluation, and radiographic studies. Cultures revealed 40% gram-negative organisms, 48% gram-positive, and 12% anaerobes. The most common bacteria were Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus aureus and viridans group streptococci. Ninety-four percent of the cefixime group were cured compared with 96% of the amoxicillin group. Staphylococcus resistance was a problem in both groups, necessitating an occasional change to amoxicillin-clavulanate potassium in the amoxicillin group. Once-a-day antibiotics offer the potential for improved compliance in the treatment of sinusitis. Cefixime offers an additional benefit of covering beta-lactamase producing strains of bacteria which are increasing in incidence and resistant to many penicillins