Faculty Bibliography

The goal of cochlear implant surgery is to insert the entire electrode array into the scala tympani. Incomplete insertion is usually attributable to the presence of new bone formation as a result of meningitis. Surgical techniques for dealing with obstruction include various degrees of drilling of the cochlea or alternative placement of the electrode array. We evaluated the postoperative performance of eight such patients implanted with the Nucleus multichannel cochlear implant at NYU Medical Center as well as data from adults and children nationwide. Scores ranging from marginal closed-set speech discrimination to 40 percent on open-set speech recognition tests were obtained. Surgical procedure, placement, and number of electrodes as well as number of channels in use affect the ultimate performance of these patients

The deterioration of speech-understanding abilities in the aged that results from factors such as reduced speed and accuracy in processing has been well documented. The purpose of this study was to evaluate whether the geriatric population could benefit from a cochlear implant, despite the possibility of reduced processing abilities. Twenty patients, ages 65 to 85 years, with bilateral profound sensorineural hearing loss received the Nucleus multichannel cochlear prosthesis at NYU Medical Center. All patients underwent extensive preoperative medical and audiologic assessments to determine candidacy. The surgical procedure was well-tolerated by all patients. Mean postoperative test results revealed significant improvements in both auditory performance and quality of life as a result of implant usage. These data support the concept that although a reduction in the processing of sensory stimulation might exist, the elderly can process a new auditory code delivered by means of a cochlear implant

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

Tumors of the cervical plexus are rare. Often these tumors are found on routine exam as asymptomatic masses. We present our experience in managing four patients with tumors with dural extension. Three of these lesions were neurilemomas and one was a meningioma. Symptoms and signs included weakness and hypoesthesia. Evaluation included complete neurologic examination with electromyography (EMG). Magnetic resonance imaging (MRI) was the best diagnostic tool to see tumor extent into the epidural and intradural space. Computed tomography (CT) or plain x-rays were used to evaluate the degree of destruction of the cervical spine. The surgical removal of these tumors was performed by a two-team approach. A posterior laminectomy was combined with an anterior neck exploration. Follow-up shows persistent upper extremity weakness in two patients, hypesthesia in three patients, and anesthesia of the anterior chest wall in two patients. Patients with these lesions should be informed of the potential neurologic consequences of removal

A retrospective study was done on 64 patients who underwent superficial or subtotal parotidectomy for a primary benign tumor of the parotid gland. Factors, such as age, sex, smoking, alcohol consumption, type of surgery, duration of surgery, pathology of lesion, and size of lesion, were reviewed in a multivariate statistical analysis to determine if any factor alone or in combination contributed to the development of functional facial nerve weakness postoperatively. Only the age of the patient was found to have a statistically significant causal relation using the Pearson chi-square method (p = 0.015). The marginal mandibular branch was affected in nine of 10 cases. Different surgical approaches cited in the literature are discussed, along with the possible role of ischemic injury to the facial nerve during parotidectomy

This study assessed the achievement of postoperative swallowing in patients undergoing partial laryngectomy surgery. Oropharyngeal swallow efficiency was used to predict time to achievement of outcome. Fifty-five patients were followed for up to 1 year in two hemilaryngectomy and four supraglottic laryngectomy groups. Within 10 days of healing, a videofluoroscopic evaluation enabled the measurement of swallowing efficiency. Times to achievement of oral intake, removal of feeding tube, preoperative diet, and normal swallow were analyzed using actuarial curves. Patients with hemilaryngectomies achieved swallowing rehabilitation sooner than patients with nonextended supraglottic laryngectomies (p < .05) who, in turn, achieved swallowing function sooner than did patients undergoing supraglottic laryngectomies with tongue base resection (p < .05). Median time to attainment of preoperative diet in these three groups was 28 days, 91 days, and > 335 days, respectively. Higher early postoperative oropharyngeal swallow efficiency was related to earlier achievement of oral food intake and of preoperative diet (p < .05). Results show that the time course for swallowing rehabilitation covers an extended postoperative period. In some surgical groups, functional swallowing and eating may be achieved within 3 months of surgery while for other types, significant impairment remains up to 9 months postoperatively Early radiographic assessments of swallowing function are useful in predicting the time to swallow recovery. Recovery of swallowing ability may be delayed in patients who have not achieved oral intake before radiotherapy is started

A prospective randomized study comparing the effectiveness of triamcinolone acetonide and beclomethasone dipropionate nasal sprays in the treatment of allergic or vasomotor rhinitis was conducted at New York University Medical Center Both medications were used at their recommended dosages. Fifty patients were evaluated during a 2-month treatment period. Nasal airflow and resistance were quantified by anterior active rhinomanometry using the Rhinotest microprocessor rhinomanometer. The patients' subjective complaints were graded on a standard questionnaire. Both steroid inhalants were highly effective in relieving local symptomatology and the subjective improvement in nasal obstruction correlated with rhinomanometric assessment of the nasal airway. Triamcinolone acetonide used once daily represents an alternative to the twice daily beclomethasone dipropionate nasal steroid spray currently available for the treatment of rhinitis

The development of inhibitory synaptic transmission is difficult to assess because the afferents usually arise from intrinsic neurons that are difficult to stimulate independently. The postnatal maturation of excitatory and inhibitory synaptic function was compared in the gerbil lateral superior olive (LSO), where it is possible to stimulate physically discrete afferent projections. Intracellular recordings obtained in a brain slice preparation revealed that transmission was prominent at birth. The EPSPs and IPSPs were up to 2 orders of magnitude longer than in more mature animals. Brief trains of electrical stimulus pulses led to a temporal summation of postsynaptic potentials (PSPs) in 1-14 d animals resulting in prolonged depolarizations or hyperpolarizations. In neonates, the depolarization could exceed 1 sec following a 70 msec stimulus train. The IPSPs in neonates were often of sufficient amplitude to evoke a rebound depolarization or action potential. The number of converging afferents was estimated from the quantized increases in PSP size. There was a significant decrease with age, suggesting that both inhibitory and excitatory afferents were eliminated during the first 3 postnatal weeks. The integration of action potentials with IPSPs was examined with conjoint stimuli to the two afferent pathways, and demonstrated that the effective IPSP duration decreased approximately 20-fold during the first 3 postnatal weeks. The magnitudes and durations of electrical stimulus-evoked PSPs suggest that spontaneous discharge of afferents to the LSO could have a substantial impact on their development, even prior to the response to airborne sound at 12 d. Furthermore, the synaptic responses obtained at 12-14 d postnatal indicated that both amplitude and temporal processing remain compromised. These immature synaptic properties would be expected to compound the inadequacies present in the cochlea and cochlear nucleus