Faculty Bibliography

The ability of surgery or bromocriptine to produce endocrine control of a prolactin macroadenoma decreases as the prolactin level increases. Guidelines for the use of multimodality therapy have not been developed for tumors associated with markedly elevated prolactin levels. We reviewed the records of 21 patients with prolactin levels greater than 200 ng/ml treated by transsphenoidal surgery and postoperative radiotherapy with or without a dopamine agonist. Values before and after treatment were available for 19 patients (13 men and 6 women). The mean basal prolactin level before treatment for the entire group was 2410 ng/ml. Surgery and radiotherapy resulted in a 90% reduction and serum prolactin levels within normal limits in 0 of 7 patients, versus the combination of surgery, radiotherapy, and dopamine agonist, which resulted in a 99.5% reduction and values within the normal range in 12 of 12 patients. Spontaneous physiological improvement was not often observed. One woman and two men were able subsequently to have children. A plan for these patients is discussed.

Recurrent aspiration pneumonia is a potentially lethal problem, and its treatment is controversial. A variety of procedures have been advocated to prevent aspiration. These are reviewed briefly. We have been dissatisfied with established procedures because they usually require external approaches with considerable complexity and potential complications. Therefore, we attempted to obstruct the glottic airway by injecting both vocal cords with Teflon in a series of patients with recurrent aspiration pneumonia secondary to severe neurologic impairments. Since Teflon injection of the vocal cords bilaterally did not reliably prevent aspiration, we cannot recommend it for routine use in the treatment of chronic aspiration.

Currently, among otolaryngologists, much attention is focused on the surgical management of paranasal sinus disease. However, transantral sphenoethmoidectomy is rarely mentioned in the literature of the past several decades. We reviewed a consecutive series of 98 patients over a 12-year period who underwent transantral sphenoethmoidectomy in the treatment of severe chronic hyperplastic pansinusitis. The major and minor complications encountered are tabulated, as are the clinical outcomes. A description of the operative technique is followed by a discussion of the indications for this approach. We believe transantral sphenoethmoidectomy has a useful place in modern paranasal sinus surgery.

Cholesterol cyst (or granuloma) of the temporal bone, a recognized clinical entity distinct from cholesteatoma, is more common than previously thought. Apparently it is caused by obstruction of previously pneumatized temporal bone air cells. Surgical cure is achieved by drainage and reestablishment of normal pneumatization. This paper reviews 14 cholesterol cysts of the temporal bone, emphasizing the importance of preoperative imaging and surgical approach. Use of magnetic resonance imaging differentiates cholesterol cysts from cholesteatoma or other neoplasms. Computed tomography delineates the location of the lesion and defines temporal bone anatomy essential to surgical approach. The two studies together allow the surgeon to properly plan drainage, as in the case of a cholesterol cyst, versus excision or exteriorization, as in the case of cholesteatoma. The infralabyrinthine approach to a petrous apex cholesterol cyst is the procedure of choice when hearing preservation is desired

Younger siblings of children with sensorineural hearing loss of possible hereditary cause underwent interval audiologic examination. Seven siblings (in unrelated families) were found to have progressive sensorineural hearing loss despite early audiograms documenting normal hearing levels for age. Continued testing of these children allowed for early identification and intervention. We advocate regular otolaryngologic and audiologic follow-up even after normal audiologic assessments are made for younger siblings of children with documented sensorineural hearing loss, unless a definite nongenetic origin of the hearing loss in the older child is known. Recessive sensorineural hearing loss with onset in infancy or childhood may present with no antecedent family history and with normal behavioral audiograms early in life

Invasive fibrous (Riedel's) thyroiditis is a rare thyroid condition of unknown origin that may be associated with inflammatory fibrosclerosing processes elsewhere in the body. Although the condition is benign and self-limiting, its importance lies in its ability to clinically mimic carcinoma almost completely, necessitating performing an open biopsy to establish the correct diagnosis. In a review of over 700 thyroid operations performed at Loma Linda (Calif) University Medical Center in the past 15 years, we encountered only one documented case of Riedel's thyroiditis. Our patient presented with a firm thyroid mass, vocal cord paralysis, and symptoms of esophageal compression. Surgery was performed to obtain a definitive diagnosis and prevent the possibility of subsequent additional tracheal compression with airway compromise. The pathologic findings, as well as the medical and surgical treatment of this condition, are reviewed.

Forty-eight patients with cerebrospinal fluid leaks comprise this retrospective study. There were 39 traumatic and 9 spontaneous leaks. Nine patients were initially managed with bed rest and spinal drainage, but 3 patients in this group ultimately required surgical intervention for repair of their persistent leaks. Thirty-nine patients had surgery as initial therapy, with 33 extracranial repairs, 2 intracranial repairs, and 4 combined approaches. The extracranial approach was used in 36 of 42 patients, with an initial success rate of 86%