Faculty Bibliography

Meticulous mastoid surgery does not always result in a dry, stable ear. Eustachian tube malfunction has been accepted as an important factor in chronic and recurrent middle ear infection. There are many parameters of eustachian tube malfunction, which form a complicated problem for investigation and analysis. Of most importance appears to be varying degrees of malformation of the nasopharynx and palate. A gradient from mild to overt deformity appears to be related to the degree of eustachian tube function. Other factors, such as nasal infection and allergy, nasopharyngeal scar tissue and tumors, and general resistance to infection, are of less importance but must be considered in the etiology of chronic ear disease. Tympanoplasty is relatively unsuccessful in a chronic discharging ear, as the infection ultimately destroys a surgical repair. Persistent otorrhea can be caused by either eustachian tube malfunction or a reservoir of chronic infection in the mastoid cavity. A mastoidectomy often controls the infection in the mastoid cells and a tympanoplasty may be done as a secondary procedure when the cavity is stable. A careful preoperative evaluation should be made in every case to determine the responsible factors for persistent ear infection. If possible, attempts should be made to eliminate the causative factors prior to the tympanoplasty. Classification of cases into four groups helps to separate those cases with a good prognosis from those that will continue to suppurate and will have a poor functional result. A dual classification of tympanoplasty has been established in which the type of reconstruction is documented and the stability of the ear against infection is estimated. Classified clinical material forms the basis for a clearer representation of the cases under investigation and the results of tympanoplastic surgery become statistically comparable. Classification of cases also aids in the selection of cases for surgery by identifying preoperatively those cases that will be successful from those that may not have a good result. With this information at hand it is possible to more accurately inform the patient preoperatively regarding hearing improvement and control of infection following a tympanoplasty.

Twelve children with laboratory evidence of human immunodeficiency virus (HIV) infection underwent diagnostic flexible bronchoscopy with washings or bronchoalveolar lavage at Bellevue Hospital Center from October 1987 to April 1989. The patients included 7 boys and 5 girls ranging from age 3.5 months to 10 years 5 months. Indications for bronchoscopy included respiratory distress with or without focal changes on chest radiograph in 11 patients, and persistent but asymptomatic right middle lobe collapse in one child. The etiology of pneumonia was diagnosed in 7 children and included Pneumocystis carinii, (PCP) (17%), Streptococcus viridans (17%), mechanical obstruction (17%) and cytomegalovirus (CMV) (8%). Bronchoscopy was non-diagnostic in 5 cases. Techniques for maximal yield of information using flexible bronchoscopy in HIV-positive children are discussed

Contrast enhanced CT and MR are complementary studies in evaluating inflammatory disease of the temporal bone. CT should be performed in preference to MR as the initial examination because of its ability to detect and delineate both soft tissue and bony abnormalities. CT should always be performed if intratympanic pathology is suspected, even if the MR examination is normal. MR can be used to distinguish effusion and cholesterol granuloma from other soft tissue masses in the tympanic cavity. Noncontrast MR cannot differentiate between cholesteatoma and granulation tissue. The efficacy of gadolinium-DTPA in inflammatory disease of the temporal bone awaits further investigation

Airway complications following elective cricothyroidotomy were reviewed in 48 adult cardiothoracic surgery patients. A 52% incidence of airway complications was found and manifested by failed or delayed decannulation, extensive subglottic granulation tissue, stenosis, vocal cord paralysis, and aspiration pneumonia. The most common cause for decannulation difficulty was subglottic stenosis (50%). Several risk factors were specifically identified, including a period of cricothyroid cannulation exceeding 30 days, the presence of diabetes, and advanced age. These findings suggest that airway sequelae following cricothyroidotomy in cardiothoracic surgery patients is higher than previously reported. Indications and risk factors for cricothyroidotomy are discussed

Various histochemical and immunocytochemical stains were useful in the diagnosis of six unusual head and neck neoplasms that included spindle-cell squamous carcinoma, synovial sarcoma, mucoepidermoid carcinoma, melanoma, T-cell lymphoma, and B-cell lymphoma. Close cooperation with a pathologist ensured rapid diagnosis and the initiation of appropriate therapy. Three cases required special histochemical stains to make a diagnosis or determined tumor differentiation. The three other cases would have been identified as poorly-differentiated tumors of unknown origin without the use of special immunocytochemical stains. These latter findings influenced our final therapeutic strategy, which emphasizes the uses of special stains and studies to accurately identify tumors of the head and neck

Eleven patients who underwent mandibular reconstruction with A-O plates were followed up for as long as 40 months. The patients underwent either immediate or delayed mandibular reconstruction. Nine patients had free cortical bone grafts included in the reconstruction. Complications in patients who underwent immediate reconstruction included loss of the bone graft due to infection, external and intraoral exposure of the reconstruction plate, pain, and infection. In the patients with immediate reconstruction, more than 50% of the bone grafts resorbed. There were less complications and minimal bone graft resorption in patients who underwent delayed reconstruction. The cosmetic results were initially good in both immediate and delayed reconstruction but deteriorated as more surgery was required for management of complications. At 40 months, 7 of 11 patients (5 of 9 with immediate reconstruction) had died of local recurrence, distant metastasis, or another primary tumor. No patients were rehabilitated prosthetically. We conclude that while A-O plating is technically easy and has a low perioperative morbidity rate, the long-term morbidity rate is high. This must be weighed against the benefits of the procedure and the probability that the patients will have a poor functional outcome

Teratomas of the head and neck are a particular type of developmental malformation or tumor that are composed of cells with a full range of histogenic potential. They occur almost exclusively in the newborn and infancy periods. Treatment is directed at complete surgical removal with preservation of normal anatomic structures