Faculty Bibliography

Historically, parotid gland surgery has evolved from an operation of surgical enucleation to that of lateral lobectomy or total parotidectomy with facial nerve dissection. While the enucleation operation originally resulted in recurrence rates as high as 45% in some series, the technique of lateral lobectomy has resulted in recurrence rates of 2% in benign tumors. However, the currently recommended procedure of lateral lobectomy or total parotidectomy with facial nerve preservation for benign or low grade malignant tumors is not a pure en bloc resection in most cases, and in fact enucleation in part or total is often the reality of the operation. Tumor characterization, technical features, and operative findings of parotid gland surgery are examined in 100 consecutive cases. In over 60% of the cases, superficial or total parotidectomy with facial nerve preservation incorporated the principle of limited enucleation or capsular dissection at some point in the technique. The illusion that en bloc removal of parotid tumors with wide surgical margins is discredited. The reality of the procedure and the reasons for its success are examined.

A 57-year-old patient became totally deaf two days after receiving excessive doses of the aminoglycosidic antibiotic lividomycin parenterally for 14 days; she died four and a half months later. Her temporal bones were examined by microdissection, surface preparation, and serial sectioning of the modiolus. Loss of inner and outer cochlear hair cells was virtually complete. Refractile concretions were scattered along the atrophic stria vascularis, especially in the middle turn. The distal half of the radial cochlear nerve fibers in the osseous spiral lamina had degenerated, but closer to the modiolus they appeared to be intact. The spiral ganglion in the basal turn showed partial loss of neurons. Scanning electron microscopy revealed hair cell loss from the vestibular end-organs, more severe in the ampullar cristae than in the utricular macula. The dark cells of the utricular wall appeared to be altered.

Ototoxic and nephrotoxic potentiation with concomitant cis-diamminedichloroplatinum, or cis-platinum II (CSP), and aminoglycoside therapy was investigated in the guinea pig. We evaluated possible potentiation of the toxic effects of CSP and kanamycin compared with CSP alone in the inner ear and kidney and quantitatively localized CSP in the cochlea with gamma emission analysis of 195mPt. Kanamycin-treated animals demonstrated cytocochleograms and ABR waveforms, absolute latencies, and interwave latencies for waves I, II, and III similar to control animals at our maximum level of acoustic stimulation. CSP treatment produced 60% to 70% mean outer hair cell (OHC) loss in the basal turn of the cochlea, a reduction in ABR waveform and amplitude, and an increase in latencies of ABR waves I, II, and III. Combined CSP and kanamycin treatment produced 90% to 100% mean OHC loss in all rows of the basal turn of the cochlea, with no discernible ABR waveform corresponding to the region stimulated by a 4500 to 7000 Hz acoustic click. Combined treatment produced the most significant cortical medullary tubular necrosis and interstitial nephritis. Furthermore, this study reports for the first time localization of platinum in the inner ear.

The diagnosis of hearing loss in children with speech and language deficits by the otorhinolaryngologist involves a large allocation of sources. The ability to assess the efficacy of intervention in order to minimize speech and language deficits is an aspect in the care of these children which has not been generally considered as part of the child's ongoing medical care. These children have speech and language deficits predominantly from hearing impairment and occasionally from a primary language disorder. The effect of intervention (usually a hearing aid), the special education program for the hearing impaired child, and the language therapy for the child with a primary language disorder are seldom measured. The ability to assess and monitor the child's progress is essential for the care of these patients. The continual monitoring of the child's progress is accomplished by periodic assessment of the child's speech and language. An instrument to do this has been developed and used by the Department of Otorhinolaryngectomy at the Albert Einstein College of Medicine for a number of years. The utilization of this instrument, as demonstrated by a series of case reports, will be presented. These will include children in which intervention was successful and those for whom it was unsuccessful, with an analysis of the reasons underlying the effectiveness for each child. It is recommended that every child with a speech and language deficit should be monitored periodically so that the child's progress, or lack of progress, can be determined. If the child is not progressing, additional remediation can be instituted to attempt to prevent a permanent speech and language deficiency.

Needle aspiration biopsies for cytology were performed on 224 patients with thyroid nodules. Diagnosis was confirmed by surgical exploration in 134 patients. Twenty-four biopsies were reported positive for malignancy; 23 were confirmed at operation and there was 1 false positive. Forty-one biopsies were reported benign. Three of these lesions were found to be malignant, representing false negatives. Sixty-nine biopsies were in the questionable category; 16 (23%) of these were malignant. None of the patients suffered complications from the biopsies. Routine employment of needle aspiration biopsy on our service has resulted in a marked increase in the incidence of carcinoma in thyroid nodules selected for surgery. This has resulted from detection of otherwise unsuspected malignancy, as well as avoidance of surgery in patients with benign lesions. Needle aspiration is not a substitute for surgery. It is a valuable diagnostic procedure, and should be performed in the evaluation of essentially all thyroid nodules. We continue to use radioiodine scanning to evaluate our patients, but have found the routine use of ultrasonography unnecessary when needle aspiration is employed. The ultimate decision regarding surgical exploration is based on a combination of factors including history, physical findings, radioiodine scan and needle aspiration biopsy

The temporal bones from a 55-year-old woman with deafness and dizzy spells caused by a right-sided acoustic neurinoma were examined by the techniques of microdissection, surface preparations, and celloidin sections. Sensorineural degeneration was present in the basal end of the right cochlea but was not severe enough to explain the deafness. The compression of the cochlear nerve by the tumor was postulated to have caused deafness by injury to neurons adjacent and central to the tumor. There was profound degeneration of the vestibular nerve and sensory cells. A gelatinous material occluded the scala vestibuli, and the vestibular fluid spaces contained an amorphous proteinaceous substance. Fewer erythrocytes were seen in the vessels of the right cochlea, but there was no atrophy of capillaries to indicate long-term reduction of circulation. Vasculoneogenesis of venous vessels had occurred in the scala tympani, probably as a result of venous stasis.

Adenomatous lesions of the temporal bone are seldom encountered in clinical practice. Four cases of primary adenocarcinoma of the middle ear are reported. All four patients presented with a mass behind an intact tympanic membrane. Two of the four patients had received radiation to the head and neck area 10 or more years prior to their developing adenocarcinoma of the middle ear space. Although this tumor is locally invasive, it does not appear to be highly aggressive and can be treated by local excision, i.e., mastoidectomy with tympanoplasty.