EPITOMES-OTOLARYNGOLOGY/HEAD AND NECK SURGERY
716
Because the technique is reversible and does not affect the recurrent laryngeal nerve's ability to regenerate, it is feasible to do it immediately after recurrent laryngeal nerve injury, offering yet another option to those patients in whom vocal cord function may return. Anastomosing the ansa hypoglossi (cervicalis) nerve to the recurrent laryngeal nerve offers a third alternative in the rehabilitation of unilateral paralysis. This procedure, although not capable of restoring cyclical vocal cord adduction and abduction, appears to restore vocal cord tone, hence improving the voice in a more physiologic manner than polytef injection or thyroplasty. Most otolaryngologists administer polytef, and some have learned the thyroplasty technique. Nerve transfer has been used in only a few centers in the United States. Until further data regarding thyroplasty and nerve transfer are available, the final decision regarding which procedure is used must be based on a laryngologist's experience. ROGER CRUMLEY, MD Irvine, California
REFERENCES Crumley RL: Teflon versus thyroplasty versus nerve transfer: A comparison. Ann Otol Rhinol Laryngol 1990; 99(Pt 1):759-763 Gardner GM, Parnes SM: Status of the mucosal wave post vocal cord injection versus thyroplasty. J Voice 1991; 5:64-73 Isshiki N, Taira T, Kojima H, Shoji K: Recent modifications in thyroplasty type I. Ann Otol Rhinol Laryngol 1989; 98:777-779 Watterson T, McFarlane SC, Menicucci AL: Vibratory characteristics of Tefloninjected and non-injected paralyzed vocal folds. J Speech Hear Disord 1990; 55:61-66
Phonatory Diagnosis and Phonosurgery PHONATORY DIAGNOSIS involves the anatomic, vocal, and physiologic examination of the larynx. In any patient with vocal dysfunction, an anatomic evaluation is essential to rule out a potentially treatable malignant, inflammatory, or neurologic disorder. Since the time of Bozzini (1806) and Garcia (1854), the larynx has been visually examined by indirect mirror laryngoscopy. Rigid telescopes now provide the clearest, best illuminated views in awake patients. Flexible nasal fiberoptic laryngoscopy also provides excellent views even in uncooperative patients or those with difficult anatomy; gagging is virtually eliminated. Flexible or rigid endoscopic images may be recorded on video equipment for restudy and for patient education. Stroboscopic illumination calibrated nearly, but not exactly, to the fundamental frequencies produced by a patient's larynx gives a slow-motion view of the cycle of the vibrating vocal cords. This and ultrahigh-speed photography have delineated a vertically oriented mucosal wave that can be disrupted by the smallest mucosal alteration. A "clean" mucosal wave is required for optimal voice production. A vocal examination of the larynx includes precise acoustic measures, such as airflow duration, frequency, range, intensity, and voice stability. The most important aspect of the vocal assessment remains subjective and is simply the "ear" of the voice professional and of the patient. Physiologic tests of laryngeal function are less commonly used. Electromyography is useful for determining denervation versus reinnervation or fixation. The procedure may also be useful in the early diagnosis of degenerative neurologic disorders. In electroglottography, a potential difference occurs across the anterior neck. Current flows when the vocal cords are in contact, which provides an electrical correlate of vocal cord approximation. The vocal cords are supported by
relatively immobile cartilaginous framework; contraction is largely isometric and leads to tension. Because vocal-fold intramuscular pressure correlates with tension, monitoring the intramuscular pressure may provide diagnostic information in a variety of neuromuscular disorders. Once the cause of the phonatory disorder is identified, proper treatment can be instituted. Malignant neoplasms and inflammatory disorders are treated as necessary. A laryngeal procedure may be done solely to change the voice. Administering polytef (Teflon) is the time-honored technique for moving the vocal cord medially, and it may be done under local or general anesthesia. It is not reversible and does not address vocal cord tension problems. When done skillfully, results may be superb, but some patients do not tolerate polytef well; granuloma formation and extrusion may occur. The laryngeal framework operation allows surgeons to alter the position and tension of the vocal cord without touching the cord itself. The vocal cord may be moved medially or laterally; it may be tensed, relaxed, or a combination thereof. By altering only the laryngeal framework, the mucosal wave is not disrupted. These procedures are done with the patient awake and vocalizing. This allows a fine tuning of the voice with simultaneous viewing of the glottis on a videoscreen. These procedures are adjustable and reversible. Reinnervating a paralyzed larynx is also occasionally an option. A traumatized nerve can be reapproximated with variable results. For recurrent laryngeal nerve paralysis, a nerve muscle pedicle transfer from the ansa cervicalis nerve can be used to help maintain vocal cord tone, position, and possibly appropriate motion with respiration. In summary, with current diagnostic techniques, the specific deficit causing vocal dysfunction may be identified. Using the proper technique, the deficit often may be reversed and the voice improved. a
ERIC F. PINCZOWER, MD Angeles, California
Los
REFERENCES
Cooper DS, Pinczower EF, Rice DH: Laryngeal intramuscular pressures. J Acoust Soc Am 1990; 88(SupplI):S151 Cummings CW (Ed): Otolaryngology: Head and Neck Surgery: Update II. St Louis, Mo, Mosby Year Book, 1990, pp 3-9, 76-85 Fried MP: The Larynx: A Multidisciplinary Approach. Boston, Mass, Little, Brown, 1988, pp 3-12, 113-119 Isshiki N, Morita H, Okamura H, Hiramoto M: Thyroplasty as a new phonosurgical technique. Acta Otolaryngol 1974; 78:451-457
Skull Base Surgery UNTIL RECENTLY, extensive tumors originating in the nose and paranasal sinuses, the orbit, the nasopharynx, and in the parapharyngeal space that extends to the bones of the undersurface of the anterior and middle cranial fossa were considered by head and neck surgeons to be inoperable and usually incurable. Tumors from the clivus, the meninges, and the skull base skeleton that extended into the deep recesses of the face were similarly considered to be unresectable by neurosurgeons. The combination of a head and neck surgeon, neurosurgeon, and, when needed for reconstruction, a plastic surgeon is now able to eradicate these tumors completely and to rehabilitate many of these patients. The team approach is paramount for a successful result. Nonsurgical disciplines such as neuroradiology and angiography in the preoperative evaluation; pathology and anesthesia intraoperatively; and radiotherapy, nursing, and prosthodontics postoperatively are integral for the overall successful care of these patients -
THE WESTERN JOURNAL OF MEDICINE
THE
WESTERN
JOURNAL
OF
MEDICINE
9 *
JUNE 1991
JUNE
1991
9 *
154
154
* *
6
Previously established barriers to complete resection, such as anterior cranial floor invasion, extension to the orbital apex, sphenoid sinus involvement, cavernous sinus and internal carotid artery involvement, and intracranial extension, can all be handled in carefully selected patients. For lesions involving the anterior cranial fossa, a transfacial incision with an approach through the maxillary and ethmoid sinuses is combined with a low anterior craniotomy. Total tumor excision can be accomplished even when dura and brain are involved. On occasion, an approach to the middle fossa through a subcranial route can achieve exposure of the cavernous sinus, eustachian tube, and internal carotid artery.
Middle fossa involvement is more difficult to manage and usually requires an infratemporal fossa and middle cranial fossa combined approach. Temporal lobe involvement and invasion of Meckel's cave, the cavernous sinus, and the petrous and cavernous carotid artery can all be safely managed through this approach. The postoperative course may be stormy, and the availability of a dedicated or a neurosurgical intensive care unit with specially trained nurses is invaluable. Three- to five-year tumor-free survival figures are being compiled by many centers doing skull base surgical procedures. Results are encouraging, especially in light of the hopeless prognosis otherwise facing these patients. PAUL DONALD. MD Sacramento, California
REFERENCES
Al-Mefty 0: Surgery of the Cranial Base. Boston, Mass, Kluwer, 1987 Donald P: Cranial facial surgery for head and neck cancer, chap 18, In Johnson JT (Ed): American Academy of Otolaryngology: Head and Neck Surgery-Vol 2, Instruction Course. St Louis, Mo, Mosby, 1988 Sekhar L, Schramm VL: Tumors of the Cranial Base: Diagnosis and Treatment. Mt Kisco, NY, Futura, 1987
Functional Endoscopic Sinus Surgery in Children FUNCTIONAL ENDOSCOPIC SINUS SURGERY is an operative approach to the paranasal sinuses in which the objective is to reestablish adequate sinus ventilation and mucociliary clearance in patients with chronic sinus disease. Narrow mucosallined channels exist in the middle meatus where there is a high potential for mucosal layers to contact each other. The various ostia of the anterior ethmoid, frontal, and maxillary sinuses drain in proximity to this area. Because of mucosal hyperplasia and inflammation following an infection or allergy, these channels (and subsequently the ostia) may be blocked with resultant sinus obstruction. The effect on the sinuses may be either reversible (acute sinusitis) or irreversible (chronic sinusitis), depending on the source and time course of the original insult to the middle meatus-anterior ethmoid complex. This middle meatus-anterior ethmoid complex has been called the ostiomeatal unit or complex. In the United States, endoscopic sinus surgical techniques have replaced open techniques in many instances. Many children treated with endoscopic sinus operations have considerable atopy, allergy, asthma, and primary and secondary immunodeficiencies. Other clinical groups include children with cystic fibrosis and immotile cilia or Kartagener's syndrome. Children with chronic sinus disease,
as
717
717
6
confirmed by the
history, physical examination, and repeated plain sinus films, may be treated with an endoscopic sinus operation. An ade-
quate allergic and immunologic workup should be done before referral to an otolaryngologist-head and neck surgeon. It should be emphasized that an adequate trial of medical therapy is always completed before any consideration of operative intervention. The initial diagnostic evaluation always includes nasal endoscopy under topical anesthesia. This may be difficult, if not impossible, depending on the age and cooperation of the child. The middle meatus is carefully examined for evidence of chronic infection. Depending on the history and extent of the disease, medical therapy is often continued or altered and the patient reevaluated at a later date. Children who continue to have persistent disease after adequate medical therapy undergo direct coronal computed tomographic evaluation of the ostiomeatal complex and paranasal sinuses. If the computed tomographic scan shows mucosal disease involving the ostiomeatal complex and ethmoid and maxillary sinuses, an endoscopic sinus operation may be considered. In children, the procedure requires a general anesthetic and is done on an outpatient basis under endoscopic visualization. The key to the operation is opening the ostiomeatal complex, but it may include a complete ethmoidectomy ifthe disease is extensive. Middle meatal antrostomies are created to open the natural ostia of the maxillary sinuses. Our experience thus far has been with 38 children who have undergone an endoscopic sinus operation. Of this number, most have been children with chronic sinus disease who are otherwise normal. As of this writing, an overall success rate of about 85% has been obtained in this group in terms of resolving symptoms of chronic sinus disease. Children with chronic sinus disease and concomitant hematologic disorders who are also receiving chemotherapeutic agents have responded similarly. Children who are atopic, with significant allergy and asthma, have responded well initially, including notable abatement of their asthma. Approximately half have had a relapse oftheir sinus and pulmonary symptoms six months to a year following the first procedure. Further follow-up and experience are necessary. DENNIS M. CROCKETT, MD Los Angeles, California
REFERENCES Gross CW, Gurucharri MJ, Lazar RH, Tong TE: Functional endonasal sinus surgery in the pediatric age group. Laryngoscope 1989; 99:272-275 Kennedy DW, Zinreich SJ: The functional approach to inflammatory sinus disease: Current perspectives and technique modifications. Am J Rhinol 1988; 2:89-96 Kennedy DW, Zinreich SJ, Rosenbaum AE, Johns ME: Functional endoscopic sinus surgery: Theory and diagnostic evaluation. Arch Otolaryngol 1985; 1 1 1:576-582 Messerklinger W: Endoscopy of the Nose. Munich, Gennany, Urban and Schwartzberg, 1978
Cochlear Implants in Children THE COCHLEAR IMPLANT is a medical device, part of which is placed surgically, that uses electrical stimulation to provide hearing. In recent years, the device has become an accepted method for providing auditory stimulation to the profoundly deaf. Two devices, the 3M/House single-channel cochlear implant and the Nucleus multichannel cochlear implant, have been formally approved by the United States Food and Drug Administration (FDA) for commercial marketing to deaf adults. More than 600 children ages 2 through 17 years have been implanted with either a single- or a multielectrode device. In September 1988, the FDXs Ear, Nose, and Throat Advisory Panel voted to recommend marketing approval of
716
Because the technique is reversible and does not affect the recurrent laryngeal nerve's ability to regenerate, it is feasible to do it immediately after recurrent laryngeal nerve injury, offering yet another option to those patients in whom vocal cord function may return. Anastomosing the ansa hypoglossi (cervicalis) nerve to the recurrent laryngeal nerve offers a third alternative in the rehabilitation of unilateral paralysis. This procedure, although not capable of restoring cyclical vocal cord adduction and abduction, appears to restore vocal cord tone, hence improving the voice in a more physiologic manner than polytef injection or thyroplasty. Most otolaryngologists administer polytef, and some have learned the thyroplasty technique. Nerve transfer has been used in only a few centers in the United States. Until further data regarding thyroplasty and nerve transfer are available, the final decision regarding which procedure is used must be based on a laryngologist's experience. ROGER CRUMLEY, MD Irvine, California
REFERENCES Crumley RL: Teflon versus thyroplasty versus nerve transfer: A comparison. Ann Otol Rhinol Laryngol 1990; 99(Pt 1):759-763 Gardner GM, Parnes SM: Status of the mucosal wave post vocal cord injection versus thyroplasty. J Voice 1991; 5:64-73 Isshiki N, Taira T, Kojima H, Shoji K: Recent modifications in thyroplasty type I. Ann Otol Rhinol Laryngol 1989; 98:777-779 Watterson T, McFarlane SC, Menicucci AL: Vibratory characteristics of Tefloninjected and non-injected paralyzed vocal folds. J Speech Hear Disord 1990; 55:61-66
Phonatory Diagnosis and Phonosurgery PHONATORY DIAGNOSIS involves the anatomic, vocal, and physiologic examination of the larynx. In any patient with vocal dysfunction, an anatomic evaluation is essential to rule out a potentially treatable malignant, inflammatory, or neurologic disorder. Since the time of Bozzini (1806) and Garcia (1854), the larynx has been visually examined by indirect mirror laryngoscopy. Rigid telescopes now provide the clearest, best illuminated views in awake patients. Flexible nasal fiberoptic laryngoscopy also provides excellent views even in uncooperative patients or those with difficult anatomy; gagging is virtually eliminated. Flexible or rigid endoscopic images may be recorded on video equipment for restudy and for patient education. Stroboscopic illumination calibrated nearly, but not exactly, to the fundamental frequencies produced by a patient's larynx gives a slow-motion view of the cycle of the vibrating vocal cords. This and ultrahigh-speed photography have delineated a vertically oriented mucosal wave that can be disrupted by the smallest mucosal alteration. A "clean" mucosal wave is required for optimal voice production. A vocal examination of the larynx includes precise acoustic measures, such as airflow duration, frequency, range, intensity, and voice stability. The most important aspect of the vocal assessment remains subjective and is simply the "ear" of the voice professional and of the patient. Physiologic tests of laryngeal function are less commonly used. Electromyography is useful for determining denervation versus reinnervation or fixation. The procedure may also be useful in the early diagnosis of degenerative neurologic disorders. In electroglottography, a potential difference occurs across the anterior neck. Current flows when the vocal cords are in contact, which provides an electrical correlate of vocal cord approximation. The vocal cords are supported by
relatively immobile cartilaginous framework; contraction is largely isometric and leads to tension. Because vocal-fold intramuscular pressure correlates with tension, monitoring the intramuscular pressure may provide diagnostic information in a variety of neuromuscular disorders. Once the cause of the phonatory disorder is identified, proper treatment can be instituted. Malignant neoplasms and inflammatory disorders are treated as necessary. A laryngeal procedure may be done solely to change the voice. Administering polytef (Teflon) is the time-honored technique for moving the vocal cord medially, and it may be done under local or general anesthesia. It is not reversible and does not address vocal cord tension problems. When done skillfully, results may be superb, but some patients do not tolerate polytef well; granuloma formation and extrusion may occur. The laryngeal framework operation allows surgeons to alter the position and tension of the vocal cord without touching the cord itself. The vocal cord may be moved medially or laterally; it may be tensed, relaxed, or a combination thereof. By altering only the laryngeal framework, the mucosal wave is not disrupted. These procedures are done with the patient awake and vocalizing. This allows a fine tuning of the voice with simultaneous viewing of the glottis on a videoscreen. These procedures are adjustable and reversible. Reinnervating a paralyzed larynx is also occasionally an option. A traumatized nerve can be reapproximated with variable results. For recurrent laryngeal nerve paralysis, a nerve muscle pedicle transfer from the ansa cervicalis nerve can be used to help maintain vocal cord tone, position, and possibly appropriate motion with respiration. In summary, with current diagnostic techniques, the specific deficit causing vocal dysfunction may be identified. Using the proper technique, the deficit often may be reversed and the voice improved. a
ERIC F. PINCZOWER, MD Angeles, California
Los
REFERENCES
Cooper DS, Pinczower EF, Rice DH: Laryngeal intramuscular pressures. J Acoust Soc Am 1990; 88(SupplI):S151 Cummings CW (Ed): Otolaryngology: Head and Neck Surgery: Update II. St Louis, Mo, Mosby Year Book, 1990, pp 3-9, 76-85 Fried MP: The Larynx: A Multidisciplinary Approach. Boston, Mass, Little, Brown, 1988, pp 3-12, 113-119 Isshiki N, Morita H, Okamura H, Hiramoto M: Thyroplasty as a new phonosurgical technique. Acta Otolaryngol 1974; 78:451-457
Skull Base Surgery UNTIL RECENTLY, extensive tumors originating in the nose and paranasal sinuses, the orbit, the nasopharynx, and in the parapharyngeal space that extends to the bones of the undersurface of the anterior and middle cranial fossa were considered by head and neck surgeons to be inoperable and usually incurable. Tumors from the clivus, the meninges, and the skull base skeleton that extended into the deep recesses of the face were similarly considered to be unresectable by neurosurgeons. The combination of a head and neck surgeon, neurosurgeon, and, when needed for reconstruction, a plastic surgeon is now able to eradicate these tumors completely and to rehabilitate many of these patients. The team approach is paramount for a successful result. Nonsurgical disciplines such as neuroradiology and angiography in the preoperative evaluation; pathology and anesthesia intraoperatively; and radiotherapy, nursing, and prosthodontics postoperatively are integral for the overall successful care of these patients -
THE WESTERN JOURNAL OF MEDICINE
THE
WESTERN
JOURNAL
OF
MEDICINE
9 *
JUNE 1991
JUNE
1991
9 *
154
154
* *
6
Previously established barriers to complete resection, such as anterior cranial floor invasion, extension to the orbital apex, sphenoid sinus involvement, cavernous sinus and internal carotid artery involvement, and intracranial extension, can all be handled in carefully selected patients. For lesions involving the anterior cranial fossa, a transfacial incision with an approach through the maxillary and ethmoid sinuses is combined with a low anterior craniotomy. Total tumor excision can be accomplished even when dura and brain are involved. On occasion, an approach to the middle fossa through a subcranial route can achieve exposure of the cavernous sinus, eustachian tube, and internal carotid artery.
Middle fossa involvement is more difficult to manage and usually requires an infratemporal fossa and middle cranial fossa combined approach. Temporal lobe involvement and invasion of Meckel's cave, the cavernous sinus, and the petrous and cavernous carotid artery can all be safely managed through this approach. The postoperative course may be stormy, and the availability of a dedicated or a neurosurgical intensive care unit with specially trained nurses is invaluable. Three- to five-year tumor-free survival figures are being compiled by many centers doing skull base surgical procedures. Results are encouraging, especially in light of the hopeless prognosis otherwise facing these patients. PAUL DONALD. MD Sacramento, California
REFERENCES
Al-Mefty 0: Surgery of the Cranial Base. Boston, Mass, Kluwer, 1987 Donald P: Cranial facial surgery for head and neck cancer, chap 18, In Johnson JT (Ed): American Academy of Otolaryngology: Head and Neck Surgery-Vol 2, Instruction Course. St Louis, Mo, Mosby, 1988 Sekhar L, Schramm VL: Tumors of the Cranial Base: Diagnosis and Treatment. Mt Kisco, NY, Futura, 1987
Functional Endoscopic Sinus Surgery in Children FUNCTIONAL ENDOSCOPIC SINUS SURGERY is an operative approach to the paranasal sinuses in which the objective is to reestablish adequate sinus ventilation and mucociliary clearance in patients with chronic sinus disease. Narrow mucosallined channels exist in the middle meatus where there is a high potential for mucosal layers to contact each other. The various ostia of the anterior ethmoid, frontal, and maxillary sinuses drain in proximity to this area. Because of mucosal hyperplasia and inflammation following an infection or allergy, these channels (and subsequently the ostia) may be blocked with resultant sinus obstruction. The effect on the sinuses may be either reversible (acute sinusitis) or irreversible (chronic sinusitis), depending on the source and time course of the original insult to the middle meatus-anterior ethmoid complex. This middle meatus-anterior ethmoid complex has been called the ostiomeatal unit or complex. In the United States, endoscopic sinus surgical techniques have replaced open techniques in many instances. Many children treated with endoscopic sinus operations have considerable atopy, allergy, asthma, and primary and secondary immunodeficiencies. Other clinical groups include children with cystic fibrosis and immotile cilia or Kartagener's syndrome. Children with chronic sinus disease,
as
717
717
6
confirmed by the
history, physical examination, and repeated plain sinus films, may be treated with an endoscopic sinus operation. An ade-
quate allergic and immunologic workup should be done before referral to an otolaryngologist-head and neck surgeon. It should be emphasized that an adequate trial of medical therapy is always completed before any consideration of operative intervention. The initial diagnostic evaluation always includes nasal endoscopy under topical anesthesia. This may be difficult, if not impossible, depending on the age and cooperation of the child. The middle meatus is carefully examined for evidence of chronic infection. Depending on the history and extent of the disease, medical therapy is often continued or altered and the patient reevaluated at a later date. Children who continue to have persistent disease after adequate medical therapy undergo direct coronal computed tomographic evaluation of the ostiomeatal complex and paranasal sinuses. If the computed tomographic scan shows mucosal disease involving the ostiomeatal complex and ethmoid and maxillary sinuses, an endoscopic sinus operation may be considered. In children, the procedure requires a general anesthetic and is done on an outpatient basis under endoscopic visualization. The key to the operation is opening the ostiomeatal complex, but it may include a complete ethmoidectomy ifthe disease is extensive. Middle meatal antrostomies are created to open the natural ostia of the maxillary sinuses. Our experience thus far has been with 38 children who have undergone an endoscopic sinus operation. Of this number, most have been children with chronic sinus disease who are otherwise normal. As of this writing, an overall success rate of about 85% has been obtained in this group in terms of resolving symptoms of chronic sinus disease. Children with chronic sinus disease and concomitant hematologic disorders who are also receiving chemotherapeutic agents have responded similarly. Children who are atopic, with significant allergy and asthma, have responded well initially, including notable abatement of their asthma. Approximately half have had a relapse oftheir sinus and pulmonary symptoms six months to a year following the first procedure. Further follow-up and experience are necessary. DENNIS M. CROCKETT, MD Los Angeles, California
REFERENCES Gross CW, Gurucharri MJ, Lazar RH, Tong TE: Functional endonasal sinus surgery in the pediatric age group. Laryngoscope 1989; 99:272-275 Kennedy DW, Zinreich SJ: The functional approach to inflammatory sinus disease: Current perspectives and technique modifications. Am J Rhinol 1988; 2:89-96 Kennedy DW, Zinreich SJ, Rosenbaum AE, Johns ME: Functional endoscopic sinus surgery: Theory and diagnostic evaluation. Arch Otolaryngol 1985; 1 1 1:576-582 Messerklinger W: Endoscopy of the Nose. Munich, Gennany, Urban and Schwartzberg, 1978
Cochlear Implants in Children THE COCHLEAR IMPLANT is a medical device, part of which is placed surgically, that uses electrical stimulation to provide hearing. In recent years, the device has become an accepted method for providing auditory stimulation to the profoundly deaf. Two devices, the 3M/House single-channel cochlear implant and the Nucleus multichannel cochlear implant, have been formally approved by the United States Food and Drug Administration (FDA) for commercial marketing to deaf adults. More than 600 children ages 2 through 17 years have been implanted with either a single- or a multielectrode device. In September 1988, the FDXs Ear, Nose, and Throat Advisory Panel voted to recommend marketing approval of
