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
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
