715
Epitomes Important Advances in Clinical Medicine
Otolaryngology/Head and Neck Surgery The Scientific Board of the California Medical Association presents the following inventory of items of progress in otolaryngology/head and neck surgery. Each item, in the judgment ofa panel ofknowledgeable physicians, has recently become reasonablyfirmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itselfand to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, or scholars to stay abreast of these items ofprogress in otolaryngology/head and neck surgery that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another. The items of progress listed below were selected by the Advisory Panel to the Section on Otolaryngology/Head and Neck Surgery of the California Medical Association, and the summaries were prepared under its direction. Reprint requests to Division of Scientific and Educational Activities, California Medical Association, PO Box 7690, San Francisco, CA 94120-7690
Intranasal Ethmoid Sinus Surgery, 1980 to 1990 IN 1985 ENDOSCOPIC INTRANASAL ethmoid sinus surgery, a more precisely done ethmoidectomy targeting earlier paranasal sinus disease and leaving a more normal-looking nose, was introduced into the United States. The procedure usually includes a middle meatal widening or opening rather than the classic nasal antral or inferior meatal window. Improved teaching methods using video equipment and observer scopes have enabled an increasing number of physicians to treat the ethmoid sinuses without the trepidation that existed previously. An increased awareness of the anatomy of the ethmoid sinus relative to the other paranasal sinuses and the use of computed tomography have helped in this breakthrough. The potential for injury due to the ethmoid sinus's proximity to the eye and anterior cranial cavity persists, however. With experience with endoscopic surgical procedures, it has become increasingly clear that limitations still exist regardless of how the procedure is done, whether with a headlight, endoscope, or an operating microscope. Important advances have also been made by nonendoscopic sinus surgeons in treating lower respiratory tract disease, in particular the triad of aspirin, nasal polyposis, and asthma. A more aggressive or thorough or even destructive type of procedure has been advocated in dealing with such disorders. In 1980, 50 patients underwent extensive sphenoidethmoidectomy and nasal antral windows. Of 28 cortisone-dependent asthma patients, 26 had a sustained reduction or elimination of corticosteroid use, with half being steroid-free for a period ranging from six months to four years.
Improved results were obtained when a more radical sphenoidethmoidectomy procedure was used in combination with nasal polypectomies and nasal antral windows. When a less destructive, anatomically conservative procedure was adhered to, no more than a 25% resolution in lower respiratory tract problems occurred. In a more recent study, a better than 75% improvement occurred in asthmatic patients, especially cortisone-dependent ones, when a more aggressive procedure was used. In a controlled study involving 25 patients with the aspirin, nasal polyposis, and asthma triad, 9 patients undergoing
aggressive pansinus surgical treatment, including nasal polypectomies, sphenoidethmoidectomies, and Caldwell-Lucs, all showed a marked resolution of the underlying disease. In 16 patients who underwent limited or less aggressive procedures, including intranasal ethmoidectomy and polypectomy, 6 required surgical revision for disease control. BERKELEY S. EICHEL, MD Torrance, Californiia REFERENCES
Eichel BS: Revision sphenoidethmoidectomy. Laryngoscope 1985; 95:300-304 Freidman WH, Katsantonis GP, Slavin RG, Kannel P, Linford P: Sphenoidethmoidectomy: Its role in the asthmatic patient. Otolaryngol Head Neck Surg 1982; 90:171-177 Kennedy DW, Zinreich JS, Rosenbaum AE. Johns ME: Theory and diagnostic evaluation. Arch Otolaryngol 1985; 1 1 1:576-582 McFadden EA, Kany RJ, Fink JN. Toohill RJ: Surgery for sinusitus and aspirin triad. Laryngoscope 1990; 100: 1043-1046
Treatment of Vocal Cord Paralysis UNILATERAL VOCAL CORD PARALYSIS is most commonly treated by the administration of polytef (Teflon) paste through direct or indirect laryngoscopy. The technique has been used for more than 40 years. It is relatively quick and inexpensive, although the vocal results achieved by the procedure have recently been questioned. Temporary injections of absorbable gelatin sponge (Gelfoam) paste and Zyplast collagen, lasting four to six weeks and three to six months, respectively, may be done in patients with acute paralysis who may recover. These techniques provide voice restoration during the recurrent laryngeal nerve's recovery period. In those patients in whom recovery does not occur, other more permanent techniques may be used. In 1974 a different approach was introduced in which a small window is cut in the thyroid cartilage and the vocal cord moved medially by placing a polymeric silicone or other alloplastic "shim" or spacer. This approach eliminates the need for an injectable permanent material. Proponents of this technique cite its reversibility and, because patients are able to phonate during the procedure, the ability to "tune" the voice intraoperatively by adjusting the implant's placement. The vocal results achieved by experienced surgeons are reported to be comparable to those with polytef injection. Voice and speech scientists cite a better mucosal wave on videostroboscopy than that achieved with polytef injection.
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 -
Epitomes Important Advances in Clinical Medicine
Otolaryngology/Head and Neck Surgery The Scientific Board of the California Medical Association presents the following inventory of items of progress in otolaryngology/head and neck surgery. Each item, in the judgment ofa panel ofknowledgeable physicians, has recently become reasonablyfirmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itselfand to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, or scholars to stay abreast of these items ofprogress in otolaryngology/head and neck surgery that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another. The items of progress listed below were selected by the Advisory Panel to the Section on Otolaryngology/Head and Neck Surgery of the California Medical Association, and the summaries were prepared under its direction. Reprint requests to Division of Scientific and Educational Activities, California Medical Association, PO Box 7690, San Francisco, CA 94120-7690
Intranasal Ethmoid Sinus Surgery, 1980 to 1990 IN 1985 ENDOSCOPIC INTRANASAL ethmoid sinus surgery, a more precisely done ethmoidectomy targeting earlier paranasal sinus disease and leaving a more normal-looking nose, was introduced into the United States. The procedure usually includes a middle meatal widening or opening rather than the classic nasal antral or inferior meatal window. Improved teaching methods using video equipment and observer scopes have enabled an increasing number of physicians to treat the ethmoid sinuses without the trepidation that existed previously. An increased awareness of the anatomy of the ethmoid sinus relative to the other paranasal sinuses and the use of computed tomography have helped in this breakthrough. The potential for injury due to the ethmoid sinus's proximity to the eye and anterior cranial cavity persists, however. With experience with endoscopic surgical procedures, it has become increasingly clear that limitations still exist regardless of how the procedure is done, whether with a headlight, endoscope, or an operating microscope. Important advances have also been made by nonendoscopic sinus surgeons in treating lower respiratory tract disease, in particular the triad of aspirin, nasal polyposis, and asthma. A more aggressive or thorough or even destructive type of procedure has been advocated in dealing with such disorders. In 1980, 50 patients underwent extensive sphenoidethmoidectomy and nasal antral windows. Of 28 cortisone-dependent asthma patients, 26 had a sustained reduction or elimination of corticosteroid use, with half being steroid-free for a period ranging from six months to four years.
Improved results were obtained when a more radical sphenoidethmoidectomy procedure was used in combination with nasal polypectomies and nasal antral windows. When a less destructive, anatomically conservative procedure was adhered to, no more than a 25% resolution in lower respiratory tract problems occurred. In a more recent study, a better than 75% improvement occurred in asthmatic patients, especially cortisone-dependent ones, when a more aggressive procedure was used. In a controlled study involving 25 patients with the aspirin, nasal polyposis, and asthma triad, 9 patients undergoing
aggressive pansinus surgical treatment, including nasal polypectomies, sphenoidethmoidectomies, and Caldwell-Lucs, all showed a marked resolution of the underlying disease. In 16 patients who underwent limited or less aggressive procedures, including intranasal ethmoidectomy and polypectomy, 6 required surgical revision for disease control. BERKELEY S. EICHEL, MD Torrance, Californiia REFERENCES
Eichel BS: Revision sphenoidethmoidectomy. Laryngoscope 1985; 95:300-304 Freidman WH, Katsantonis GP, Slavin RG, Kannel P, Linford P: Sphenoidethmoidectomy: Its role in the asthmatic patient. Otolaryngol Head Neck Surg 1982; 90:171-177 Kennedy DW, Zinreich JS, Rosenbaum AE. Johns ME: Theory and diagnostic evaluation. Arch Otolaryngol 1985; 1 1 1:576-582 McFadden EA, Kany RJ, Fink JN. Toohill RJ: Surgery for sinusitus and aspirin triad. Laryngoscope 1990; 100: 1043-1046
Treatment of Vocal Cord Paralysis UNILATERAL VOCAL CORD PARALYSIS is most commonly treated by the administration of polytef (Teflon) paste through direct or indirect laryngoscopy. The technique has been used for more than 40 years. It is relatively quick and inexpensive, although the vocal results achieved by the procedure have recently been questioned. Temporary injections of absorbable gelatin sponge (Gelfoam) paste and Zyplast collagen, lasting four to six weeks and three to six months, respectively, may be done in patients with acute paralysis who may recover. These techniques provide voice restoration during the recurrent laryngeal nerve's recovery period. In those patients in whom recovery does not occur, other more permanent techniques may be used. In 1974 a different approach was introduced in which a small window is cut in the thyroid cartilage and the vocal cord moved medially by placing a polymeric silicone or other alloplastic "shim" or spacer. This approach eliminates the need for an injectable permanent material. Proponents of this technique cite its reversibility and, because patients are able to phonate during the procedure, the ability to "tune" the voice intraoperatively by adjusting the implant's placement. The vocal results achieved by experienced surgeons are reported to be comparable to those with polytef injection. Voice and speech scientists cite a better mucosal wave on videostroboscopy than that achieved with polytef injection.
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 -
