Beruflich Dokumente
Kultur Dokumente
Otolaryngology—Head
and Neck Surgery®
VOLUME 12
ADVANCES IN
Otolaryngology—Head
and Neck Surgery®
VOLUME 12
Editor-in-Chief
Eugene N. Myers, M.D.
Professor and Chairman, Department of Otolaryngology, University of
Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Associate Editor
Charles D. Bluestone, M.D.
Eberly Professor of Pediatric Otolaryngology, University of Pittsburgh
School of Medicine; Director, Department of Pediatric Otolaryngology,
Children's Hospital of Pittsburgh. Pittsburgh, Pennsylvania
Editorial Board
Derald E. Brackmann, M.D.
Clinical Professor of Otolaryngology and Neurosurgery, University of
Southern California School of Medicine; President, House Ear Clinic;
Board of Directors, House Ear Institute, Los Angeles, California
M Mosby
St. Louis Baltimore Boston Carlsbad Naples New York Philadelphia Portland
WW A Times Mirror
U Company
Mosby, Inc.
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St. Louis, Missouri 6 3 1 4 6
International Standard Serial Number: 0 8 8 7 - 6 9 1 6
International Standard Book Number: 0 - 8 1 5 1 - 9 8 2 1 - 3
Preface
xi
xii Preface
Contributors vii
Preface xi
xiii
xiv Contents
Interferon 107
lndol-3-Carbinol 109
Acyclovir 1 10
Isotretinoin 1 11
Methotrexate 1 11
Ribavirin 112
Disease Complications 112
Treatment Complications 113
Summary 1 14
S u p r a c r i c o i d p a r t i a l l a r y n g e c t o m i e s (SCPL) are f u n c t i o n a l p r o -
cedures suitable for the treatment of m o d e r a t e l y advanced la-
ryngeal cancers. T h e y p r o v i d e a surgical alternative to the c o n v e n -
tional partial laryngectomies (either horizontal or vertical) a n d the
classic total l a r y n g e c t o m y . A c t u a l l y , there w a s a gap for some bor-
d e r l i n e cases ( f o r e x a m p l e , a t u m o r o f t h e i n f r a h y o i d e p i g l o t t i s
reaching or slightly involving, d o w n w a r d , the anterior commis-
sure; or a t u m o r of an entire v o c a l c o r d o v e r l a p p i n g the anterior
commissure and i n v o l v i n g the anterior part of the contralateral
c o r d ) . I n fact, t h e r e are t w o d i f f e r e n t t y p e s o f S C P L . U s u a l l y , S C P L
w i t h c r i c o h y o i d o e p i g l o t t o p e x y (CHEP) is indicated for the surgi-
cal treatment of glottic cancer, a n d SCPL w i t h c r i c o h y o i d o p e x y
(CHP) is i n d i c a t e d for supraglottic cancer or glottic cancer w i t h su-
praglottic extension. These t e c h n i q u e s p r o v i d e a large resection of
the laryngeal structures. T h e y do n o t n e e d any k i n d of flap for clo-
sure because the laryngeal r e c o n s t r u c t i o n is p e r f o r m e d w i t h the la-
r y n g e a l s t r u c t u r e s left i n p l a c e (Fig 1). I n b o t h p r o c e d u r e s , i t i s nec-
essary t o preserve a t least o n e a r y t e n o i d cartilage, t h e h y o i d b o n e ,
t h e c r i c o i d cartilage a n d , i n t h e case o f CHEP, t h e e p i g l o t t i s t o a l -
l o w speech, s w a l l o w i n g , and decannulation.
HISTORY
T h e p r i n c i p l e s of a s u p r a c r i c o i d l a r y n g e c t o m y w e r e first described
1
i n 1959 b y Majer a n d Rieder i n V i e n n a . Their f i r s t experience was
9
Advances in Otolaryngology-Head and Neck Surgery , vol. 12
«1998, Mosby, Inc.
J.-L. Lefebvre and D. Chevalier
FIGURE 1.
Sketches of supracricoid partial laryngectomies. Left, preoperative sketch;
upper right, cricohyoidopexy; lower right, cricohyoidoepiglottopexy.
a c h i e v e d i n a l l t h e cases, w h e r e a s t w o p a t i e n t s r e l a p s e d i n t h e
5
neck. In 1976, Piquet redefined b o t h the techniques a n d the i n d i -
cations o f S C P L w i t h C H P a n d C H E P i n a series o f 6 1 p a t i e n t s .
This surgery became very p o p u l a r in France and several reports
confirmed, in terms of oncologic a n d functional results, the reli-
6 - 1 3
ability of S C P L . T h i s surgery has been w r i t t e n about u n d e r v a r i -
ous names, i n c l u d i n g " s u b t o t a l l a r y n g e c t o m i e s , " " r e c o n s t r u c t i v e
laryngectomies," "supracricoid laryngectomies," or "cricos."
SURGICAL TECHNIQUES
S u p r a c r i c o i d l a r y n g e c t o m i e s w i t h C H P o r C H E P are b a s e d o n t h e
same p r i n c i p l e s , b u t t h e p r o c e d u r e s are q u i t e d i f f e r e n t (Fig 2 ) a n d
m u s t be described separately.
FIGURE 2.
Larynx resection in supracricoid partial laryngectomies. Left, cricohyoi-
doepiglottopexy. Right, cricohyoidopexy.
Supracricoid Partial Laryngectomy 5
FIGURE 3.
Surgical specimen of SCPL with CHP. Tumor of the infrahyoid epiglottis
involving the left ventricle and the anterior commissure mucosa with se-
vere dysplasia on the right true vocal cord.
FIGURE 4.
Surgical specimen of SCPL with CHEP. Tumor of the right true vocal cord
involving the anterior commissure (plus thyroid cartilage), the right ven-
tricle, and the right arytenoid (resected).
f.-L. Lefebvre and D. Chevalier
r e t r a c t e d laterally. T h e s t e r n o t h y r o i d m u s c l e s are t r a n s e c t e d
a n d the prelaryngeal fibrofatty tissue is dissected along w i t h
the Delphian l y m p h node. The larynx is rotated using a hook,
a n d t h e c o n s t r i c t o r m u s c l e s are t r a n s e c t e d a l o n g t h e p o s t e r i o r
border of the t h y r o i d cartilage l a m i n a b e g i n n i n g at the supe-
rior cornu. The external thyroid p e r i c h o n d r i u m is elevated, and
the p i r i f o r m sinus is released. The superior laryngeal neuro-
v a s c u l a r p e d i c l e i s i d e n t i f i e d . T h e artery a n d t h e v e i n are l i -
gated, sparing the superior laryngeal nerve. The procedure is
s i m i l a r on b o t h sides of the l a r y n x . T h e surgeon's a t t e n t i o n is
t h e n d i r e c t e d i n f e r i o r l y w h e r e the c r i c o t h y r o i d m u s c l e s are
carefully transected anteriorly to expose the cricothyroid m e m -
brane. T h e subglottic mucosa overlying the cricoid cartilage is
elevated on the side of the glottic t u m o r using a s m a l l elevator,
to achieve w i d e r resection on the tumor-bearing side. T h e
i n f e r i o r c o r n u is t r a n s e c t e d at its base on t h e side o p p o s i t e to
the t u m o r to avoid injuring the recurrent laryngeal nerve dur-
i n g the excision of the t h y r o i d cartilage. T h e inferior c o r n u on
the side of the t u m o r is disarticulated to a l l o w the paraglottic
space to be c o m p l e t e l y r e m o v e d . T h e n the i s t h m u s of the
t h y r o i d gland is transected and ligated. A l o w tracheotomy is
performed.
2. Excision. Once the exposure is completed, the larynx is
opened. The t h y r o h y o i d membrane is incised and the epiglot-
tis is t r a n s e c t e d at its base by a c l e a n c u t u s i n g a b l a d e at the
base of the petiole. T h i s step is i m p o r t a n t , because m a i n t a i n -
i n g the integrity of the epiglottis guarantees an o p e n i n g for the
reconstructed larynx. T h e larynx is opened f r o m above just su-
p e r i o r t o the false v o c a l cords, t h u s a l l o w i n g g o o d t u m o r e x p o -
sure. On the side opposite the tumor, a cut is m a d e anterior to
the arytenoid, thus preserving the vocal process, a n d is con-
t i n u e d i n f e r i o r l y t o the s u p e r i o r b o r d e r o f the c r i c o i d . T h e lat-
eral c r i c o a r y t e n o i d m u s c l e is spared on this side because it w i l l
assist t h e a n t e r i o r m o t i o n o f t h e r e m a i n i n g a r y t e n o i d . O n the
s i d e o f t h e t u m o r , t h e e x c i s i o n i s w i d e r ; cuts are m a d e o v e r t h e
arytenoid, conserving the posterior mucosa, then continued
vertically in the posterior subglottis through the interarytenoid
muscle. Anteriorly, this incision joins the incision in the cri-
cothyroid membrane by making a right-angle turn from medial
to lateral. T h e excision of the t u m o r w i t h the t h y r o i d cartilage
i s p e r f o r m e d a n d removes t h e entire paraglottic space w i t h the
specimen.
3. C l o s u r e . A f t e r c a r e f u l hemostasis, the p i r i f o r m sinuses are
checked. A probe is inserted in the ventricle to verify that it
Supracricoid Partial Laryngectomy 9
has been c o m p l e t e l y r e m o v e d , as a r e m a i n i n g p o r t i o n of v e n -
tricle m u c o s a s h o u l d d e v e l o p i n t o a cyst. If necessary, t h e re-
m a i n i n g arytenoid mucosa is s e w n over the d e n u d e d cricoid
c a r t i l a g e (3-0 V i c r y l ) o n t h e s i d e o f t h e a r y t e n o i d r e s e c t i o n s o
t h a t t h e b u l k o f t h e m u c o s a f o r m s a p s e u d o a r y t e n o i d . T h e lar-
y n x i s c l o s e d u s i n g t h r e e s t i t c h e s (2-0 V i c r y l ) , o n e m i d l i n e a n d
t w o lateral. These stitches e n c i r c l e t h e c r i c o i d , cross t h e e p i -
glottis a n d the base o f the t o n g u e , a n d t h e n encircle the h y o i d
b o n e . A f t e r t h e k n o t s are t i e d , t h e c r i c o i d c o m e s i n t o c o n t a c t
w i t h t h e b a s e o f t h e t o n g u e a n d t h e h y o i d b o n e . A s i s t h e case
after S C P L w i t h CHP, t h e t r a c h e o t o m y site s h o u l d c o m e t o rest
in the skin incision, and the anterior borders of the h y o i d bone
a n d cricoid cartilage m u s t be carefully aligned.
POSTOPERATIVE CARE
Intravenous antibiotic treatment is a d m i n i s t e r e d for 10 days. A na-
sogastric t u b e r e m a i n s i n place. T h e t r a c h e o t o m y tube i s p l u g g e d
as soon as can be tolerated by the patient, usually a r o u n d the eighth
day, a n d t h e n c a n be r e m o v e d . O r a l f e e d i n g begins as s o o n as t h e
p a t i e n t c a n s w a l l o w saliva, u s u a l l y a r o u n d t h e t e n t h day. D u r i n g
the p o s t o p e r a t i v e course, the p a t i e n t is asked to p h o n a t e early, a n d
the speech therapist m u s t be i n v o l v e d in the rehabilitation of the
patient. It is important to motivate the patient so that the postop-
erative course is quicker and smoother.
INDICATIONS
SCPL WITH CHP
Supraglottic carcinoma: SCPL w i t h CHP is indicated w h e n supra-
glottic c a r c i n o m a s are n o l o n g e r s u i t a b l e for h o r i z o n t a l s u p r a g l o t -
tic l a r y n g e c t o m y a n d w h e n a total l a r y n g e c t o m y seems too ex-
tensive.
J.-L. Lefebvre and D. Chevalier
T h e i n d i c a t i o n s are:
7
Those t w o particular indications were presented by Chevalier
and Laccourreye" and need a precise preoperative imaging
evaluation.
G l o t t i c c a r c i n o m a s : A n y case w i t h s u p r a g l o t t i c e x t e n s i o n .
W h a t e v e r t h e p r i m a r y site, c o n t r a i n d i c a t i o n s are:
C o n t r a i n d i c a t i o n s are:
• A r y t e n o i d cartilage fixation
• Anterior commissure t u m o r w i t h deep invasion
• Subglottic extension more than 7 mm anteriorly and 5 mm pos-
teriorly, as these t e n d to i n v o l v e the c r i c o i d cartilage
• Preoperative respiratory function i m p a i r m e n t
RESULTS
T h e m e d i c a l charts a n d operative files o f 318 patients w h o h a d u n -
dergone SCPL w i t h C H P o r C H E P b e t w e e n 1972 a n d 1995 w e r e ret-
r o s p e c t i v e l y r e v i e w e d . T h e p r i m a r y site w a s the glottis i n 238 a n d
the supraglottic larynx in 80 patients.
GLOTTIC CANCERS
P o p u l a t i o n : In t h i s series, 207 patients u n d e r w e n t a C H E P a n d 31
p a t i e n t s a C H P . T h e m e a n age w a s 5 6 y e a r s ( r a n g e : 37—77). T h e r e
w e r e 2 3 0 m a l e s a n d e i g h t f e m a l e s . D e t a i l s o n t u m o r e x t e n s i o n are
presented in Table 1.
Postoperative courses: O n e patient d i e d of a cervical hemor-
rhage d u r i n g the postoperative p e r i o d (CHEP). For the other
patients, the nasogastric tubes w e r e r e m o v e d , on average, on day
15 (range: 9-38) for the CHEPs a n d day 19 (range: 1 1 - 4 0 ) for the
CHPs. T h e t r a c h e o s t o m y tubes w e r e left in place, on average, 19
days (range: 8-38) for the CHEPs a n d 27 days (range: 2 0 - 9 0 ) for
the CHPs.
Disease c o n t r o l a n d s u r v i v a l : I n the C H E P g r o u p , local recur-
rences o c c u r r e d in 10 patients (4.8%). Surgical salvage w a s
attempted in seven patients a n d was successful in three. Cervical
recurrences occurred in 14 patients (6.7%) a n d were successfully
managed by neck dissection followed by radiotherapy in 11 of 14
patients. The most frequent type of failure was metachronous can-
cers, w h i c h o c c u r r e d i n 2 5 p a t i e n t s . T h e o v e r a l l 5-year s u r v i v a l rate
was 7 6 . 8 % . Causes o f d e a t h w e r e local recurrences i n seven pa-
tients, cervical metastasis in three patients, metachronous cancer
in 17 patients, a n d i n t e r c u r r e n t disease in 18 patients. F o u r patients
w e r e lost to f o l l o w - u p . H e n c e the adjusted s u r v i v a l rate w a s as h i g h
as 8 5 . 4 % .
J.-L. Lefebvre and D. Chevalier
TABLE 1.
Clinical Data of Patients W i t h Glottic Carcinoma
CHEP CHP
n = 207 n = 31
Site of o r i g i n
True vocal cord 193 23
Anterior commissure 13 8
Posterior commissure 1 —
T-stage
Tla 2 0
Tib 25 1
T2 164 29
T3 16 1
N-stage
N0 204 30
N1 30 1
Specific site involved
Anterior commissure 128 18
False vocal cord 2 14
Floor of the ventricle 98 7
Petiole of the epiglottis 2 2
Anterior aspect of arytenoid 102 10
Lateral subglottis 30 1
True vocal cord motion
Normal 82 23
Impaired 85 7
Fixed 15 1
Abbreviations: CHEP, cricohyoidoepiglottopexy; CHP,
c:rk:ohyoidopexy.
SUPRAGLOTTIC CANCERS
Population: A l l the patients u n d e r w e n t a SCPL w i t h C H P T h e
m e a n age w a s 5 3 y e a r s ( r a n g e : 29—68). T h e r e w e r e 7 5 m a l e s a n d
f i v e females. D e t a i l s o f t u m o r e x t e n s i o n are p r e s e n t e d i n Table 2 .
Postoperative courses: No patient d i e d d u r i n g the postopera-
tive p e r i o d . T h e nasogastric tubes w e r e r e m o v e d , o n average, o n
day 25 (range: 6 - 8 0 ) . In 56 patients, the t r a c h e o s t o m y t u b e w a s re-
TABLE 2.
Clinical Data of Patients W i t h
Supraglottic Carcinoma
CHP
n = 80
Site of o r i g i n
False v o c a l c o r d 31
Infrahyoid epiglottis 23
Ventricle 16
Petiole of the epiglottis 10
T-stage
Tl 2
T2 52
T3 22
T4 4
N-stage
N0 67
N1 12
N2a 1
Specific site i n v o l v e d
True vocal cord 25
A r y t e n o i d cartilage 28
True vocal cord m o t i o n
Normal 66
Impaired 12
Fixed 2
CONCLUSION
The rationale supporting this n e w surgical approach, w h e n it was
d i s c u s s e d i n t h e e a r l y 70s w a s , o n o n e h a n d , t h e g a p b e t w e e n c o n -
v e n t i o n a l h o r i z o n t a l a n d total laryngectomies a n d , on the other, the
r i s k o f l o c a l recurrences after s o m e v e r t i c a l l a r y n g e c t o m i e s i n the
case o f p a r a g l o t t i c s p a c e i n v a s i o n . T o d a t e , t h e v a r i o u s F r e n c h e x -
periences p r o v i d e c o n v e r g i n g data. Local c o n t r o l w a s achieved i n
a b o u t 9 5 % o f t h e c a s e s ; f u n c t i o n a l f a i l u r e s o c c u r r e d i n less t h a n
1 0 % , w h e r e a s 5-year s u r v i v a l r a n g e d f r o m 8 0 % after C H P t o 8 5 %
after CHEP.
T h i s surgery appears to be suitable for patients free of notable
p u l m o n a r y d y s f u n c t i o n , w h o h a v e m o d e r a t e l y a d v a n c e d diseases
for w h i c h other partial procedures c o u l d be insufficient. In this re-
spect, SCPL a l l o w s the surgeon to a v o i d h a v i n g to p e r f o r m a total
laryngectomy, w h i l e p r o v i d i n g satisfactory surgical margins. T h i s
surgery m u s t be considered as one of the tools we have at our dis-
posal for n o n m u t i l a t i n g m a n a g e m e n t of laryngeal cancers a n d ,
therefore, for l a r y n x f u n c t i o n preservation. Nevertheless, it m u s t
be underscored that this surgery requires t h o r o u g h evaluation for
a p p r o p r i a t e selection of patients regarding t u m o r e x t e n s i o n , per-
f o r m a n c e status, a n d m o t i v a t i o n . Finally, an early re-education dur-
ing the postoperative p e r i o d is, in a d d i t i o n to the attention p a i d to
major technical key points during resection and pexy, the w a y to
i m p r o v e t h e f u n c t i o n a l r e s u l t s a n d t o r e d u c e t h e p o s t o p e r a t i v e stay.
REFERENCES
1. Majer E, Rieder W: Technique de laryngectomie permettant de con-
server la perméabilité respiratoire. Ann Otolaryngol 7 6 : 6 7 7 - 6 8 1 , 1 9 5 9 .
Supracricoid Partial Laryngectomy 15
T o p i c a l i n s t i l l a t i o n o f i n t r a t y m p a n i c (IT) m e d i c a t i o n s t o treat
i n n e r ear d i s o r d e r s o f f e r s d i s t i n c t a d v a n t a g e s o v e r t h e m o r e
c o n v e n t i o n a l m e t h o d s of systemic p h a r m a c o t h e r a p y or surgery. As
c o m p a r e d w i t h systemic m e d i c a t i o n s , it offers a m o r e direct ap-
p r o a c h t o t h e i n n e r ear w h i l e a v o i d i n g s y s t e m i c d o s i n g a n d its i n -
herent complications. The technique is simpler and m u c h more
c o s t e f f e c t i v e t h a n s u r g e r y , a n d a r g u a b l y m u c h safer. B l a k l e y
recently published an excellent comprehensive review of the
1
subject.
To date, this t e c h n i q u e has been used for three m a i n types of
i n n e r ear d i s o r d e r s : t i n n i t u s , w h i c h has r e c e i v e d v e r y l i t t l e a t t e n -
t i o n i n the literature; M e n i e r e ' s disease, w h i c h has received the
m o s t a t t e n t i o n ; a n d i n f l a m m a t o r y i n n e r ear d i s o r d e r s , c u r r e n t l y t h e
most topical of the three.
T h r e e g e n e r a l classes of d r u g s are u s e d for IT i n j e c t i o n . It
s h o u l d be noted that none of these drugs was specifically devel-
o p e d n o r m a r k e t e d f o r d i r e c t t r a n s t y m p a n i c t r e a t m e n t o f i n n e r ear
d i s o r d e r s . O n e i s the a m i n o g l y c o s i d e class o f a n t i b i o t i c s , w h i c h has
been u s e d extensively for the treatment of M e n i e r e ' s disease, b o t h
transtympanically and systemically. Here, what is normally an u n -
t o w a r d side effect of t h e d r u g , its o t o t o x i c i t y , is c h a n g e d i n t o a
t h e r a p e u t i c c l i n i c a l a p p l i c a t i o n . T h e s e c o n d class o f d r u g s i s l o c a l
anesthetics, w h i c h have also been used b o t h systemically a n d trans-
t y m p a n i c a l l y t o treat t i n n i t u s . F i n a l l y , t h e class that has r e c e i v e d
the most attention recently is the corticosteroids. To date their pre-
Advances in Otolaryngology-Head and Neck Surgery'", vol. 12
«1998, Mosby, Inc. 1'
18 L.S. Parnes
TINNITUS
A l t h o u g h m u c h has been w r i t t e n o n the i n t r a v e n o u s a d m i n i s t r a -
t i o n of lignocaine a n d lidocaine for the treatment of t i n n i t u s , most
c i t a t i o n s a d d r e s s i n g its I T a p p l i c a t i o n appear i n t h e Japanese lit-
erature. There is no d o u b t i n g the efficacy of the intravenous route,
2
w i t h marked tinnitus suppression in most individuals. H o w -
ever, t h e t r e a t m e n t poses a great r i s k to t h e c a r d i o v a s c u l a r a n d c e n -
tral neurologic systems a n d as such, m u s t be performed in a
h o s p i t a l - t y p e setting w i t h close m o n i t o r i n g . F u r t h e r m o r e the effect
is s h o r t - l i v e d . For these reasons, it has n o t b e e n a c l i n i c a l l y u s e f u l
modality.
I n t r a t y m p a n i c a d m i n i s t r a t i o n w o u l d s e e m t o b e a n a t u r a l off-
shoot of this technique, w i t h the advantage of avoiding the trouble-
some systemic side effects. H o w e v e r , it s t i l l does n o t a v o i d the
p r o b l e m o f the l i m i t e d d u r a t i o n o f efficacy. F u r t h e r m o r e , the ves-
t i b u l a r side effect o f severe a n d p r o l o n g e d vertigo w i t h nausea a n d
v o m i t i n g renders the technique completely impractical.
3
Sakata a n d c o l l e a g u e s h a v e b y far t h e w o r l d ' s largest e x p e r i -
ence u s i n g IT corticosteroids to treat t i n n i t u s . T h e i r i n i t i a l report
of t h e b e n e f i t s of d e x a m e t h a s o n e a p p e a r e d s o m e 15 years ago b u t
4
has never b e e n substantiated in a c o n t r o l l e d study. Coles et a l .
f o u n d l i t t l e if a n y benefit in a s m a l l scale t r i a l of six p a t i e n t s . Sakata
et a l / recently reported their experience using IT dexamethasone
t o t r e a t s o - c a l l e d c o c h l e a r t i n n i t u s i n 1,466 ears o f 1,214 p a t i e n t s
d u r i n g a 2-year p e r i o d . A s s u m i n g , therefore, that t h e y h a v e treated
several t h o u s a n d patients over the years seems reasonable. T h e y
c l a i m to have an overall efficacy rate of 7 2 % , w i t h several differ-
e n t v a r i a b l e s a f f e c t i n g o u t c o m e s . T h e s e i n c l u d e t h e age o f t h e p a -
tient, t h e u n d e r l y i n g cause o f t h e t i n n i t u s , its d u r a t i o n , p i t c h a n d
l o u d n e s s , a n d t h e h e a r i n g l e v e l i n t h e a f f e c t e d ear. S i l v e r s t e i n
5
e t a l . r e p o r t e d t i n n i t u s i m p r o v e m e n t i n 4 7 % o f treated ears, m o s t l y
i n patients w i t h M e n i e r e ' s disease, u s i n g various I T corticosteroid
preparations. A g a i n , theirs was an u n c o n t r o l l e d study. Clearly a
d o u b l e - b l i n d e d , c o n t r o l l e d , c r o s s o v e r t r i a l i s n e e d e d t o assess p r o p -
erly the efficacy of IT steroids for tinnitus.
MENIERE'S DISEASE
M o s t patients w i t h M e n i e r e ' s disease c a n g a i n s y m p t o m a t i c c o n -
trol of their vertigo through conservative medical management. For
Intratympanic Pharmacotherapy 19
p o i n t s f o r t h e t r e a t m e n t s are a s f o l l o w s : (1) a s i g n i f i c a n t r e d u c t i o n
in hearing (a drop in pure tone acuity [PTA] of more than 15 dB or
a d r o p in speech d i s c r i m i n a t i o n score [SDS] of m o r e t h a n 1 5 % ) per-
s i s t i n g f o r m o r e t h a n 2 c o n s e c u t i v e w e e k s ; (2) o n s e t o f c o n s t a n t v e s -
tibular symptoms such as dysequilibrium or m o t i o n sensitivity,
v e r y d i f f e r e n t f r o m t h e i r M e n i e r e ' s a t t a c k s ; (3) o n s e t o f a s p o n t a n e -
ous paralytic nystagmus or f l o r i d post-headshake nystagmus that
w a s n o t p r e s e n t b e f o r e t r e a t m e n t ; o r (4) t h e f o u r s c h e d u l e d t r e a t -
m e n t s . If, a f t e r t h e c o m p l e t i o n o f t h i s f i r s t c o u r s e o f t r e a t m e n t , t h e
patient continues to have troublesome vertigo spells, another
course of treatment m a y be considered. However, if the first course
d i d not result in any significant reduction in the caloric response,
and if there were no obvious anatomical or technical problems dur-
ing the i n i t i a l injections, I w o u l d t h e n offer surgical i n t e r v e n t i o n
rather than more IT gentamicin.
RESULTS
To date, I have treated 83 patients using this titration p r o t o c o l , of
w h o m 68 have been available for detailed f o l l o w - u p assessments.
T h e r e w e r e 3 5 w o m e n a n d 3 3 m e n , w i t h a n a v e r a g e age o f 5 4 . 6
y e a r s ( r a n g e 3 2 - 8 3 y e a r s ) . T h e s u b j e c t s r e c e i v e d a n a v e r a g e o f 3.6
i n j e c t i o n s ( r a n g e 1—8).
Vertigo
1 7
The A A O - H N S r e c o m m e n d e d formula for calculating vertigo
control was used. The formula is as follows:
Caloric Responses
Sixty-two of the 68 patients had both pre- and post-gentamicin ENG
assessments. The mean caloric response before therapy in the
treated ears was 24 7s (range 5 - 5 0 7 s ) . After gentamicin treatment,
the average response decreased to 7 7s (range 0 - 4 0 7 s ) . In com-
paring caloric function from before and after the gentamicin injec-
tions, patients were classified into four groups. Twelve of the 62
subjects displayed posttreatment caloric responses between 5 0 %
to 1 0 0 % of their pretreatment score (group 1). Twelve patients dem-
onstrated posttreatment responses between 1 0 % and 5 0 % of their
pretreatment value (group 2). Ten subjects ( 1 6 % ) displayed less
than 1 0 % of their pretreatment caloric responses on posttreatment
assessment (group 3). This group also included those subjects who
responded to ice water stimulus only. Twenty-eight patients ( 4 5 % )
displayed a completely absent ice water caloric response after gen-
tamicin therapy (group 4).
Overall, there was a significant association (P < .05) between
reduction in caloric response and improvement in vertigo control.
Of the seven patients who did not obtain either complete or sub-
stantial vertigo control, four were in group 1, one was in group 2,
and one was in group 3. In one case, the continued severity of the
24 L.S. Parnes
Meniere's attacks w a r r a n t e d t i m e l y surgical i n t e r v e n t i o n , a n d c o n -
sequently no follow-up E N G testing was possible.
DISCUSSION
Using the titration protocol, 8 4 % of patients were completely
relieved of their Meniere's vertigo attacks, whereas an a d d i t i o n a l
6 % o b t a i n e d substantial c o n t r o l . T h i s 9 0 % success rate c o m p a r e s
1 0 , 1 4
favorably w i t h the results of the shot-gun protocol s t u d i e s .
T h i s v a l u e also compares favorably w i t h the results f r o m vestib-
1 8 1 9
ular n e u r e c t o m y . ' As for the hearing results, at the 6 - m o n t h
f o l l o w - u p , only five patients (8%) h a d a hearing drop, whereas a
larger n u m b e r (nine patients) h a d actually s h o w n a n i m p r o v e -
m e n t . These results far e x c e e d those of t h e s h o t - g u n studies.
Perhaps most important, using the titration protocol, there were
n o cases o f e x t r e m e h e a r i n g l o s s ( m o r e t h a n 3 0 d B ) , a s c o m p a r e d
w i t h the 1 0 % t o 2 4 % incidence associated w i t h the shot-gun
1 0 1 4
technique. "
W h e t h e r t h e results w i t h s t a n d t h e test o f t i m e r e m a i n s t o b e
seen. Because t h e rate of h e a r i n g loss is so l o w , no bridges w i l l h a v e
been b u r n e d for the treatment failures. M o r e g e n t a m i c i n can always
b e i n j e c t e d ; c o n v e r s e l y , a l l t h r e e t y p e s o f s u r g e r y (sac s u r g e r y ,
neurectomy, labyrinthectomy) remain viable options depending on
the degree of r e s i d u a l hearing a n d vestibular f u n c t i o n . U n d o u b t -
edly, a p a t i e n t e v e n t u a l l y m a y r e s p o n d w i t h an i d i o s y n c r a t i c reac-
t i o n to gentamicin, as others have described (personal c o m m u n i -
cation). T h a t is, a n i r r e v e r s i b l e e x t r e m e h e a r i n g loss m i g h t o c c u r
after one o r t w o I T i n j e c t i o n s . Based o n m y e x p e r i e n c e t o date, the
chances o f t h i s o c c u r r i n g w i t h t h e t i t r a t i o n p r o t o c o l are e x t r e m e l y
s m a l l , a n d p r o b a b l y n o greater t h a n the e x t r e m e h e a r i n g loss that
might occur w i t h vestibular neurectomy, the gold standard com-
parative treatment. As such, I strongly r e c o m m e n d IT gentamicin
t i t r a t i o n injections as the first l i n e i n t e r v e n t i o n a l treatment for i n -
tractable M e n i e r e ' s disease.
TABLE 1.
B r e a k d o w n of Patients Undergoing
Intratympanic Corticosteroid Treatments
N u m b e r of Number
Disorders Patients Improved
S u d d e n deafness 13 7
Cochlear hydrops 8 0
Sudden drop in 7 0
pre-existing
h e a r i n g loss
Surgically induced 3 3
Cogan's s y n d r o m e 2 2
Delayed 2 0
postmeningitis
A u t o i m m u n e inner 1 1
ear d i s e a s e
Ramsay H u n t 1 0
syndrome
Totals 37 13
Intratympanic Pharmacotherapy 27
CASE REPORT 1 . — A 2 6 - y e a r - o l d w o m a n p r e s e n t e d i n A u g u s t o f 1 9 9 0
w i t h a l e f t - s i d e d s e n s o r i n e u r a l h e a r i n g loss [ s p e e c h r e c e p t i o n
t h r e s h o l d (SRT) 60 d B ; SDS 5 2 % ] w h i c h progressed over several
week s . She w a s also n o t e d to h a v e an isolated h i g h f r e q u e n c y
( > 3 k H z ) s e n s o r i n e u r a l l o s s i n t h e r i g h t ear. S h e c o m p l a i n e d o f v e r -
tigo, a n d vestibular testing s h o w e d an absent caloric response in
t h e l e f t ear. A c o m p l e t e w o r k u p f o r r e t r o c o c h l e a r a n d s y s t e m i c d i s -
ease w a s n e g a t i v e , a n d s h e w a s s t a r t e d o n p r e d n i s o n e , 6 0 m g d a i l y .
A l t h o u g h there was no i m p r o v e m e n t , d u r i n g the next m o n t h her
h e a r i n g r e m a i n e d stable a n d her p r e d n i s o n e w a s s l o w l y tapered t o
30 mg/day.
S o o n after, p o l y a r t h r i t i s d e v e l o p e d w i t h a h i g h l y e l e v a t e d
e r y t h r o c y t e s e d i m e n t a t i o n rate (ESR). T h e 3 0 m g / d a y dose o f p r e d -
n i s o n e w a s m a i n t a i n e d . O n e m o n t h later, t h e p a t i e n t h a d a s p l e n i c
i n f a r c t d e v e l o p i n c o n j u n c t i o n w i t h a f u r t h e r d e c l i n e i n h e r hear-
i n g i n b o t h ears. T h e l e f t ear b o t t o m e d o u t t o t h e p r o f o u n d l e v e l ,
w h e r e a s t h e r i g h t ear d r o p p e d t o a 4 5 - d B l e v e l i n t h e l o w f r e q u e n -
cies w h i l e m a i n t a i n i n g a 1 0 0 % SDS. She also b e c a m e e x t r e m e l y
vertiginous.
T h e presumptive diagnosis of systemic vasculitis was treated
by increasing her p r e d n i s o n e dose to 80 m g / d a y a n d starting her
o n m o n t h l y pulse treatments o f c y c l o p h o s p h a m i d e , 750 m g . O n
t h i s r e g i m e n , h e r h e a r i n g i n t h e r i g h t ear g r a d u a l l y i m p r o v e d o v e r
1 m o n t h to the original level, except for an isolated but persistent
h i g h f r e q u e n c y loss. T h e left p r o f o u n d h e a r i n g loss n e v e r recov-
ered. W h i l e o n t h e h i g h dose o f p r e d n i s o n e , she h a d b i l a t e r a l o c u -
lar i n f l a m m a t i o n develop. T h e ophthalmologists i d e n t i f i e d a bilat-
eral n o n s y p h i l i t i c interstitial keratitis a n d the diagnosis of Cogan's
s y n d r o m e was made w i t h certainty.
D u r i n g the next 3 months, the patient's prednisone was s l o w l y
tapered to 25 mg/day w h i l e her hearing was closely monitored. In
M a r c h 1 9 9 1 , she presented w i t h another p r e c i p i t o u s 30-dB d r o p i n
h e r b o n e l e v e l s i n h e r r i g h t ear, a s w e l l a s a n i n c r e a s e i n t h e d i z z i -
ness. T h e p r e d n i s o n e w a s i n c r e a s e d t o 5 0 m g / d a y a n d h e r h e a r i n g
i m p r o v e d to the baseline level during the next m o n t h . Her keratitis
flared up at this p o i n t a n d she was g i v e n azathioprine, 100 mg/day.
On this n e w regimen, the systemic component seemed w e l l
c o n t r o l l e d . Other t h a n persistent b u t u n e x p l a i n e d left otalgia, there
were no n e w problems. Gradually, during a 6-month period, the
p r e d n i s o n e was tapered to a m a i n t e n a n c e dose of 12 m g / d a y a n d
the azathioprine was m a i n t a i n e d at 100 mg/day.
I n June o f 1992, the p a t i e n t presented w i t h severe a b d o m i n a l
d i s c o m f o r t that, after i n v e s t i g a t i o n , w e n t u n d i a g n o s e d . H e r p r e d -
L.S. Parries
Results
Table 2 details the 13 patients who were treated for sudden senso-
rineural deafness, one of whom had bilateral involvement and
treatment. S i x patients showed a significant improvement in audi-
tory thresholds, five progressing from a severe/profound loss to
relatively normal hearing thresholds.
One patient (RB.) presented 3 weeks after a bilateral sudden
hearing loss, with associated vertigo. He had been initially man-
aged elsewhere with conventional medical measures, yet his hear-
ing continued to deteriorate. Intratympanic methylprednisolone
abruptly halted the progression of his hearing loss and eventually,
over the long term, led to a slight hearing improvement, especially
in his S D S ' s . As seen in Table 2, his treatments were notably more
numerous than the other patients in this group. On repeated occa-
sions, after stopping the treatments, his auditory thresholds
dropped slightly, along with a significant subjective drop in hear-
ing. When the treatments resumed, there would be objective and
subjective improvement. Eventually the problem burned itself out,
allowing for cessation of therapy. At no time did this patient re-
ceive systemic corticosteroids.
Most of the patients in this group received treatment early af-
ter the onset of hearing loss. Although the numbers are small, there
seemed to be no correlation between the time of treatment after the
onset of hearing loss, the drug used, the number of treatments, and
the final hearing result.
Unlike the sudden idiopathic hearing loss group, the seven
patients with subacute unilateral deterioration of a pre-existing bi-
lateral sensorineural loss all did uniformly poorly. Although none
TABLE 2.
Sudden Hearing Loss Group [n = 13]
DISCUSSION
2 0
In our prior animal study, transtympanic corticosteroid adminis-
tration p r o d u c e d very h i g h drug levels in b o t h e n d o l y m p h a n d
p e r i l y m p h . Therefore, if the i n f l a m m a t o r y process is w i t h i n the
membranous or bony labyrinth, transtympanic delivery should be
e f f e c t i v e . If, h o w e v e r , t h e d i s e a s e p r o c e s s i s o u t s i d e t h e l a b y r i n t h ,
Intratympanic Pharmacotherapy 35
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Intratympanic Pharmacotherapy 39
S o c i o e c o n o m i c a t t e m p t s to s t e m t h e r i s i n g cost of h e a l t h care
have r e s u l t e d in a significant e m p h a s i s on o u t p a t i e n t surgery.
Most otolaryngologists have readily accepted this trend, as evi-
denced by statistics s h o w i n g otolaryngology to be the t h i r d most
1
c o m m o n specialty using ambulatory surgical centers. The most
frequent otolaryngologic operations p e r f o r m e d on an outpatient ba-
sis are t h o s e t h a t i n v o l v e c h i l d r e n , s p e c i f i c a l l y b i l a t e r a l m y r i n g o t -
omy w i t h ventilation tube placement and adenotonsillar proce-
2
dures.
T h e substantial financial savings resulting f r o m the e l i m i n a t i o n
of o v e r n i g h t h o s p i t a l i z a t i o n has u n f o r t u n a t e l y led to insurance
c o m p a n y mandates that m a n y otolaryngologic procedures, i n c l u d -
i n g a d e n o t o n s i l l e c t o m y , b e p e r f o r m e d o n a n o u t p a t i e n t basis except
3
under extenuating circumstances. The appropriateness of outpa-
tient a d e n o t o n s i l l e c t o m y in specific patient p o p u l a t i o n s is debat-
able. Concerns also r e m a i n as to the p r o p e r d u r a t i o n of postopera-
tive m o n i t o r i n g to ensure patient safety relative to the p o t e n t i a l for
serious a n d even life-threatening postoperative complications.
PROCEDURE COMPLICATIONS
A n y discussion of inpatient vs. outpatient surgery needs to i n c l u d e
t h e r i s k s a s s o c i a t e d w i t h t h e p r o c e d u r e i t s e l f , a s w e l l a s t h o s e as-
sociated w i t h the patient p o p u l a t i o n on w h i c h it is performed. T h e
Advances in Otolaryngohgy-Head and Neck Surgery®, vol. 12
4 1
»1998, Mosby, Inc.
M.J. Cunningham
Crysdale and Retrospective 7,707 TA Not applicable; • Primary hemorrhage 2 . 1 5 % Children younger than 4 yrs
Russell 4
case series 267 T all inpatients ( 7 6 % episodes within 6 hrs) had a lower relative frequency
1,435 A ( 8 7 % episodes within 9 hrs) of bleeding but a higher
Age < 1 7 yrs • Severe emesis 3 . 1 % incidence of fever, inadequate
oral intake, and respiratory
distress
Carithers, Retrospective 2 3 8 0 TA Not applicable; Primary hemorrhage 1.2% Using a definition of less than a
Gebhart and, case series 183 T all inpatients ( 4 1 % episodes within 4 hrs) 1 0 % risk of complications,
Williams 5
381 A ( 7 4 % episodes within 8 hrs) adenotonsillectomy patients
Age 1-23 yrs Severe emesis 7 . 5 % should be observed at least 8
hrs, and possibly 10 hrs,
postoperatively
Richmond, Retrospective 6 3 0 TA Not applicable; Primary hemorrhage 0 . 2 6 % 5 0 % of children with known
Wetmore case series 61 T all inpatients Emesis 5 5 % (severity not hematologic disorders had
and, B a r a n a k 6
93 A defined) postoperative bleeding
Age 9 m o s - 1 9 yrs Prolonged hospitalization 8 0 % o f children with
Airway obstruction 7 2 % or readmission due to poor postoperative airway
Recurrent infection 1 7 % oral intake 2 . 9 % complications had other
Both indications 1 4 % Major airway complications significant medical problems
1.3% 2 7 % of of children with Down
syndrome and other types of
congenital disorders had major
respiratory complications
Guida and Prospective 1,000 TA, T, A • Not applicable; 0-6 6-24 Outpatient adenotonsillectomy
7
Mattucci case series Age 2 - 3 5 yrs all inpatients hrs hrs is safe, provided a minimum of
( 8 0 % < 1 2 yrs) • Primary 6 hrs of postoperative
hemorrhage 0.7% 0.7% observation
• Severe
emesis 0.7% 0.7%
Berkowitz and Retrospective 1 9 0 TA, T • Not applicable; • Average blood loss 5 . 4 % Complications necessitating
Zalzal 20
case series Age <3 yrs all inpatients total blood volume prolonged hospital stay or
Airway obstruction 8 5 % • Loss of 1 0 % or more of readmission in 1 0 . 5 % patients;
Recurrent infection 1 5 % blood volume in 8% significant association with
greater than 1 0 % intraoperative
patients
blood volume loss
Rothschild, Retrospective 153 TA, T • Not applicable; • Primary hemorrhage 0% T h e most frequent
Catalano, case series Age 1-18 yrs all inpatients • Delayed oral intake 1 6 % postoperative problem was
8
and B i l l e r • Respiratory compromise delay in adequate oral
7% hydration. Airway problems
were less common, although of
greater concern
Two "at risk" subgroups
identified: patients S 3 yrs o f
age and patients with
obstruction
9
Tom et a l . Retrospective 223 TA, T • Not applicable; • Primary hemorrhage 0% Notably low incidence of
case series Age <3 yrs. all inpatients • Emesis 3 2 . 3 % (severity not postoperative bleeding and
Airway obstruction defined) dehydration
70.5% • Dehydration 1.8% High incidence of postoperative
Recurrent infection • Postoperative PICU care respiratory complications in
8.5% 7.6% this young patient population
Both indications 2 1 % • Management beyond
standard care 5 2 . 5 %
Maniglia, Retrospective 1,290 TA, T, A Not specified Not specified Primary Outpatient
Kushner and case series Age < 1 8 yrs hemorrhage 0 . 1 4 % adenotonsillectomy is
Cozzi 10
safe
Colclasure and Retrospective 3,340 TA, T, A Not specified 1.5-5.5 hrs Primary (tonsillar) Major complication
Graham 11
case series Age 1 - 3 9 yrs Mean 2.25 hrs hemorrhage 0 . 3 5 % rate of only 1.4%
(92% £ 1 6 Dehydration 0 . 3 % Less than 1% patients
yrs) required hospital
admission
Five of 7 patients who
bled were older than
16 yrs
Haberman, Retrospective 5 0 0 TA, T Not specified Not specified Primary Outpatient
Shattuck and case series Age range? hemorrhage 0 . 6 % adenotonsillectomy
Dion 12
(58% £ 1 2 Dehydration 0 . 6 % safe in a private
yrs) practice, community
hospital setting
Nicklaus, Retrospective 2 3 3 TA, T Age less than 3 yrs Average 2 hr Primary Short duration
Herzon, and case series Age £ 1 8 yrs Bleeding diathesis 16 mins hemorrhage 1.4% monitoring of
Steinle 13
Comorbid disease {e.\ Mean duration Severe emesis 2 . 5 % postadenotonsillectomy
asthma) 1 3 6 ± 48 mins patients is safe
Gabalski, Prospective 534 TA, T Obstructive sleep 5 - 6 hrs Complication rate Absence of
Steinle 13
• Comorbid disease (e.g., • Mean duration Severe emesis 2 . 5 % postadenotonsillectomy
asthma) 1 3 6 ± 48 mins patients is safe
Gabalski, Prospective 534 TA, T Obstructive sleep 5 - 6 hrs Complication rate Absence of
Mattucci, case series Age < 1 5 yrs apnea for first 4 complications in 5th
Setzen, et al. Morbid obesity postoperative hrs and 6th postoperative
Pickwickian syndrome not reported hrs. suggests that a 4-hr
Mucopolysaccharidoses Complication rate postadenotonsillectomy
Craniofacial anomaly for 5th and 6th monitoring period is
Congenital heart postoperative hrs safely appropriate
disease 0 . 1 9 % combined
Mental retardation
Known coagulopathy
Previous anesthesia
complication
Traveling distance
greater than 30 mins
from hospital
Poor parental care
situation
Mitchell, Retrospective 102 TA Obstructive sleep Minimum 4 hrs No reported Outpatient
Pereira, case series Age 1.5- 3 yrs apnea primary adenotonsillectomy is a
Friedman, Chronic illness hemorrhage safe procedure in
1 5
et a l . Previous anesthesia No reported children younger than
complications respiratory 3 yrs who are carefully
Bleeding diathesis complications selected
Living distance more 9 % hospital
than 1 hr from hospital admission rate
Unavailable personal from ambulatory
transport unit due to poor
No adult companion in oral intake
attendance
Duration of
Study Study Outpatient Exclusion Postoperative Procedure Study Observations and/or
Author(s) Study Type Demographics Criteria Monitoring Complications Conclusions
Lee 1
Retrospective 3,240 TA Significant systemic Outpatients Primary 3 . 4 % children planned as
case series Age < 1 4 yrs disease 6 hrs hemorrhage 0 . 7 % outpatients admitted to
Planned inpatient Negative parental Inpatients hospital
32% attitude overnight 1 6 . 6 % children planned as
Planned Unfavorable inpatients discharged home
outpatient 6 8 % logistics same day
(distance/transport)
Intractable patient
(age/mentation)
Shott, Myer, Prospective 4 2 1 TA, T Age less than 3 yrs Outpatients Primary 1 1 % children planned a s
and C o t t o n 17
case series Age < 1 6 yrs Obstructive sleep 6 hrs hemorrhage 2 . 1 % outpatients admitted to
Planned inpatient apnea Inpatients Dehydration 1.9% hospital
22% Coexisting medical overnight
Planned problem
outpatient 7 8 % Living distance
over 1 hr from
hospital
Inadequate social
circumstances
Peritonsillar
abscess
Schloss, Tan, Retrospective 5 5 5 TA, T Age younger than Outpatients Primary 1 6 . 2 % children planned as
Schloss, case series Age not specified, 3 yrs not specified hemorrhage 5 . 4 % outpatients admitted to
1 8
et a l . but all children Living distance Inpatients ( 1 . 9 % required hospital
and adolescents more than 1 hr overnight operative Upper respiratory tract
Planned inpatient from hospital management) infection within 3 wks of
19% Obstructive sleep operation associated
Planned apnea significantly with
outpatient 8 1 % Coexisting medical postoperative hemorrhage
problem and aerodigestive tract
complications
Reiner, Retrospective 1,000 TA, T, A Associated cardiac Outpatients Primary Lower complication rates
Sawyer, case series Age 1-57 yrs or pulmonary 6 - 8 hrs hemorrhage in outpatient cases
Clark, et a l . 1
Planned disease Inpatients Inpatients 3 . 3 % attributed in part to
inpatients 4 0 % Central apnea or overnight Outpatients 1.2% selection of higher risk
Planned obstructive Poor oral intake patients for inpatient
outpatients 6 0 % episodes requiring Inpatients 4 . 8 % surgery
hospitalization Outpatients 1.2% No significant difference in
Abnormal complication rates between
coagulation indices operative diagnoses of
or bleeding history chronic infection and
Adverse upper airway obstruction
transportation, No significant difference in
distance from complication rates between
hospital inpatients and outpatients
Adverse social younger than 3 yrs of age,
situation regardless of procedure
performed or the surgical
indication
TABLE 4.
Tonsillectomy and Adenoidectomy Inpatient Guidelines:
Recommendations of the AAO-HNS Pediatric Otolaryngology
Committee (1996)*
Abbreviation: C.H.A.R.G.E., coloboma, heart disease, atresia choanae, retarded growth and
retarded development, genital hypoplasia, and ear anomalies or deafness.
'Reprinted with permission from the American A c a d e m y of Otolaryngology-Head and
Neck Surgery Bulletin, September 1 9 9 6 , pp. 1 3 - 1 5 .
4
Crysdale and Russell noted a higher incidence of postopera-
tive fever, inadequate oral intake, and respiratory distress in pa-
tients younger than age 4.
20
Berkowitz and Z a l z a l documented that a significant percent-
age ( 1 0 . 5 % ) of children younger than 3 years of age who undergo
adenotonsillectomy experience complications necessitating pro-
longation of their hospitalization beyond a planned single over-
52 M.J. Cunningham
n i g h t stay. T h e c o m p l i c a t i o n r a t e w a s p a r t i c u l a r l y h i g h i n t h o s e
c h i l d r e n w h o s e i n t r a o p e r a t i v e b l o o d loss e q u a l e d o r exceeded 1 0 %
of their total blood volume.
9
T o m e t a l . r e t r o s p e c t i v e l y r e v i e w e d 2 2 3 c h i l d r e n age 3 o r
younger w h o underwent adenotonsillectomy. The majority of this
patient p o p u l a t i o n u n d e r w e n t operative i n t e r v e n t i o n for obstruc-
tive airway indications alone (70.5%) or in association w i t h chronic
recurrent p h a r y n g o t o n s i l l i t i s episodes (21%). O n l y 8.5% of these
y o u n g c h i l d r e n h a d solely infectious i n d i c a t i o n s for surgery. A p -
proximately 8% of the children in this study required an intensive
care u n i t stay p o s t o p e r a t i v e l y , a n d m o r e t h a n 5 0 % n e e d e d s u p p l e -
mental therapy such as oxygen support, intravenous steroids, or i n -
travenous antiemetics. T h e incidence of postoperative emesis was
p a r t i c u l a r l y h i g h (32.5%), w i t h secondary i n t r a v e n o u s h y d r a t i o n re-
quirements to avoid dehydration in this young population.
8
R o t h s c h i l d , Catalano, a n d B i l l e r r e t r o s p e c t i v e l y r e v i e w e d 153
p a t i e n t s 1 8 y e a r s o f age o r y o u n g e r w h o u n d e r w e n t a d e n o t o n s i l -
lectomy. T w e n t y - t w o percent of the patients w e r e 3 years o l d or
younger; w i t h i n this subgroup, airway obstruction was the surgi-
cal i n d i c a t i o n for 8 1 % of these c h i l d r e n . T h e authors d o c u m e n t e d
a statistically significant difference in the time-to-oral-intake in pa-
t i e n t s y o u n g e r t h a n 4 y e a r s o f age c o m p a r e d t o t h o s e 4 y e a r s o f age
a n d o l d e r ; t h e y o u n g e r age g r o u p a l s o t o o k s i g n i f i c a n t l y l o n g e r t o
be discharged, p r i m a r i l y for this reason. A m o n g those c h i l d r e n u n -
dergoing adenotonsillectomy for relief of u p p e r a i r w a y obstruction,
7% experienced respiratory compromise in the immediate postop-
e r a t i v e p e r i o d . T h i s p e r c e n t a g e w a s h i g h e r ( 1 1 % ) i n t h e age g r o u p
y o u n g e r t h a n 4 years of age.
2 6
Gerber et a l . d o c u m e n t e d an even higher percentage (38%)
o f c h i l d r e n y o u n g e r t h a n 3 y e a r s o f age u n d e r g o i n g a d e n o t o n s i l -
lectomy for a i r w a y obstruction indications w h o developed postop-
erative respiratory c o m p r o m i s e . T h e relative risk of postoperative
respiratory c o m p r o m i s e w a s five t i m e s greater for patients y o u n g e r
t h a n 3 y e a r s o f age i n t h i s s t u d y .
N o t a l l s t u d i e s , h o w e v e r , h a v e i n d i c a t e d t h a t age a l o n e i s a s i g -
nificant risk factor for postadenotonsillectomy complications.
1 9
R e i n e r e t a l . f o u n d n o s i g n i f i c a n t d i f f e r e n c e i n c o m p l i c a t i o n rates
b e t w e e n i n p a t i e n t s a n d o u t p a t i e n t s y o u n g e r t h a n 3 years o f age,
regardless of the procedure p e r f o r m e d or the surgical i n d i c a t i o n .
1 5
M i t c h e l l et a l . , i n a r e v i e w o f 1 0 2 c h i l d r e n 3 y e a r s o f age o r
younger undergoing outpatient adenotonsillectomy, h a d a 10% ad-
m i s s i o n rate d u e to p o o r oral intake b u t r e p o r t e d no respiratory
compromise in this patient group postoperatively. They concluded
Guidelines for Adenotonsillectomy in Children 53
a n d ear a n o m a l i e s ) a s s o c i a t i o n , a c h o n d r o p l a s i a , a n d D o w n s y n -
d r o m e are p r o n e t o a i r w a y o b s t r u c t i o n f r o m a d e n o t o n s i l l a r h y p e r -
6
trophy. In such children, even physiologically normal amounts of
oropharyngeal a n d nasopharyngeal l y m p h o i d tissue m a y result in
a i r w a y c o m p r o m i s e . S u c h c h i l d r e n are s i m i l a r l y a t h i g h e r r i s k for
2 6
postoperative a i r w a y c o m p r o m i s e . Gerber et a l . d o c u m e n t e d the
risk of postoperative respiratory c o m p r o m i s e to be nearly eight
times greater if the patient h a d an u n d e r l y i n g c h r o m o s o m a l
3 1
anomaly. McColley et a l . likewise observed an increased risk of
severe obstructive apnea i n c h i l d r e n w i t h craniofacial s y n d r o m e s ,
particularly those associated w i t h midface hypoplasia.
2 6
I n t h e r e a l m o f associated a i r w a y p r o b l e m s , Gerber e t a l . also
established that postoperative respiratory c o m p r o m i s e was three
times more likely to develop in patients w h o had an upper respi-
ratory tract i n f e c t i o n w i t h i n 4 weeks of their adenotonsillectomy.
This increased risk of postadenotonsillectomy complications in
c h i l d r e n w i t h recent respiratory tract i n f e c t i o n has been d o c u -
1 8
m e n t e d by other authors as w e l l , strongly suggesting that a his-
tory of recent respiratory tract illness warrants overnight observa-
t i o n , if not delay of surgery.
CLINICAL INTANGIBLES
T h e d i s t a n c e o f t h e f a m i l y ' s h o m e f r o m t h e site o f s u r g i c a l care,
extended travel time due to weather conditions or transportation
issues, a n d i n a d e q u a t e h o m e s u p e r v i s i o n m a y create a s i t u a t i o n
that is not consistent w i t h appropriate h o m e m o n i t o r i n g and the
ability to return the c h i l d to the hospital quickly. Parental c o m p l i -
a n c e , l a n g u a g e i s s u e s , a n d a c c e s s t o a c a r o r t e l e p h o n e are a l l i m -
p o r t a n t variables that i n f l u e n c e the safety o f h o m e discharge a n d
warrant consideration of overnight observation.
CONCLUSION
T h e d e c i s i o n t o p e r f o r m o u t p a t i e n t vs. i n p a t i e n t adenotonsillec-
t o m y d e p e n d s o n t h e s u r g i c a l i n d i c a t i o n ( s ) , t h e age a n d m e d i c a l
background of the patient, the family's social situation, and the pro-
fessional j u d g e m e n t of the operating surgeon. In general, it appears
t h a t o t h e r w i s e h e a l t h y c h i l d r e n 3 y e a r s o f age a n d o l d e r c a n s a f e l y
undergo adenotonsillectomy for either infectious or obstructive i n -
dications on an outpatient, a m b u l a t o r y basis. P r o l o n g e d i n p a t i e n t
o b s e r v a t i o n s h o u l d be c o n s i d e r e d for c h i l d r e n y o u n g e r t h a n 3 years
o f age, e s p e c i a l l y t h o s e u n d e r g o i n g a d e n o t o n s i l l e c t o m y f o r treat-
m e n t o f o b s t r u c t i v e s l e e p d i s o r d e r , a n d f o r p a t i e n t s o f a n y age w h o
are i d e n t i f i e d a s h a v i n g a s i g n i f i c a n t r i s k f a c t o r f o r a c o m p l i c a t e d
p o s t o p e r a t i v e c o u r s e . W h e n m u l t i p l e r i s k f a c t o r s are p r e s e n t , o v e r -
night hospitalization is required, and observation in an intensive
care u n i t o r s i m i l a r m o n i t o r e d setting m a y a c t u a l l y b e the m o s t p r u -
dent postoperative course.
REFERENCES
1. Leopold DA, Lagoe R. Patterns of otolaryngologic surgery utilization
in Syracuse, New York. Arch Otolaryngol Head Neck Surg 1 1 2 : 6 2 3 -
627, 1986.
2. Derkay CS. Pediatric otolaryngology procedures in the United States:
1 9 7 7 - 1 9 8 7 . Inter J Pediatr Otorhinolaryngol 2 5 : 1 - 1 2 , 1993.
3. Raymond CA. Study questions safety, economic benefits of outpatient
tonsil/adenoid surgery. JAMA 2 5 6 : 3 1 1 - 3 1 2 , 1986.
4. Crysdale W S , Russel D. Complications of tonsillectomy and adenoid-
ectomy 9,409 children observed overnight. CMAJ 1 3 5 : 1 1 3 9 - 1 1 4 2 ,
1986.
5. Carithers )S, Gebhart DE, Williams JA. Postoperative risks of pediat-
ric tonsilloadenoidectomy. Laryngoscope 9 7 : 4 2 2 - 4 2 9 , 1 9 8 7 .
58 M.J. Cunningham
3
1
in 1 9 4 7 and later modified by Leroux Robert, Sanchez Ro-
4 5 r>
driguez, B o c c a , Banfai in Europe, and Ogura and S o m in the
2
cinomas. The risk for a local recurrence is low if the cases are care-
fully chosen. The oncologic outcome depends much more on the
metastases to local lymph nodes and to distant sites and on the
8, 9
occurrence of secondary malignancies.
Despite the good oncologic results, the acceptance of open su-
praglottic partial resections is distinctly limited because of its post-
operative morbidity. The high tendency of aspiration combined
with swallowing difficulties must be mentioned. A permanent tra-
cheostomy or a percutaneous gastric feeding tube is often required.
10 11
In many cases, a secondary laryngectomy cannot be a v o i d e d . '
The nondecannulation rate after open supraglottic partial resec-
tions amounts to about 2 5 % in supraglottic tumors and to about
1 2
5 0 % in tongue-base tumors according to Suarez et a l . The
12
completion laryngectomy rate rises after the age of 65 y e a r s . Af-
ter additional radiation therapy, the morbidity rate is higher than
10
after surgery a l o n e .
Prior to the introduction of the C O laser, endoscopic transoral
z
13-15
resections of supraglottic tumors were only done s p o r a d i c a l l y ,
Advances in Otolaryngology-Head and Neck Surgery®, vol. 12 „ .
e
1 9 9 8 , Mosby, Inc.
H.H. Rudert
ANESTHESIA
The operations are always performed under orotracheal intubation.
Tubeless operations under jet ventilation or with the apneic tech-
nique are not helpful since the tracheal tubes remain outside the
operational area anyway. For beginners, the use of so-called laser-
resistant endotracheal tubes is recommended. They are, however,
42
very costly and not absolutely safe from the risk of tube fires. We
use normal thin-walled polyvinyl tubes with the smallest possible
diameter, the cuff of which is filled with Ringer's solution. The
tubes are protected with moist neurosurgical cottonoid. It is impor-
4 2
tant that the O content of the gas mixture does not exceed 4 0 % .
z
FIGURE 1.
A, bivalved supraglottiscope (STORZ Comp., Tuttlingen); B, view of the supra-
glottic larynx exposed with the supraglottiscope.
to the mouth of the instruments (Fig 2), because the suction tubes
of the laryngoscopes do not have adequate suction power because
46
of their small diameter and the great distance to the o b j e c t .
The majority of the C 0 lasers on the market are suitable for
2
FIGURE 2.
Instruments for laser surgery.
68 H.H. Rudert
vessels remain closed during the incision through the tissue. Under
the microscope, the targeted hemostasis allows good recognition of
the border between healthy and tumorous tissue on the surface of
17
the incision. As early as 1 9 7 8 , Vaughan used these characteristics
to undertake a staging of advanced tumors. It is our opinion that,
contrary to conventional oncosurgical rules, even tumors that can-
not be endoscopically removed in one piece can be divided and re-
sected in two or three pieces, due to the sealing of the capillary
blood vessels and lymphatic vessels. Of course, the final margin of
the resected piece of the remaining laryngeal stump must be free of
tumor cells. This can best be achieved by taking edge slices from
the remaining laryngeal stump after the resection of the tumorous
area of the supraglottis and examining them histologically. If it is
not possible to obtain adequate tumor-free margins, the operation
should be stopped. The great advantage of transoral laser surgery is
that the option for all other methods of treatment remains open.
RESECTION TECHNIQUES
Laser surgical resection techniques and open supraglottic partial
resections both represent operation methods, which must be
learned and practiced systematically. This can best be done on
larynges of cadavers.
FIGURE 4.
Resection lines for partial resection of the supraglottis. T h e epiglottis is split
in the midline. Depending on the extent of the tumor, the vestibular fold and
the aryregion can be included into the resection. (From Rudert H: Technique
and results of transoral laser surgery of supraglottic carcinoma. Adv Otorhi-
70 H.H. Rudert
FIGURE 5.
A, B, C, several resection types, depending on the extent of the supraglottic tu-
mors. Because of the characteristics of the CO;, laser, it is possible to resect the
tumor in parts. (From Rudert H, Werner JA: Endoskopische Teilresektionen mit
dem CO^-Laser bei Larynxkarzinomen. Laryngorhinootologie [Stuttgart, Thieme]
7 3 : 7 1 - 7 7 , 1 9 9 4 . Used with permission.)
dially to unite with the first vertical incision. The position and
course of the third incision line is determined by the extent of the
tumor. In this way, the tumor can be excised and removed well into
the healthy tissue.
glottic membrane to the hyoid. From the hyoid bone, the incision
continues caudally, along the hyothyroid membrane, until the su-
perior edge of the thyroid cartilage is reached. From here, the en-
tire contents of the pre-epiglottic space, up to the anterior commis-
sure of the vocal cords, along the inside surface of the laminae of
the thyroid cartilage are removed with the laser. Separating the su-
prahyoid part of the epiglottis from the infrahyoid part after the
exposure of the hyoid is recommended to facilitate the resection
before the caudal dissection along the hyothyroid membrane and
FIGURE 6.
Resection lines marked in a median sagittal section of the larynx. T h e up-
per line marks the resection of a suprahyoid tumor, the other includes the
pre-epiglottic space in case of an infrahyoidal tumor. In case of a ventricu-
lar fold tumor, the inferior cut runs through the ventricle.
72 H.H. Rudert
the inner surface of the laminae of the thyroid cartilage. The dis-
section is then stopped either in the area of the vestibular folds or
of the ventricle, depending on the caudal extension of the tumor.
TABLE 1.
Results of Laser Surgery of 27 Supraglottic Carcinomas
1981-1993
4 0 1 0 0 3
10 3 1 2 2 5
6 2 2 1 1 2
7 4 2 0 3 1
Total 27 9 6 3 6 11
ONCOLOGIC RESULTS
A total of 30 patients with supraglottic carcinoma has been treated
between 1981 and 1993 with laser surgery in curative intention. A
follow-up was available in 27 patients (Table 1). Six of these pa-
tients died of causes unrelated to the carcinoma: four of advanced
cardiopulmonary disease, one of esophageal bleeding, and one of
liver failure. T h e statistics clearly show the risk factors of the pa-
tients, who were to a great percentage smokers and drinkers. They
also show that the transoral technique can be applied to multimor-
bid patients. The patients did not die of their carcinomas or of the
effects of the operation, but because of their other, mostly medical
problems, without the carcinoma affecting their quality of life.
Three patients died of a secondary carcinoma, six of their tumor,
of which the majority (four) died of the metastases and only two
of recurrence of the primary tumor. One patient is still alive with
his carcinoma, and 11 patients have been living without evidence
of disease for more than 3 years.
Most favorable are the results of the T and T carcinomas. Of
1 2
2 3 , 2 4 4 7 25
In Europe, S t e i n e r , ' and Eckel and Thumfart have,
26 27, 28
along with R u d e r t and Rudert and W e r n e r reported transoral
Laser Surgery for Supraglottic Larynx and Hypopharynx Carcinoma 75
TABLE 2.
Result s of Laser Surgery of 13 Hypopharyngeal Carcinomas
1981-1994
Alive with
Death Tu. Death Tu. Distant Alive
T-Class. Pat. Unrel. Rel. Metastesis NED
T a
2 0 0 0 2
T 2
9 2 2 2 3
T 3
2 0 2 0 0
Total 13 2 4 2 5
N0: 4; N1: 2; N2: 5; N3: 2.
Follow-up minimum 23 months, mean 33 months. Completion of the study
31.12.96.
76 H.H. Rudert
stage T and two each were stages T and T . Two patients died of
2 a 3
FUNCTIONAL RESULTS
The main advantage of transoral resection techniques is the low
rate of morbidity according to the discussion in the literature. To
the patients, the laser surgical operation is not more invasive than
a microlaryngoscopy. They have no impairment of swallowing
functions and do not aspirate unless an arytenoid cartilage or the
entire supraglottic larynx up to the anterior commissure is re-
moved. Postoperative edema is minimal so that the airway is not
compromised. Because the superior laryngeal nerves are not dam-
aged by the transoral resections, the sensitivity of the pharynx re-
mains intact. The sphincter of the supraglottis during swallowing
remains functional. There is a certain tendency toward aspiration,
but only after the resection of an arytenoid cartilage, similar to what
occurs after an arytenoidectomy with bilateral recurrent nerve pa-
ralysis. We only performed a prophylactic temporary tracheostomy
on patients with poor pulmonary function, and occasionally after
bilateral neck resection in very old patients or those with a very
short neck. In 1994, a retrospective comparative examination of 20
5
patients " who had been operated on through an external approach
and 26 patients who had been treated by laser microsurgery,
showed that only five patients from the laser group, but 17 of the
conventionally operated group required tracheotomy. Twenty pa-
tients of the conventionally operated patients had aspiration pneu-
monia develop, but only three of the laser group. Eight of the
twenty conventionally operated patients had to be fed through a
nasogastric tube for longer than 2 weeks, compared to only four of
the laser group. These good functional results in patients after trans-
oral supraglottic laryngectomy were also observed by us in patients
after treatment of hypopharyngeal carcinoma. Only those patients
in whom an arytenoid cartilage had to be removed along with a
carcinoma of the piriform sinus needed a great amount of time un-
til they could swallow clear fluids without aspiration.
Laser Surgery for Supraglottic Larynx and Hypopharynx Carcinoma 77
CONCLUSION
Transoral laser surgery is a safe method for removal of T and T a 2
REFERENCES
1. Alonso JM: Conservative surgery of cancer of the larynx. Trans Am
Acad Ophthalmol Otolaryngol 5 1 : 6 3 3 - 6 4 2 , 1947.
2. Leroux Robert J: La chirurgie conservatrice dans le cancer du larynx.
Ann Otolaryngol 7 4 : 4 0 - 7 4 , 1957.
3. Sanchez Rodriguez A: Fundamentos indicaciones técnicas y compli-
caciones de la laringectomia horizontal supraglotica. Acta Otorrino-
laringol Esp 1 8 : 1 3 3 - 1 3 9 , 1967.
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19. Davis RK, Kelly SM, Hayes J: Endoscopic C 0 laser excisional biopsy
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2 5 2 : 1 4 6 - 1 4 8 , 1995.
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80 H.H. Rudert
TABLE 1.
Obstructions of the Airway Rostrad from the Larynx
Allergic rhinitis
Midface hypoplasia
3 0
Deviated nasal septum, especially prevalent in cleft l i p and palate
patients
31
Intranasal stenosis (e.g., after nasal C P A P )
Foreign body
Nasolacrimal duct mucocele
Choanal atresia, stenosis
Adenoids
Cyst, polyp
Encephalocele
Teratoma, ectopic brain
Glossoptosis
Tonsils
Hypotonia of pharyngeal and tongue musculature
Thickened, poorly compliant soft tissues (e.g., mucopolysaccharidoses,
myxedema)
Small craniofacial dimensions
Tongue cysts, tumors, lingual thyroid gland
Neuromuscular dysfunction/incoordination
Inflammation, due to: mechanical trauma (e.g., suction catheter),viral or
bacterial infection, inhalant pollutants, chemical irritation (e.g., from
gastroesophageal reflux)
should have endoscopic assessment from the tip of the nose con-
tiguously into the bronchi: 1 1 . 5 % have lesions in more than one
anatomical site.
NOMENCLATURES
Universally meaningful terms are necessary. A "special child" is
one born extremely small (less than 1,500 g), is syndromic or dys-
morphic, or has neuromuscular impairment. The term "airway ros-
trad from the larynx" is preferable to "upper airway," because the
latter is neither precise nor unanimously defined. For example,
"upper airway" sometimes includes the larynx and even the bron-
chi (Table 2). Eponyms, often historic and honorable (e.g., Pierre
Robin), are no substitute for specific descriptive terms. Topo-
graphic and directional terms must be relative to a person, not nec-
essarily standing or supine. Hence, terms such as superior and in-
ferior, and above and below, are to be used cautiously.
Similar problems exist with the terms "normal" and "abnor-
mal." Is the special child "abnormal"? What is normal growth for
a child with Down's syndrome? This author prefers to avoid such
terms, electing instead to interpret tests and goals that are appli-
cable for each special child.
PATIENT ASSESSMENTS
HISTORY
What is the concern? Is it the cardiologist's worry that the pulmo-
nary arterial hypertension is disproportionate for the heart disease?
Does the family fear that the child will not be able to get another
breath during sleep? Is the endocrinologist wondering that chronic
airway compromise during sleep may explain the nonprogression
along the "normal" age/height graph?
What has the family noticed? During sleep, does the child
struggle to inhale, but no air flows (obstructive apnea)? Or, during
sleep, does the child sometimes make no motion whatever to
breathe? Can the child breathe normally when awake? When
awake, but supine? Does feeding or swallowing exacerbate the
breathing problem? Choking? Is the sleep breathing problem
present nightly? Is the problem inhaling, or exhaling, or both? Are
there birth marks—hemangioma? Cafe au lait? What does the fam-
ily wish? Is the family's depiction of the problem consistent or
vague? What other practitioners have been sought? Did the chiro-
practor manipulate the neck of a child with stigmata of Klippel-
Feil syndrome? Are there neurologic problems—seizures, a weak
hand, arm, or leg, bed-wetting, encopresis?
84 N.W. Todd
TABLE 2.
Nomenclatures
Term Meaning
Upper airway The supraglottic airway, i.e., the velopharynx,
32 33
oropharynx and h y p o p h a r y n x '
"from the nares or mouth to and including the
26 3 4 3 5
larynx" ' '
28 3 6 , 3 7
the trachea and a b o v e '
38
the bronchi and a b o v e
"special child" ex-premie ( < 1 . 5 g), syndromic, dysmorphic, or
neuromuscularly impaired
stridor noisy breathing, sufficiently intense to be heard at
the bedside
retrognathia posterior displacement of the chin; a more accurate
39
and inclusive term than micrognathia
macroglossia large tongue, either absolutely or relatively
glossoptosis tongue falling backward in the throat
sleep apnea lack of air movement for at least 10 seconds
Muller maneuver deep inspiration with partial occlusion of the nares
and mouth
obstructive sleep cessation of airflow for at least 10 seconds, despite
apnea continuing ventilatory effort, five or more
episodes per hour, usually associated with a
lowering of S a 0 of at least 4%
2
PHYSICAL EXAMINATION
Both a general and airway-focused physical examination are ap-
propriate. What is the child's general status? Frail? Small for age?
Of short stature but obese? Ambulatory? Wheelchair bound? A bas-
ket case? That is literally, being carried about, unable to even roll
over? Measure the patient's length (height), weight, and head cir-
cumference, and plot these data on a normative growth chart and,
with prior data, check the progression.
Is the midface hypoplastic? Is there air flow through each
nostril, at the cotton wisp test? Is the mandible small? Is the
The Special Child's Airway From Nose to Larynx 85
ENDOSCOPY
Just as the parents' description and the clinical physical examina-
tion provide information about the child's breathing problem, so
does visualizing the interior of the breathing passages. Note, how-
ever, the obvious: endoscopy reveals the interior perspective and
does not provide information about subjacent tissues. For example,
endoscopy may reveal that the nasal vestibule is narrowed but only
hint at the fact that the narrowing is due to bony stenosis of the
pyriform aperture. Careful palpation, CT, and surgical exploration
identify the correct diagnosis.
Flexible fiberoptic scopes have revolutionized endoscopic as-
sessment of the airways. Steerable scopes smaller than 1 mm in
diameter are available. In general, the smaller the diameter of the
scope, the poorer the resolution, the more graininess, the less steer-
able (operator-controlled off-axis bending), the dimmer the illumi-
nation, the less the suction capability, and the greater fragility and
higher cost of the instrument. Notwithstanding these marvelous in-
struments, user training and experience are challenging. Few en-
doscopists have a practical working knowledge of (1) the periph-
eral distortion of the optical image, (2) the imprecision of estimat-
ing the size of items viewed, and (3) that "what you see, depends
on where you stand," that is, the image is determined by the posi-
tion of the tip of the scope. Change the angular orientation of the
tip of the scope, its depth in the lumen, or its position within the
lumen and a very different view is appreciated. A snapshot is not
sufficient; rather, multiple contiguous images are demanded.
The endoscopic appearance of the interior of the nose is not
affected by neck or mandible position or by swallowing or phonat-
86 N.W. Todd
ing or the Miiller maneuver. In contrast, the velum and entire phar-
ynx and tongue are greatly affected, and endoscopy should include
the evaluation of these effects on the airway lumen. Also, fiberop-
tic endoscopy may include assessing the effects of sedation or an-
esthesia; to our diagnostic advantage, sites that intermittently ob-
struct may thus be recognized. Using these techniques, faucial ton-
sils that were unimpressively small at intraoral inspection may be
appreciated to be important obstructions.
The cervical spine may be at risk during endoscopic and
other procedures in "special" children. Patients at extra risk
include those with Down's and Hurler's syndromes, as well as
those with skeletal dysplasia syndromes (e.g., Morquio's, spondy-
loepiphyseal dysplasia, pseudoachondroplastic dysplasia,
Klippel-Feil). Although hyperextension of the neck is sometimes
advocated for both rigid bronchoscopy and endotracheal intuba-
tion, the sniff position is generally preferable, particularly in
special children, for two reasons. The genioglossus muscle, which
helps keep the tongue from falling posteriorly, is laxed by neck
extension, and by anesthesia and sedatives ("Neck flexion reflexly
5
activates genioglossal discharge. . . , " ) A second reason to use
the sniff position is safety. Laxness of the cervical spine, espe-
cially recognized in patients with Down's syndrome, may result
in the odontoid process not only being aimed at the medulla
oblongata, but damaging it.
IMAGING
Traditional plain radiographs, fluoroscopy, CT (including three-
dimensional reconstruction), and MR studies all have roles in as-
sessing the airway of the special child. The role typically to con-
firm a diagnostic impression (from the aggregate of history, physi-
cal, and endoscopy), and helping to plan a therapeutic maneuver
(e.g., whether to approach choanal atresia transpalatally or trans-
nasally). Conferring with the radiologist is the optimal means of
deciding the appropriate study for a particular patient.
When a diagnostic impression is formed before imaging is ob-
tained, consider other pertinent information that imaging may pro-
vide. For example, if the diagnostic impression is nasal pyriform
aperture stenosis, then obtaining images that include the midface
and skull is reasonable, because the nasal deformity is associated
8
with absence of the anterior pituitary gland.
A false positive study, especially common in young infants im-
aged during exhalation with the neck flexed, is prominent retro-
pharyngeal soft tissues. Imaged during inhalation with the neck ex-
The Special Child's Airway From Nose to Larynx 87
POLYSOMNOGRAPHY
Most clinicians consider partial airway obstructions to have the
same consequences (hypoxemia and sleep disturbance) as com-
plete airway obstructions during sleep. Decreases in hemoglobin
oxygen saturation ( S a 0 ) below 9 0 % may be clinically significant,
2
8
and below 8 0 % are significant.
Concerns about polysomnography in children, not only special
children, include (1) no universal agreement on definitive stan-
dards for normal and abnormal respirations in different stages of
sleep; (2) the assumption that sleep in the laboratory is represen-
3
tative of the patient's usual sleep; and, (3) expense. There are no
first-night second-night polysomnography repeatability studies in
a pediatric population. The assumption is that the sensitivity of
polysomnography on a single night's study is sufficient to identify
9
the patient who suffers from frequent sleep apnea.
Interpreting the polysomnograms of children requires extra
considerations. The respiratory physiology of premature and term
infants, and probably of special children beyond infancy, differs
from adults in four ways. First, brain neural networks that initiate
and control breathing are incomplete even in term infants. Second,
there are differences in chemoreceptor sensitivity and brain activ-
ity, with age-dependent differences in response to hypoxia. Third,
respiration can be depressed by afferent impulses originating in the
upper airway. Fourth, the coordination between posterior cricoary-
3
tenoid muscles and diaphragm is incomplete. Normal infants tend
to enter rapid-eye-movement (REM) sleep directly, rather than pro-
10
gressing first through non-REM s l e e p .
Notwithstanding the concerns about test-retest agreement, nor-
mative data, and differences in respiratory physiology of infants
and adults, the general classification of sleep apneas seems appro-
priate to all ages of patients. The central apneas involve two sub-
types: (1) true central neurologic abnormalities with insensitivity
or adaptation to hypercapnia and/or hypoxia; and, (2) the neuro-
muscular disorders that include bulbar palsy, the muscular dystro-
phies, and so on. The obstructive apneas involve congenital or de-
velopmental airway obstructions (Table 1). Confusingly, even at
polysomnography, the distinction between central and obstructive
apnea is not always straightforward.
88 N.W. Todd
DIFFERENTIAL DIAGNOSIS
Table 1 shows an approach to the various diagnostic considerations
for airway compromise rostrad from the larynx. Multiple site of in-
volvement may exist rostrad from, within, and caudal to the lar-
ynx. Some obstructions are more assuredly addressed than others.
The cross-check principle, that all data from various sources
(history, physical, endoscopy, imaging, polysomnography) as-
semble into a meaningful whole, is especially applicable to the di-
agnosis of airway problems in special children. The data in these
special children often are inexact, accurate diagnoses are elusive,
and therapeutic endeavors are risky and ethically problematic. In
these regards, the challenges are daunting—just as daunting as ap-
plying the cross-check principle to a battery of audiologic data, or
for the aircraft pilot integrating continuously updating information.
If the history is variable and/or inconsistent with the other data,
then consideration should be given to a disordered parent-child re-
lation (e.g., Munchausen syndrome by proxy, child abuse).
Hundreds of syndromes involving the nose and throat are rec-
11
ognized. About 44 are associated with short or small nose and/or
anteverted nostrils; about 15 with cleft nose or bifid tip of nose;
about 12 with hypoplastic, small, flared nostrils or coloboma of
nostrils; and, about 12 with choanal atresia or stenosis. About 191
syndromes are associated with congenital anomalies of mouth, pal-
ate, and pharynx. Table 3 depicts some of the syndromes.
THERAPEUTIC INTERVENTIONS
ETHICS
Is it appropriate to consider a rigorously defined nonnormal
polysomnogram as "OK" for a now-tracheostomy-decannulated
CHARGE association child, whose family refuses the only remain-
ing therapy (another tracheostomy)? Or, considering management
options, what was the wisdom of obtaining that polysomnogram?
Why prolong the suffering of the child? Considering quality of life
issues for the special child with a tracheostomy, and the family's
quality of life, when is it "right" to perform a tracheostomy, and
when is it "right" to not perform a tracheostomy? For a child with
Down's syndrome, is it appropriate to use a standard growth chart,
or a growth chart based on Down's syndrome children of a genera-
tion ago? For each of these questions, the author's only answer is
to carefully and repeatedly work with the patient, family, pediatri-
cian, and others appropriately involved, to arrive at a consensus
with which all are comfortable.
TABLE 3.
Some Syndromes That Have Obstructive Apne a as a Finding, and Contributors to the Obstruction
Choanal Cranial
Hypoplastic atresia/ base Hypotonic Macro-
Syndrome Retrognathia maxilla stenosis anomaly pharynx glossia Other anomalies
Achondroplasia + + + Foramen magnum
Apert's + + + Trachea
Beckwith-Wiedemann +
Camptomelic + Trachea, bronchi, CNS
CHARGE + + CNS, ear, eye
Crouzon's + + + Trachea
de Lange + + CNS
Down's + + + + Lax cervical spine
Fetal alcohol + + Microcephaly
Fetal hydantoin + CNS
Hallermann-Streiff + +
Hemifacial microsomia + + Pharyngeal asymmetry
Holo-prosencephaly + + + + CNS
Larsen's + Dislocations, cleft velum
Marshall-Smith + + + + + CNS
Nager's + + + +
Otopalatodigital + + Cleft palate
Pfeiffer's + + + Trachea
Prader-Willi + Marked obesity, CNS
Robin sequence (isolated) +
Rubinstein-Taybi + + + + CNS
Shprintzen + + + Cardiac (conotruncal)
Stickler + + + Eye
Treacher Collins' + + + +
11
About 275 syndromes involve the nose and throat.
40
(Adapted from Shprintzen in Sher. By permission).
90 N.W. Todd
MANAGEMENT
Remove Obstruction
The most gratifying management of airway obstruction is to remove
the obstruction, e.g., obstructing adenoids and tonsils, foreign bod-
ies, choanal atresia, pyriform bony aperture stenosis, large naso-
lacrimal duct mucoceles, or nasopharyngeal teratoma. Notwith-
standing the gratifying results, the postoperative course can be
stormy. For example, patients with cerebral palsy undergoing ton-
sillectomy and adenoidectomy often have postoperative breathing
and feeding problems, so that hospitalization for them averages
12
nearly 1 w e e k .
The most difficult obstructions of the airway laryngrad from
the nose are those related to chronic inflammation or neuromus-
cular dysfunction. Mucosal inflammations attributable to viral or
bacterial infections, allergic response, mechanical trauma (e.g.,
repeated suctioning of the nose and pharynx with a catheter),
gastroesophageal reflux all the way into the choanae, inhalant
pollutants, and the edema of hypothyroidism are often sneaky
and may involve more than one etiology. Anecdotally, patency of
the inflamed nasal airway may be helped by injecting the inferior
turbinates with depot triamcinolone (10 mg/mL) after thoroughly
shrinking the turbinates with sympathomimetics, so that the risk
of vascular embolization of particles to the brain and eyes is
13
supposedly r e d u c e d .
For patients with Down's syndrome with obstructive sleep ap-
14
nea, Lefaivre et a l . report that "an aggressive surgical approach
aimed at correcting all anatomic abnormalities associated with up-
per airway obstruction was applied successfully" to seven chil-
dren. At a single operation for each patient, combined soft-tissue
and skeletal alterations included tonsillectomy (5), adenoidectomy
(6), tongue reduction (6), tongue hyoid suspension (4), septoplasty
(1), uvulopalatopharyngoplasty (7), inferior turbinectomy (6), max-
illary or midface advancement (2), and genioplasty (2). The patients
had intensive care for a mean of 10.3 days.
Numerous surgical maneuvers for positioning the glossoptotic
tongue to achieve airway patency have been made. In a consecu-
tive series of 53 infants with Robin sequence (micrognathia, wide
U-shaped cleft palate, and upper airway obstruction), nine got tra-
cheotomy and 24 got glossopexy. Twenty had "definitive" manage-
ment with a nasopharyngeal tube (stabilized with tape). The single
most successful procedure, at least short term, was nasopharyngeal
15
intubation.
The Special Child's Airway From Nose to Larynx 91
FIGURE 1.
Plain lateral radiograph of the head of a 7-month-old child with Apert's
syndrome. (See Challenging Airway, Worsened by Closure of Cleft Palate.)
Note the hard-wired nasopharyngeal airway tubes, the intracranial shunt
hardware, and the hardware from the craniofacial procedure.
92 N.W. Todd
turn, where the wire penetrates the wall of each tube, thence rout-
ing through each tube's lumen anteriorly, where each wire is in-
serted through the floor of the vestibule, to be tied "under" the up-
per lip, immediately anterior and caudal to the anterior nasal spine.
The patients can be fed by mouth. Cleansing of the tube lumen is
with saline drops, and gently suctioning with a catheter (just the
length of the tube), or gently puffing air with a bulb syringe. Con-
trary to the admonition that choking and vomiting are induced if
the tube is caudal to the epiglottis, at least some "special" children
tolerate such position.
Bypass With Tracheostomy
Although tracheostomy involves many practical and quality-of-life
issues for special children, it is necessary for some patients.
GROWTH CONSIDERATIONS
18
Children with obstructed airways are usually small in stature.
Such a statement is reminiscent of an old adage: a child who is
growing well but snores some, is doing OK. That is, do not worry
about sleep apnea in such a child. Sleep disturbances are associ-
ated with abnormalities in growth hormone secretion, which is
closely linked to the first period of slow-wave sleep (i.e., stages 3
19
and 4 of non-REM s l e e p ) . Presumably, the child who has such
troubled breathing that slow-wave sleep is not attained does not
secrete the normal spikes of growth hormone. Hence, the child's
height does not track typically with age.
The larynx of Homo sapiens is more caudal in adults than in
newborns. The laryngeal descent is a feature that distinguishes man
20
from monkeys and other m a m m a l s . The larynx descends one half
vertebral body from the seventh to ninth months of gestation. Nev-
ertheless, in the term newborn, the tip of the epiglottis is posterior
to the soft palate (in the so-called intranarial position), and the true
vocal cords are at the level of the junction of C1-C2. The larynx
descends nearly two vertebral bodies by age 2 years. In adults, the
true vocal cords are at the level of the junction of vertebral bodies
21
C4-C5.
Newborns with a small mandible do not necessarily have
growth catch-up with resolution of either the airway obstruction
The Special Child's Airway From Nose to Larynx 93
22
or the micrognathia. In normal individuals, the angle joining the
posterior/caudal borders of the mandibular ramus and body
changes from 130 degrees to 100 degrees from the newborn to the
23
adult.
In adults with vocal disturbances, a peculiar orientation of the
hyoid bone to the thyroid cartilage, in which the larynx is enclosed
in the concavity of the hyoid, may represent persistence of an em-
24
bryonal relation. Noted in some "special" children, such laryn-
geal enclosure may be exaggerated by long-term orotracheal intu-
bation. Other than a contributor to consternation in the care of
some children, the clinical significance of laryngeal enclosure by
the hyoid is unknown.
nose and pharynx, so that the tip of the tube is adjacently rostrad
from the arytenoids. Rather than relying on "rules of thumb" to es-
timate the length of such a tube, use a fiberoptic scope to assess
tube position. Another maneuver is the combination of adequately
decongesting the nasal mucosa and suctioning secretions, then in-
tubating the trachea "over" a flexible fiberoptic scope. Until a tra-
cheostomy can be placed, a colleague can digitally stabilize the tip
of an "endotracheal" tube in the introitus of the larynx, so that the
patient is ventilated.
Most, but certainly not all, of these emergency summons can
be avoided by a thoughtful preoperative assessment. The three
more subtle problems are limited cervical spine mobility, "high and
anterior" larynx, and limited mouth-opening mobility (e.g., due to
ankylosis of the temporomandibular joints, or faucial stenosis], A
combination of two (or more) of these snakes may well make oro-
tracheal intubation impossible. Difficult intubations have an ana-
tomical abnormality, even if that abnormality is not obviously rec-
ognizable.
ILLUSTRATIVE PATIENT V I G N E T T E S
BAD AIRWAY; DIFFICULT ETHICS
The fetal ultrasound study revealed multiple abnormalities, includ-
ing absent corpus callosum. The mother (a nurse) disagreed with
the father's admonition to have a "therapeutic abortion," or else
he would leave the home. Delivered after 33 weeks' gestation, the
baby had features of Opitz-Frias syndrome, the most desperate
problem being a glossoptotic airway. Trials of positioning and na-
sopharyngeal positive pressure did not relieve the intermittent "dy-
ing spells." After soul-searching, deliberate discussions with the
neonatologist, family, and ethicist, the child was taken to the op-
erating room for airway endoscopy and airway improvement, rec-
ognizing that tracheostomy may be required. A severely glossop-
totic airway, made more difficult by the small mandible, was found.
A tracheostomy was placed, while the child was ventilated through
a rigid bronchoscope.
Recall the initial meaning of the term patient: "one who suf-
fers, endures, or is victimized."
GRAVITATIONAL GLOSSOPTOSIS
A 7-week-old boy was emergently hospitalized because of troubled
breathing so frightening that the parents, pediatrician, and cardi-
ologist feared that he would not get another breath. A twin, the in-
fant had been delivered after 33 weeks' gestation, weighing 1.4 kg.
Tetralogy of Fallot had prompted Blalock-Taussig shunting at age
4 weeks. The child was discharged home on the eighth postopera-
tive day. Among the instructions for home care was the precaution
that he sleep supine (because the risk of "sudden infant death syn-
29
drome" is increased in prone-sleeping infants). He was given
medicines for presumptive gastroesophageal reflux.
Otolaryngic emergency consultation at age 7 weeks, when the
child had been transported by ambulance from the cardiologist's
office to the hospital, revealed inhalatory low-pitched stridor (ster-
tor) with frequent total airway obstruction during inhalation. When
placed prone, or into a lateral decubitus position, the child
breathed comfortably. When he held his mouth open, the breath-
ing was fine. He had dysmorphic features reminiscent of Noonan's
syndrome. His weight was 3.0 kg. Flexible fiberoptic nasopharyn-
goscopy revealed the tongue to be too posterior, so as to touch the
96 N.W. Todd
posterior wall of the pharynx and occlude the airway, but only
when the infant was supine. The pharyngeal airway was patent
when the baby was positioned into a lateral decubitus position. The
larynx appeared normal.
After verifying that the child did satisfactorily for 2 nights in
the hospital, he was sent home. The instructions were to avoid the
supine position, and to use the lateral decubitus position. In the
subsequent 5 weeks, he did well, became stronger, gained an addi-
tional 1.0 kg, and became able to sleep supine.
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1. Lowe AA: The tongue and airway. Otolaryngol Clin North Am 2 3 : 6 7 7 -
6 9 8 , 1990.
2. O'Connor DM: Developmental anatomy of the larynx and trachea, in
Myer CM III, Cotton RT, Shott SR (eds): The Pediatric Airway. Phila-
delphia, JB Lippincott, 1 9 9 5 , pp 1 5 - 2 4 .
3. Roloff DW, Aldrich M S : Sleep disorders and airway obstruction in
newborns and infants. Otolaryngol Clin North Am 2 3 : 6 3 9 - 6 5 0 , 1990.
4. Friedman EM, Williams M, Healy GB, et al: Pediatric endoscopy: A
review of 616 cases. Ann Otol Rhinol Laryngol 9 3 : 5 1 7 - 5 1 9 , 1984.
5. Norton ML: Normal practice of endoscopy and intubation, in Norton
ML, Brown ACD (eds): Atlas of the Difficult Airway: St. Louis,
Mosby-Year Book, 1 9 9 1 , pp 9 - 2 3 .
6. Beregszaszi M, Leger J, Garel C, et al: Nasal pyriform aperture steno-
sis and absence of the anterior pituitary gland: Report of two cases.
/ Pediatr 1 2 8 : 8 5 8 - 8 6 1 , 1996.
7. Schlesinger AE, Hernandez RJ: Radiographic imaging of airway
obstruction in pediatrics. Otolaryngol Clin North Am 2 3 : 6 0 9 - 6 3 7 ,
1990.
8. Rundell OH, Jones RK: Polysomnography methods and interpreta-
tions. Otolaryngol Clin North Am 2 3 : 5 8 3 - 5 9 2 , 1990.
98 N.W. Todd
VIRAL TRANSMISSION
It has been theorized for some time that juvenile disease is acquired
during birth by passage through an infected birth canal, and adult
disease is acquired by sexual contact. However, neither of these
theories has been well substantiated, and there is evidence for other
forms of transmission. For example, the database maintained by the
Recurrent Respiratory Papilloma Foundation reports the occur-
rence of RRP in 13 of 220 newborns delivered by cesarean section.
It is possible that the virus is present in amniotic fluid, and it is
also possible that the adult presentation is a latent infection
acquired perinatally rather than by sexual contact.
104 F.L. Rimmell
SURGICAL MANAGEMENT
ANESTHESIA AND AIRWAY MANAGEMENT
Many techniques have been proposed for management of the air-
way during surgery to treat RRP. The more common technique is
probably intubation with a laser-protected endotracheal tube. Our
preferred method is Venturi ventilation with a ventilating needle
attached to the laryngoscope placed above the larynx. Patients are
given propofol and fentanyl intravenously and lidocaine topically
over the laryngeal inlet and allowed to breath spontaneously. Once
the airway is secured, they are given a neuromuscular blocking
agent to maintain muscle paralysis throughout the remainder of the
procedure.
A difficult situation that may arise during use of the Venturi
technique is obstruction of the larynx, which can lead to pneumo-
thorax. In such cases we quickly debulk the larynx manually (us-
ing cup forceps) while the patient is apneic and then open the air-
way sufficiently to allow for ventilation.
Others avoid using Venturi ventilation during surgical manage-
ment of RRP because it is believed to lead to spread of the virus to
the distal trachea. We have used Venturi ventilation during opera-
tions to treat laryngeal or tracheal papillomas in more than 70 pa-
7, 1 0 , 1 6 1 7
tients, ' and distal tracheal spread is rare in our patients.
In addition, many of our patients have been referred to us after tra-
cheal spread occurred after treatment at institutions where Venturi
ventilation was never used.
Other techniques for ventilation during surgery to debulk pap-
illomas in the larynx and trachea include the apneic technique
with multiple intubations and transtracheal jet ventilation. In this
Management of Respiratory Papillomatosis 105
LASER SURGERY
The advent of laser surgery has not altered the goal of surgical man-
agement of RRP: to debulk as much as possible while maintaining
the airway and doing no harm.
The carbon dioxide laser greatly enhances the surgeon's abil-
ity to debulk disease. However, overzealous application of laser en-
TABLE 1.
18
The K a s h i m a Respiratory Papilloma Staging System
Location
Epiglottis 1 1 1
False vocal cord 1 1 1
Ventricle 1 1 1
True vocal cord 1 1 1
Subglottis 1 1 1
Tracheotomy site 1 1 1
Trachea 1 1 1
Carina 1 1 1
Mainstem bronchi 1 1 1
Total possible score = 27. Total score of 1-5 = mild; 6-11 = moderate;
> 1 2 = severe.
106 F.L. Rimmell
ergy can lead to significant scarring that can result in residual air-
way or vocal cord dysfunction, even after the disease goes into re-
20 21
m i s s i o n . ' In addition, a patient will not be cured of RRP disease
by vaporization of visible papillomata.
It is best to leave disease in the anterior and posterior commis-
sure, because most complications that occur after remission are re-
lated to damage and scar tissue in these areas. In an adult or older
child who has minimal disease and for whom preservation of voice
is more important than increasing airway diameter, we will care-
fully debulk the free edge of the vocal fold and the anterior com-
missure region, removing papillomata by hand, under the operat-
ing microscope.
Three other lasers are in common use for surgery: the argon
laser, neodymium yttrium-aluminum-garnet (Nd-YAG) laser, and
the potassium titanyl phosphate (KTP) laser. These lasers offer no
major advantages over the carbon dioxide laser in terms of achiev-
ing remission of RRP. However, energy from these lasers can be
transmitted by fiberoptic cable, which is an advantage in treating
disease in the distal airway. For example, the fiberoptic cable can
be passed alongside a Hopkins rod telescope or through the suc-
tion channel of a flexible bronchoscope for superior visualization
and control of disease in the distal trachea and bronchi of small
22
children.
Another surgical laser technique that has been studied for treat-
ment of RRP involves photodynamic therapy. Abramson et al.
found a statistically significant decrease in the rate of papilloma
23
growth after photodynamic t h e r a p y in a study in which they ad-
ministered 2.5 mg/kg of a dihematoporphyrin agent intravenously
48 to 72 hours before photoactivation using a tunable argon pump
dye laser emitting red light (630 nm) through a 4 0 0 m flexible fi-
ber. Duration of photoactivation varied from 100 to 200 seconds at
2
a light dose of 50 J / c m with no additional benefit found when this
2 2 4
dose was increased to 80 J / c m . Although the results are encour-
aging, there was no control group for comparison (each patient
served as his or her own control), and many of these patients might
have improved without treatment over the natural history of the
disease.
An additional problem with the method described by Abram-
son et al. is that argon pump dye lasers are expensive, not widely
available, and currently have few clinical uses. During the last 5
years, however, various pulse dye lasers have become relatively in-
expensive and more widely available. Often such lasers may be
found in the offices of local dermatologists and facial plastic sur-
geons. Reports in the dermatology literature indicate that use of
Management of Respiratory Papillomatosis 107
pulse dye lasers alone can lead to remission of cutaneous HPV, and
studies are underway in which these lasers are being used to treat
RRP in the larynx.
TRACHEOTOMY
Performing tracheotomy on a patient with laryngeal papillomato-
sis is frowned upon and thought to cause distal tracheal papillo-
matosis. However, from our experience, we have come to believe
that patients with tracheal papillomatosis have a more aggressive
form of the disease and thus require different management than the
17
majority of patients with R R P .
In our series of 35 children, 13 required tracheotomy, in six
cases as an emergency procedure to manage airway obstruction.
The more aggressive disease in these 13 patients was usually
1 6
caused by HPV l l . They presented to us at an earlier age (21.4
months vs. 52.3 months) and required more surgery before trache-
otomy (an average of 0.95 procedures per month vs. 0.62). Ten of
the 13 children have been decannulated, usually when the disease
went into remission, at an average age of 6 years and 4 months.
Distal tracheal disease developed in 2 patients who did not
undergo tracheotomy.
Our current recommendation is that if a child is presenting
more frequently than every 6 weeks for a procedure due to airway
obstruction, tracheotomy should be considered. Although papillo-
mas will grow around the tracheotomy site due to squamous meta-
plasia at the site, these lesions will typically disappear when the
disease goes into remission.
MEDICAL MANAGEMENT
A number of adjunctive medical therapies have been tried for pa-
tients with RRP. To date only interferon has been studied in large,
controlled clinical trials, and the benefits of this drug are still in
question.
INTERFERON
Interferons are polypeptides produced by cells in response to vari-
ous protein stimuli, particularly viral particles. Interferons are clas-
sified by cell of origin and type of inducer. Type 1 interferons are
induced by viruses and include leukocyte (alpha) and fibroblast
(beta) interferons; type 2 interferons include immune gamma in-
terferon, which is secreted by lymphocytes.
The first report of interferon therapy for RRP was published
in 1981 and showed improvement in two children with tracheal-
108 F.L. Rimmell
INDOL-3-CARBINOL
Indol-3-carbinol is a vitamin supplement. Initial reports of the re-
sults of administering this agent in uncontrolled fashion to patients
with RRP patients showed a substantial slowing in the visible
growth of lesions. Multi-institutional controlled studies are cur-
rently being carried out.
Although the exact mechanism by which indol-3-carbinol
might reduce papillomatous growth is unclear, the substance is
known to induce 2-hydroxylation of estradiol resulting in
2-methoxy-estrone. This effect on estrogen metabolism may be
related to the observation that RRP will typically go into remission
at about the time of puberty.
Alternatively, 16 hydroxylation of estradiol forms estriol,
which is thought to enhance papilloma proliferation. Newfield et
34
a l . demonstrated in tissue culture that 16 hydroxylation was sub-
stantial in the normal larynx, which is rich in estrogen receptors.
It was further demonstrated in culture that 2 hydroxylation
induced by indole-3-carbinol abrogates the proliferative effects of
34
estriol.
110 F.L. Rimmell
ACYCLOVIR
A report of an uncontrolled study in three patients showed an im-
35
pressive response of RRP lesions to acyclovir. The first patient re-
ported on was a 5-year-old child whose lesions disappeared after
she received 300 mg per day of acyclovir intravenously for 5 days.
Two additional children received between 500 and 600 mg a day for
35
6 months with resolution of visible lesions in both c h i l d r e n .
The rationale for the use of acyclovir to treat RRP is that it pre-
vents replication of DNA viruses. However, acyclovir is a purine
nucleoside recognized by the enzyme thymidine kinase, which
converts it to a triphosphate form and incorporates it into replicat-
ing DNA where it causes breaks in the replication cycle. Because
HPV does not use acyclovir-sensitive thymidine kinase for viral
replication, there is no explanation at present for any effects acy-
clovir may have against disease due to HPV.
Morrison and Evans used acyclovir to treat four children with
31
R R P . The first child suffered from severe laryngotracheal disease
that failed to respond to 6 months of treatment with both acyclo-
vir (500 mg per day) and interferon. The second child, a 3-year-old
also with laryngotracheal disease, showed some decrease in the
number of lesions after 2 months of treatment with 500 mg per day
of acyclovir; however, the evaluations were subjective and the de-
crease in lesions could have been due to the variation in lesion bur-
den over the natural history of the disease. The other two children
in this series showed no response to acyclovir.
Endres studied the effects of acyclovir in six patients, two of
36
whom stopped taking interferon to begin acyclovir. They admin-
istered doses of 10 mg/kg five times a day for 10 days, then 10
mg/kg twice a day for 6 weeks. There were no control subjects.
18
Evaluation of change in disease grade using both the K a s h i m a and
19
L u s k scoring systems showed statistically significantly more im-
provement in the four patients who had not received interferon
first, probably because the two children withdrawn from interferon
had such a strong rebound in papillomatous disease after with-
drawal.
Management of Respiratory Papillomatosis 111
ISOTRETINOIN
Isotretinoin is a retinoid and therefore an analogue of vitamin A.
Retinoids inhibit the proliferation of both normal and neoplastic
cells. They can also modulate the differentiation of epithelial tis-
sue, including the human laryngeal keratinocyte. These actions
make it reasonable that isotretinoin would help to control RRP by
stabilizing squamous epithelium.
Reppucci et al. studied the effects of retinoic acid on epithe-
lial cells in culture infected by HPV and found that the epithelium
changed from squamous epithelium to columnar and that the con-
37
tent of HPV DNA decreased.
Alberts et al. treated five patients with doses of between 0.5
mg and 2.0 mg/kg per day for between 5 and 24 months; within 9
months of the start of therapy, two patients experienced complete
38
remission and one responded partially.
Bell enrolled six patients in a randomized study of high dose
2
isotretinoin (100 m g / m ) vs. no drug and noted no clinical
39
improvement in those receiving isotretinoin.
Lippman et al. treated three patients with severe resistant dis-
ease with a combination of interferon alpha-2a (Roferon) at a dose
of 3 X 106 U per day and isotretinoin at a dose of 1 mg/kg per day.
The combined therapy greatly increased the time until the next sur-
40
gery compared to interferon a l o n e .
When we prescribe isotretinoin for our patients we follow liver
enzymes closely. We have obtained mixed results with this drug
and possibly would have had similar results if the disease were
allowed to follow its natural history. The combination of interferon
and isotretinoin seems promising; multidrug therapy with agents
that attack the virus in various ways may be necessary to keep rep-
lication of the virus in check.
METHOTREXATE
Avidano and Singleton reported treating three patients with meth-
41
otrexate with good results. Two patients received an oral dose of
112 F.L. Rimmell
1 mg/kg per week and one patient received one dose intravenously
followed by leucovorin rescue every other week. Although the
amount of disease was decreased, no patient achieved a complete
remission.
We have used methotrexate to treat a few of our patients with
severe disease, with mixed results.
RIBAVIRIN
Ribavirin is a synthetic nucleoside with low toxicity that is active
in the inhibition of both viral DNA and RNA synthesis. Ostrow, et
al studied rabbits infected by the Shope papilloma virus and found
a significant, dose-dependent reduction in wart production in those
42 4
receiving ribavirin. In an initial study in four patients, ' two
adults had complete remission and one adult and one infant had a
partial response to a ribavirin loading dose of 23 mg/kg adminis-
tered intravenously, followed by 23 mg/kg per day taken orally in
four divided doses. The goal was to achieve a blood level of 20 to
30 umiol/L of ribavirin. From these preliminary data, a full random-
ized blinded study was started and is near completion. Results
from the study at the University of Minnesota are encouraging;
however, the Shope papilloma virus is not the same as HPV, so the
effects of ribavirin for RRP remain in question.
DISEASE COMPLICATIONS
Pulmonary metastasis of HPV is one of the most feared complica-
tions of RRP. Metastasis occurs during the active stage of HPV rep-
lication and currently may be diagnosed by changes on the chest
x-ray and confirmed by finding lesions on a computed tomography
44
(CT) scan of the c h e s t . These lesions may be either solid or cavi-
tated, single or multiple (Figure 1 ) .
Metastasis of RRP is thought to result from surgical manipula-
tions in the airway during Venturi ventilation, jet ventilation, or
tracheotomy. However, we believe the metastasis is more likely due
to pathogenic spread of a more virulent form of the virus, prob-
ably in combination with decreased host immune response to the
HPV infection.
Pulmonary metastasis is difficult to manage and in most cases
results in death of the patient. Often, especially in patients whose
disease has persisted from early childhood, metastatic papillomas
45
contain evidence of squamous cell c a r c i n o m a . It is therefore our
policy to take an aggressive approach once the diagnosis of pul-
monary spread is made. If the disease is resectable, i.e., only a few
lesions are found, we refer the patient to a cardiothoracic surgeon
Management of Respiratory Papillomatosis 113
FIGURE 1.
Computed tomography (axial plane) scan through the chest of a 3-year-
old girl with metastasis of recurrent respiratory papillomatosis to both dis-
tal lung fields. Metastatic lesions appear as multiple high-density solid
masses (white arrow).
TREATMENT COMPLICATIONS
Many complications can arise as the result of surgical or nonsur-
gical treatment of patients with RRP, including damage due to a
laser fire during surgery, laryngeal web, laryngeal stenosis, subglot-
tic stenosis, posterior glottic stenosis, and pneumothorax.
Webs and stenosis are not uncommon problems in the treat-
ment of patients with RRP. They are usually due to aggressive sur-
gical technique but may also represent residual effects of the dis-
ease process that appear during remission. It has been our policy
114 F.L. Rimmell
SUMMARY
Overall, the treatment of HPV infection has changed little over the
last 50 years. The fundamentals of treatment continue to be debulk-
ing grossly visible lesions, maintaining an adequate airway, and
managing symptoms until remission occurs. Significant progress
has been made, however, in our ability to maintain an airway.
We have also gained in our understanding of virus behavior.
We now know that once the squamous epithelium of the airway is
infected by HPV, it is infected for life. Although infection is
chronic, changes in virus activity lead to periods of remission.
Human papilloma virus spreads by squamous metaplasia down
the airway. Laryngeal infection can be controlled by carbon diox-
ide laser surgery, and distal visible lesions can be removed with a
fiberoptic laser in a flexible bronchoscope. Patients may be offered
a trial of one or more adjunctive medications to induce remission
or control aggressive disease. Interferon has been the most exten-
sively studied, but its effectiveness is still in question. Interferon
should be reserved for those who require surgery at less than
8-week intervals or who have aggressive disease. To date, acyclo-
vir, indol-3-carbinol, methotrexate, cis-retinoic acid, and ribavirin
have all failed to show any great benefit for RRP. The cure for this
disease may involve multidrug therapy with a number of antiviral
agents; it is still over the horizon.
REFERENCES
1. Derkay CS: Task force on recurrent respiratory papillomas: A prelimi-
nary report. Arch Otolaryngol Head Neck Surg 1 2 1 : 1 3 8 6 - 1 3 9 1 , 1995.
2. Dollard SC, Broker TR, Chow LT: Regulation of the human papilloma-
virus type 11 E6 promoter by viral and host transcription factors in
primary keratinocytes. / Virol 6 7 : 1 7 2 1 - 1 7 2 6 , 1 9 9 3 .
3. Lindberg H, Fey S J , Ottosen PD, et al: Human papilloma virus and
carcinomas of the head and neck. Clin Otolaryngol 13:447—454, 1988.
4. Ward P, Coleman DV, Malcom AD: Regulatory mechanisms of papil-
lomavirus. Trends Genet 5 : 9 7 - 9 9 , 1989.
5. McGlennen RC, Ghai J, Ostrow R S , et al: Cellular transformation by a
unique isolate of human papillomavirus type 1 1 . Cancer Res
1 5 2 : 5 8 7 2 - 5 8 7 8 , 1992.
6. Liu Z, Ghai J, Ostrow R S , et al: The expression levels of the human
Management of Respiratory Papillomatosis 115
22. Rimell FL, Shapiro AM, Mitskavitch MT, et al: Pediatric fiberoptic la-
ser rigid bronchoscopy. Otolaryngol Head Neck Surg 114:413-417,
1996.
23. Abramson AL, Shikowitz MJ, Mullooly VM: Clinical effects of photo-
dynamic therapy on recurrent laryngeal papillomas. Arch Otolaryn-
gol Head Neck Surg 118:25-29, 1992.
24. Abramson AL, Shikowitz MJ, Mullooly VM, et al: Variable light-dose
effect on photodynamic therapy for laryngeal papillomas. Arch Oto-
laryngol Head Neck Surg 120:852-855, 1994.
25. Leventhal B, Kashima H, Levine A, et al: Treatment of recurrent la-
ryngeal papillomatosis with an artificial interferon inducer (poly IC-
LC). / Pediatr 99:614-616, 1981.
26. McCabe BF, Clark KF: Interferon and laryngeal papillomatosis—The
Iowa experience. Ann Otol Rhinol Laryngol 92:2-7, 1983.
27. Leventhal BG, Kashima HK, Week PW, et al: Randomized surgical ad-
juvant trial of interferon Alpha-nl in recurrent papillomatosis. Arch
Otolaryngol Head Neck Surg 114:1163-1169, 1988.
28. Kashima H, Leventhal B, Clark K, et al: Interferon alpha-Nl in juve-
nile onset recurrent respiratory papillomatosis: Results of a random-
ized study in twelve collaborative institutions. Laryngoscope 98:334-
340, 1988.
29. Mullooly VM, Abramson AL, Steinberg BM, et al: Clinical effects of
alpha-interferon dose variation on laryngeal papillomas. Laryngo-
scope 98:1324-1329, 1988.
30. Healy GB, Gelber RD, Trowbridge AL: Treatment of recurrent respira-
tory papillomatosis with human leukocyte interferon. N Engl J Med
319:401-406, 1988.
31. Morrison GAJ, Evans JNG: Juvenile respiratory papillomatosis: Acy-
clovir reassessed. Int } Pediatr Otorhinolaryngol 26:193-197, 1993.
32. Leventhal BG, Kashima HK, Mounts P, et al: Long-term response of
recurrent respiratory papillomatosis to treatment with lymphoblastoid
interferon Alpha-nl. N Engl J Med 325:613-617, 1991.
33. Heberhold C, Walther EK: Combined laser surgery and adjuvant in-
tralesional interferon injection in patients with laryngotracheal papil-
lomatosis, in Lasers in Otorhinolaryngology, and in Head and Neck
Surgery. Adv Otorhinolaryngol. Basel, Karger 49:166-169, 1995.
34. Newfield L, Goldsmith A, Bradlow LH, et al: Estrogen metabolism and
human papillomavirus-induced tumors of the larynx: Chemo-
prophylaxis with indole-3-carbinol. Anticancer Res 13:337-342, 1993.
35. Aguado DL, Pinero BP, Betancor L, et al: Acyclovir in the treatment of
laryngeal papillomatosis. Int J Pediatr Otorhinolaryngol 21:269-274,
1991.
36. Endres DR, Bauman NM, Burke D, et al: Acyclovir in the treatment of
recurrent respiratory papillomatosis. Ann Otol Rhinol Laryngol
103:301-305, 1994.
37. Reppucci AD, DiLorenzo TP, Abramson AL, et al: In vitro modulation
Management of Respiratory Papillomatosis 117
DIAGNOSIS
The most common symptom at initial diagnosis is enlarged cervi-
cal lymph nodes. Other common nasal symptoms are epistaxis, na-
sal obstruction, or blood-stained postnasal drip. Otologic symp-
toms such as otalgia, tinnitus, and deafness are also frequently evi-
dent. Less often, the patient's chief complaint is of headache, or
symptoms and signs of cranial nerve palsies are present.
Examination of the nasopharynx is difficult with the postnaso-
pharyngeal mirror. Endoscopes, either flexible or rigid, can be used
for thorough examination of the nasopharynx, and biopsies of sus-
picious areas in the nasopharynx may be carried out under direct
vision. The extent of tumor on the mucosal surface can be ascer-
tained by endoscopic examination, whereas the extent of deep in-
filtration may only be determined by radiologic examination such
as computed tomography (CT) or magnetic resonance imaging
(MRI).
CT
Plain X rays of the skull base and conventional tomography for the
examination of the nasopharynx for assessment of bony erosion
around the nasopharynx have now been replaced by CT. When ad-
justed to visualize osseus outlines, CT reveals unequivocal evi-
dence as to whether there is bony erosion. Computed tomography
with contrast gives superior images of soft tissues and provides in-
formation on the deep extension of the primary tumor and its lat-
eral extent. Enlarged paranasopharyngeal lymph nodes more than
1 cm in diameter may also be detected. A CT examination of the
neck can detect enlarged cervical lymph nodes and provide infor-
mation concerning the lymphatic spread of the disease.
The exact extension of the tumor is important in the staging of
11
the disease and in the planning of radiotherapy. Computed to-
mography is now considered essential in the assessment of patients
who have NPC.
MRI
Computed tomography can reveal the lateral and deep extension
of a tumor; however, differentiation of tumor from the surround-
ing mucosal and submucosal inflammation of the nasal cavity and
sinuses is sometimes not possible. Assessment of the vertical ex-
Carcinoma of the Nasopharynx 121
TREATMENT
RADIOTHERAPY
Because NPC is radiosensitive, the primary treatment modality is
external radiotherapy. The irradiation field covers the tumor in the
nasopharynx with its infiltration of surrounding tissue as deter-
mined by CT or MRI and enlarged metastatic lymph nodes in the
neck. The usual radiation dose delivered to the nasopharynx ranges
from 66 to 70 Gy and approximately 60 Gy to the neck. This dos-
age is usually given in 1.8 to 2 . 0 Gy daily fractions through two
13
lateral opposing fields with or without an anterior field. Because
there is a high propensity for metastasis of NPC to cervical lymph
nodes, the neck is always included in the irradiation field even
though there may be no clinically positive neck nodes. With the
delivery of 50 Gy to the clinically negative neck, improvement in
14
survival has been demonstrated. Current radiation treatment
gives an overall survival of 5 0 % in patients with NPC. The 5-year
survival rates for early stages range from 5 0 % to 9 0 % and that of
1 5 > 16
stages III and IV from 7% to 6 0 % .
In recent years, improved tumor control has been possible with
the modification of radiotherapy treatment plans. As an alternative
to conventional fractionation, accelerated hyperfractionation of ra-
17
diation dosage was shown to be beneficial. The development of
conformal radiation treatment after accurate delineation of the pri-
mary tumor by CT and MRI has also contributed to better tumor
122 W.I. Wei
SURGERY
In the management of NPC, surgery is reserved for the treatment of
recurrent or residual disease after external radiotherapy. Surgical
salvage may be considered when recurrent or residual tumor is ei-
ther in the nasopharynx or in the neck. When tumor is present both
at the primary site and in the cervical region, extensive disease is
probable and at present, surgery with curative intent should be con-
sidered with caution.
Carcinoma of the Nasopharynx 123
FIGURE 1.
Histologic slide of neck dissection specimen showing more tumor-bearing
lymph nodes pathologically (arrows) than are clinically evident (hema-
toxylin and eosin x 4 0 ) .
124 W.I. Wei
FIGURE 2.
Left, hollow nylon tubes placed accurately in the tumor bed after radical neck
dissection. Right, deltopectoral flap was used for resurfacing, covering the
irridium wires placed in the nylon tubes for brachytherapy.
SURGICAL RESECTION
Recurrent or persistent tumor in the nasopharynx may be too ex-
tensive locally for gold grain implantation to be useful. Occasion-
ally, the tumor may have extended into the paranasopharyngeal
space, and brachytherapy is not applicable. In these circumstances
surgical resection offers the only option for salvage.
Because the nasopharynx is located in the center of the head,
32
it is not easy to gain exposure to allow oncologic resection. Vari-
ous transantral and transnasal approaches to the nasopharynx en-
able visualization of the tumor but are inadequate for an oncologic
33
surgical procedure to be carried out. Whereas the inferior
approach through the palate can expose the entire tumor to allow
126 W.I. Wei
FIGURE 3.
Schematic CT. Upper, planned osteotomies of the maxilla (dotted line) and
posterior part of nasal septum. Lower, the maxilla is swung laterally while
remaining attached to the anterior cheek flap. The posterior part of the sep-
tum is removed to gain exposure.
128 W.I. Wei
FIGURE 4.
Nasopharyngectomy specimen delivered en bloc. Eustachian tube marked
by plastic tube (arrow).
FIGURE 5.
Histologic slide of nasopharyngeal carcinoma. Upper, tumor (T) encroach-
ing onto the eustachian tube crura (arrow) (hematoxylin & eosin X 4 0 ) .
Lower, high-power view showing tumor cells close to the crural cartilage
(hematoxylin & eosin X 1 8 0 ) .
130 W.I. Wei
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CHAPTER 8
The Use of Biological
Therapy in Cancer of the
Head and Neck
Jeffrey N. Myers, M.D., Ph.D.
Assistant Professor of Head and Neck Surgery, T h e University of Texas
M.D. Anderson Cancer Center, Houston, Texas
nally, some of the strategies for using gene therapy for the treat-
ment of neoplastic diseases will be addressed.
HISTORY
The ability to stably transfer or transfect DNA fragments into eu-
karyotic cells growing in vitro in tissue culture and to demonstrate
the expression of the transferred genes in the recipient cells
evolved as a research tool. It has led to tremendous advances in
identifying proteins important for the regulation of cell growth.
Subsequently, investigators have tried to adapt this technology to
the treatment of diseases in vivo. However, many issues needed to
be resolved to make this leap.
A group of scientists working at the National Institutes of
Health in the late 1980s and early 1990s were the first investiga-
tors to treat a patient using gene transfer methodology. In Septem-
ber of 1 9 9 0 , Drs. Michael Blaese, William French Anderson, and
Steven Rosenberg carried out the retrovirally mediated replace-
ment of the adenosine deaminase gene, the specific defect in a com-
bined immunodeficiency disorder known as adenosine deaminase
14
deficiency, in a patient with this disease. These same investiga-
tors were the first to use gene therapy to treat human cancers. They
initially treated two melanoma patients using the ex vivo admin-
istration of the gene encoding tumor necrosis factor (TNF) to the
patients' lymphocytes, followed by readministration of the lym-
phocytes to target the patients' cancer.
The use of gene therapy in these patients paved the way, in
terms of technology and overcoming ethical and regulatory issues,
for further developments in this area to take place.
Retroviruses
Retroviruses were the first viruses used for the transduction of
genes into the cells of higher organisms, and their biology has been
1 1
extensively characterized and optimized for this purpose. ' Retro-
viruses are RNA viruses that attach to cells and deliver their ge-
nome to the host, where it becomes "reverse transcribed," yielding
a double-stranded DNA intermediate known as a proviral genome.
The proviral genome can in turn become integrated into the host
chromosome, which enables the virus' genetic material to be effi-
ciently replicated as the cell proliferates. This stable integration of
the foreign gene into the host genome allows for long-term expres-
sion, which may be particularly beneficial in the treatment of cer-
tain chronic conditions.
To prevent these viruses from infecting new target cells, sev-
eral genes encoding proteins essential for production of the virus
are deleted. The result is that once the virus enters the cell, its ge-
nome can be replicated and the desired gene of interest can be ex-
pressed, but the virus cannot produce future generations of retro-
1(>
virus. Retroviruses have been proven to be safe in preclinical
studies and in several human clinical trials. However, the random
nature of viral DNA integration means there is a risk of viral inte-
gration that would disrupt the qualitative or quantitative expres-
sion of proteins important for maintaining cellular homeostasis or
preventing oncogenesis thereby promoting rather than inhibiting
tumor progression.
Other problems that have been encountered with practical
evaluation of retroviral vectors is their inherently low infectivity
rate and the loss of viral expression over time. Recent research
into retroviruses has focused on targeting specific receptors on the
recipient cells of interest to increase the infectivity of these
viruses and to improve the therapeutic ratio of virally mediated
17
therapies.
Another area that remains to be resolved is the optimization of
delivering a replication-defective retrovirus to an entire tumor. Be-
cause tumors are believed to arise from a single cell, it is believed
that the most successful strategies will be those that can target all
of the cells within a tumor. Because retroviral vectors used in gene
138 J.N. Myers
Adenoviruses
Adenoviruses, double-stranded DNA viruses, have become another
appealing system for gene delivery. Vectors based on the A d 5 vi-
rus have been particularly useful because of their ability to effi-
ciently transduce a wide variety of cell types, independent of their
13 15
mitotic s t a t u s . "
Like retroviral vectors, adenoviral vectors are constructed by
replacing host genes important for viral replication with the gene
of therapeutic interest. Generation of recombinant adenovirus
through homologous recombination at the El or E3 regions,
followed by passage through a packaging cell line that provides the
requisite El gene product in trans leads to a replication-defective
virus. In contrast to retroviral vectors, recombinant adenoviruses
can be produced at high titers. An additional advantage of these
recombinant viruses is their high level of transduction efficiency,
which results in excellent gene expression in a wide range of host
cells.
Naturally, the adenovirus system is not without disadvantages.
A humoral immune response to viral proteins, including the E2a
gene product, makes repeated administration of recombinant virus
potentially less effective. Strategies to overcome this problem have
been developed, including temperature-sensitive E 2 a mutations
and other viral gene deletions. Cytokines and immunosuppressant
medications have also been used to decrease the humoral as well
as the cell-mediated immune response to viral proteins.
The cellular toxicity of other viral proteins that may be
expressed in host cells can lead to cell death, which can make long-
term expression difficult to achieve. Long-term expression is also
inhibited by the lack of integration of adenoviral sequences into
the host genome. There is also a limitation on the length of DNA
that adenoviruses can accept. As with retroviral systems, issues of
specific delivery of adenovirus to the target cells of interest still
must be resolved.
Biological Therapy in Cancer of the Head and Neck 139
Antisense Strategies
During the past decade, antisense oligonucleotides and antisense
gene therapy vectors for the treatment of cancer have been areas of
54
intensive research activity. These novel technologies provide very
specific means of decreasing the expression of gene products es-
sential for the maintenance of the cancerous state. Antisense thera-
peutics take advantage of the specific base pairing of nucleic acids:
a short oligonucleotide or an antisense RNA transcript complemen-
tary to a gene of interest can bind to the gene's sense transcript and
prevent translation of functional protein by several mechanisms.
Through steric hindrance, the oligonucleotide can inhibit ribosome
assembly, message capping, splicing, and polyadenylation. In ad-
dition, oligonucleotide DNA/RNA hybrids can serve as substrates
for cellular RNAse H, which degrades the mRNA. An additional
mechanism through which some antisense reagents can decrease
gene expression is through nucleotide-mediated catalytic cleavage.
If designed properly, antisense therapeutics not only can recognize
a target gene of interest, it can also acquire a tertiary structure that
enables them to cleave the target message. These oligonucleotides
are known as hammerhead ribozymes, and their potential therapeu-
tic value is under investigation in preclinical studies.
Several qualities are requisite to the success of antisense nucle-
otides as therapeutic agents. A successful oligonucleotide must be
stable in serum and cells, must be readily taken up by cells, must
have only limited interactions with other cellular components, and
must have very specific base pair binding to cellular nucleic acid
54
targets. Because the normal phosphodiester backbone of nucleic
acid is readily degraded by a variety of serum and cellular nucle-
ases, chemically modified oligonucleotides have been designed to
resist nuclease destruction. However, certain chemically altered
oligonucleotides have nonspecific cellular toxicity. To enhance the
uptake of oligonucleotides by cells, oligonucleotides may be com-
plexed with cationic liposomes, polylysine, or other cationic com-
pounds.
Biological Therapy in Cancer of the Head and Neck 145
ies with this cytokine have shown it to have potent antitumor ef-
124
fects when administered either locally or s y s t e m i c a l l y . In addi-
tion, transduction of syngeneic fibroblasts with the IL-12 gene pro-
vides a cellular vehicle for IL-12 gene therapy that has also been
effective in preventing tumor establishment and inducing the re-
50
gression of established tumors in tumor m o d e l s . Initial studies
of systemic recombinant IL-12 in the treatment of immunocompe-
tent mice implanted with SCCVII squamous cell carcinoma cells
using systemic recombinant IL-12 and IL-12 gene therapy indicate
52
that this might be a useful agent in the treatment of SCCHN. Cur-
rently, phase I and II trials of recombinant IL-12 and IL-12 gene
therapy are underway.
tion, data accumulated during the past several years indicate that
the presence of a sufficient number of costimulatory molecules ex-
pressed on the surface of the APCs can enhance the immune re-
sponse to the tumor. The cell-surface proteins CD40, B 7 - 1 , and B7-2
in particular have been shown to be important for costimulating
1 2 6 1 2 7
the activation of antigen-specific T c e l l s . '
Dendritic cells are bone marrow-derived cells that express
CD40, B 7 - 1 , and B7-2 abundantly. They also express MHC antigens
and DEC-205, another antigen-presenting molecule and are be-
1 2 5 1 2 6
lieved to be the most potent APCs characterized to d a t e .
Studies have shown a more favorable prognosis in patients with
SCCHN whose tumors had more infiltration with dendritic cells on
1 2 8 , 1 2 9
immunohistochemical e v a l u a t i o n . This observation suggests
that the presence of dendritic cells in head and neck tumors may
more effectively stimulate the immunosurveillance and therefore
improve the patient's prognosis. Cancer immunobiologists are cur-
rently trying to exploit the potent APC activity of dendritic cells
to therapeutic benefit. Preclinical data using murine dendritic cells
pulsed in vitro with known tumor-specific peptides have been
shown to be an effective antitumor agent when the antigen-pulsed
1 1 3 1
cells are administered to tumor-bearing syngeneic m i c e . ' " ' ' Ad-
ditional work has shown that human dendritic cells pulsed with
specific tumor antigens are capable of inducing tumor specific
T-cells in tissue culture. The goal of current clinical investigations
at the University of Pittsburgh Cancer Center under the direction
of Dr. Michael Lotze and Dr. Walter Storkus is to generate tumor
reactive T cells in vivo by administering autologous dendritic cells
pulsed with tumor-derived peptides to enhance the antitumor im-
mune response.
SUMMARY
Exciting progress in the molecular and cell biology of head and
neck cancer has provided us with new ways to target cancer cells
more specifically. The possibility now exists with gene therapy of
targeting specific genetic defects found in certain tumor types us-
ing any one of a number of possible gene delivery systems.
Although specific problems with currently existing gene therapy
strategies remain to be addressed, encouraging preclinical and
clinical data indicate that this is a very promising area. In addi-
tion, the exquisite sensitivity of antibodies directed at tumor-
specific targets should make antibody-conjugated toxins, radioim-
munoconjugates, and antibodies alone viable therapeutic options.
Biological Therapy in Cancer of the Head and Neck 155
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Biological Therapy in Cancer of the Head and Neck 163
PATHOPHYSIOLOGY
Whereas the etiology of external nasal deformities is generally self-
evident and often discussed, the pathophysiology of septal deflec-
Septoplasty and Rhinoplasty in Pediatric Group 167
PEDIATRIC CONSIDERATIONS
Uncorrected facial trauma in the growing child can impair growth
of the midface. Periosteal elevation of the maxilla and miniplate
fixation of craniotomies have both been shown to stunt normal
7 9
growth in the animal m o d e l . " Canady, et al used the frontonasal
suture of weanling rabbits to show a continuum of restricted
growth from the sham operation, to semirigid fixation (analogous
10
to resorbable plates), to standard rigid fixation. It is our feeling
that significant maldevelopment can occur from displaced facial
fractures that are left unrepaired. Although exposure and perios-
teal elevation may compromise bony viability and potential
growth, displaced or distracted fragments probably have a greater
impact on facial maldevelopment. Accurate closed reduction usu-
ally represents the method of choice for managing craniofacial frac-
tures in the pediatric age group.
These observations of impaired development after significant
early facial trauma have led authors to extrapolate to the care of
nasal fractures as well as elective nasal and septal surgery. Studies
have attempted to identify those areas of the nasal septum that are
168 S.S. Park and C.W. Gross
FIGURE 1.
The nasal septum with growth centers shaded.
TECHNIQUE
There is an array of techniques for septoplasty in the pediatric age
group that maximize preservation of tissues. The closed reduction
of a septal fracture is performed in the acute setting whenever ap-
propriate. Silastic septal splints may be necessary to maintain
structural support to the fractured septum. The "septal swing" is
another technique of improving nasal airway while avoiding ex-
cessive resection of the quadrilateral cartilage. In this technique,
the mucoperichondrial flap is elevated on one side and the bony
cartilaginous junction is disarticulated posteriorly and inferiorly.
At times, a "boomerang" strip of cartilage is excised from the pos-
terior and inferior borders to allow more complete mobilization of
the cartilaginous septum. This is always necessary when a dislo-
cation and subluxation of cartilage over bone has occurred. The
septal cartilage remains hinged along its dorsal aspect to the up-
per lateral cartilages and the nasal bones. The septum will now
come to rest in the midline and can be sewn in place with fixation
to the periosteum of the nasal spine. Septal spurs and longitudinal
fractures require resection and are usually done under direct vi-
sion with bilateral flap elevation. When the cartilage has intrinsic
deviations and a bowed configuration, we prefer to alter the shape
rather than resect. Partial-thickness or full-thickness incisions on
the concave side of the cartilage will alter the intrinsic forces and
allow the cartilage to straighten. This scoring serves as relaxing in-
172 S.S. Park and C.W. Gross
FIGURE 2.
Endoscopic burr [Linvatec, 1 1 3 1 1 Concept Boulevard, Largo, FL 33773).
Burrs are 4 mm in outer diameter and the distal tip is circumferentially
protected by the outer sheath.
Septoplasty and Rhinoplasty in Pediatric Group 173
FIGURE 3.
A, lateral view of endoscopic burr position to reduce a septal spur. B, an-
terior view demonstrating retained septal cartilage continuity.
and bone while protecting the surrounding soft tissues from the
cutting surfaces (Fig 2). The drill is inserted under the flap and used
to reduce the cartilaginous or bony septal spur under direct vision
(Fig 3). Usually a partial reduction is needed before one can safely
dissect the flap off the posterior surface of the spur. The end point
is when the spur is reduced and access achieved. The contralat-
eral mucoperichondrium and a thin strut of cartilage in the area of
the spur remain, maintaining septal continuity.
Rhinoplasty in the pediatric age group is performed selectively,
and only rarely is native tissue resected. Aggressive changes such
as a dome division or a dorsal hump reduction through osteoto-
mies are not performed until pubertal growth is completed. Once
that has occurred, a standard intercartilaginous incision provides
the usual access to the nasal dorsum, and the profile is modified
with a Rubin osteotome, followed by a sharp resection of the car-
tilaginous dorsum, and finally lateral osteotomies. More subtle
asymmetries and contoured deformities can be addressed at an ear-
lier age with the endoscopic rhinoplasty drill (Fig 4). Access is
174 S.S. Park and C.W. Gross
FIGURE 4.
Lateral view of endoscopic burr used to modify the nasal bony dorsum.
26
gressive dome divisions and cartilage resections. These sutures
can be placed through the delivery or open approaches. A 4.0 clear
PDS (Ethicon, Somerville, New Jersey) suture is used for this, al-
though permanent nylon or polypropylene sutures can be used as
well. The intention is to reorient and reshape the tip cartilages
rather than remove them, which will allow continued growth and
development.
For closure, the mucoperichondrial flaps from the septoplasty
are reapposed with a through-and-through "quilting" technique
with an absorbable catgut suture. Sufficient flap apposition and
septal support can be achieved through this technique, obviating
the need for septal splints or intranasal packing. Only with rare
exception is intranasal packing used for the pediatric septoplasty.
The cartilage splitting incision is closed with 5.0 gut sutures in
simple stitches. Care is taken to use extremely small bites and avoid
grasping the lateral crura. Aggressive sutures here will cause some
distortion, particularly along the alar rim. When closing the open
rhinoplasty, 6.0 fast-absorbing gut sutures are used along the mar-
ginal incision with the same attention to placing small bites. The
columellar flap is similarly closed with simple stitches at each of
the corners. The rhinoplasty dressing is with V2-inch brown paper
tape alone. It serves to apply diffuse pressure over the nose and
minimize edema and hematoma formation. The nasal cast is usu-
ally not necessary unless bilateral osteotomies have been created.
REPRESENTATIVE CASE
A 19-year-old man was interested in a rhinoplasty that would re-
duce his nasal "hump" (Fig 5). Examination revealed a mild bony
prominence but with a subtle supratip depression and marked
blunting of the nasal frontal angle. Resection of the bony dorsum
alone would result in complete loss of the root of the nose and an
unnatural profile. We elected to augment the supratip area with a
septal cartilage onlay graft and only minimally reduce the bony na-
sal dorsum. This subtle contouring of the nasal bones and nasion
was achieved with the endoscopic rhinoplasty burr. The bony dor-
sum was lowered only slightly to match the augmented cartilagi-
nous dorsum, leaving the illusion that the hump had been resected
while preserving the nasal frontal angle (Fig 6).
CONCLUSION
Advances in septoplasty and rhinoplasty in the pediatric age group
have allowed us to revisit the concept that nasal surgery in chil-
176 S.S. Park and C.W. Gross
FIGURE 5.
Preoperative view of a 19-year-old man requesting resection of dorsal
hump. A, anterior view. B, lateral view.
Septoplasty and Rhinoplasty in Pediatric Group
FIGURE 6.
S i x months postoperatively after supratip augmentation and slight reduc-
tion of bony dorsum with the rhinoplasty burr. A, anterior view. B, lateral
view.
178 S.S. Park and C.W. Gross
REFERENCES
1. Adams W: T h e treatment of the broken nose by forcible straightening
and mechanical apparatus. Br Med J 2 : 4 2 1 , 1 8 7 5 .
2. Asch M: Treatment of nasal stenosis due to deflective septum with and
without thickening of the convex side. Laryngoscope 6:340, 1 8 9 9 .
3. Freer OT: T h e correction of deflections of the nasal septum with a
minimum of traumatization. JAMA 3 8 : 6 3 6 , 1 9 0 2 .
4. Cottle M, Loring R: Corrective surgery of the external nasal pyramid
and the nasal septum for restoration of normal physiology. EENT
Monthly 26:147, 1947.
5. Cottle M: Nasal surgery in children: Effect of early nasal injury. EENT
Monthly 30:32, 1 9 5 1 .
6. Sessions R B , Wenig BL: T h e nasal septum, in Cummings CW, Fredrick-
son JM, Harker LA, et al (eds): Otolaryngology—Head and Neck Sur-
gery. St. Louis, CV Mosby Company, 1 9 8 6 , pp 6 7 3 - 6 9 7 .
7. Munro IR: T h e effect of total maxillary advancement on facial growth.
Plast Reconstr Surg 6 2 ( 5 ) : 7 5 1 - 7 6 2 , 1 9 7 8 .
8. Hellquist R: Facial skeleton growth after periostial resection. Scand J
Plast Reconstr Surg(suppl) 1 0 : 1 , 1972.
9. Lin KY, Bartlett SP, Yaremchuck MJ, et al: An experimental study of
the effects of rigid fixation on the developing craniofacial skeleton.
Plast Reconst Surg 8 7 ( 2 ) : 2 2 9 - 2 3 5 , 1 9 9 1 .
10. Canady JW, Wayne I, Fellows DR, et al: Craniofacial growth in rabbits
after rigid or semi-rigid fixation of the frontonasal suture. Plastic Re-
constr Surg 9 8 ( 3 ) : 4 1 0 - 4 1 9 , 1996.
1 1 . Verwoerd CDS, Verwoerd-Verhoef HL: Developmental aspects of the
deviated nose. Facial Plast Surg 6 ( 2 ) : 9 5 - 1 0 0 , 1989.
12. Nolst-Trenit GJ, Verwoerd CD, Verwoerd-Verhoef HF: Reimplantation
of autologous septal cartilage in the growing nasal septum. I. T h e in-
fluence of resection and reimplantation of septal cartilage upon nasal
growth: An experimental study in rabbits. Rhinology 2 5 ( 4 ) : 2 2 5 - 2 3 6 ,
1987.
13. Vetter U, Pirsig W, Heinze E: Growth activity in human septal carti-
lage: Age dependent incorporation of labeled sulfate in different ana-
tomic locations. Plastic Reconstr Surg F e b : 1 6 7 - 1 7 1 , 1 9 8 3 .
14. Bejar I, Farkas LG, Messner AH, et al: Nasal growth after external sep-
toplasty in children. Arch Otolaryngol Head Neck Surg 1 2 2 : 8 1 6 - 8 2 1 ,
1996.
15. Gray LP: T h e development and significance of septal and dental de-
formity from birth to eight years. Int J Pediatr Otolaryngol 5 : 2 6 5 - 2 7 7 ,
1983.
Septoplasty and Rhinoplasty in Pediatric Group 179
HISTORY
More than 30 years has passed since the first report of a program for
12
newborn hearing assessment. Earliest techniques used loud
noisemakers and systematic observation of infant startle or arousal.
These initial, valiant efforts to identify hearing loss in the newborn
period were flawed by poor stimulus control, lack of specificity (ear
or hearing level), and the subjectivity in detection of an infant "re-
sponse." In addition, these programs were time and labor intensive.
CRIB-O-GRAM
loss. In the 70s, the Crib-o-Gram was developed by Simmons and col-
13
l e a g u e s in an attempt to automate the detection of startle with
motion sensors attached to the infant's crib. Sounds were presented
to the sleeping infant via loud speakers and movement on the part
of the baby that was coincident with the sound was assumed to be
response to the sound. All activity was recorded and stored in a
computer. Crib-o-Gram assessments could take between 1 and 24
hours to complete and although attempts had been made to address
the issue of objectivity, problems with time, cost, response habitu-
ation, and false positive identification of hearing loss as high as
3 2 % using the Crib-o-Gram made this technology infeasible for
1 4 , 1 5
widespread use.
Infants
Neonates Infants Requiring Periodic
(Birth to 28 days) (29 days-3 years) Monitoring
Family history of Concern regarding Family history of
hereditary childhood hearing, speech, hereditary childhood
sensorineural hearing language, or sensorineural hearing
loss developmental delay loss
In utero infection Bacterial meningitis In utero infection
(cytomegalovirus, and/or other (cytomegalovirus,
rubella, syphilis, herpes, infections associated rubella, syphilis,
and toxoplasmosis) with sensorineural herpes, and
hearing loss toxoplasmosis)
Craniofacial anomalies Head trauma (loss of Neurofibromatosis type
including pinna and ear consciousness) or II and
canal skull fracture neuro-degenerative
disorders
Birth weight < 1 , 5 0 0 g Stigmata of syndromes Recurrent or persistent
known to include otitis media with
sensorineural or effusion
conductive hearing
loss
Hyperbilirubinemia at Ototoxic medications Anatomic deformities
serum levels requiring used in multiple and other disorders
exchange transfusion courses or in that affect eustacian
combination with tube function
loop diuretics
Ototoxic medications Recurrent or persistent Neurodegenerative
used in multiple courses otitis media with disorders
or in combination with effusion for at least 3
loop diuretics months
Bacterial meningitis
APGAR scores of 0 - 1 (1
minute) or 0 - 6 (5
minutes).
Mechanical ventilation >
10 days
Stigma associated with
syndromes known to
include sensorineural
hearing loss
186 Y.S. Sininger
ABR
The 1980s brought about a flurry of activity from scientists and cli-
nicians on the use of ABR in the newborn nursery, usually within
the newborn intensive care unit (NICU), with infants having some
or many of the high-risk factors. Automatic detection of ABR had
not yet been introduced; standard ABR measures were evaluated
visually for response detection by audiologists, physicians, and sci-
entists. Comparisons with behavioral observation audiometry
(BOA) found the ABR to be much more sensitive to hearing disor-
14
ders and more specific (fewer false positives). Visual reinforce-
ment audiometry (VRA) is far superior to BOA for detection of hear-
ing loss but cannot reveal accurate hearing estimates in nonrisk in-
fants younger than about 6 months of age and in NICU graduates
2 2 , 23
until about 8 months of a g e .
A summary of ABR studies from the early to mid-1980s of in-
fants from high risk populations found that the technique would
fail about 1 5 % of the infants, whereas follow-up of these infants
24
determined that 3 . 5 % had sensorineural hearing l o s s . This con-
stituted a significant improvement over behavioral assessment, but
the general impression was that ABR was still too time consuming
and costly to perform on all newborns.
ure rates of ABR and OAE testing will be given in subsequent sec-
tions of this manuscript. Although the publication of their argu-
ments in Pediatrics may have done a great deal to convince pedia-
tricians against the need for universal screening, it has led to a
flurry of publication of important data and perhaps helped to unify
and intensify the efforts of groups who endorse universal NHS.
PRINCIPLES OF SCREENING
The World Health Organization has established a set of principles
for screening for any disease process that can be used to justify the
effort. These principles include the following: (1) Is the burden cre-
ated by the problem (disease) significant? (2) Is effective treatment
for the problem available? (3) Is the performance of the screening
device(s) adequate? (4) Is there evidence that early identification
and treatment improve outcomes over the alternative of waiting?
(5) Have costs been considered and evaluated? (6) Are there suffi-
cient resources and appropriate strategies to implement screening?
This section will discuss the ways in which the third principle
can be evaluated. Much of the controversy surrounding the imple-
mentation of NHS involves the adequacy of our screening tools.
However, based on current studies and application of basic prin-
ciples used to evaluate performance, it can be shown that adequate
screening tools are available for NHS.
TARGET DISORDER
Screening for a disorder first requires an exact specification of the
target disorder. Hearing thresholds lie on a continuum from nor-
mal to profound loss. In addition, hearing loss can differ by fre-
quency regions, can be conductive, sensory, or neural, and can be
different in the two ears. The type, degree, and configuration of
hearing loss that is targeted will influence the incidence of the dis-
order. Mild, unilateral conductive loss, for example, is much more
common than profound, bilateral sensory loss. The performance of
the screening tests relative to detection of the disease will also be
influenced by the defined target disorder. For example, it is much
easier and takes less time to screen for hearing loss using a high-
level ABR stimulus that will be sensitive to a moderate or severe
loss than to use a low-level stimulus in an effort to detect a mild
hearing loss.
A basic consensus on the target disorder for NHS has been
reached with surprisingly little controversy. The target designated
in the NIDCD-funded study is mild (30 to 40 dB), unilateral, or bi-
lateral hearing loss within the speech frequencies (500-4,000 Hz)
190 Y.S. Sininger
OPERATING CHARACTERISTICS
Once the target disorder is defined, the true presence or absence of
the disorder needs to be determined in some acceptable way. In
the case of hearing loss, the "gold standard" is usually a behav-
ioral measure of hearing that is administered sometime after the
newborn period, inasmuch as such tests are not accurate in infants
younger than 6 to 8 months of age. In some instances, a new test
will be compared to a more established procedure as a gold stan-
dard. This was the case in initial evaluations of OAE as a screener,
using ABR as a gold standard. There are four possible combina-
tions of results of the screening test and gold standard. The out-
comes are true positive (screening test positive and disorder is
present), false positive (screening test positive and disorder is ab-
sent), false negative (screening test negative and disorder is
present), and true negative (screening test negative and disorder is
absent).
Operating characteristics essentially compare the outcome of
the screening device and the gold standard test in some meaning-
ful way. Sensitivity defines the ability of the test to correctly
identify the disorder. In this case, sensitivity of a screening test
for newborn hearing loss is defined as the percentage of infants
with hearing loss who have a positive test. Sensitivity is com-
puted as the true positive divided by true positive plus false
negative.
It is important to note that to determine false negative rate, all
screened individuals must have the gold standard test. For
example, all infants screened, whether they pass or fail the screen-
ing test, would need to have a behavioral evaluation of hearing.
Because of the enormous cost of following up with a large number
of infants for 6 to 8 months or more, most studies merely assume
that all infants who pass the initial screen do not have hearing loss.
This assumption is invalid, and test sensitivity cannot be stated
explicitly unless the appropriate follow-up is done. Because of a
lack of follow-up on all infants, many studies do not report test
sensitivity.
Screening for Hearing Loss in Neonates 191
of all infants should fail a screening test because they have hear-
ing loss, the more that failure rates exceed this number, the less
value the test is seen as having. In other words, a test that can pass
only 7 0 % or 8 0 % of newborns will have an excessive false posi-
tive rate. Adequate screening tests today should have a pass rate
of more than 9 0 % to 9 5 % .
otitis media. Because this condition may not have been present at
birth, it is unclear if these constitute a false negative on the new-
born screening. This issue will need to be addressed in all studies
in which a follow-up behavioral test of hearing, say at 6 months or
later, is used as a gold standard to validate the newborn test.
The most current findings with TEOAE show that it is very im-
portant to clear the ear canal of debris before testing and to ma-
nipulate the ear canal to ensure against occlusion. When this is
done, and when evaluations are delayed until more than 24 hours
after birth, a much more acceptable pass rate (> 9 0 % ) can be ob-
tained for TEOAE universal newborn screening.
The ABR occurs during the first 10 to 20 ms after the stimulus and,
as the name implies, is generated in the auditory nerve and brain
46,47
stem auditory p a t h w a y . This evoked potential is present as
4
early as 25 weeks' gestational age and can be reliably recorded
regardless of sleep state. Consequently, the ABR is the most com-
monly used measure of auditory function, especially hearing sen-
sitivity, in newborns and young children.
Unlike the OAE, which does not depend on neural input, the
ABR is a representation of the neural impulses generated in the co-
chlea and transmitted via the auditory nerve to the brain stem. For
that reason, the ABR is sensitive to cochlear damage and sensory
hearing loss but will also be affected by neural disorders. This can
be both a strength and a weakness of this technique.
The ABR is generally divided into two categories for the pur-
poses of newborn screening. The ABR is referred to as "automated"
or conventional ABR. The test procedure is similar for both; how-
ever, the decision regarding the presence or absence of response is
made by computer algorithm in the automated version and by an
examiner via visual inspection of waveforms in the other. (For a
detailed description of automated objective analysis of ABR, see
48
Hyde, Sininger, and D o n . ) The distinction between automated
and standard ABR is an important one for several reasons. Auto-
mated detection should give fairly consistent results that reflect the
character of the population tested, whereas subjective detection
may show large variability across studies due to differences in judg-
ments across examiners. Automated detection also takes advantage
of optimizing the number of averages or sweeps needed to reach
an acceptable response in a given infant, rather than assuming that
a fixed number of sweeps is necessary, as is common with conven-
196 Y.S. Sininger
AUDITORY NEUROPATHY
Screening for auditory disorders has assumed that the nature of the
hearing loss to be detected was either sensory (cochlear hair cell)
or conductive in nature. In that case, we would expect similar but
not exact results from ABR and OAE. However, as the OAE and
ABR techniques have been more readily applied and refined, so
has the ability to distinguish cochlear and neural function. A sig-
198 Y.S. Sininger
PARENTAL CONCERNS
Among the arguments against NHS is the feeling that early identi-
fication of hearing loss may destroy the bond between infant and
parent. Other than concern, no real evidence of this happening
has been published. In my experience, parents bond as well with
their children with hearing loss as they do with children who have
normal hearing sensitivity, but in many instances, they are frus-
trated by the breakdown in communication. Dramatic advances in
language abilities of early-identified children with hearing loss
Screening for Hearing Loss in Neonates 199
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tials: Possible brain stem components detected on scalp. Science
167:1517, 1970.
2. Hecox K, Galambos R: Brainstem auditory evoked response in human
infants and adults. Arch Otolaryngol 9 9 : 3 0 - 3 3 , 1 9 7 4 .
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sponses in premature infants. / Speech Hear Res 1 8 : 4 5 6 - 4 6 5 , 1975.
4. Starr A, Amlie RN, Martin WH, et al: Development of auditory func-
tion in newborn infants revealed by auditory brainstem response. Pe-
diatrics 6 0 : 8 3 1 - 8 3 9 , 1977.
5. Salamy A, McKean CM, Buda F B : Maturational changes in auditory
transmission as reflected in human brainstem potentials. Rrain Res
9 6 : 3 6 1 - 3 6 6 , 1975.
6. Anderson SD, Kemp DT: T h e evoked cochlear mechanical response
in laboratory primates: A preliminary report. Arch Otorhinolaryngol
2 2 4 : 4 7 - 5 4 , 1979.
7. Kemp DT: Towards a model for the origin of cochlear echoes. Hear
Res 2 : 5 3 3 - 5 4 8 , 1 9 8 0 .
8. Johnsen NJ, Bagi P, Elberling C: Evoked acoustic emissions from the
human ear. III. Findings in neonates. Scand Audiol 12:17—24, 1 9 8 3 .
9. Bonfils P, Uziel A, Pujol R: Evoked otoacoustic emissions from adults
and infants: Clinical applications. Acta Otolaryngol 1 0 5 : 4 4 5 - 4 4 9 ,
1988.
10. Bess FH, Paradise JL: Universal screening for infant hearing: Not
simple, not risk-free, and not necessarily beneficial, and not presently
justified. Pediatrics 9 8 : 3 3 0 - 3 3 4 , 1994.
1 1 . Yoshinaga-Itano C, Sininger Y S , Finitzo T: From advocacy to interven-
tion: Steps for successful establishment of universal infant hearing de-
tection programs, 1997 (abstract).
12. Downs MP, Sterritt GM: A guide to newborn and infant hearing screen-
ing programs. Arch Otol 8 5 : 1 5 - 2 2 , 1967.
13. Simmons F B , Russ FW: Automated newborn hearing screening: The
Crib-o-Gram. Arch Otolaryngol 1 0 0 : 1 - 7 , 1974.
14. Durieux-Smith A, Jacobson JT: Comparison of auditory brainstem re-
sponse and behavioral screening in neonates. / Otolaryngol 14(suppl
14):47-53, 1985.
15. Durieux-Smith A, Picton T, Edwards CG, et al: T h e Crib-o-Gram in the
NICU: An evaluation based in brainstem electric response audiometry.
Ear Hear 6 : 2 0 - 2 4 , 1985.
Screening for Hearing Loss in Neonates 201
16. Northern JL, Hayes D: Universal screening for infant hearing impair-
ment: Necessary, beneficial and justifiable. Audiology Today 6 : 1 0 - 1 3 ,
1994.
17. Mahoney T: High-risk hearing screening of large general newborn
populations. Seminars in Hearing 5 : 2 5 - 3 7 , 1994.
18. Mauk GW, White KR, Mortensen L B , et al: The effectiveness of screen-
ing programs based on high-risk characteristics in early identification
of hearing impairment. Ear Hear 1 2 : 3 1 2 - 3 1 9 , 1 9 9 1 .
19. Watkin PM, Baldwin M, Laoide S: Parental suspicion and identifica-
tion of hearing impairment. Arch Dis Child 6 5 : 8 4 6 - 8 5 0 , 1 9 9 0 .
20. Epstein S, Reilly J S : Sensorineural hearing loss. Pediatr Clin North Am
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mature infants utilizing visual reinforcement audiometry (VRA). Ear
Hear 1 3 : 1 8 7 - 1 9 4 , 1 9 9 2 .
24. Jacobson JT, Jacobson CA: Principles of design analysis in high risk
infants. Seminars in Hearing 8 : 1 3 3 - 1 4 1 , 1987.
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loss associated with otitis media. Acta Otolaryngol 1 1 6 : 2 1 9 - 2 2 1 , 1 9 9 6 .
27. Bess FH, Tharpe AM: Performance and management of children with
unilateral sensorineural hearing loss. Scand Audiol 3 0 : 7 5 - 7 9 , 1 9 8 8 .
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202 Y.S. Sininger
EPIDEMIOLOGY
The patulous eustachian tube is a common occurrence inasmuch
as the tube has been found to be patulous in otherwise normal in-
dividuals. This condition has been identified in a small percent-
age of asymptomatic subjects when eustachian tube function is
tested. Zollner cited an incidence of 0 . 3 % in the general popula-
6
tion. Munker diagnosed a patulous eustachian tube in 6 . 6 % of 100
6
women who had a normal otoscopic examination. Elner and col-
leagues assessed eustachian tube function in a group of 102 adults
who had a negative history for middle ear disease and a normal
9
otologic examination, in a pressure chamber in Malmo, Sweden.
Of these 102 subjects, four ( 4 % ) were found to have patulous eu-
stachian tubes. It is likely that a small number of individuals who
have no symptoms of a patulous tube have a tube that is closed at
rest but its response to applied positive and negative pressure re-
veals a patulous tube; probably the tube is semipatulous.
Although the abnormally patulous eustachian tube that is
symptomatic is relatively uncommon, it is not rare. At the Mayo
Clinic, the diagnosis was made in 41 patients between 1940 and
1959 and in 95 patients during the 7-year period from 1960 to
1 0
1 9 6 6 . Chen and Luxford reported that 46 patients at the Oto-
logic Medical Group in Los Angeles had the diagnosis of a
1 1
symptomatic patulous eustachian tube from 1974 to 1 9 8 1 .
Pregnancy may be associated with symptoms of eustachian
tube dysfunction in which the tube may either be obstructed or pa-
tulous. The definitive study of this problem was conducted by
12
Derkay. He assessed eustachian tube function using the nine-step
tympanometric test and sonotubometry in three groups of women:
(1) 20 pregnant volunteers who had symptoms of eustachian tube
dysfunction; (2) 20 asymptomatic trimester-matched pregnant sub-
jects; and (3) 20 aged-matched women with no otologic symptoms
who acted as controls. Of the 20 symptomatic women, 16 (80%)
had eustachian tube dysfunction, whereas only nine ( 4 5 % ) of the
asymptomatic pregnant subjects and six ( 3 0 % ) of the control sub-
jects had dysfunction, a significant difference. Of these 60 women,
Abnormally Patulous Eustachian Tube 207
FIGURE 1.
T h e eustachian tube is part of a system that includes the palate, nose, and
nasopharynx at its proximal end and the middle ear and mastoid gas cells
at its distal end.
208 CD. Bluestone
PROTECTIVE FUNCTION
The eustachian tube normally protects the middle ear from
unwanted sound pressure (breathing and speech-produced) and
foreign substances (secretions) from the nasopharynx when the
tube is physiologically closed, and from nasopharyngeal secretions
during active opening due to its anatomical structure, which also
depends on an intact middle ear and mastoid so that a middle ear
and mastoid gas cushion is present. In the healthy individual, dur-
ing swallowing activity the nasopharynx is separated from the me-
sopharynx and hypopharynx and oral cavity due to velopharyn-
geal closure. Thus the nasopharynx—and eustachian tube-middle
ear—is protected from normal (saliva and food) and abnormal ma-
Abnormally Patulous Eustachian Tube 209
Pressure Regulation
Protection
Mucociliary
activity
Clearance
FIGURE 2.
Three physiologic functions of the eustachian tube (ET) related to middle
ear (ME). Abbreviations: NP, nasopharynx; TVP, tensor veli palatini
muscle; TM, tympanic membrane; Mast, mastoid gas cells; EC, external au-
ditory canal.
210 CD. Bluestone
FIGURE 3.
Physiologic active opening of the eustachian tube (ET) during swallowing
activity at which time the tensor veli palatini muscle (TVP) contracts and
dilates the tubal lumen. Abbreviations: NP, nasopharynx; ME, middle ear;
Mast, mastoid gas cells; EC, external auditory canal.
b e e n l i k e n e d t o a flask w i t h a n a r r o w n e c k , i n w h i c h l i q u i d i n t h e
n e c k (or t h e l u m e n o f t h e e u s t a c h i a n t u b e ) i s i m p e d e d from
e n t e r i n g t h e b u l b o u s p o r t i o n o f t h e flask (or t h e m i d d l e ear-
m a s t o i d gas c e l l s ) d u e t o t h e r e l a t i v e p o s i t i v e p r e s s u r e ( t h e m i d d l e
2 3
e a r "gas c u s h i o n " ) t h a t d e v e l o p s i n t h e b o d y o f t h e f l a s k .
FIGURE 4.
Ventilatory function in the normal and patulous eustachian tube (ET). In
the normal condition, the tube is closed at rest (A) and actively opens,
due to contraction of tensor veli palatini muscle (TVP) during swallow-
ing, which allows pressure regulation (i.e., ventilation) of gas between na-
sopharynx (NP) and middle ear (ME) (B). When the tube is patulous, the
ET lumen is open at rest (C), as well as during active opening (D). Abbre-
viations: TM, tympanic membrane; Mast, mastoid gas cells; EC, external
auditory canal.
212 CD. Bluestone
Sound p r e s s u r e
C e s s a t i o n of C e s s a t i o n of
breathing & s p e e c h breathing & speech
FIGURE 5.
Effect of nasopharyngeal (NP) sound pressure on the middle ear (ME) in
the normal and patulous eustachian tube (ET). In the normal ear, the ET
is closed at rest, which protects the ME from sound pressures produced
in the NP by breathing and speech (i.e., protective function of ET) (A).
During swallowing—and active opening of the tube—breathing and pho-
nation ceases (B). When the tube is patulous, NP sound pressures are trans-
mitted to the ME, inasmuch as the ET is open at rest (C), but sound pres-
sures are not transmitted during swallowing (D). Abbreviations: TVP, ten-
sor veli palatini muscle; Mast, mastoid gas cells; EC, external auditory
canal.
Abnormally Patulous Eustachian Tube 213
CLINICAL PRESENTATION
It is important to understand that the eustachian tube may be pa-
tulous periodically in normal individuals who are relatively
asymptomatic. Some patients will describe activities, such as vig-
orous exercise, that precipitate the condition, but the associated
symptoms are self limited and not troublesome. It is not uncom-
mon for women to have a short interval of symptoms of a patulous
tube during the menstrual cycle, which rarely comes to the atten-
tion of the clinician. But on the other hand, some patients have a
chronic problem with the condition. T h e most frequent symptom
associated with an abnormally patulous eustachian tube is auto-
phony, which is usually fluctuating and does not become apparent
until the patient has been erect for several minutes. Relief comes
from assuming a supine position or by placing one's head between
42
the k n e e s . These maneuvers effectively increase venous conges-
tion in the peritubal area. Acute rhinitis or any increase in edema
of the nasal mucosa and postnasal space usually is associated with
1
an improvement in symptoms. Symptoms may be exacerbated by
2
topical or systemic decongestants, fatigue, or nervousness.
Patients may present with an apparent psychoneurotic condi-
3 , 4 3
tion. Manipulation of the mandible as a means to close off the
eustachian tube may give the appearance of a tic or manifestation
of neurotic behavior. I have seen one young woman, who had a
long-standing unilateral patulous eustachian tube, turn her head
to the opposite side every 1 to 2 minutes as if she had a tic. In
reality, she was closing her tube with this maneuver, which allevi-
ated her symptoms. This aberration disappeared after successful
management (see "Catheter Obstruction of the Eustachian Tube,"
below).
Hyponasality and hyporhinolalia secondary to the attempt to
close the eustachian tube is a less common presentation of a patu-
1 , 4 4
lous eustachian t u b e . Ringing tinnitus, conductive hearing loss,
and vestibular symptoms are uncommon characteristics of a patu-
lous eustachian tube. Robinson reported an association between
45
patulous eustachian tubes and sensorineural hearing l o s s .
An important aspect of the failure of the tube to adequately
2b
close has been emphasized recently by Falk and Magnusin, who
Abnormally Patulous Eustachian Tube 215
DIAGNOSTIC TESTS
When a diagnosis of an abnormally patulous eustachian tube is sus-
pected from the clinical presentation, an intensive search for an
etiology is necessary, because a serious underlying disease may be
present. The diagnostic evaluation of the patient suspected of hav-
ing a patulous eustachian tube starts with a comprehensive history.
Symptoms of autophony as previously described are the hallmark
of the patulous eustachian tube. Autophony improves when the pa-
tient is supine or the head is in a dependent position, with the on-
set of symptoms developing within minutes or hours of assuming
42
an upright position. Otoscopy may be normal; however, tympanic
membrane findings may include atrophic changes. Synchronous
movement of the tympanic membrane with respiration has been
4 4 6 4 7
documented by Schwartze, Hartman, and V o l t o l i n i . ' - Oto-
scopy should be performed using a microscope with the patient in
the upright position, because engorgement of the eustachian tube
45
while in the recumbent position relieves the c o n d i t i o n . Move-
ment of the tympanic membrane is enhanced by occlusion of one
nares and closure of the mouth during forced inspiration and ex-
piration, or by using the Toynbee or Valsalva maneuvers. Gentle
pneumatic pressure in the external auditory canal may give the ap-
pearance of a flail tympanic membrane. Rarely, respiration and
speech may be heard with a microphone placed in the external au-
ditory canal. Video documentation of a flail tympanic membrane
can also identify a patulous eustachian tube.
TYMPANOMETRY
If a patulous eustachian tube is suspected and the tympanic mem-
brane is intact, the diagnosis can be confirmed by tympanometry.
The first report of using acoustic impedance in the diagnosis of a
4 8
patulous tube was by Metz in 1 9 5 3 . We have described a tympa-
n o m e t r y patulous eustachian tube test that is conducted with the
49 50
patient in the sitting position. ' One tympanogram is obtained
while the patient holds his or her breath and a second is obtained
while the patient is breathing normally. The fluctuation in the tym-
panometric line should coincide with breathing (Fig 6). The fluc-
tuation can be exaggerated by asking the patient to occlude one nos-
tril with the mouth closed during forced inspiration and expira-
216 CD. Bluestone
Normal Ear
Breath-Holding
Breathing
Forced Respirations
Breath-Holding
Breathing
Forced Respirations
TIME ( s e c o n d s )
FIGURE 6.
Examples of tympanometric patulous eustachian tube test. Upper panel
shows a normal test procedure of an ear of an asymptomatic individual.
Trace is relatively unchanged when breath-holding, during quiet breath-
ing, and even during forced respirations with one nostril closed. No naso-
pharyngeal pressure is transmitted to the middle ear: the eustachian tube
is not patulous. In contrast, the lower panel is a typical outcome when
the eustachian tube is patulous. T h e trace is unchanged during breath-
holding, but when breathing, the trace shows synchronous changes that
are exaggerated during forced respirations.
MANOMETRY
A more precise characterization of a patulous eustachian tube is
possible with determination of the passive eustachian tube open-
ing pressure when the tympanic membrane has a tympanostomy
tube or a perforation present. The patulous eustachian tube and
middle ear will not maintain applied positive middle ear pressure,
or the opening pressure is extremely low, such as 50 to 1 0 0 mm
4 9
H 0 , or there is no opening pressure (Fig 7 ) . In the clinical set-
2
FIGURE 7.
Manometric assessment when the tympanic membrane is not intact (i.e.,
tympanostomy tube or perforation present). When positive pressure is ap-
plied to the middle ear in which the eustachian tube is normal, a normal
opening pressure, such as 3 0 0 mm to 4 0 0 mm H 0 , is present (A). In con-
2
trast, when the eustachian tube is patulous, the middle ear will not main-
tain any positive pressure, that is, no opening pressure (B).
218 CD. Bluestone
OTHER TESTS
An audiogram should be obtained as part of the evaluation, as hear-
ing loss is often a part of the constellation of complaints associ-
ated with a patulous eustachian tube. Although some reports de-
scribe a unilateral sensorineural hearing loss of unknown etiology
on the same side as a patulous eustachian tube, no clear associa-
tion has been established between a patulous eustachian tube and
45
sensorineural hearing l o s s . Also, all patients should have an au-
diogram before any nonsurgical or surgical procedure to manage
the disorder.
Because a recent history of a patulous eustachian tube may be
present in patients with a central nervous system etiology such as
multiple sclerosis, a magnetic resonance imaging (MRI) scan of the
brain may be diagnostic, and a computed tomographic (CT) scan
of the base of the skull may be of benefit if a neoplasm of the na-
sopharynx was radiated in the past. Tolley and Phelps reported on
the usefulness of CT scans in diagnosing a patulous tube, with ex-
53
amples that included patients with hemifacial m i c r o s o m i a .
MANAGEMENT
Management of the patulous eustachian tube is related to the se-
verity of the condition and the patient's ability to deal with the
symptoms. However, all patients who have an underlying cause, if
found, should be managed appropriately. When a clear etiology is
not apparent, medical and surgical therapy is instituted, which is
aimed at ultimately decreasing patency of the eustachian tube lu-
men. The severity of symptoms will dictate the urgency with which
treatment is implemented.
NONSURGICAL METHODS
Children and adolescents rarely present with a patulous eustachian
tube. In this population, therapy is usually not indicated as the
symptoms are self-limited. An occasional, otherwise healthy child,
usually early in puberty, will have symptoms of autophony with-
out evidence of middle ear effusion, in whom the diagnosis of a
patulous eustachian tube is made by tympanometry. Autophony in
young school-aged children may not be described as such, but they
complain of vague symptoms that are referable to the ear, such as
Abnormally Patulous Eustachian Tube 219
SURGICAL METHODS
Surgical therapy is an alternative when less invasive methods of
treatment have failed. Although the middle ear should be ad-
equately ventilated when the eustachian tube is abnormally patu-
lous, myringotomy and tympanostomy tube insertion may be help-
11, 3 1 , 6 0
ful. It is likely that these patients have a tubal dysfunction
in which the tube is semipatulous, that is, the patulous condition
alternates with degrees of tubal obstruction. In my experience, myr-
ingotomy with tube placement is an appropriate first surgical thera-
peutic step for this condition. Chen and Luxford reported that of
the 60 ears of 46 patients with a diagnosis of a patulous tube, 32
ears ( 5 3 % ) were successfully treated with tympanostomy tube in-
11
sertion. Also, a more accurate assessment of eustachian tube
function—using manometry, the eustachian tube has either a very
low opening pressure when positive pressure is applied or the
middle ear will not maintain any positive pressure—can be
obtained when a patent tympanostomy tube is in place, rather than
using tympanometry (or sonotubometry) when the tympanic mem-
brane is intact.
Surgical reconstruction of the eustachian tube orifice has been
proposed as a management option to correct a patulous eustachian
tube. Simonton recommended closure of the eustachian tube ori-
81
fice in which a portion of the cartilage is inserted. This proce-
dure had either been unsuccessful in alleviating the symptoms or
led to complete stenosis of the eustachian tube and refractory
middle ear effusion, and is not advised today. Stroud and col-
Abnormally Patulous Eustachian Tube 221
42 62
leagues, and later Virtanen and P a l v a advocated a surgical pro-
cedure on the soft palate that involved transposition of the tendon
of the tensor veli palatini muscle with or without hamulotomy.
With limited follow-up, this procedure was reported to be success-
ful in approximately 7 0 % of cases; long-term follow-up of patients
treated with this method has not been reported. When we
performed this procedure in the monkey model, the animals did
indeed develop negative middle ear underpressures, or effusion,
63
or both, but these outcomes resolved with t i m e . It is highly un-
likely that this surgical procedure is effective for control of the pa-
tient's symptoms for the long term and is not recommended.
Various methods of blocking the pharyngeal opening of the eu-
stachian tube have been reported. Zollner infiltrated paraffin
around the eustachian tube orifice with transient improvement in
6
patulous symptoms. Ogawara and associates infused an absorb-
able Gelfoam glycerin mixture into the eustachian tube with a high
64
recurrence rate within 1 month of the procedure. O'Connor and
Shea injected polytetrafluoroethylene—Teflon paste—into the eu-
1
stachian tube orifice with transient relief. Pulec succeeded in re-
solving patulous symptoms in 19 of 26 patients with an injection
of Teflon paste at the anterior inferior margin of the pharyngeal eu-
10
stachian tube orifice. In my experience, it is difficult to obtain a
desired result using this procedure, even when the amount of Te-
flon injected is controlled by simultaneous monitoring of eusta-
chian tube function. More importantly today, Teflon injection in
the nasopharynx is contraindicated, because serious complications
1
have been reported, such as cerebral thrombosis and death. Most
likely this complication was the result of injection of the Teflon
directly into a blood vessel, inasmuch as initial aspiration to de-
termine if the needle was in a vessel is not possible with the metal
syringe used for this type of injection.
FIGURE 8.
Incision for anterior tympanomeatal flap (i.e., anterior tympanotomy) in a
right external auditory canal; if the anterior canal wall obscures adequate
visualization of operative site, a microdrill is used for anterior canalplasty,
or endaural approach is used.
224 CD. Bluestone
FIGURE 9.
Anterior tympanomeatal flap elevated and orifice of eustachian tube iden-
tified.
Abnormally Patulous Eustachian Tube 225
FIGURE 10.
Small-bore polyethylene catheter (e.g., No. 90) introduced into orifice of
eustachian tube to determine site, direction, and approximate length of 18-
gauge Medicut angiocath (Argyle Medicut, Sherwood Medical Industries,
St. Louis, Mo. 6 3 1 0 3 ) to be inserted.
FIGURE 11.
Small length of Medicut catheter cut to maintain a portion of flared tip.
226 CD. Bluestone
FIGURE 12.
Bone wax inserted into lumen of catheter.
FIGURE 13.
Narrow end of Medicut catheter inserted into orifice of eustachian tube
until tightly in place; flared end is in middle ear but not touching mal-
leus.
Abnormally Patulous Eustachian Tube 227
M a n o m e t e r or
Tympanometer
FIGURE 14.
Pressure manometer tests if eustachian tube is obstructed at this stage.
228 CD. Bluestone
FIGURE 15.
If the manometric assessment reveals a persistent low tubal opening pres-
sure, a small portion of tissue, such as fat, fascia, or pate can be inserted
laterally between the catheter and the middle ear end (i.e., bony or pro-
tympanic portion) of the eustachian tube.
Postoperative Care
The tympanostomy tube should be left in place until it spontane-
ously extrudes. Some patients will not require replacement of the
tympanostomy tube if their middle ear remains aerated and they
are without middle ear symptoms of a patulous tube or middle ear
negative pressure/effusion. Apparently there is sufficient gas pass-
ing from the nasopharynx around the catheter and into the middle
ear, but their eustachian tube is no longer patulous. Presumably,
there is enough gas exchange from the nasopharynx into the middle
ear to effectively ventilate the middle ear. However, if middle ear
negative pressure or effusion develops, then a tympanostomy tube
Abnormally Patulous Eustachian Tube 229
FIGURE 16.
Tympanomeatal flap is replaced and a tympanostomy tube is inserted into
anteroinferior portion of tympanic membrane.
Outcome
Of the 12 patients in whom relatively long-term follow-up (2 to 17
years) has been possible, half have had significant, long-lasting re-
lief of their symptoms and have not had complications related to
the tympanostomy tubes. Two patients have extruded their eusta-
chian tube catheters and tympanostomy tubes with continued re-
lief from their patulous tube symptoms. It is felt that these patients
developed adequate scarring of the eustachian tube lumen to ef-
fectively eliminate the patulous condition. Two patients with cath-
eters in place and extruded tympanostomy tubes with intact tym-
panic membranes have not experienced any episodes of middle ear
effusion. This finding supports the concept that in some patients,
there is gas exchange around the Medicut catheter. Because of the
tympanostomy tube, patients have not complained of aural fullness
after catheter placement. One patient who complained of postop-
erative tinnitus wanted the catheter removed, which was done
without any complication. However, that patient still has symp-
toms of a patulous tube bilaterally and has persistent tinnitus in
the previously operated ear, as well as in the unoperated one.
The success of the operation has improved greatly since the ad-
dition of the intraoperative assessment of eustachian tube function
to determine the degree of occlusion of the eustachian tube by the
catheter. Patients operated on early in this series had variable out-
comes.
REFERENCES
1. O'Connor AF, Shea JJ: Autophony and the patulous eustachian tube.
Laryngoscope 9 1 : 1 4 2 7 - 1 4 3 5 , 1 9 8 1 .
2. Miller J B : Patulous eustachian tube: Report of 30 cases. Arch Otolar-
yngol 7 3 : 3 1 0 - 3 2 1 , 1 9 6 1 .
3. Moore PM, Miller J B : Patulous eustachian tube. Arch Otolaryngol
54:643-650, 1951.
4. Schwartze H: Respiratarische bewegung des trommelfelles. Arch
Ohrenheilk 1:139, 1864.
5. Jago J: Functions of the tympanum. J5r For Med Chir Rev 39:496-520,
1867.
6. Zollner F: Widerstandsmessungen an der ohrtrapete zui prufung ihrer
weg sankeit: Eine neues verfakren und bisherige ergeanisse an ohrge-
sunden undkranken. Arch Ohren Nasen Kehlkapflteilk 140:137,1939.
Abnormally Patulous Eustachian Tube 231
43. Perlman HB: The eustachian tube: Abnormal patency and normal
physiologic state. Arch Otolaryngol 30:212-238, 1939.
44. Landes BA: Hyporhinolalia associated with eustachian tube dysfunc-
tion. Laryngoscope 77:244-246, 1967.
45. Robinson PJ, Hazell JWP: Patulous eustachian tube syndrome: The re-
lationship with sensorineural hearing loss. Treatment with eustachian
tube diathermy. J Laryngol Otol 103:739-742, 1989.
46. Hartman A: Experimentelle studien iiber die function der eustachis-
chen rohre. Veit Comp, 1879.
47. Voltolini R: Zwei eigenthiimliche Ohrenkrenkheiten Monatsschr
Ohrenheilkd 17:1-6, 1883.
48. Metz O: Influence of the patulous eustachian tube on the acoustic im-
pedance of the ear. Acta Otolaryngol 105:(Suppl 109)105-112, 1953.
49. Bluestone CD, Klein JO: Otitis media, atelectasis, and eustachian tube
dysfunction, in Bluestone CD, Stool SE, Kenna M (eds). Pediatric Oto-
laryngology, ed 3. Philadelphia, WB Saunders, 1996.
50. Bluestone CD: Assessment of eustachian tube function, in Jerger J,
Northern J (eds). Clinical Impedance Audiometry. Acton, Massachu-
setts, American Electromedics Corporation, 1980.
51. Henry DF, DiBartolomeo JR: Patulous eustachian tube identification
using tympanometry. J Am Acad Audiol 4:53-57, 1993.
52. Virtanen H: Patulous eustachian tube. Diagnostic evaluation by sono-
tubometry. Acta Otolaryngol (Stockh) 86:401-407, 1978.
53. Tolley NS, Phelps P: Patulous eustachian tube: A radiological perspec-
tive. J Laryngol Otol 104:291-293, 1990.
54. Dyer RK, McElveen JT: The patulous eustachian tube: Management op-
tions. Otolaryngol Head Neck Surg 105:832-835, 1991.
55. Morita M, Matsunaga T: Effects of an anti-cholinergic on the function
of the patulous eustachian tube. Acta Otolaryngol (Stockh) 458:63-
66, 1988.
56. Bezold K, Siebenman: Textbook of Otology for Physicians and
Students, Holinger J, translator. Chicago, EH Colgrove Co., 1908, p 141.
57. Halstead TH: Pathology and surgery of the eustachian tube. Arch Oto-
laryngol 4:189-195, 1926.
58. Eisner MF, Alexander MH: Silver nitrate cautery, in Coates CM,
Schenck MF (eds): Otolaryngology, vol 1. Hagerstown, Maryland, Prior
& Co., 1957, pp 17-19.
59. McAliffe GB: Dilatation and stenosis of the eustachian tube. NY Eye
Ear Infirm Rep 6:116-118, 1898.
60. Thaler S, Yamagisawa E: The abnormally patent eustachian tube. Arch
Otolaryngol 84:418-421, 1966.
61. Simonton KM: Abnormal patency of the eustachian tube-surgical
treatment. Laryngoscope 67:342-359, 1957.
62. Virtanen H, Palva T: Surgical treatment for patulous eustachian tube.
Arch Otolaryngol 108:735-739, 1982.
234 CD. Bluestone
6 3 . Cantekin EI, Phillips DC, Doyle WJ, et al: Effect of surgical alterations
of the tensor veli palatini muscle on eustachian tube function. Ann
Otol Rhinol Laryngol 89(suppl 6 8 ) : 4 7 - 5 3 , 1980.
64. Ogawara S, Satoh I, Tanaka H: Patulous eustachian tube. Arch Otolar-
yngol 1 0 2 : 2 7 6 - 2 8 0 , 1980.
6 5 . Bluestone CD, Cantekin EI: Management of the patulous eustachian
tube. Laryngoscope 9 1 : 1 4 9 - 1 5 2 , 1 9 8 1 .
66. Bluestone, CD: Otologic surgical procedures, in Bluestone CD, Stool
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ders Co., 1 9 9 5 , pp 2 7 - 1 2 8 .
C H A P T E R 12
Contemporary Aspects of
Nasal Reconstruction
Shan Baker, M.D.
Professor and Chief, Section of Facial Plastic and Reconstructive
Surgery, Department of Otolaryngology; Director, Center for Facial
Cosmetic Surgery, University of Michigan Medical Center, Ann Arbor,
Michigan
HISTORICAL APPROACHES
Previous methods of reconstructing full-thickness nasal defects
started with unlined flaps of the forehead, limited in length by the
hairline. The external contour of the nose and the airway became
distorted by scar contraction on the raw undersurface of the flap.
This led surgeons to provide a lining by folding the distal portion
of the covering flap on itself, thereby creating an internal and ex-
ternal surface with the same flap. Although this eliminated the raw
surfaces, a normal hairline position limited the availability of tis-
sue for infolding unless hair was transferred to the nose. Some sur-
geons attempted to modify the classic midline Indian forehead flap
to gain length and provide more tissue for nasal repair, often re-
sulting in unsatisfactory scarring of the forehead. Other surgeons
attempted to provide nasal lining by seeking sources other than
forehead skin. Residual skin from the nose was turned down as a
hinged flap based on scar tissue at the margin of the defect. Local
cutaneous flaps in the form of melolabial flaps were rolled over to
line the ala and columella. Split-thickness and full-thickness skin
grafts were also used for lining, either in a delayed fashion, plac-
ing them on the raw surface of the flap during a preliminary op-
eration, or placed at the time of the flap transposition. In the
former instance, the prelaminated flap was transferred to the nose
a few weeks later. Similarly, free mucosal or composite septal
mucoperichondrial-cartilage grafts were placed beneath the fore-
head flap and then the compound flap was transferred a few weeks
later. Each of these techniques provided both internal and external
epithelial surfaces for full-thickness nasal defects. However, each
method invariably provided a thick, stiff, and often contracted
mass of tissue with compromised vascularity. These methods of
providing nasal lining distorted the shape of the nose and often
contracted, causing obstruction of the airway.
Contemporary Nasal Reconstruction 237
CONTEMPORARY APPROACHES
During the last decade, reconstructive rhinoplasty has been raised
to a higher level of sophistication, with enhancement of aesthetic
6 8
results thanks to the contributions of Burget and M e n i c k . " These
surgeons have perfected sophisticated methods of nasal repair.
They emphasize replacing surgically ablated tissue with like tis-
sue. Skin is replaced with skin that matches in color and texture
as closely as possible. Cartilage and bone are replaced and mucosa
is used to replace any loss of the nasal lining. The concept of na-
sal aesthetic units has emerged, with an emphasis on reconstruct-
ing an entire unit, even if only a portion of the unit is missing.
Another important concept that has led to enhancement in the re-
sults of restorative surgery has been the emphasis on the placement
of incisions for local flaps along borders of aesthetic regions or
units to maximize camouflage of scars. Whenever possible, local
238 S. Baker
flaps are designed so that they are not transferred across the bor-
ders of aesthetic regions, particularly if the border has a concave
topography. An example of such a border is the alar facial sulcus,
which represents a concave border between three aesthetic facial
regions: the nose, the cheek, and the upper lip.
FIGURE 1.
A, topographic aesthetic nasal units; B, topographic aesthetic nasal units.
Contemporary Nasal Reconstruction 239
LINING FLAPS
Burget and Menick have studied the vascularity of the septal mu-
cosa and have discovered that the entire ipsilateral septal muco-
perichondrium can be transferred with a narrow pedicle contain-
6
ing the septal branch of the superior labial artery. Likewise, the
entire contralateral mucoperichondrium can be turned laterally as
a dorsally based hinge flap to line the sidewall of the nose based
Contemporary Nasal Reconstruction 241
fi
on the anterior and posterior ethmoid arteries (Fig 2). Burget and
Menick have also shown that if both right and left septal branches
are included in the pedicle, the entire septum can be rotated out
of the nasal passage as a composite flap containing a sandwich of
(l
cartilage between the two mucoperichondrial leaves (Fig 3). Such
flaps, whether they be composite or simple mucoperichondrial
hinge flaps, can be designed to extend from the floor of the nose to
within 1 cm of the junction of the upper lateral cartilage and car-
tilaginous septum. The flaps may extend posteriorly well beyond
the bony-cartilaginous junction of the septum, producing a hinged
0
mucosal flap measuring as much as 3 cm wide and 5 cm long.
These authors have also described a bipedicle flap of vestibular
skin and mucosa based medially on the septum and laterally on
the floor of the nasal vestibule. Such a flap is elevated off the un-
dersurface of the lateral c m s and mobilized inferiorly to reline alar
defects (Fig 4 and Fig 6, C). All of these lining flaps have a reliable
vascularity and are thin, providing natural physiologic material for
FIGURE 2.
A, the septal branch of the superior labial artery can supply a large ipsilateral
mucoperichondrial flap hinged on the caudal septum; B, exposed septal cartilage
is removed, maintaining an adequate dorsal and caudal strut; (Continued.)
242 S. Baker
FIGURE 2.
C, contralateral mucoperichondrial flap hinged on the dorsum can be turned lat-
erally to line the cephalic portion of the sidewall; D, a contralateral mucoperi-
chondrial flap hinged on the dorsum can be turned laterally to line the cephalic
portion of the sidewall; E, the ipsilateral flap is used to line the caudal portion of
nasal sidewall and ala.
Contemporary Nasal Reconstruction 243
FIGURE 3.
A, composite flap based on the dual blood supply of the septal branches of the
superior labial artery. A wedge of cartilage is removed to allow flap to be turned
outward; B, composite flap turned outward; C, bilateral hinged mucoperichon-
drial flaps are turned downward to provide lining for the reconstructed nasal ves-
tibule.
244 S. Baker
FIGURE 4.
A, full-thickness defects of the ala that do not extend cephalically more than 1.5
cm may be lined by a bipedicle vestibular mucosal flap based medially on the
septum and laterally on the floor of the nasal vestibule; B, the donor site for the
bipedicle flap is covered with a thin full-thickness skin graft; C, any remaining
skin of the ala is discarded. Auricular cartilage provides structural support to the
nostril margin.
Contemporary Nasal Reconstruction 245
the interior of the nasal passage. Because these flaps are thin and
supple, they do not distort the external shape of the nose nor do
they compromise the airway. Importantly, these well-vascularized
lining flaps allow the primary placement of cartilage grafts for
framework that, when properly fashioned, prevents excessive scar
contraction and nasal distortion.
FRAMEWORK
The dorsum of the nose is supported by the nasal bones and carti-
laginous septum: the sidewalls by the frontal processes of the max-
illae and upper lateral cartilages, the lobule by the intermediate and
lateral crura of the alar cartilages, the columella by the medial
crura, and the ala and soft triangles by stiff fibrofatty connective
tissue. If missing, the nasal framework of each unit must be com-
pletely replaced. Cartilage grafts can be used to replace the miss-
ing framework of the dorsum, lobule, and sidewalls. Additionally,
a strip of cartilage must be placed along the reconstructed nostril
margin whenever the connective tissue framework is missing. In
instances of alar reconstruction, this usually means placing a car-
tilaginous strip that spans the distance from the alar junction with
the cheek to the region of the soft triangle, even though these areas
do not normally contain cartilage. This is required to support the
nostril rim to prevent upward contraction of the nostril margin dur-
ing wound healing.
The function of the framework is to provide contour and main-
tain a patent airway. Framework grafts must be placed at the time
of initial reconstruction and should consist of grafts that, as nearly
as possible, replicate the exact size, shape, and contour of the miss-
ing framework. When covered by a thin, conforming cutaneous
flap, the contour of the framework is distinctively manifested and
produces a normal-appearing restoration of the missing part. The
framework grafts fix in place the soft tissues used in nasal repair
by virtue of providing a skeletal support of both lining and cover.
Bone and cartilage are the tissue grafting materials available to
the surgeon for replacing the framework of the nose. The frame-
work of the nasal dorsum may be replaced with bone or cartilage.
Cranial bone is the preferred material anchored to the frontal bone
with microplates. Limited inferior dorsal defects are best replaced
with septal or auricular cartilage when available. The dorsal frame-
work prevents cephalic contraction and subsequent shortening of
the nose. It also provides shape and projection to the bridge.
The framework of the sidewall can be replaced with septal
bone and cartilage or cranial bone formed into a trapezoid shape
246 S. Baker
and fixed to the dorsum and maxilla. It supports the middle vault
and prevents collapse. It also serves as a foundation for attaching
the lower framework of the nose, specifically the alar cartilages or
their replacements.
The lobule is shaped by the alar cartilages and the preferred
replacement framework is conchal cartilage grafts. By coincidence,
when turned upside down, the contralateral conchal cymba often
closely resembles the shape of the dome cartilage (intermediate
crura), and the conchal cavum resembles the shape of the lateral
crus. Grafts 5 mm wide from this area can be scored and bent to
replace the entire lower lateral cartilages. These grafts can be
placed bilaterally or unilaterally as needed and are fixed to any re-
sidual stumps of the medial and lateral crura. They support the
dome and recreate the contour of the nasal lobule. Additional pro-
jection and shape of the tip can be accomplished with Peck-type
4 X 9 mm cartilage grafts anchored on top of the reconstructed alar
7
cartilages or the fabrication of shield-shaped tip grafts placed cau-
dal to the cartilages.
Structural support for the columella can be provided by con-
chal cartilage grafts described for the lobule, but placed in such a
way as to span the gap in the medial crus or extend all the way to
the nasal spine if the entire medial c m s is absent. Septal cartilage
grafts are very effective for this purpose as well. Grafts must be
scored and bent so they replicate the diverging angle that naturally
occurs at the junction of the medial and intermediate crura.
An alar batten of septal or conchal cartilage 5 mm wide can be
used for the framework of the ala and soft triangles. The natural
curvature of the conchal cartilage makes this material preferable
to septal cartilage when available. A graft should be placed along
the proposed margin of the missing nostril from the alar base to
the nostril apex (Fig 4, C). It is inserted into a deep tissue pocket
in the alar facial sulcus and is attached medially to the framework
of the dome. Similar to the grafts used for the framework of the
dome, grafts must be thinned, scored, and bent to replicate the
bulging contour of the ala. If the nasal defect extends into the soft
triangle, the batten should extend beneath the diverging angles of
the intermediate and lateral crura to span any gap present (Fig 7,
C). The batten fixes the reconstructed alar rim in position, prevent-
ing upward migration and notching of the rim.
In summary, the surgeon must determine what part of the na-
sal framework is missing and replace it completely. Each replace-
ment part must be carefully shaped, thinned, scored, bent, and
fixed with regard to nasal projection, contour, alar rim position, and
Contemporary Nasal Reconstruction 247
COVERING FLAPS
Small defects of the nasal skin 2 cm or less can sometimes be re-
paired with local flaps harvested from the remaining nasal skin, if
there is sufficient redundancy of skin. Most notable of the local
9
flaps is the bilobe flap as modified by Zitelli. The bilobe flap was
originally designed for repair of nasal tip defects. Each lobe and
the defect were separated by 90 degrees for a total transposition
over a 180-degree arc. Although this recruited tissue for repair at
some distance from the defect, it also maximized the standing cu-
taneous deformities and the likelihood of development of a trap-
door deformity or pincushioning of both the primary and second-
ary flaps. Zitelli has emphasized the use of narrow angles of trans-
fer, such as 45-degree angles between lobes, so that the total arc of
tissue transferred occurs over no more than 90 to 100 degrees.
9
(Fig 5 ) . This reduces the standing cutaneous deformity and pin-
cushioning effects. Bilobe flaps are double transposition flaps that
transfer the wound closure tension from the initial defect through
FIGURE 5.
Bilobe flap designed so that each lobe has a linear axis 45 degrees from
the other. Each lobe is designed around one arc through the center of the
defect and another through the peripheral border of the defect.
248 S. Baker
secured with sutures, and the donor site of the secondary flap is
closed primarily. Lastly, the secondary lobe is transposed and
trimmed appropriately to fit without redundancy the donor defect
of the primary lobe.
The bilobe flap is most useful in patients with thin nasal skin
and laxity of skin along the nasal sidewall. The surgeon can esti-
mate the laxity by pinching the lateral nasal skin between the
thumb and index finger. Patients with thick sebaceous skin have a
higher risk of flap necrosis and development of trapdoor deformity.
Dermabrasion, 6 weeks after flap transfer, is recommended for most
patients reconstructed with a bilobe flap.
Although local nasal flaps can be used to repair defects 2 cm
or less on the nose, the majority of surface defects are best repaired
with skin from the forehead or cheek.
FIGURE 6.
A, full thickness defect of ala. Vertical height of defect is 1.5 cm; B, base view
shows loss of internal lining of ala. Vertical height of defect is 1.5 cm. (Continued.)
gives the flap an axial nature with an excellent blood supply. The
base is tapered superiorly to facilitate transposition and to reduce
the loss of skin from the upper portion of the melolabial fold where
the fold is more prominently manifested. A standing cutaneous de-
formity is marked distally so that the scar resulting from its exci-
sion will follow the line of the melolabial sulcus. The distal one
third of the flap is thinned, leaving 1 mm to 2 mm of subcutane-
ous fat in place. The donor site is closed primarily through
advancement. The pedicle is then divided 3 weeks later, at which
time the flap inset is partially elevated to allow for removal of ex-
cessive subcutaneous fat and scar from the proximal two thirds of
the covering flap. The flap is then trimmed of its tail of skin (car-
ried with it from the superior melolabial fold at the time of the ini-
tial transfer] and inset into the ala by joining it to the cheek skin
in the alar facial sulcus and to the nasal sill.
FIGURE 6. (cont.)
C, bipedicle vestibular mucosal flap is mobilized to provide lining to the defect.
A superiorly based subcutaneous pedicled interpolation flap is designed as a cov-
ering flap. T h e standing cutaneous deformity is excised distally in such a way
that the scar follows the melolabial and labiomandibular skin creases; D, flap in
position. Subcutaneous pedicle is visible at inferior border of flap. The pedicle is
divided 3 weeks after initial transfer. (Continued.)
FIGURE 6. (cont.)
E, three months after surgery. Note normal contour of alar facial sulcus; F, auricu-
lar cartilage graft placed at time of reconstruction provides structural support,
maintaining a normal contour to the nostril.
FIGURE 7.
A, full-thickness loss of ala and hemitip. Defect extends into medial cheek.
(Continued.)
FIGURE 7. (cont.)
B, ipsilateral mucosal flap hinged on caudal septum provides internal lining to
ala and hemi-tip. This flap is detached from septum 3 weeks after initial transfer;
C, auricular cartilage grafts replace missing lateral crus and provides structural
support to ala. Septal cartilage graft (arrows) provides structural support to soft
triangle; D, paramedian forehead flap is used to provide covering flap. Cheek ad-
vancement flap repairs the cheek and lip defect. (Continued.)
Contemporary Nasal Reconstruction 255
FIGURE 7. (cont.)
E, one year after surgery; F, note restoration of alar-facial sulcus and nasoalar
crease.
DEFECT CLASSIFICATION
Defects of the nose may be classified according to location, depth,
and size. The skin of the upper two thirds of the nose, columella,
and soft triangles is thin, nonsebaceous, and mobile. In contrast,
the lobule and ala are covered with immobile, thick, sebaceous
skin. Single-lobe transposition flaps may be satisfactory for smaller
defects of the upper nose because of the redundancy and mobility
of the skin covering the sidewall of the nose where the donor site
is located. They work less well for the nasal tip and poorly for the
ala because of secondary movement of adjacent free margins from
excessive wound closure tension. Full thickness skin grafts har-
vested from the preauricular area or forehead along the hairline
match the thickness and texture of the upper nose and if derm-
abraded postoperatively, often produce a satisfactory result. A skin
graft is also useful for limited defects of the columella and soft tri-
angles. Skin grafts are less favorable for the lobule and ala where
Contemporary Nasal Reconstruction 257
RECONSTRUCTION OF COLUMELLA
The columella is the most difficult region of the nose to reconstruct.
Small defects limited to 1.5 cm in greatest dimension can occasion-
ally be repaired with composite grafts from the auricle in nonsmok-
ers. The grafts should be chilled for 3 days after transfer, and sys-
temic steroids should be administered for 1 week. Preferably, al-
low the initial defect to heal by second intention and then perform
the composite graft after preparing a fresh recipient site by remov-
ing all scar and neoepithelialization. The graft should be oversized
by 2 mm to accommodate wound contraction.
Larger defects of the columella are best repaired, depending on
the extent of the tissue loss, with unilateral or bilateral, superiorly
based, interpolated melolabial flaps. Septal cartilage grafts should
be used for the framework. The initial flap transfer will produce a
thick columella that will require secondary thinning. Defects that
extend into the lobule from the columella require structural sup-
port with cartilage grafts and a paramedian forehead flap for cover.
258 S. Baker
By extending the incision for the forehead flap into or below the
brow, the flap can be made to reach the upper lip without exces-
sive wound closure tension.
Full-thickness defects of the columella and lobule are best re-
constructed with a tilt-out, hinged composite nasal septal flap (Fig
3). Mucosa of the flap is peeled downward bilaterally to provide
internal lining. Auricular cartilage grafts are attached to the com-
posite flap to replace structural support laterally. A paramedian
forehead flap provides an exterior covering.
RECONSTRUCTION OF LOBULE
Small, skin-only superficial defects of the nasal tip, may be cov-
ered with a local bilobe flap or full-thickness skin graft. However,
a paramedian forehead flap will usually give a more natural result,
because the entire esthetic unit is covered by the flap, placing scars
in aesthetic unit boundaries. Cartilage grafts should be used rou-
tinely along the margin of the nostril when the defect extends from
the lobule into the soft triangle. This is in addition to any missing
lower lateral cartilage that must be replaced as well.
Bilateral full-thickness defects of the lobule should be repaired
with a tilt-out, hinged composite septal flap as discussed (Fig 3).
Unilateral full-thickness defects, however, can be nicely recon-
structed with an ipsilateral intranasal hinge mucosal flap (Fig 7).
This flap spans the nasal passage on the affected side to provide
internal lining to the hemitip. After restoration of the absent carti-
laginous framework, a paramedian forehead flap provides surface
replacement. In instances of a hemitip defect, I usually only resur-
face the hemidome rather than the entire lobule (Fig 7 ) . Concomi-
tant with detachment of the forehead flap 3 weeks after transfer,
the hinged mucosal flap is released from the septum, restoring pa-
tency of the nasal airway.
SUMMARY
Reconstruction of the nose has progressed during the last decade
to a new level of finesse that allows the surgeon to restore near-
normal form and function to all but the most extensive defects of
the nose. These advances are based on the contemporary concepts
of respecting the borders of aesthetic units of the nose. The nose is
reconstructed separately from any extension of nasal defects onto
the cheek or lip, which in turn are repaired by tissue within their
respective aesthetic regions. The other concept that has contributed
to this higher level of surgical achievement is the replacement of
missing tissue with like tissue. Internal lining is replaced with na-
sal mucosal flaps that, because of their nature, provide adequate
vascularity to nourish and sustain the cartilage and bone grafts
used in skeletal replacement. Missing bone and cartilage are
replaced with similar tissue, which is carefully crafted to replicate
the exact size, configuration, and contour of the missing nasal skel-
eton. Surface defects are covered with cheek or forehead skin trans-
ferred by interpolation so as not to violate the aesthetic boundary
between the nose and the other regions of the face. This surgical
Contemporary Nasal Reconstruction 261
REFERENCES
1. Goepfert H, Arredondo R, McNeese MD: Cancers of the skin of the
nose. Otolaryngol Head Neck Surg 9 0 : 2 3 4 - 2 4 0 , 1982.
2. Barton FE Jr, Cottel WI, Walker B: The principle of chemosurgery and
delayed primary reconstruction in the management of difficult basal
cell carcinomas. Plast Reconstr Surg 6 8 : 7 4 6 - 7 5 2 , 1 9 8 1 .
3. Baker SR, Swanson NA: Management of nasal cutaneous malignant
neoplasms: An interdisciplinary approach. Arch Otolaryngol 1 0 9 : 4 7 3 -
4 7 9 , 1983.
4. Baker SR, Swanson NA: Reconstruction of midfacial defects follow-
ing surgical management of skin cancer: The role of tissue expansion.
J Dermatol Surg Oncol 2 0 : 1 3 3 - 1 4 0 , 1994.
5. Baker SR, Swanson NA, Grekin RC: Mohs surgical treatment and re-
construction of cutaneous malignancies of the nose. Facial Plast Surg
5:29-47, 1987.
6. Burget GC, Menick FJ: Nasal support and lining: The marriage of
beauty and blood supply. Plast Surg 8 4 : 1 8 9 - 2 0 3 , 1989.
7. Menick FJ: Reconstruction of the nose, in Baker SR, Swanson NA
(eds): Local Flaps in Facial Reconstruction. St. Louis, Mosby, 1995,
pp 3 0 5 - 3 3 7 .
8. Burget GC, Menick FJ: Aesthetic Reconstruction of the Nose. St. Louis,
Mosby, 1 9 9 3 .
9. Zitelli JA: Bilobe flaps, in Baker SR, Swanson NA (eds): Local Flaps
in Facial Reconstruction. St. Louis, Mosby, 1995, pp 1 6 5 - 1 8 0 .
10. Baker SR, Alford EL: Mid-forehead flaps: Operative techniques. Oto-
laryngol Head Neck Surg 4 : 2 4 - 3 0 , 1993.
1 1 . Menick FJ: Aesthetic refinements in use of the forehead flap for nasal
reconstruction: The paramedian forehead flap. Clin Plast Surg 1 7 : 6 0 7 -
622, 1990.
CHAPTER 13
Anesthesia for the
Pediatric Otolaryngic
Patient
Jimmy Scott Hill, M.D
Fellow, Department of Pediatric Otolaryngology, University of Pittsburgh
School of Medicine and Children's Hospital of Pittsburgh, Pittsburgh,
Pennsylvania
PREOPERATIVE EVALUATION
PSYCHOLOGICAL
The preoperative period is an extremely stressful time for both the
9
child and the parent. During this time, the anesthesiologist and/or
otolaryngologist must be able to address the child's otolaryngic dis-
order and other preexisting medical conditions, as well as the
child's and family's psychological and emotional needs. The goals
of the preoperative evaluation are, first, to alleviate the anxiety of
the parent and child, and second, to obtain an adequate medical
history and do a good physical examination. Preparation before ad-
mission to the hospital varies with the age of the child. Psychologi-
cal preparation of the child is paramount and must be tailored to
the individual according to his or her age. It is important that pri-
mary health care providers participate in the medical evaluation
10
and psychological preparation for a procedure. The psychological
11
reaction of the child can be separated into five basic fears : the fear
of separation from parent, the fear of physical harm or pain, the fear
of the unknown, the uncertainty of expectations or fear of punish-
ment, and the fear of loss of control, privacy, or autonomy.
Not every child will experience every reaction, but age groups
tend to exhibit fairly typical reactions. Clinically, the young infant
probably represents the greatest challenge to the physician. Be-
cause these children do not yet exhibit anxiety about strangers, the
Anesthesia for Pediatric Otolaryngic Patient 265
PHARMACOLOGY
Even with appropriate psychological preparation, a large number
of children will need preanesthetic medication to allay their anxi-
ety. For children, there are numerous options, as well as a vast ar-
ray of methods to administer these preanesthetic medications. In
some ways, the route of drug administration is just as important as
the drug itself. The different routes of administering preanesthetic
medications to children include intravenous (IV), intramuscular
(IM), oral (ingested), and transmucosal (nasal, rectal, or buccal)
(Table 1).
TABLE 1.
Dosage of Common Premedicant Drugs
Route of Administration
Oral
Class Drug per kg Oral IM Nasal Rectal Transmucosal Sublingual IV
ANTICHOLINERGICS Atropine mg .02-.04 .02-.03 — — — .02-03 .01-02
Glycopyrolate mg — 0.01 — — — — 0.005
Scopolamine mg — 0.01 — — — — 0.01
OPIOIDS Fentanyl M-g — 1-2 — — 10-15 — 1-2
Meperidine mg 2-3 1-2 — — — — .5-1
Morphine mg .1-.2 .1-.2 — .1-2 — — .05-1
Sufentanil M-g — ,2-.6 1.5-3.0 — — — —
BARBITURATES Methohexital mg — 7-10 — 20-30 — — .25-1
Pentobarbital mg 2-6 3-5 — 3.5 — — —
Secobarbital mg 2-6 3-5 — 4-5 — — —
Thiopental mg — — — 30 — — 1-2
SEDATIVE-HYPNOTICS Chloral hydrate mg 30-50 — — — — — —
Diazepam mg .1-2 — — .5-.75 — — .05-.1
Ketamine mg 3-6 2-3 3-6 5-10 — — .2-.3
Midazolam mg .5-1 .1-.2 .2-. 3 .3-1 — .1-.2 .07-.1
Propofol mg — — — — — — .3-. 6
Triazolam mg 0.02 — — — — — —
Triclofos mg 70 — — — — — —
ALPHA 2 AGONISTS Clonidine mg 4 — — — — — —
Abbreviations: kg, kilogram; mg, milligram; \xg, microgram; IM, intramuscular; IV, intravenous.
Anesthesia for Pediatric Otolaryngic Patient 267
REGARDING FASTING
Questions regarding fasting requirements occur frequently with pe-
diatric patients. Recently, guidelines for preoperative oral intake
have undergone extensive changes. Studies have shown that intake
of a clear liquid up to 2 to 3 hours before anesthesia does not sig-
nificantly change the volume in the stomach or alter the pH of gas-
1 3 - 1 5
tric c o n t e n t s . Clear fluids 3 hours before surgery do not affect
1 6 , 1 7
the gastric fluid contents of c h i l d r e n . We currently recommend
that children be allowed to have clear liquids freely until 3 hours
before induction. The fasting period after ingestion of solids is 6
hours. Each hospital will have its own policy, and the physician
involved should know the hospital policy when discussing fasting
requirements with the family.
BLOOD TRANSFUSION
A frequent question regards the risk to the child who requires a
blood transfusion. Each situation should be handled according to
the type of procedure to be performed and the surgeon's or anes-
thesiologist's experience in frequency of transfusion. Although au-
tologous donation is an option for children, this is frequently not
possible because of body size. Other alternatives, such as the use
of directed donor blood, are controversial because of the associ-
268 J.S. Hill and P.J. Davis
SURGICAL RISK
It is the primary task of the anesthesiologist to speak in detail to
the parent about risk directly related to the anesthesia (e.g., dental
trauma, postoperative apnea, drug reaction, aspiration pneumonia,
hypoxemia, malignant hyperthermia, cardiac arrest, death, and
10
brain i n j u r y ) . The discussion of potential complications specifi-
cally related to the procedure itself should be discussed by the
surgeon.
HISTORY
The history of the child's present illness is usually the first por-
tion of the interview. The medical evaluation should include a
survey of the patient's general health, as well as specific health
problems, including previous surgical procedures. A history of pre-
vious anesthetic experiences and problems such as nausea, vomit-
ing, or muscle weakness should be noted. It is also important to
note a family history of such problems. Any medical problems
should be noted, especially cardiac and respiratory disease. Aller-
gic history, both drug and environmental, should be sought.
Patients at increased risk for untoward reactions should be duly
noted. One example of this is the increased incidence of latex
allergy in patients with meningomyeloceles or in those who self
18
catheterize.
Anesthesia for Pediatric Otolaryngic Patient 269
ANESTHETIC INDUCTION
The anesthesiologist should discuss various methods of adminis-
tering the anesthetic with each family, and the patient should
participate in the choice as much as possible. For children,
induction of anesthesia is accomplished with inhaled or intrave-
nous anesthetic agents. Inhaled inductions obviate the need for
needles and catheters being placed in awake patients. Although
intravenous access in an awake child can be traumatic, the role of
EMLA cream (Astra, USA, Inc; Westborough, MA) has signifi-
cantly removed the pain but not the fear of needle injections.
EMLA cream, a eutectic mixture of lidocaine and prilocaine, can
penetrate intact skin to provide topical analgesia when applied to
the site and covered with an occlusive dressing for at least 60
minutes.
In children, inhaled inductions are accomplished with nitrous
oxide along with either halothane or sevoflurane in a scented mask.
In clinical trials, sevoflurane, with its low solubility, allows for
26-28
faster induction than h a l o t h a n e . In addition, it has fewer nox-
ious airway properties and provides less myocardial depression
29
than halothane.
270 J.S. Hill and P.J. Davis
AIRWAY MANAGEMENT
For all but the shortest procedures, intubation of the patient's tra-
chea is usually performed for otolaryngic procedures. For routine
procedures, the trachea is intubated with the aid of a nondepolar-
izing muscle relaxant (vecuronium, cisatracurium, mivacurium,
pancuronium). If muscle relaxants are to be avoided, the patient is
deeply anesthetized and the vocal cords are sprayed with 1% xy-
locaine. T h e endotracheal tube size is selected based on the
patient's age and weight (Table 2).
Because many otolaryngic patients are anesthetized to further
evaluate the airway, a different approach to the airway and the ad-
ministration of the anesthetic agents must be used. Because the air-
way is shared between the anesthesiologist and otolaryngologist,
Anesthesia for Pediatric Otolaryngic Patient 271
TABLE 2.
Endotracheal Tube Size
Inner diameter
Age Weight (kg) (mm)
Premature 0.7--1.0 2 5
Premature 1.0--2.5 3 0
Newborn 2.5--3.5 3 5
3 months 3.5--5.0 3 5
3—9 months 5.0--8.0 3 5-4.0
9 - 1 8 months 8.0--11.0 4 0-4.5
1.5—3 years 11.0--15.0 4 5--5.0
4—5 years 15.0--18.0 5 0--5.5
6—7 years 19.0--23.0 5 5--6.0
8—10 years 24.0--30.0 6 0--6.5
1 0 - 1 1 years 30.0--35.0 6 0--6.5*
1 2 - 1 3 years 35.0--40.0 6 5--7.0*
1 4 - 1 6 years 45.0--55.0 7 0--7.5*
* Cuffed tube
MAINTENANCE ANESTHESIA
Like induction, the maintenance of anesthesia can be achieved
with the use of either inhaled or intravenous anesthetic agents. Ni-
trous oxide is the most frequently used inhaled anesthetic agent.
272 J.S. Hill and P.J. Davis
Its low potency limits its use as a sole anesthetic agent. Conse-
quently, nitrous oxide is used in combination with more potent in-
haled anesthetic agents, such as sevoflurane, halothane, isoflurane,
or desflurane. Nitrous oxide is relatively insoluble and has no car-
diovascular depressant effects. In contrast, the more potent inhaled
anesthetic agents have significant cardiovascular depressant ef-
fects. Thus, the addition of nitrous oxide to the administration of
the other agents attenuates the cardiovascular depressant effects of
the more potent inhaled anesthetic agents while adding to the an-
esthetic potency of the administered drugs. Generally, the choice
of anesthetic agents relates to their relative cardiovascular depres-
sant effects, their affects on airway irritability, and their ability to
readily induce anesthesia and hasten the emergence and recovery
from anesthesia (Table 3).
The choice of intravenous agents for maintenance of anesthe-
sia includes the nonbarbiturate hypnotic agents such as propofol
and the opioids. Propofol is an alkyl phenol whose rapid redistri-
bution and elimination produce a short duration of action and al-
low the drug to be administered by repeat injections or continu-
ous infusion. In addition to its anesthetic properties, propofol also
has antiemetic properties in pediatric patients undergoing otolar-
35
yngic procedures.
TABLE 3.
Comparative Effects of the Inhaled Anesthetic Agents in Children
PULMONARY
Upper Respiratory Infection
Otolaryngologists are frequently confronted with the dilemma of
proceeding with an elective surgical procedure on a child with an
274 J.S. Hill and P.J. Davis
FIGURE 1.
Algorithm for clinical decision making in URI. (From Martin LD: Anes-
thetic implications of an upper respiratory infection in children. In Wet-
zel RC, editor: Pediatr Clin North Am 4 1 : 1 2 1 , 1994.)
Asthma
Asthma and cystic fibrosis are the most common chronic pulmo-
nary diseases of childhood. It appears that the incidence of asthma
52 54
is i n c r e a s i n g . " It is known that various environmental factors
precipitate airway hyperactivity and trigger asthma. Familial pre-
52 55
disposition appears to be the strongest such factor. ' Some of
the environmental factors that may trigger the development of air-
56
way hyperactivity are viral lower respiratory i n f e c t i o n s , chronic
mechanical ventilation, and congenital diaphragmatic hernia re-
5 7 - 6 0
pair. Other factors include prematurity, gastroesophageal re-
6 1 - 6 3
flux, and parental or patient s m o k i n g . Although most children
are not routinely symptomatic from asthma, URIs or another ill-
ness can exacerbate their underlying airway hyperreactivity.
The pathophysiology of asthma can be described as a chronic
inflammation of the airway secondary to mast cell and eosinophilic
release of cytokines, lipid mediators, and preformed substances
64
of inflammation. The release of these inflammatory mediators re-
sults in increased airway inflammation with mucosal edema and
hypersecretion of mucous. This increased mucous may result in
focal atelectasis and air trapping. The subsequent ventilation-
perfusion inequality may result in hypoxemia and hypercapnia and
in the worst situations may cause respiratory failure. Signs and
symptoms include bronchospasm responsive to bronchodilator
therapy, expiratory wheezes, decreased air movement, cyanosis
65
and/or hypoxemia, and pulses paradoxes. Symptoms of asthma
range from none to wheezing, coughing, dyspnea, and respiratory
distress.
Anesthesia for Pediatric Otolaryngic Patient 277
Cystic Fibrosis
Cystic fibrosis is the most common, fatal, congenital disease of
whites. There is a 4 . 5 % incidence of the heterozygous genotype in
the general population. This gives a gene frequency of 1 in 25
whites. It has been reported to occur in 1 of 3 , 0 0 0 live births and
8 7 8 8
is inherited as an autosomal recessive g e n e . ' The basic defect
in cystic fibrosis is abnormal epithelial chloride and sodium trans-
port resulting in an increase of electrolyte content of secretions,
89, 90
with altered transluminal potential difference. This results in
a dehydration and a thickening of mucous and in abnormal muco-
91
ciliary c l e a r a n c e . The patients are chronically colonized with
Haemophilus influenzae and Staphylococcus aureus and eventu-
280 J.S. Hill and P.J. Davis
CARDIOVASCULAR DISORDERS
Murmurs
Heart murmurs are the findings that necessitate a cardiac consul-
tation most frequently. At least 5 0 % of children will demonstrate a
murmur at some point in their childhood. The vast majority of these
murmurs are "innocent" and not associated with subsequent car-
112
diovascular d i s e a s e . Innocent murmurs are simply flow mur-
113
murs arising from normal cardiovascular f l o w . Congenital heart
Anesthesia for Pediatric Otolaryngic Patient 283
1 1 4 - 1 1 6
disease is present in less than 0 . 0 8 % . A history of cyanosis,
decreased exercise tolerance, poor weight gain, diaphoresis, abnor-
mal peripheral pulses, or the presence of a precordial heave are sug-
gestive of congenital heart disease. If the child is normally growing,
112
it is less likely that it is a physiologically significant m u r m u r . In-
nocent murmurs tend to decline with age because the normal flow
vibrations become more difficult to hear as the chest wall becomes
thicker.
HEMATOLOGIC/ONCOLOGIC/IMMUNOLOGIC DISORDERS
The most important pieces of information in the preoperative
evaluation for bleeding disorders are the past history and the fam-
ily history. These items will help to direct further testing. Unfor-
tunately, pediatric patients often have not had their clotting cas-
cade challenged in a way that would demonstrate a subtle bleed-
ing disorder. Because of significant family histories and a high
incidence of spontaneous bleeding, the majority of patients with
classic hemophilia (hemophilia A) or Christmas disease (hemo-
philia B) are known to have disease at the time of presentation.
However, patients with von Willebrand disease (vWd) and other
mild hereditary coagulopathies are often undiagnosed at presenta-
tion for routine otolaryngic procedures.
von Willebrand disease encompasses a family of molecular de-
fects with multiple subtypes affecting 0 . 8 % to 2% of the popula-
118
t i o n . Clinical problems arise from either a quantitative or quali-
tative defect in von Willebrand factor. This results in a hybrid he-
TABLE 4.
Regimen for Dental, Oral, Upper Respiratory Tract, or Esophageal
Procedures—All Patients
Oncologic Diseases
Children with oncologic diseases frequently present to the otolar-
yngologic surgeon for surgical resection of tumor or tissue biopsy
for diagnosis or management of opportunistic infections of the head
and neck. Often, the treatment of their malignant disease will di-
rectly affect their anesthetic and surgical management.
In preparation for a procedure, a summary of their disease pro-
cess and all chemotherapeutic agents they have received should
be obtained before administration of any anesthetic. Historical
questions should include inquiries about dyspnea, orthopnea,
cough, fainting, cyanosis, or other physical signs of compromise.
Children who have a mass in the mediastinum, especially of the
anterior mediastinum, may have special risk during the induction
1 3 6 , 1 3 7
of a n e s t h e s i a . Care should be taken to note any anesthetics
that are known to produce cardiac or pulmonary toxicity. Areas of
radiation therapy should be duly noted, especially when these in-
volve areas of the airway or thoracic cavity. A chest radiograph and
complete blood count with appropriate white cell evaluation
should be obtained before any procedure is begun. Chest x-rays are
particularly important in children who may have thoracic involve-
10
ment with their malignancy.
Various chemotherapeutic agents such as cisplatinum, metho-
trexate, and cyclophosphamide have documented nephrotoxicity.
These patients may also receive antimicrobials such as aminogly-
cosides and amphotericin that may further damage their kidneys.
Anesthesia for Pediatric Otolaryngic Patient 289
Transplanted Patients
There has been a significant increase in the number of organ trans-
plantation programs in the country. Survival statistics have im-
proved significantly with the advent of improved immunosuppres-
sive regimens. These increased survival rates have resulted in a
growing number of patients presenting for surgical procedures un-
related to their transplant, as well as those related to transplanta-
tion. Chronic sinusitis, especially with fungal agents, neck ab-
scesses, and ear disease are the most frequent otolaryngologic pre-
sentations. It is important that the anesthesiologist understand the
implications of transplantation in these children and how it will
affect the administration of anesthesia. Often the transplantation
will directly impact the efficacy of a drug. One example is the lack
of effect that atropine has on the denervated transplanted heart.
Other aspects of general anesthesia are the same for the trans-
planted child as in the normal child; however, there are specific
problems unique to the transplanted patient. The old chart must
be available for review, as these patients have usually had multiple
admissions as well as anesthetics. Often they have other associated
congenital anomalies. These are very complex patients, and it is a
difficult task to balance the physiologic, psychological, and func-
tional needs of the child during the perioperative period. The main
risks in a transplanted patient are potential for infection and rejec-
tion, as well as the side effects of chronic immunosuppressive
158
therapy.
Immunosuppression protocols vary widely among hospitals, as
well as among types of transplant patients. The patient may
receive a myriad of drugs including azathioprine, cyclosporine A,
antilymphocyte globulin and monoclonal antibodies, FK-506, and
corticosteroids. These immunosuppressive drugs can influence
the type of anesthesia administered, as well as interact with
various anesthetic medications. Examples of this include the
prolongation of neuromuscular blockade with atracurium and
1 5 7 1 5 8
vecuronium with c y c l o s p o r i n e . ' In addition, cyclosporine
can be hepatotoxic and nephrotoxic. Drugs that may have addi-
tive renal toxic effects, such as nonsteroidal anti-inflammatory
medications, are contraindicated. In addition, drugs such as
morphine which are renally excreted may have to be modified in
their administration. Steroids are often given in high doses and
can result in a cushingoid appearance, electrolyte and glucose
abnormalities, hypertension, and diabetes. Chronic immunosup-
pression with steroids places the patient at an increased risk
292 J.S. Hill and P.J. Davis
NEUROLOGIC
Down Syndrome
Down syndrome is a relatively common disorder with an incidence
159
of approximately one in 800 b i r t h s . It is the most common con-
genital chromosomal anomaly. Often these patients have multiple
disorders and anomalies related to their Down syndrome. In the
past, their life expectancy was short, with very few patients living
until adulthood. Now these patients enjoy a much greater life ex-
pectancy. Yet they often have multiple congenital anomalies that
160
may have great implications on the administration of a n e s t h e t i c .
It is generally believed that these patients have a higher risk than
1 6 0 , 1 6 1
otherwise healthy p a t i e n t s . Kobel reviewed 100 patients
1 6 2
with trisomy 2 1 . His findings showed a very low incidence of
complications when optimal anesthetic care was given.
Preoperative evaluation should include the usual history and
physical examination, as well as laboratory studies. In addition,
there are multiple systemic areas that need special attention.
Twenty-three percent of children with Down syndrome have been
shown to have respiratory infection in the immediate preoperative
period. Individuals with Down syndrome tend to have immune de-
163
ficiency. Although there is an increase in susceptibility to all in-
fections, they are particularly predisposed to upper respiratory in-
164
f e c t i o n s and hepatitis B infection. Patients with Down syndrome
Anesthesia for Pediatric Otolaryngic Patient 293
MISCELLANEOUS DISORDERS
Malignant Hyperthermia
Malignant hyperthermia (MH) is a rare autosomal-dominant trait
with incomplete penetrance that induces susceptible individuals
Anesthesia for Pediatric Otolaryngic Patient 295
SUMMARY
The opportunities for operative intervention in treating various
childhood illnesses have grown exponentially in recent years. The
physician involved in the care of the child in the perioperative pe-
riod must not become complacent with the status quo. The anes-
thesiologist and otolaryngic surgeon must accept full responsibil-
ity for planning the safest and best-tolerated anesthetic and proce-
dure possible in every patient.
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306 J.S. Hill and PJ. Davis
309
310 Index
framework, 245-247 o
l i n i n g flaps, 240-245 Obstructive sleep disorder, as risk
melolabial interpolation flap, factor for adenotonsillectomy,
249-250 56
paramedian forehead flap, Oligonucleotides, antisense, in head
250-256 and neck cancer, 144
defect classification and, 256-257 Oncologic diseases, pediatric
ala, 258-259 anesthesia and, 288-290
columella, 257-258 O p i o i d s , in pediatric anesthesia, 266,
lobule, 258 273
nasal dorsum, 259 Otoacoustic emissions, in neonatal
sidewall of nose, 260 screening, 1 8 1 , 192-195
historical approaches, 236-237 w i t h auditory brain stem
Nasopharyngeal carcinoma, 119-132 responses, 197
cervical l y m p h node metastases, auditory neuropathy and, 197-198
123-125 operating characteristics, 191
diagnosis, 1 2 0 - 1 2 1 research o n , 187
epidemiology, 119 Otopalatodigital syndrome, 89
histology, 128-129 Otoscopy, for patulous eustachian
radiotherapy, 121-122, 125 tube, 215
surgical treatment, 122, 125-130
Nasopharyngeal sound pressure, 208, P
212 Papillomatosis, recurrent respiratory,
National Institute on Deafness and 101-117
Other C o m m u n i c a t i o n benign and aggressive disease,
Disorders, 186-187 103
National Institutes of Health, complications
hearing loss in neonates and, of disease, 112-113
186-189 of treatment, 113-114
Natural k i l l e r cells, in head and neck juvenile and adult disease, 102
cancer, 151 medical management
Neonates, hearing loss in [see acyclovir, 1 1 0 - 1 1 1
Hearing loss screening in indol-3-carbinol, 109-110
neonates) interferon, 107-109
Neuropathy, auditory, neonatal isotretinoin, 111
screening for, 197-198 methotrexate, 111-112
Nitrous oxide, i n pediatric r i b a v i r i n , 112
anesthesia, 272, 282, 295 pathologic characteristics,
NK cells, in head and neck cancer, 101-102
151 surgical management
Nose anesthesia and airway
deformities [see also Septoplasty management, 104-105
and rhinoplasty) evaluation and staging, 105
pathophysiology, 166-167 laser surgery, 105-107
embryology and anatomy, 165-166 tracheotomy, 107
reconstruction [see Nasal v i r a l transmission, 103-104
reconstruction) Paramedian forehead flap, 250-256
318 Index