David W. Kennedy

Endoscopic management of cerebrospinal fluid leaks and cephaloceles

The excellent visualization and atraumatic surgical techniques of endoscopic sinus surgery have been applied to the management of five cerebrospinal fluid leaks and two nasal cephaloceles. In all cases, the exact site of the lesion was identified. Four cerebrospinal fluid leaks were grafted with a free or pedicled septal mucosal graft. The fifth cerebrospinal fluid leak came from a narrow sphenoethmoid recess and stopped after the mucosa was abraded. The two cephaloceles were reduced intranasally and covered with bone and mucosal grafts. Not all cases seen in the same time period were treated endoscopically; two additional cerebrospinal fluid leaks were treated with conventional techniques because of severe nasal inflammatory disease and intracranial complications. The technique and indications for endoscopic management of cerebrospinal fluid leaks and cephaloceles are discussed.

Endoscopic sinus surgery for mucoceles: A viable alternative

Functional endoscopic surgery affords the potential for dramatically reducing operative morbidity of surgery for paranasal sinus mucoceles by offering a minimally invasive approach under local anesthesia. Following surgery, direct endoscopic visualization of the area enables accurate follow‐up. Unlike sinus obliteration, the ability to accurately image the sinus by CT is also preserved. This paper presents our preliminary experience with 18 mucoceles in which endoscopic sinus surgery was attempted. Five patients had preoperative proptosis and diplopia, three had Potts puffy tumor and five had erosion of the posterior table of the frontal sinus. Fifteen patients were satisfactorily treated endoscopically, two lesions could not be satisfactorily approached and required external surgery, and one patient had persistent disease, No disease recurrence has been noted to date with endoscopic follow‐up of up to 42 months.

Chronic fungal sinusitis in apparently normal hosts

Several fungal species are capable of causing either noninvasive fungal sinusitis or invasive disease characterized by erosion into mucosa, submucosa, bone, and deeper contiguous structures. The diagnosis of invasive infection becomes firmly established only after histologic demonstration of hyphae within these areas. Computerized tomography and magnetic resonance imaging can assist in distinguishing between invasive and noninvasive disease by outlining bone and adjacent structures. The 2 forms of chronic fungal sinusitis mandate different therapeutic approaches. While patients with noninvasive infection require only surgical removal of hyphal masses and the reestablishment of sinus drainage for a successful outcome, invasive infection necessitates not only thorough surgical debridement of abnormal tissues but may also require prolonged antifungal chemotherapy. All patients require long-term follow-up. Even the combined approach has sometimes proven disappointing during long-term follow-up of disease, rendering investigational therapy appropriate in some patients.

Multichannel intracochlear electrodes: mechanism of insertion trauma.

Cochlear damage from electrode insertion, a potential cause of further neural degeneration, is a major concern in the use of intracochlear electrodes. A study was undertaken to evaluate mechanisms by which damage may occur. Fresh human temporal bone preparations were created to allow direct intracochlear observation during round window insertion of a free‐fitting multichannel intracochlear electrode array. The path taken by the electrode, point of first resistance, and any resulting damage were documented.

The versatile midface degloving approach

The exposure obtained using the degloving approach is superb and the absence of resultant facial scar or deformity provides a dramatic new addition to the otolaryngologists surgical repertoire. The advantages of the degloving technique in exposure of the midface, nasal cavities, paranasal sinuses, nasopharynx, skull base, and clivus have led to its increasing importance in the otolaryngology literature. Within 2 years of the techniques introduction in our department, it had been used 48 times for a wide variety of problems, including inverting papilloma, juvenile angiofibroma, chordoma and selected cases of fungal disease of the sinuses.

Transsphenoidal approach to the sella: The johns hopkins experience

The transsphenoidal hypophysectomy has become a relatively frequent procedure in recent years, with the otolaryngologist playing a major role in its renewed popularity. This paper reviews the evoluation of pituitary surgery, duscusses the surgical technique currently used, and reviews the results and complications of 114 cases over a 13‐year period.

3-D CT for cranial facial and laryngeal surgery.

Three‐dimensional imaging is a new digital technology which interpolates two‐dimensional computer tomography information to render a “life‐like” anatomic display of the diagnostic information. We have found that this new methodology significantly improves the assessment and therapy of patients undergoing surgical procedures of the head and neck. The technique has been used in cranial‐facial and laryngeal pathology, and in preoperative planning of tumor resection, particularly skull‐base neoplasms.

Physiologic mucosal changes within the nose and ethmoid sinus: Imaging of the nasal cycle by MRI

Magnetic resonance studies frequently demonstrate increased T u2009u20092 ‐weighted signal in the nasal area. To further evaluate this phenomenon, several MRI examinations of the nasal cavity were performed within an 8‐ to 12‐hour period. The study demonstrated that changes alternated from side to side and were interrupted by the administration of topical vasoconstriction, confirming imaging of the normal nasal cycle. Changes were also observed within the ethmoid sinuses. Signal intensity on T u2009u20092 ‐weighted images during the congested phase was similar to inflammatory mucosa. Occasionally, these changes make interpretation of the extent of pathology difficult in patients with sinus disease, and raise the possibility of inflammatory pathology in asymptomatic patients. Awareness of MRI imaging of nasal cycle should reduce the likelihood of diagnostic errors and provides another method for study of this physiologic phenomenon.

The jugular bulb in otologic surgery: anatomic, clinical, and surgical considerations.

The jugular bulb varies widely in position and dimensions. In certain pathologic conditions there is an increased incidence of jugular bulb enlargement, but such enlargement also occurs without an obvious underlying cause. Jugular bulb enlargement may lead to clinical symptoms for the patient and particular difficulties for the otologic surgeon, not only in the middle ear but also in neurotologic approaches. The different clinical aspects and problems associated with jugular bulb enlargement are discussed with illustrative cases and temporal bone histologic findings.

• CROSS-SECTIONAL IMAGING OF THE NASAL CAVITY AND PARANASAL SINUSES

The choice radiographic modality for the evaluation of the nasal cavity and paranasal sinuses is computed x-ray tomography (CT). Coronal CT imaging affords optimal display of the osteomeatal channels and facilitates the surgeons perception of regional morphology. The object of this communication is to outline the parameters we feel will optimize the CT examination and to describe the regional anatomy as displayed primarily in the coronal plane. Magnetic resonance imaging, although less optimal for the display of chronic inflammatory disease, is felt to be beneficial in identifying fungal disease and diagnosing neoplastic disease.