Douglas E. Mattox

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.

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.

Evaluation of a 'shotgun' regimen for sudden hearing loss

One hundred nine patients with idiopathic sudden hearing loss were treated with a “shotgun” regimen that included dextran, histamine, Hypaque, diuretics, steroids, vasodilators, and carbogen inhalation. Thirty-three patients received the entire protocol and 76 patients received most, but not all, of the protocol drugs. Some improvement of hearing (>10 dB in pure-tone average) was seen in 52% of patients treated with the complete protocol and in 54% of patients who received the partial protocol. All patients were analyzed for potential prognostic indicators. Patients with thresholds at 8000 Hz better than at 4000 Hz fared better than the group as a whole. Vertigo at the time of onset of hearing loss was a sign of poor prognosis. There was no correlation between hearing improvement and the age of the patient or the sedimentation rate. Most importantly, there was no statistically significant difference in outcome between patients treated with the complete protocol and those who received only part of the protocol. Furthermore, when the effect of each drug was examined individually, there was no significant difference between those patients receiving and not receiving treatment. The results suggest that this “shotgun” approach for treatment of sudden hearing loss offers no better outcome than is reported in the literature for spontaneous recovery.

Acute management of laser-ignited intratracheal explosion.

The laser‐ignited airway explosion is a shocking emergency. Techniques available for prevention of an airway fire minimize the risk, but they are not applicable in all circumstances. The severity of the patients injury depends on the duration and intensity of the burn. Prompt, appropriate management is facilitated if the operating team has previously discussed and “rehearsed” this potential disaster. The distal airway burn produced by an ignited endotracheal tube differs from an inhalation burn in character and severity. The anatomic and respiratory effects occurring subsequent to the laser‐induced burn are examined. Emergency care requires immediate elimination of the fire, removal of the tube and any foreign body or debris, and usually a tracheostomy. A program of medical and endoscopic management is suggested.

Patency of the internal jugular vein after functional neck dissection.

The objective of this study was to determine the immediate patency rate for internal jugular veins preserved in functional neck dissections. Thirteen patients had contrast‐enhanced CT scans 2 to 4 weeks postoperatively. Ten veins were patent and had a diameter comparable to that seen on the preoperative scan; one vein was narrowed but patent; two were occluded. Probable factors associated with occlusion include trauma of the vessel and extrinsic compression of the vein by the skin or myocutaneous flaps.

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.

Surgical correction of congenital atresia of the ear.

Severe congenital atresia of the ear often requires—or indicates the need for—reconstructive surgery. We have developed a new technique for reconstruction of the external auditory canal. What follows is description of this technique and the results of its implementation.

High-dose cisplatin for locally advanced or metastatic head and neck cancer. A phase ii pilot study

High‐dose cisplatin (40 mg/m2 every day × 5) was administered to 14 patients (11 men, three women) with locally advanced or metastatic head and neck cancer not curable by surgery or refractory to previous chemotherapy and/or radiation therapy. All 14 patients were evaluable for toxicity; one patient was inevaluable for response due to early death. A total of 24 courses of therapy were administered. The dose‐limiting toxicity was myelosuppression with 73% of patients experiencing Grade III or IV neutropenia. Grade II or above thrombocytopenia occurred in 30% of the patients. Renal and neurologic toxicity was minimal. Two patients experienced laryngeal edema from vigorous hydration with one of them requiring a tracheostomy for respiratory compromise. Partial responses were seen in six patients (46%). Two of the six patients had received previous treatment with standard dose cisplatin. Two patients achieved long‐term responses (54+, 44+ months, respectively). Both of these patients were previously untreated, inoperable (T4N3MO, T3NIMO), and subsequently received radiation therapy after two cycles of chemotherapy. Median duration of response in the remaining responders was 3 months (range, 3‐10 months). High‐dose cisplatin may benefit selected patients with inoperable, advanced head and neck tumors. However, further randomized trials need to be conducted before firm conclusions can be established.

The effects of DFMO on polyamine metabolism in the inner ear

Difluoromethylornithine (DFMO) is a novel antineoplastic agent that was associated with an unexpected hearing loss in Phase II clinical trials. DFMO interferes with polyamine synthesis by inhibition of the enzyme ornithine decarboxylase (ODC). The objective of the current study was to establish a methodology to determine the effect of DFMO on polyamine levels and ODC activity in the cochlea. Guinea pigs received DFMO in their drinking water and were tested for auditory brainstem response threshold shifts. The organ of Corti, the lateral wall, and the acoustic nerve were assayed for both ODC activity and polyamine levels. In DFMO treated animals there was an inhibition of ODC activity in cochlear tissues as well as in intestinal mucosa. In addition, a significant depletion of cochlear polyamines was observed in the treatment animals. This study suggests that systemically administered DFMO inhibits ODC activity and interferes with polyamine synthesis in the cochlea.