George T. Singleton

Frey's syndrome: incidence related to skin flap thickness in parotidectomy.

Symptomatic gustatory sweating and inflammation of the skin over the site of the parotidectomy occurs in from 5 to 25% of cases. In a series of 164 studied, 6 of 48 patients with thin flaps developed significant Freys syndrome. These figures are significant at the 95% confidence level.

Adjuvant drug strategies in the treatment of recurrent respiratory papillomatosis

The purpose of this study was to evaluate adjuvant drug therapies combined with standard laser excision in the treatment of recurrent respiratory papillomatosis. Previous studies have presented conflicting data on the efficacy of various treatments, including interferon and isotretinoin. A retrospective study of 34 patients with moderate to severe papillomatosis who underwent both laser surgery and adjuvant therapy was therefore performed. All patients were treated with interferon. Five interferon failures received isotretinoin, and three with recalcitrant disease received methotrexate. Interferon produced a complete response in 16 patients and partial response in 12 patients. Juvenile-onset disease had a slightly higher response to interferon than adult-onset disease. isotretinoin produced no response in all five patients. Methotrexate demonstrated a marked improvement in both severity of disease and treatment interval in all three patients. Serious side effects were limited to one interferon patient with febrile seizures, which resolved with discontinuation of therapy. We conclude that adjuvant therapy including interferon and methotrexate is clearly of benefit in the treatment of patients with respiratory papillomatosis. A detailed approach to surgery combined with an interferon dosing regimen is presented. Further study of methotrexate appears warranted.

Myringotomy Tube Materials: Bacterial Adhesion and Infection

Postoperative infection after placement of myringotomy tubes is common. Surgeons and manufacturers of surgical devices have frequently substituted one material for another in middle ear prostheses without analyzing the interaction of material and infection. Implant material attributes are reviewed. Scanning electron micrographs are presented that demonstrate characteristic surface differences between materials and between the same material of different manufacturers. A preliminary clinical controlled study of the covariance of purulence with silicone vs fluorocarbon tubes demonstrates statistically significant differences. The implications of this information are discussed.

Diagnosis and Treatment of Perilymph Fistulas without Hearing Loss

In 1978, I reported on the diagnostic criteria and therapy based on the treatment of 34 cases of perilymph fistula. Of that group, 20 patients had no hearing loss associated with the fistula. Since that time, an additional 30 cases of fistula—15 without hearing loss—have been seen and treated operatively. The 30 significant variables of history and physical findings identified in the first study were statistically reviewed, along with a new finding that seems highly significant. Twenty-three of the 26 new cases so evaluated had a positive “eyes-closed turning test” (staggering when turning to the side of the lesion after walking with eyes closed). A further finding has been the presence of an abnormally placed round window membrane, in most cases involving the round window. The total operative population of fistulas, both those with and without hearing loss, is reviewed to identify the operative technique best suited for each window and the graft material most likely to succeed. Perichondrium is the choice tissue for graft material, except for very small fistulas at the annular ligament. The graft must be held firmly in place, with either a prosthesis or appropriate packing, carefully avoiding adhesions between the round window and the tympanic membrane.

Intratympanic Gentamicin Treatment for Meniere's Disease

OBJECTIVES: The purpose of this study was to evaluate the safety and efficacy of a modified intratympanic gentamicin technique in patients with intractable unilateral or bilateral Menieres disease. METHODS: A retrospective review of 25 consecutive patients who underwent gentamicin treatment for Menieres disease was conducted between 1992 and 1996. Two separate delivery systems were used during this study, with the last 13 subjects undergoing placement of the new system (flanged polyethylene tubing). RESULTS: Follow-up averaged 23 months. Absence of vertigo spells was reported in 88%, and substantial control was achieved in 12%. Four of five patients with bilateral disease achieved complete control. Results for the two delivery systems were not significantly different. Absence of ice-water caloric response was seen in 75% (15 of 20) patients. Clinically significant sensorineural hearing loss occurred in 5 (20%) of 25 ears. Nonserviceable hearing developed in only two (8%) patients. CONCLUSIONS: Our results support the previously reported efficacy and relative safety of gentamicin infusion therapy for intractable Menieres disease. Polyethylene tubing may be more advantageous than T-tube delivery because of anatomic concerns in certain patients. (Otolaryngol Head Neck Surg 1998;118:589–96.)

Treatment of paragangliomas with radiation therapy

Paragangliomas of the head and neck may be treated successfully with surgery, radiation therapy, or stereotactic radiosurgery. The choice of treatment depends on the location and extent of the tumor, the presence of multiple tumors, the age and health of the patient, and the preference of the patient and attending physician. This article reviews the role of radiation therapy in the treatment of patients with paragangliomas of the head and neck.

Immune‐mediated inner ear disease and parvovirus b19

Human parvovirus B19 (HP‐B19), the etiologic agent of the common childhood illness erythema infectiosum, has been implicated in systemic immune disorders. Patients presenting with sensorineural hearing loss and/or dizziness, not readily categorized, were evaluated for immune‐mediated inner ear disease. Appropriate serologic studies including parvovirus B19 antibody titers were conducted. Thirty patients with suspected immune‐mediated inner ear disease were treated with corticosteroid trial for 5 to 7 days, then reexamined with repeat audiogram and/or vestibular testing. Seventeen patients with clinical response were treated with long‐term corticosteroids and cyclophosphamide. Six patients had positive HP‐B19 immunoglobulin M (IgM) titers and 8 patients had positive parvovirus immunoglobulin G (IgG) titers. All 14 patients responded to therapy. Parvovirus B19, therefore, is a possible etiology of immune‐mediated inner ear disease.

Temporal Bone Histopathologic Findings in Congenital Anomalies of the Oval Window

The histopathologic findings in five temporal bones from three cases showing various stages of oval window development arrest are presented. The anomalies ranged from complete absence of the oval window to congenital cartilaginous fixation of the stapedial footplate. Surgical approaches for establishment of a new oval window must take into consideration the frequent association of facial nerve anomalies with anomalies of the oval window.

Canalplasty for chronic tympanic membrane atelectasis

PURPOSE Canalplasty to prevent accumulation of squamous debris has been proposed as an alternative to tympanoplasty for the treatment of tympanic membrane atelectasis and early cholesteatoma. The goal of this article is to report our experience with canalplasty for the treatment of advanced middle ear atelectasis. MATERIALS AND METHODS A retrospective review was performed on all patients that underwent tympanoplasty or canalplasty at the University of Florida since 1992. Eight ears (seven patients) with severe atelectasis were found to have been treated with canalplasty (without middle ear reconstruction) to marsupialize the retraction pockets. RESULTS Follow-up was conducted at an average of 22 months. Four ears required repeat surgical intervention after an average of 12 months: three required canal wall down mastoidectomies for cholesteatoma, and a tympanoplasty was necessary in one case for persistent perforation. Four ears not requiring revision were without cholesteatoma or perforation at an average follow-up time of 26 months. Mean audiometric thresholds were stable or improved, irrespective of the need for revision surgery. CONCLUSIONS Canalplasty may be an alternative for the treatment of atelectasis in selected patients; however, close follow-up after surgery is necessary because of the potential for progression to cholesteatoma.

9:08 AM: Intratympanic Gentamicin Treatment for Meniere's Disease

Objectives: The efficacy of intratympanic gentamicin infusion for vertigo control in Menieres disease has been established. Technical difficulties have been encountered with described techniques, particularly in subjects with narrow external auditory canals. The purpose of the present study was to evaluate the safety and efficacy of a modified intratympanic gentamicin technique in patients with intractable unilateral or bilateral Menieres disease. Methods: A retrospective review of 19 consecutive patients who underwent gentamicin treatment for Menieres disease between 1992 and 1995. Two separate delivery systems were used during this study, with the last seven 7 subjects undergoing placement of the new system (flanged polyethylene tubing). The gentamicin treatment protocol for all subjects and drug delivery system for the first 12 patients (T tube) were identical to previously described methods (Nedzelski et al., 1992). Results: Follow-up averaged 15 months (range, 2 to 41 months). Absence of vertigo spells was reported in 89.5% of patients, and substantial control was achieved in all of the remaining patients (10.5%). All of the patients treated with the new delivery system experienced complete control of vertigo. Drop attacks were completely eliminated in both affected patients. Absence of ice-water caloric response was seen in three of six patients. Clinically significant sensorineural hearing loss occurred in 4 of 19 ears (21%). Nonserviceable hearing developed in only one patient (5.3%). Repeat treatments were necessary in 3 of 12 patients treated with the old system and zero of seven with the new system. Cumulative symptom scores (tinnitus, nausea, and fullness) improved for all subjects postoperatively. Permanent posttympanostomy perforation did not occur in any patients. Conclusions: Our results support the previously reported efficacy and (relative) safety of gentamicin-infusion therapy for intractable Menieres disease. Gentamicin titration to complete ablation of vestibular responses may not be necessary to achieve clinical success (most relevant for patients with bilateral disease). Polyethylene tubing may be advantageous over T tube delivery because of anatomical concerns in certain patients.