Jeffery J. Kuhn

Laser-assisted tympanostomy.

Laser‐assisted tympanostomy (LAT) was performed in 70 ears to ventilate the middle ear space without using a pressure‐equalizing tube. Using a CO2 laser attached to an operating microscope with a Microslad (microscope laser adaptor device), tympanostomies of 1.0 to 3.0 mm (average, 1.6 mm) in diameter were created and remained patent for an average of 3.14 weeks. Patency time was directly related to the size of the opening. Nearly all (97.9%) of the tympanostomies healed with no noticeable scarring and no persistent perforations. Seventy‐eight percent of patients at the Florida Ear & Sinus Center (FESC, Sarasota, Fla.) and 84% of patients at the Head & Neck Surgery Group (New York) showed no evidence of recurrent effusion after a minimum follow‐up of 3 months. LAT appears to be a safe, cost‐effective procedure which can easily be performed in an office setting when bloodless opening in the tympanic membrane is needed for either treatment or diagnosis using endoscopes.

Understanding the Dizzying Array of Diagnostic Dizziness Tests

Program Description: The “dizzy” patient can be a diagnostic challenge. Symptoms can be nonspecific and result from numerous etiologies. While most otolaryngologists realize that a complete and accurate history provides the basis for the diagnosis and management of balance disorders, the use and diagnostic significance of balance tests can be unclear. In this miniseminar, we will discuss the use and interpretation of a variety of balance tests including electrocorticography, vestibular evoked myogenic potential, videonystagmography testing, rotational chair testing, head impulse tests, and posturography. The goal of this miniseminar is to educate and discuss the use of these tests in a modern practice. Educational Objectives: (1) Identify history and physical examination findings that indicate the need for further diagnostic testing. (2) Decide which balance tests to order when further testing is necessary. (3) Interpret balance function testing for diagnostic and prognostic purposes.

Cochlear Implant Failures: Experiences and Recommendations

Program Description: Pediatric laryngology has experienced recent tremendous growth with increased focus on voice-related quality of life issues in the pediatric airway. Much of the development in pediatric laryngology reflects complementary efforts of laryngologists and pediatric otolaryngologists with support by key technological advancements. This miniseminar incorporates the viewpoints of several clinicians experienced in the management of pediatric laryngeal and voice disorders. The presenters will focus on clinically relevant matters for the general and specialty otolaryngologists, including diagnosis, common pathologies, and operative and nonoperative approaches/techniques. The interactive session will address several questions: What is the role of videostroboscopy in children? What techniques are useful in obtaining a quality exam from children? Who should be referred for pediatric laryngology? Fundamental pathologies will be reviewed, including benign vocal lesions, vocal fold paralysis, RRP, webs, subglottic stenosis, and hemangioma. Nonoperative innovations will be discussed, including voice therapy, laryngeal EMG, steroids, propanolol, botox, and fillers. Operative innovations will include use of cold versus laser technique for benign lesions, open techniques for vocal fold paralysis and subglottic pathology and recent augmentations to standard open techniques. Differing practical approaches to challenging cases will be discussed in panel format after initial diagnostic, pathological, and interventional options are discussed in lecture format.

Cemented Titanium Ventilation Tube in the Chinchilla

Problem The use of long-term ventilation tubes in patients with chronic eustachian tube dysfunction is an acceptable form of initial surgical treatment. Despite improvements in composition and design, early extrusion, occlusion, and need for repeated procedures continue to be frequent problems encountered in the course of treatment. The purpose of this study was to develop a novel technique for establishing permanent middle ear ventilation. The study was conducted following the refinement of surgical techniques and long-term follow-up in a pilot group of animals. Methods Heat cautery myringotomy was used to expose the middle ear space in both ears of 15 chinchillas. A titanium ventilation tube was fixed to the medial wall of the hypotympanum in each ear using OtoMimix hydroxyapatite bone cement. At four months, both ears in 12 animals were re-explored and the integrity of the cemented tube was assessed clinically. One animal was euthanized and the temporal bones obtained for histopathologic analysis. Results A stable fixation of the titanium tube to the medial wall of the hypotympanum was demonstrated in 23 of 24 ears at four months re-exploration. The titanium tube-bone cement fixture was covered with healthy vascularized mucosa in all ears. Two ears showed mild mucosal inflammation adjacent to the fixed tube. The histologic findings will be reviewed. Conclusion The use of hydroxyapatite bone cement to permanently secure a titanium tube to the middle ear wall appears to have some promise as a technique for establishing long-term ventilation of the middle ear space. A prototype titanium tube is currently being developed for this purpose. Significance By incorporating the proven technologies of titanium implants and hydroxyapatite bone cement, this study provides a novel technique for establishing a permanent means of middle ear ventilation. Support The ventilation tubes (Gyrus ENT LLC) and bone cement (Walter Lorenz Surgical, Inc.) were supplied by their respective manufacturers.

Management of Congenital Incudostapedial Anomalies in Stapes Surgery: Retracted

OBJECTIVES:: The management of developmental anomalies of the ossicular chain and otic capsule in stapes surgery tests the otologists diagnostic skills and flexibility in technique and prosthesis choice. Although congenital malleus fixation and perilymph gusher are important clinical entities that have received considerable attention in the otolaryngology literature, congenital anomalies of the incus and stapes are less well described, can often be subtle, and have a distinct influence on management choice and hearing outcome. STUDY DESIGN AND PATIENTS:: A review of more than 200 stapes procedures yielded eight cases of identified congenital anomalies of the stapes or incudostapedial complex including congenital absence of the oval window with malformed incus and stapes, columellar-type stapes with promontory fixation, stapes superstructure fixation to the fallopian canal, and malformed incus with stapes superstructure fixation to the promontory. The developmental anatomy and surgical technique in each case are reviewed and hearing outcome is presented. RESULTS:: The surgical technique used in each case varied depending on the nuances of the ossicular anomaly and whether both the stapes and incus were affected. All eight ears (seven patients) that underwent a stapes procedure for either an isolated congenital stapes anomaly or a combined incudostapedial anomaly had a favorable hearing outcome with seven ears improving to within 10-dB and one ear to within 13-dB air-bone gap on postoperative audiometry. CONCLUSION:: Despite unanticipated findings of congenital anomalies of the stapes and incus during middle ear exploration for conductive hearing loss, a flexible management approach can lead to successful hearing outcomes.

R070: Permanent Ventilation Tube Fixation in the Chinchilla

(1983-2005), comparing the results of conventional surgery versus laser resection, were compared. METHODS: Eighteen consecutive cases of oncocytic lesions of the larynx, diagnosed over the period 1983-2005 were analysed, taking into account the histological diagnosis, site of the lesion and the primary and secondary treatment. Follow-up data were obtained in all cases. RESULTS: Primary (cold steel) surgical resection was used in eight patients. Six patients (75%) had recurrence following primary conventional surgery (p 0.157). CO2 laser was used in ten primary cases and in five cases of recurrence following primary conventional surgery. There was no recurrence following primary laser surgery. Unfortunately 4 out of 5 patients had recurrence following secondary laser surgery (for recurrent lesions) requiring further revision surgery. All patients were subsequently rendered disease free. CONCLUSION: The real advantage of the use of laser as a primary tool is the reduced rate of recurrence in excision of such lesions as shown in the present study (0%). Diffuse multifocal cystic lesion or recurrent lesions are always difficult to excise completely and, hence, have the higher probability of recurrence. SIGNIFICANCE: This study suggests that the patient with suspected oncocytic lesions present in the false cord or laryngeal ventricle area should be considered for primary laser surgery. Chances of complete excision of the cyst and reduced recurrence are the prime advantage. SUPPORT: None

R165: Chronic TM Perforation Model in the Chinchilla

PROBLEM: In vitro aminoglycosides exposure and acoustic overstimulation impair the intracellular calcium homeostasis of outer hair cells (OHCs). The role of intracellular calcium homeostasis in these effects needs to be clarified in vivo. METHODS: Degrees of OHC damage were characterized by DPOAE. Using fura-2 microspectrofluorimetry, the authors measured the intracellular calcium concentration ([Ca2 ]i) of OHCs during either a resting state or high K -induced depolarization. Animals were grouped and exposed to broadband noise at 105 dB SPL for 12 h and/or injected intramuscularly with either amikacin (100 mg/kg/day) or saline for 10 days. DPOAE amplitudes were measured before treatment and immediately before sacrifice. RESULTS: DPOAE amplitudes decreased immediately after noise exposure and recovered 7 days after noise exposure. Amikacin alone did not cause significant DPOAE amplitudes changes on the 30th day after initiation of treatment. Significant depressions of DPOAE amplitudes resulted from combination of noise and amikacin were still observed on the 30th day after treatment. At the resting state, the baseline [Ca2 ]i or the effect of changing bathing solution did not show any significant difference in both apical and basal OHCs after different treatments. As in the increase in [Ca2 ]i evoked by high [K ]-depolarization in apical OHCs, no significant intergroup difference was found. Amikacin, plus noise or not, significantly attenuated the [Ca2 ]i elevation in basal OHCs. CONCLUSION: The [Ca2 ]i homeostasis after in vivo acute noise trauma was not significantly disturbed. Amikacin, but not noise, disturbs basal OHCs’ response to depolarization-increased [Ca2 ]. Changes in depolarization-increased [Ca2 ]i are not well correlated with the changes of DPOAE amplitudes. SIGNIFICANCE: The mechanism of [Ca2 ]i homeostasis disturbance may be different between in vivo acoustic overstimulation and amikacin ototoxicity. The changes in K depolarization-increased [Ca2 ]i are not well correlated with the changes of DPOAE amplitudes. SUPPORT: This work was supported by the National Science Council of the Republic of China Grants NSC-89-2314-B-002238 and NSC-89-2314-B-002-579, and by the National Taiwan University Hospital Grant NTUH-88S1020.

Pediatric intensive care unit or main OR for bilateral myringotomy and tympanostomy tube: Which is more cost-effective, efficient, and safe?

Objectives: To ascertain if a cost savings, time efficiency, and parental/patient satisfaction differential exists between bilateral myringotomy and tympanostomy tube (BMTT) procedures performed in the main operating arena compared to the Pediatric Intensive Care Unit (PICU) at our institution over a 6-month period; with ultimate implication for performance improvement implementation. Methods: Over a 6-month period at our institution (NMCP), children meeting criteria for bilateral myringotomy and tympanostomy tube placement (BMTT) were enrolled through either: (1)the standard route requiring an initial otolaryngologic evaluation, a separate preoperative evaluation, a third anesthesia/administrative appointment, and the subsequent surgery/procedure occurring in the main operating arena; or (2)through an alternative route consisting of initial otolaryngologic evaluation, phone follow-up soon thereafter and a subsequent surgical/procedural date for the BMTT to be performed in the PICU, still under general anesthesia by board certified anesthesiologists. Exact time differential, personnel hours, and estimated cost differential were compared between the two “routes for enrollment” and sites for the BMTT. Parental postprocedural questionnaires were completed and analyzed for qualitative data. Results: As per discussion/ordinal data. Conclusion: The performance of pediatric BMTTs in the PICU, compared to the accepted route at our institution via the main operating arena, has produced a significant cost savings, improved efficiency in terms of time and man-hours, and improved overall parental satisfaction regarding the efficiency, safety, and quality of care delivered at our institution for this routine, commonly performed procedure. This has implications for policy and procedural modifications for our institution in general, as well as national relevance.

Management of incudostapedial congenital anomalies in stapes surgery

Abstract Objectives: The management of developmental anomalies of the ossicular chain and otic capsule in stapes surgery tests the otologist’s diagnositic skills and flexibility in technique and prosthesis choice. Although congenital malleus fixation and perilymph gusher are important clinical entities that have received considerable attention in the otolaryngology literature, congenital anomalies of the incus and stapes are less well described, can often be subtle, and have a distinct influence on management choice and hearing outcome. Methods: A review of over 200 stapes procedures yielded 8 cases of identified congenital anomalies of the stapes or incudo-stapedial complex including congenital absence of the footplate and malformed incus, columellar stapes, and incudo-stapedial joint fixation to the promontory. The developmental anatomy and surgical technique in each case is reviewed and hearing outcome presented. Results: The management technique for each case varied depending on the nuances of the ossicular anomaly and whether both the stapes and incus were affected. All 8 ears (7 patients) that underwent a stapes procedure for either an isolated congenital stapes anomaly or a combined incudo-stapedial anomaly experienced improvement to within 10 dB air-bone gap on postoperative audiometry. Conclusions: Despite unanticipated findings of congenital anomalies of the stapes and incus during middle ear exploration for conductive hearing loss, a flexible and creative management approach can lead to successful hearing outcomes.

Vestibular function in aircrew after schwannoma surgery

ond group with defects smaller than 5 cm was reconstructed with free iliac or calvarial bone grafts aligned by local, pedicled buccal fat pad, or temporal vessels periost flaps. Cases with postoperative radiotherapy were given a 3to 5-week window, and the bone grafts were combined with revascularized soft tissue flaps. Results: Survival of the free revascularized flaps was 97%. Resorption of the bone resulting in nonunion or loosening of the hardware was manifested in 10% of this group. In the second group resorption of more than 30% was observed in only 5%, and dental implant failure was seen in 8%. The functional results concerning the midface were significantly better in the second group. Conclusion: Keeping to the guidelines the indications for free revascularized flaps can be reduced to only the relevant indications as confirmed by the outcome in this series.