Mark J. Syms

Management of lateral sinus thrombosis.

Objectives: Review the clinical signs and symptoms, management, bacteriology and outcomes of patients treated for lateral sinus thrombosis.

Overview of Telemedicine Applications for Otolaryngology

Objective/Hypothesis: As we evolve into the managed care era, telemedicine technologies can help to provide efficiencies for the entire health care system. Our practice is centered around a residency training program in a federal facility. Our goal was to lay the groundwork for an entire service being on‐line.

Kawasaki disease presenting as a retropharyngeal phlegmon.

Sir, We saw an interesting presentation of Kawasaki disease (KD) as a retropharyngeal phlegmon. A 4-year-old black boy was seen in the emergency department with fever to 103 F, headache, cough, vomiting, and sore throat. Physical examination was remarkable for oropharyngeal erythema and conjunctival injection, as well as bilateral anterior and posterior cervical lymphadenopathy. The child was drooling, and the tonsils were erythematous but without exudate. A white-blood-cell count revealed a moderate leukocytosis of 18,200 mm3. A soft-tissue lateral view of the neck was performed (Fig.1a) demonstrating mild prevertebral soft-tissue swelling, followed by a CT of the neck with IV contrast (Fig. 1b) demonstrating low density in the retropharyngeal space. The patients fever persisted, though serial airway examinations continued to demonstrate no evidence of compromise. On hospital day 4, a repeat CT was performed, revealing no significant change in the appearance of the retropharyngeal soft tissues. The patient remained febrile, and antibiotics were changed without response. On hospital day 7 further laboratory analysis revealed an elevated erythrocyte sedimentation rate of 118 mm/h. An EKG and echocardiogram at this time were normal. Physical examination at this time revealed increasing bilateral conjunctivitis and iritis, fissured and erythematous lips, a fine papular rash on the trunk and extremities, and palmar erythema, and edema; the diagnosis of KD was made. Therapeutic oral nonsteroidal inflammatory medication and intravenous immunoglobulin therapy were instituted. The patient rapidly defervesed over 24 h, and was discharged 48 h later. An echocardiogram performed 2 weeks later revealed the presence of a small (3.5-mm) aneurysm of the left coronary artery. Kawasaki disease, also known as mucocutaneous lymph-node syndrome, is an acute febrile illness generally seen in young children, usually between ages 1 to 5 years. The disease is characterized by a multisystem vasculitis which results in mucosal inflammation, rash, cervical lymphadenopathy without suppuration, edema of the hands and feet, and late desquamation of the soles of the feet and palms of the hands. The diagnosis of KD rests on the demonstration of characteristic clinical signs and symptoms. Diagnostic criteria established by the North American participants of the Third International Kawasaki Disease Symposium include the following [1]:

Telemedicine: teleproctored endoscopic sinus surgery.

Objective/Hypothesis Teleproctored surgery projects a surgeons expertise to remote locations. The objective of the present study was to evaluate the safety and feasibility of this technique as compared with the current standard of care.

Cerebrospinal fluid fistulae in a canine model

Various diagnostic techniques currently are used to detect the presence of a cerebrospinal fluid fistula. High resolution computerized tomography scanning with the instillation of an intrathecal nonionic contrast medium yields the most accurate diagnostic results. Occasionally, even with optimal conditions, little information is gained other than the confirmation of the presence of a fistula. Intrathecal fluorescein can provide accurate information on the exact location of the fistula. The current study was designed to refine the clinical examination for cerebrospinal fluid fistulae with the use of intrathecal fluorescein. The canine model that we used also served as a vehicle to investigate the histopathologic effects of fluorescein on the central nervous system. We modified a commonly used xenon light source to enable examination with 490 nm light. In the canine model, this allowed accurate visualization of surgically created fistulae using very low doses of intrathecal fluorescein. An examination of the histopathologic features of the central nervous system of the canine model after acute instillation of a higher dose of fluorescein revealed microscopic changes consistent with the introduction of an irritant material. The changes induced by the chemical trauma may explain the serious neurologic sequelae sometimes seen in patients after the instillation of intrathecal fluorescein. Recommendations on the correct dosage of intrathecal fluorescein for diagnosis of cerebrospinal fluid fistulae are proposed.

Safety of Magnetic Resonance Imaging of Stapes Prostheses

Objective: Assess the safety of performing magnetic resonance imaging (MRI) on patients with stapes prostheses.

Incidence of carcinoma in tonsil asymmetry

mance. Temporal bone imaging can define the relationship of the FMT to the promontory, oval window niche, and incus, but it is unable to accurately define the axis of the FMT. Conclusions: Surgical placement of the Vibrant Soundbridge can be complicated by the anatomic variation of the temporal bone. These variations, however, did not prevent successful placement of the device. While temporal bone imaging techniques are helpful, they are limited by the size of the FMT and by the fact that the stapes cannot always be imaged accurately enough to provide a reliable point of reference.

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.

Von Hippel-Lindau disease and endolymphatic sac tumors

defect was then packed with bone pate to reconstitute the normal forehead contour. Gelfilm was placed over the bone pate, and the wound was closed. Results: The scalp staples were removed at 10 days, and with the exception of a small postoperative seroma (which quickly resolved after aspiration), the patient has had an uneventful postoperative course. One year after surgery the patient maintains an excellent cosmetic result. A comparison of preoperative and postoperative photographs reveals no evidence of persistent frontal bone embossment or deformity. Conclusion: With the introduction of acrylics and, more recently, hydroxypatite cement, the cranioplasty literature has emphasized allografts over autografts. This is most likely due to the ready availability and ease in handling of these materials. While alloplasts are effective, they incur greater cost and possibly greater risk of infection. Bone pate used in cranioplasty is more cost-effective, has equal ease of handling, and yields equivalent aesthetic results.