Michael H. Fritsch

The versatile cartilage autograft in reconstruction of the nose and face.

This paper deals with the long‐term follow‐up of cartilage autografts taken from various parts of the body to reconstruct areas of the nose, ear, trachea, eyelid, and other areas of the body which require augmentation, effacement, and long‐term support. Our thesis will be that the cartilage autograft is the implant of choice in many of these areas, and that fate of autogenous cartilage is well known and should be given strong priority in facial grafting.

Diagnosis and management of paragangliomas of the skull base

In appropriately selected patients, glomus tumors of the head and neck are best treated surgically. Unresectability is not a factor in therapeutic planning for local disease control. Existing techniques and exposures for tumor removal can be reliably applied to these paragangliomas, with acceptable morbidity and mortality. A team approach to this problem is mandatory.

Operating Room Sound Level Hazards for Patients and Physicians

Hypothesis: Exposure to certain new surgical instruments and operating room devices during procedures could cause hearing damage to patients and personnel. Background: Surgical instruments and related equipment generate significant sound levels during routine usage. Both patients and physicians are exposed to these levels during the operative cases, many of which can last for hours. The noise loads during cases are cumulative. Occupational Safety and Health Administration (OSHA) and National Institute for Occupational Safety and Health (NIOSH) standards are inconsistent in their appraisals of potential damage. Implications of the newer power instruments are not widely recognized. Methods: Bruel and Kjaer sound meter spectral recordings for 20 major instruments from 5 surgical specialties were obtained at the ear levels for the patient and the surgeon between 32 and 20 kHz. Results: Routinely used instruments generated sound levels as high as 131 dB. Patient and operator exposures differed. There were unilateral dominant exposures. Many instruments had levels that became hazardous well within the length of an average surgical procedure. The OSHA and NIOSH systems gave contradicting results when applied to individual instruments and types of cases. Background noise, especially in its intermittent form, was also of significant nature. Some patients and personnel have additional predisposing physiologic factors. Conclusion: Instrument noise levels for average length surgical cases may exceed OSHA and NIOSH recommendations for hearing safety. Specialties such as Otolaryngology, Orthopedics, and Neurosurgery use instruments that regularly exceed limits. General operating room noise also contributes to overall personnel exposures. Innovative countermeasures are suggested.

Preservation of Hearing in Neurofibromatosis 2

Preservation of hearing in the neurofibromatosis 2 (central neurofibromatosis) patient has been Infrequently documented. This goal can be attained in selected patients and should be more frequently accomplished in the future with improved diagnostic capabilities and improved surgical techniques. We report three patients in whom this elusive goal has been accomplished.

Phylogeny of the stapes prosthesis.

Objective: To create the first ever stapes prosthesis phylogenetic tree for the evolution of the stapes prosthesis. Study Design: Retrospective literature review, personal interviews. Setting: University Medical Center. Patient: Not applicable. Intervention: Not applicable. Main Outcome Measures: Construction of a stapes prosthesis phylogenetic tree with branches capable of including all stapes prostheses. Results: One hundred five different stapes prostheses were reviewed, starting with the first-ever prosthesis used in the first stapedectomy and continuing up to the present time. The stapes prosthesis family tree contains 4 main branches that allow for categorization of all the commercial prostheses currently used. Many examples of atavistic prostheses, single surgeon use, and dead-end characteristics exist. Conclusion: An overview of the complicated phylogenetic tree for stapes prostheses gives great perspective to the history of stapedectomy and insights into many characteristics that are useful for designing new stapes prostheses.

Sigmoid sinus thrombosis diagnosis by contrasted MRI scanning

Septic thrombosis of the transverse-sigmoid sinuses and the jugular bulb is a highly lethal condition. The presenting signs and symptoms of this disease entity are subtle and not in proportion to the magnitude of the problem. Later in the disease course, sudden fulminant findings appear. A high index of suspicion, combined with scanning techniques of either enhanced MRI or CT, allows prompt diagnosis and treatment. MRI enhanced with gadolinium-DTPA (Gd) is a valuable adjunct that confirms the diagnosis and delineates the extent of suspected pathology.

Ferromagnetic movements of middle ear implants and stapes prostheses in a 3-T magnetic resonance field.

Hypothesis: A 3-T magnetic resonance field may cause motion or displacement of middle ear implants not seen in studies with 1.5-T magnets. Background: Previous publications have described the safety limitations of some otologic implants in 1.5-T magnetic resonance fields. Several company-wide recalls of implants were issued. No studies to date have been reported for otologic implants within a 3-T magnetic resonance field, nor have there been comparisons with a 1.5-T field strength. Methods: Eighteen commonly used middle ear implants and prostheses were selected. In Part 1, the prostheses were placed in Petri dishes and exposed to a 3-T magnetic resonance field. In Part 2, the particular prostheses that showed movement in Part 1 were placed into their intended use positions within temporal bone laboratory specimens and exposed to a 3-T field. Both parts were repeated in a 1.5-T field. Results: In Part 1, three prostheses moved dramatically from their start positions when exposed to the 3-T magnetic resonance field. In Part 2, the three particular prostheses that showed movement in Part 1 showed no gross displacement or movement from their start positions within the temporal bone laboratory specimens. No implants moved in the 1.5-T field in either Part 1 or Part 2. Conclusion: Certain stapes prostheses move dramatically in Petri dishes in 3-T fields. When placed into temporal bone laboratory specimens, the same prostheses show no signs of movement from the surgical site in a 3-T field, and it appears that the surgical position holds the implants firmly in place. Results of published 1.5-T field studies should not be used directly for safety recommendations in a 3-T magnetic resonance. Heat, voltage induction, and vibration during exposure to the magnetic resonance fields should be considered as additional possible safety issues. Preference should be given to platinum and titanium implants in manufacturing processes and surgical selection.

EarLens transducer behavior in high-field strength MRI scanners:

T EarLens transducer device was developed by the EarLens Corporation beginning in 1995 and has been previously described. Because the lens resides on the eardrum, movement of the magnet causes the eardrum to move (Fig 1). Patients with the device residing on the eardrum may voluntarily, or in an unconscious state, be exposed to MRI scanners of various strengths. This study was undertaken to determine the device’s behavior and safety implications in MRI magnetic fields in vitro and ex vivo.

Chorda tympani and facial nerve neurofibroma presenting as chronic otomastoiditis.

A28-year-old woman was referred for left-sided conductive hearing loss and chronic otitis media. Physical examination was significant for an opacified, intact, retracted left tympanic membrane. Facial nerve function was intact with House-Brackmann grade I/VI. Audiometry revealed moderate left-sided conductive hearing loss. A computerized tomography (CT) scan showed a nonenhancing soft tissue lesion within the left mastoid and epitympanum with ossicular erosion, suggesting a chronic infection or cholesteatoma. Intraoperatively, during a canal wall-up mastoidectomy, a mass of fibrous tissue was encountered on the medial surface of the incus. A frozen-section biopsy revealed “benign nervous tissue.” The facial nerve was thickened from the stylomastoid foramen through the tympanic portion of the nerve. The chorda tympani was markedly enlarged because of tumor infiltration. This portion of tumor rejoined the main mass in the epitympanum, with the facial recess preserved (Fig 1). Nerve stimulation along the course of the facial nerve caused robust contraction of the ipsilateral face; the portion of tumor involving the chorda tympani did not stimulate. The tumor was decompressed 180° along its entire intratemporal course and was left intact. The malleus and incus were partially eroded and were removed. A temporalis fascia graft was placed, covering the tumorous nerves and creating an aerated mesotympanum. Postoperatively, the patient did well with House-Brackmann grade I/VI facial nerve function and no dysgeusia. Final pathologic analysis revealed “neurofibroma.” The patient had no family history of neurofibromatosis, and magnetic resonance imaging of the patient’s central nervous system showed no synchronous lesions. Close clinical follow-up will continue until facial nerve paralysis develops, at which time resection of the neurofibroma with cable grafting of the facial nerve will be performed.

Management of sword-swallower injuries

OBJECTIVE To report an unusual case of hypopharyngeal perforation in a sword-swallower, with emphasis on management options. METHOD Case report and review of the English language literature concerning sword-swallowing injuries to the hypopharynx and oesophagus. RESULTS A 29-year-old male sword-swallower suffered hypopharyngeal perforation during a performance. The patient received conservative management, with intensive care unit admission, infectious disease consultation, intravenous antibiotics, discontinuation of oral intake and close observation. He progressed well, resumed oral intake on hospital day six, and was discharged home on hospital day eight. CONCLUSION Sword-swallowing is an unusual vocation which may lead to potentially devastating injuries. This case report and review of the literature illustrates the management options for such hypopharyngeal and oesophageal injuries.