Paul W. Gidley

Contemporary management of deep neck space infections

Deep neck infections continue to be seen despite the wide use of antibiotics. These infections follow along fascial planes to create deep neck space abscesses. The clinical presentation often points to the space involved. Understanding the regional anatomy gives the surgeon the ability to treat these grave infections. The records of 24 patients with a diagnosis of deep neck space abscess admitted to Hermann Hospital between 1988 and 1993 were reviewed. Fifty percent of the patients had received antibiotics for an infection of the ear, nose, or throat before the development of a neck space abscess. Ten patients had parapharyngeal abscesses, seven had retropharyngeal abscesses, six had submandibular space abscesses, and one had parotid space abscess. Thirty-five organisms were isolated in 18 cases (1.9 isolates per patient). The most common organism cultured was Streptococcus (13 of 18), followed by Staphylococcus (6 of 18), Bacteroides (5 of 18), Micrococcus (2 of 18), and Neisseria (2 of 18). One case each of Candida, Enterobacter, Enterococcus, Peptostreptococcus, Proteus, Proprionobacter, and Pseudomonas was cultured. Six patients had no growth on culture but did have organisms found on Grams stain. The operative techniques and antibiotics used are discussed. The main complications of jugular vein thrombosis, carotid artery rupture, and mediastinitis are described, as well as an unusual case of meningitis from a large retropharyngeal-parapharyngeal abscess.

Facial Nerve Grading System 2.0

Objective: To present an updated version of the original Facial Nerve Grading Scale (FNGS), commonly referred to as the House-Brackmann scale. Study Design: Controlled trial of grading systems using a series of 21 videos of individuals with varying degrees of facial paralysis. Results: The intraobserver and interobserver agreement was high among the original and revised scales. Nominal improvement is seen in percentage of exact agreement of grade and reduction of instances of examiners differing by more then one grade when using FNGS 2.0. FNGS 2.0 also offers improved agreement in differentiating between grades 3 and 4. Conclusion: FNGS 2.0 incorporates regional scoring of facial movement, providing additional information while maintaining agreement comparable to the original scale. Ambiguities regarding use of the grading scale are addressed.

Squamous cell carcinoma of the temporal bone

To study the survival outcomes of patients with squamous cell carcinoma (SCC) of the temporal bone. A secondary purpose was to evaluate the University of Pittsburgh staging system as a predictor of survival.

Treatment selection for carcinoma of the base of the tongue

Between 1974 and 1984, 173 patients were treated for squamous cell carcinoma of the tongue base. Fifty-four patients had T1 or T2 primaries, while 115 patients had T3 or T4 tumors (4 were not staged). Lymph node metastasis was present in 120 patients. Early primary tumors treated with surgery or radiotherapy had a control rate of 83% (5 of 6 tumors) and 89% (40 of 45 tumors), respectively. For advanced primary tumors, definitive radiotherapy produced a local control rate of 55% (42 of 76 tumors), compared with 79% (23 of 29 tumors) for surgery and postoperative radiotherapy. If primary control was obtained, the regional failure rate was less than 10%. Tumor growth patterns were predictive of the response to radiotherapy. The primary control rate at 2 years for 21 patients with exophytic tumors was 84% as opposed to 58% for 62 patients with ulcerative-infiltrative tumors (p = 0.04). Radiotherapy is effective for early stage or exophytic tumors, whereas for advanced or deeply invasive tumors combined therapy enhances local control.

Low early ototoxicity rates for pediatric medulloblastoma patients treated with proton radiotherapy.

BackgroundHearing loss is common following chemoradiotherapy for children with medulloblastoma. Compared to photons, proton radiotherapy reduces radiation dose to the cochlea for these patients. Here we examine whether this dosimetric advantage leads to a clinical benefit in audiometric outcomes.MethodsFrom 2006-2009, 23 children treated with proton radiotherapy for medulloblastoma were enrolled on a prospective observational study, through which they underwent pre- and 1 year post-radiotherapy pure-tone audiometric testing. Ears with moderate to severe hearing loss prior to therapy were censored, leaving 35 ears in 19 patients available for analysis.ResultsThe predicted mean cochlear radiation dose was 30 60Co-Gy Equivalents (range 19-43), and the mean cumulative cisplatin dose was 303 mg/m2 (range 298-330). Hearing sensitivity significantly declined following radiotherapy across all frequencies analyzed (P < 0.05). There was partial sparing of mean post-radiation hearing thresholds at low-to-midrange frequencies and, consequently, the rate of high-grade (grade 3 or 4) ototoxicity at 1 year was favorable (5%). Ototoxicity did not correlate with predicted dose to the auditory apparatus for proton-treated patients, potentially reflecting a lower-limit threshold for radiation effect on the cochlea.ConclusionsRates of high-grade early post-radiation ototoxicity following proton radiotherapy for pediatric medulloblastoma are low. Preservation of hearing in the audible speech range, as observed here, may improve both quality of life and cognitive functioning for these patients.

The impact of radiotherapy on facial nerve repair

To study the impact of radiotherapy on the success of primary facial nerve repair and cable nerve grafts.

Adenoid Cystic Carcinoma of the External Auditory Canal

Objective/Hypothesis: To describe the clinical history and outcome of patients with adenoid cystic carcinoma (ACC) of the external auditory canal (EAC).

The oncology of otology

To describe the population of patients with malignancy affecting the ear canal and temporal bone.

Endolymphatic sac tumor (aggressive papillary tumor of middle ear and temporal bone): sine qua non radiology-pathology and the University of Texas MD Anderson Cancer Center experience

Endolymphatic sac tumor (ELST) is a rare lesion of the skull base for which the origin has recently been ascertained. The endolymphatic sac is derived from neuroectoderm and is located subjacent to the posteromedial surface of the temporal bone. Patients characteristically present with hearing loss, tinnitus, and vertigo; facial nerve paralysis occurs less commonly. An indolent clinical course and long-standing symptom history is typical. Endolymphatic sac tumors are known to occur more frequently in patients with von Hippel-Lindau disease, but this is not a prerequisite for diagnosis because sporadic occurrence is common. Morphologically, all of the ELSTs showed a papillary and glandular architecture. The papillary and glandular structures were lined by a single layer of flattened cuboidal-to-columnar cells that were variably ciliated. Surgery is the treatment of choice for small ELST. Remission may last for years, but local recurrence after surgery, likely secondary to incomplete resection, can occur. Radiotherapy has a 50% cure rate with large or residual tumors. Endolymphatic sac tumor is a rare tumor that can easily be confused with other papillary lesions on histopathologic grounds, with significant treatment implications. Precise preoperative anatomic localization and computed tomography and magnetic resonance imaging feature interpretation play a paramount role in achieving an accurate final diagnosis.

Comprehensive management of temporal bone defects after oncologic resection

To evaluate reconstructive outcomes following oncologic temporal bone resection.