Peter G. Von Doersten

Bell's Palsy Treatment with Acyclovir and Prednisone Compared with Prednisone Alone: A Double-Blind, Randomized, Controlled Trial

In a double-blind study, we compared the final outcome of 99 Bells palsy patients treated with either acyclovir-prednisone (53 patients) or placebo-prednisone (46 patients). For patients receiving acyclovir, the dosage was 2,000 mg (400 mg 5 times daily) for 10 days. Electrical tests included electroneurography and the maximal stimulation test. Univariate comparisons of outcome and electrical tests between the two groups were made with χ2 analysis, Fishers exact test, and t-tests. The outcome in acyclovir-prednisone-treated patients was superior to that in placebo-prednisone-treated patients. Treatment with acyclovir-prednisone was statistically more effective in returning volitional muscle motion (recovery profile of 10; p = .02) and in preventing partial nerve degeneration (p = .05) than placebo-prednisone treatment. The t-tests indicated that the recovery profile and index means were significantly better for the acyclovir-treated group (recovery profile t = 1.99, p = .051; recovery index t = 2.10, p = .040). We conclude that acyclovir-prednisone is superior to prednisone alone in treating Bells palsy patients and suggest that herpes simplex is the probable cause of Bells palsy.

THE FACIAL NERVE: Current Trends in Diagnosis, Treatment, and Rehabilitation

Facial paralysis is a potentially devastating disorder with numerous implications. Multiple entities must be considered in its etiology, and recent advances in microbiology, radiographic imaging, electrodiagnostic testing, and microsurgery have provided great insight into the pathophysiology, diagnosis, treatment, and rehabilitation of the facial nerve. Recent DNA PCR testing has shed new insight into the potential cause for Bells palsy. This article focuses on the evaluation, differential diagnosis, medical treatment, and rehabilitation of facial nerve pathology with primary emphasis on facial paralysis. Surgical management is also discussed, including reanimation of the paralyzed face.

Ventricular dysphonia: a profile of 40 cases.

Ventricular dysphonia is a poorly understood disorder involving ventricular fold participation during phonation. A population of ventricular dysphonia patients was evaluated using phonatory function studies such as laryngovideostroboscopy, advanced acoustic analysis, and electroglottography to identify shared epidemiologic characteristics and to discuss possible neuromuscular mechanisms and causes. Forty patients with ventricular dysphonia were studied and epidemiologic, acoustic, and histologic data were analyzed. In almost all cases, the authors found abnormalities affecting the glottis caused by a related medical condition. The abnormalities included true vocal cord (TVC) aperiodicity in 100% of the patients, TVC asymmetry in 65%, a laryngeal mass or foreign body (usually Teflon®) in 35%, TVC erythema or edema in 32.5%, and TVC bowing in 22.5%. Ventricular dysphonia seems to be primarily a compensatory mechanism for glottic dysfunction. Therapy is based on identifying and correcting the underlying abnormalities. Laryngovideostroboscopy is a particularly important tool in examining chronic dysphonia.

Endoscopic Zenker's Diverticulotomy (Dohlman Procedure): Forty Cases Reviewed

Pharyngoesophageal diverticula, first described in 1769, occur in an area of natural weakness between the inferior pharyngeal constrictor muscles of the pharynx and the cricopharyngeus muscle. The cause of these acquired diverticula is controversial, although most likely it is related to cricopharyngeus muscle dysfunction. Treatment is directed toward correcting the underlying sphincter dysfunction and managing the diverticulum. Endoscopic diverticulotomy requires division of the cricopharyngeus and the common wall between the esophagus and diverticulum, a technique popularized by Dohlman. We reviewed the results of 40 endoscopic diverticulotomy patients, ranging in age from 46 to 88 years, many of whom had significant existing comorbidities. The mean size of the diverticula was 4.1 cm, mean surgery time was 41 minutes, and mean hospital stay was 4.5 days. Thirty-seven of 40 patients, including 3 whose previous external procedure was not successful, returned to a regular diet, reported no regurgitation and were satisfied with the procedure. Complications in order of occurrence were pneumomediastinum (4 patients), urinary tract infection (2), upper respiratory tract infection (2), and lip laceration (1). Our results compare favorably with those of external approaches. The technique should be considered safe, expedient, and effective, particularly in patients with existing comorbidities.

Relation between age and head and neck cancer recurrence after surgery: A multivariate analysis☆☆☆★

Recent reports have described an increase in squamous cell carcinoma of the upper aerodigestive tract in young adults. As the preponderance of epidemiologic data exists for the population between 50 and 70 years of age, controversy has developed regarding the clinical course of head and neck cancer in youth. Some authors advocate more aggressive management, calling attention to the lack of “classic” predisposing factors and suggesting genetic disorders or Immunodeficiency. Basic science researchers have reported greater DNA fragility, sensitivity to carcinogens, and altered immune responses in young patients with carcinoma. To further elucidate the clinical aspects of this controversy, we performed a retrospective review using multivariate analysis to determine factors that affect recurrence. After screening 820 charts, 155 patients were found who met strict entrance criteria to the study. The patients were separated into five age groups, and 16 clinical variables were collected on each patient. Cox proportional hazards modeling revealed no significantly higher likelihood of recurrence in the 15- to 39-year-old age group. The model did find that metastatic adenopathy was predictive of recurrence (p = 0.034). The overall model further suggested a trend toward higher relative risk of recurrence in the middle-aged groups (p = 0.0541). In our review of the English biomedical literature, this is the first study to directly compare the outcome of young head and neck cancer patients with that of old patients using multivariate analysis. Future research is indicated in developing precise outcome predictions according to TNM staging, aneuploidy status, and DNA fragility In young patients. Efforts at limiting carcinogen exposure Should continue.

The maximal stimulation and facial nerve conduction latency tests: Predicting the outcome of bell's palsy

To test the hypothesis that the facial nerve conduction latency test is a better and earlier indicator of prognosis than other electrodiagnostic tests, 86 patients with Bells palsy were followed for a minimum of 4 months. To select control subjects for our own research clinic and for comparison with the patient population, latency values in 25 normal volunteers (50 sides) were determined. Serial maximal stimulation tests (MST) and latency tests were conducted to determine disease severity and prognosis in Bells palsy patients. Outcome was graded using the Facial Paralysis Recovery Profile (FPRP) and Facial Paralysis Recovery Index (FPRI) as well as the House grading system. The capability of the two tests to accurately predict outcome was evaluated. The MST accurately predicted outcome in 94% of patients studied. In the control group, normal latency values were a mean 3.8 msec with a standard deviation of 0.49. In the patient population, latency values were either within normal limits or absent. When done within 4 days of onset of Bells palsy, neither test was capable of predicting axonal degeneration. Statistical analyses included Fishers Exact Test, the paired Students t test, and correlation coefficient calculations.

Pediatric Neurotologic Skull Base Surgery

The objectives of neurotologic skull base surgery are complete resection of the lesion and high‐grade function following surgery. There is a perception that these goals are more difficult to achieve in children than in adults. Skull base disease in children and adolescents is rare. Of the 292 skull base tumors treated from 1970 to 1995 by The Otology Group in Nashville, 15 were in patients 21 years of age or younger, with only 5 patients under 10 years old. In this retrospective study, the authors review these 15 cases and compare them to their adult series.

Facial nerve outcome in lateral skull base surgery for benign lesions

Objective: To statistically identify factors most important in affecting CN7 outcome in lateral skull base surgery for benign lesions. Study Design: A retrospective review of 217 nonmalignancy lateral skull base procedures from 1970 to 1995 at the Otology Group in Nashville. Methods: Charts were reviewed for epidemiology, histopathology, staging, type of CN7 mobilization (none, short, long, severance with reanastomosis, and resection), preoperative and postoperative CN7 function, surgery performed, and survival. Results: Average House‐Brackman (HB) scores for mobilizations were as follows: short, 1.65: long, 2.74: and grafting, 4.33. Factors found to affect outcome in a statistically significant fashion were preoperative HB score, staging, type of CN7 manipulation, and surgical approach. Meningiomas were found to have a worse outcome than glomus tumors. Conclusions: Complete resection of tumors should be performed with minimal manipulation of the facial nerve based on regional anatomy and tumor anatomy. Laryngoscope, 108:1480–1484, 1998