Peter J. Catalano

Applications of Fast-Setting Hydroxyapatite Cement: Cranioplasty

A variety of autogenous and synthetic materials have been used to repair cranial defects resulting from traumatic and iatrogenic causes. In theory, the ideal material should be readily available and safe. It should adequately protect the underlying central nervous system, resist cerebrospinal fluid fistula formation, and be easily contoured. One promising synthetic biomaterial that has been used for cranioplasty is hydroxyapatite cement. This biomaterial has successfully restored cranial contour in most patients in whom it has been used; however, difficulties have arisen because of the materials prolonged water solubility. When exposed to cerebrospinal fluid or blood, inadequate setting of the cement occurs, resulting in loss of its structural integrity. This problem can be alleviated with the use of fast-setting hydroxyapatite cement, which hardens 6 to 12 times faster than the traditional cement. We present, to the best of our knowledge, the first series of the use of this material in 21 patients requiring cranioplasty. The advantages and limitations of fast-setting hydroxyapatite cement will be discussed. (Otolaryngol Head Neck Surg 2000; 123:409-12.)

Jugular foramen: microscopic anatomic features and implications for neural preservation with reference to glomus tumors involving the temporal bone.

OBJECTIVEOur goals were to study the normal histological features of the jugular foramen, compare them with the histopathological features of glomus tumors involving the temporal bone, and thus provide insight into the surgical management of these tumors with respect to cranial nerve function. METHODSTen jugular foramen blocks were obtained from five human cadavers after removal of the brain. Microscopic studies of these blocks were performed, with particular attention to fibrous or bony compartmentalization of the jugular foramen, the relationships of the caudal cranial nerves to the jugular bulb/jugular vein and internal carotid artery, and the fascicular structures of the nerves. In addition, we studied the histopathological features of 11 glomus tumors involving the temporal bone (10 patients), with respect to nerve invasion, associated fibrosis, and carotid artery adventitial invasion. RESULTSA dural septum separating the IXth cranial nerve from the fascicles of Cranial Nerves X and XI, at the intracranial opening, was noted. Only two specimens, however, had a septum (one bony and one fibrous) producing internal compartmentalization of the jugular foramen. The cranial nerves remained fasciculated within the foramen, with the vagus nerve containing multiple fascicles and the glossopharyngeal and accessory nerves containing one and two fascicles, respectively. All of these nerve fascicles lay medial to the superior jugular bulb, with the IXth cranial nerve located anteriorly and the XIth cranial nerve posteriorly. All nerve fascicles had separate connective tissue sheaths. A dense connective tissue sheath was always present between the IXth cranial nerve and the internal carotid artery, at the level of the carotid canal. The inferior petrosal sinus was present between the IXth and Xth cranial nerves, as single or multiple venous channels. The glomus tumors infiltrated between the cranial nerve fascicles and inside the perineurium. They also produced reactive fibrosis. In one patient, in whom the internal carotid artery was also excised, the tumor invaded the adventitia. CONCLUSIONWithin the jugular foramen, the cranial nerves lie anteromedial to the jugular bulb and maintain a multifascicular histoarchitecture (particularly the Xth cranial nerve). Glomus tumors of the temporal bone can invade the cranial nerve fascicles, and infiltration of these nerves can occur despite normal function. In these situations, total resection may not be possible without sacrifice of these nerves.

Diagnosis and Management of Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo

Objective: Describe the diagnosis, treatment, and outcome of a group of 20 patients with lateral semicircular canal benign paroxysmal positional vertigo (LSC-BPPV). Study Design and Setting: Retrospective review of 20 patients with LSC-BPPV (10 with geotropic and 10 with apogeotropic nystagmus) presenting to a tertiary balance center. Diagnosis was confirmed with infrared nystagmography in Dix-Hallpike positioning tests and supine positional tests. Patients were treated with one or more particle repositioning maneuvers. Results: Addition of supine positional nystagmus tests to Dix-Hallpike positioning testing improves sensitivity in the diagnosis of LSC-BPPV. Treatment outcomes in the apogeotropic LSC-BPPV group were poorer than the geotropic LSC-BPPV group. Significance: Adding supine positional testing to routine vestibular diagnostic testing will increase the identification of LSC-BPPV. Apogeotropic LSC-BPPV is more challenging to treat.

Tympanic Membrane Repair With a Dermal Allograft

Objectives To assess the use of an acellular dermal allograft in the repair of chronic tympanic membrane perforations. Chronic tympanic membrane perforations are a common problem in otolaryngology, and although surgical tympanoplasty using either temporalis fascia or rice paper has proven to be highly successful, these materials are not without their own limitations. The search has continued for a simpler, yet equally effective, means of repairing persistent tympanic membrane perforations in an office setting. In this study we experimentally evaluated the use of an acellular dermis (AlloDerm, (LifeCell Corporation, The Woodlands, TX) as an alternative to traditional tympanoplasty materials.

Evaluation of middle meatal stenting after minimally invasive sinus techniques (MIST).

OBJECTIVES In this study, we compared postoperative synechia rates and morbidity for different middle meatal (MM) stents after minimally invasive sinus techniques (MIST). STUDY DESIGN In a prospective study, we included 100 patients with bilateral chronic sinusitis undergoing MIST at a tertiary care facility with a single surgeon. METHODS For all patients, MeroGel stents were placed in the right MM, Gelfilm stents were placed in the left MM. Follow-up consisted of 3 postoperative visits between weeks 1 and 12 with endoscopic evaluation for synechia, granulation tissue, stent retention, nasal obstruction, headache, and infection. RESULTS Synechia developed in 4 patients on the left and in none on the right (P = 0.04). There were no significant side-specific differences regarding postoperative nasal congestion, headache, or sinusitis. Mean stent retention time was 7.9 days for MeroGel and 5.6 days for Gelfilm (P = 0.0004). CONCLUSION Compared with Gelfilm, Merogel MM stents produced less synechia; Merogel retains its position in the MM longer than Gelfilm; and the incidence of postoperative MM synechia can be reduced when absorbable MM stents are used in conjunction with MIST.

Radiographic evaluation and diagnosis of the failed frontal osteoplastic flap with fat obliteration.

In the absence of evidence of suppurative disease, clinical assessment of the symptomatic patient after frontal osteoplastic flap with fat obliteration is difficult because the cause of the pain is often neuralgic or from chronic vascular headache. Among 59 patients who have undergone this procedure at our institution since 1979, four required revision surgery. These patients were evaluated by computed tomographic and magnetic resonance scans, and the radiographic findings were compared with those present in 20 asymptomatic subjects. On the basis of the results of this study, we believe we can objectively identify those patients with chronic pain in whom the operation has been unsuccessful. A review of our experience with this procedure is presented along with criteria that enable early diagnosis of recurrent disease in the frontal sinus after osteoplastic sinusotomy.

Envoy Esteem Totally Implantable Hearing System: Phase 2 Trial, 1-Year Hearing Results

Objectives. (1) To assess outcomes of the Envoy Esteem Totally Implantable Hearing System as measured by hearing results compared with preimplant baseline unaided (BLU) and best-fit aided conditions (BLA) and (2) to determine safety of the device. Study Design. Prospective, nonrandomized, multicenter, subject-as-own-control, US Food and Drug Administration (FDA) trial. Setting. Private practice and hospital-based. Subjects and Methods. Between January 2008 and August 2009, an FDA trial was performed at 3 sites. Fifty-seven subjects with bilateral, mild to severe sensorineural hearing loss, with discrimination greater than 40%, were implanted. Implanted components were (1) a sound processor and (2) 2 piezoelectric transducers (a sensor and a driver). A sound processor was implanted in the temporal bone. Transducers were coupled to the ossicles. Devices were activated 2 months postimplant. Hearing results were compared with ipsilateral BLU and BLA. Results. Speech reception thresholds (SRTs) improved from BLA of 41.2 dB to 29.4 dB with the Esteem (P ≤ .001). Word recognition score (WRS) at 50 dB hearing level (HL) improved from BLA of 46.3% to 68.9% with the Esteem. Pure tone averages improved by 27 ± 1 dB (confidence interval, 30-25). There were no changes in bone conduction. QuickSIN results showed no change. There were 6 serious adverse device effects: 2 wound infections (1 resolved medically, 1 required explantation), 1 delayed facial paralysis that resolved with medication, and 3 revisions due to limited benefit. Conclusion. Phase 2 results at 12 months post implant demonstrated that (1) hearing results with the device are statistically superior to baseline best-fit hearing aids for SRT and WRS and (2) the device is safe.

Outcome in patients with chronic sinusitis after the minimally invasive sinus technique.

Background Controversy persists regarding the use of minimally invasive sinus techniques (MIST) to treat chronic sinusitis primarily because of an absence of comparative outcome data. Methods In this prospective study of 85 patients with chronic sinusitis treated surgically with MIST, the long-term postoperative outcome was assessed using the duration-based Chronic Sinusitis Survey (CSS) quality of life instrument. Patient age ranged from 4 to 81 years old (mean age, 42 ± 16.7 years). Forty-three subjects were male patients and 42 were female patients. Mean follow-up time was 23.8 ± 2.2 months. Results At follow-up, there was a 124.0% improvement in the mean CSS symptom score (p < 0.00001), a 30.1% improvement in the mean CSS medication score (p < 0.00001), and a 62.0% improvement in the mean CSS total score (p < 0.00001). An overall improvement was found in 78.8% of patients; 12.9% of patients were worse and 8.2% of patients were unchanged. Thirty-four patients (40.0%) had postsurgical CSS total scores within the normative interquartile range obtained in healthy controls. Twenty-six of these patients had postsurgical scores that actually surpassed the mean normative CSS total score. Before follow-up evaluation, 5 of the 85 patients (5.9%) had revision surgery after the initial procedure. All had revision MIST procedures and all were found to have an overall improvement at the time of follow-up. Conclusion We conclude that MIST significantly improves the outcome in patients with chronic sinusitis and should strongly be considered as the initial surgical option for such patients.

Balloon catheter dilatation of eustachian tube: a preliminary study.

Objective Eustachian tube dysfunction is a common problem and transnasal endoscopic balloon dilation of the Eustachian tube (ET) is a new surgical technique. The goal of this study is to review the evolution of this novel technique and study the preliminary outcomes. Subjects and Methods Balloon catheter dilation of the 100 Eustachian tubes in 70 adults was performed at a tertiary medical center from January 2009 to January 2011. A 5-mm sinus balloon catheter was endoscopically placed transnasally into the proximal ET to dilate the cartilaginous ET. Cases were reviewed with respect to indications, outcomes, and complications. Results Of the 100 ETs, ear fullness and pressure were improved in 71% of patients studied for 26.3 weeks (±3.6). Of 8 patients followed for a minimum of 34 months, 87% reported persistent improvement. One complication is reported. Conclusion Endoscopic transnasal ET balloon dilation is a novel approach to treating ET dysfunction. Benefits can be durable up to 3 years. This technique holds much promise and merits further investigation.

Balloon dilation of the frontal recess in patients with chronic frontal sinusitis and advanced sinus disease: an initial report.

Objectives: Balloon dilation of the sinus ostia and transition spaces is a relatively new tool in the management of chronic rhinosinusitis. Although studies of its safety and application have been reported, its efficacy in specific indications has yet to be clearly defined. The purpose of this study was to evaluate the use of balloon dilation of the frontal recess for the treatment of chronic frontal sinusitis in patients with advanced sinus disease. Methods: This was a prospective study of 20 patients who presented with chronic frontal sinusitis that had failed medical therapy and required operative intervention. Balloon dilation of the frontal recess was performed to improve drainage and ventilation of the frontal sinus. Preoperative and postoperative computed tomography scans were compared for change in the radiologic stage of disease based both on the Lund-Mackay staging system and on the Lund grade (extent of mucosal thickening). Results: Twenty patients met the inclusion criteria during the study period and were followed for several months after operation. All patients underwent a frontal sinus procedure with balloon dilation either alone or in concert with other minimally invasive techniques. A total of 29 sinuses were available for analysis. No significant complications resulted from the procedure. Pretreatment and posttreatment Lund-Mackay scores showed significant improvement in patients with certain subsets of chronic rhinosinusitis. Conclusions: Balloon dilation of the frontal recess is a relatively safe intervention that can be used in the treatment of chronic frontal sinusitis, even in patients with advanced disease.