Robert B. Parke

Nasal high-flow therapy delivers low level positive airway pressure

Background The aim of this prospective study was to determine whether a level of positive airway pressure was generated in participants receiving nasal high flow (NHF) delivered by the Optiflow™ system (Fisher and Paykel Healthcare Ltd, Auckland, New Zealand) in a cardiothoracic and vascular intensive care unit (ICU). Methods Nasopharyngeal airway pressure was measured in 15 postoperative cardiac surgery adult patients who received both NHF and standard facemask therapy at a flow rate of 35 litre min−1. Measurements were repeated in the open mouth and closed mouth positions. Mean airway pressure was determined by averaging the pressures at the peak of inspiration of each breath within a 1 min period, allowing the entire pressure profile of each breath to be included within the calculation. Results Low level positive pressure was demonstrated with NHF at 35 litre min−1 with mouth closed when compared with a facemask. NHF generated a mean nasopharyngeal airway pressure of mean (sd) 2.7 (1.04) cm H2O with the mouth closed. Airway pressure was significantly higher when breathing with mouth closed compared with mouth open (P≤0.0001). Conclusions This study demonstrated that a low level of positive pressure was generated with NHF at 35 litre min−1 of gas flow. This is consistent with results obtained in healthy volunteers. Australian Clinical Trials Registry www.actr.org.au ACTRN012606000139572.

Does the severity of sinus computed tomography findings predict outcome in chronic sinusitis

OBJECTIVES: We studied the association between the severity of pretreatment CT scan findings and the improvement in symptoms of chronic sinusitis after treatment. METHODS: We analyzed data from an ongoing prospective, nonrandomized clinical outcomes study of patients treated for chronic sinusitis at a tertiary-care academic medical center (n = 57, mean age 46.8 years). Disease-specific symptom severity was measured with a validated health status instrument, and CT stage was quantified with the Harvard CT staging system. RESULTS: In a multivariate analysis, symptom severity based on CT findings emerged as a strong predictor of both improvement in symptom score outcome (β = 0.47, P = 0.01) and absolute symptom level after treatment (P = −0.58, P = 0.001). CONCLUSIONS: Severity as assessed by a pretreatment CT scan is a strong predictor of outcome. Patients with higher symptom severity based on CT scans showed significantly larger improvement and lower absolute levels of symptom severity after treatment. This study links CT scan findings and subjective patient-based outcomes (symptom scores) using a validated outcomes instrument.

Endoscopic management of Zenker's diverticulum: factors predictive of success or failure.

Objectives: We review our experience with endoscopic management of Zenkers diverticulum. We sought to analyze and determine risk factors for success or failure of endoscopic diverticulum treatment. Methods: We performed a retrospective review of 72 consecutive patients who underwent attempted endoscopic management of a Zenkers diverticulum between January 2000 and April 2006. The procedures were performed by either of 2 otolaryngologists. There were 50 men and 22 women ranging in age from 44 to 93 years. A total of 85 procedures were performed. The medical records were reviewed for preoperative diverticulum size (small, 1 to 2 cm; moderate, 2.1 to 3.0 cm; and large, more than 3.0 cm), intraoperative diverticulum characteristics, patient anatomic limitations that prevented adequate endoscopic visualization, surgical complications, and management of recurrences. Results: Of our 72 patients, 61 (85%) were able to undergo endoscopic cricopharyngeal myotomy with diverticulum elimination. Of the 61 endoscopic procedures, 47 (77%) resulted in complete symptom resolution. The most common risk factors for recurrence were diverticulum size (more than 3 cm) and amount of redundant mucosa. Of the 14 patients with a recurrence, 10 (71%) underwent a repeat procedure. Six of the 14 (43%) had a successful excision via a cervical approach, and 4 of the 14 (29%) underwent a repeat endoscopic myotomy. There was 1 major complication (esophageal tear), and there were 3 minor complications (mucosal abrasions). Conclusions: Most patients with a Zenkers diverticulum are good candidates for endoscopic management. In our series, 84% of those who underwent endoscopic treatment ultimately achieved relief of symptoms. The patient morbidity is minimal. A large diverticulum with redundant mucosa is a risk factor for recurrence after endoscopic treatment.

Combined transconjunctival/intranasal endoscopic approach to the optic canal in traumatic optic neuropathy.

Surgical decompression of the optic canal is indicated in patients with traumatic optic neuropathy who fail to respond to corticosteroids. Traditional surgical approaches to the orbital apex have been effective in achieving optic nerve decompression but require either a craniotomy, provide limited exposure with late identification and protection of the optic nerve, or require external incisions. The combined transconjunctival/intranasal endoscopic approach to the optic canal offers sufficient exposure, allows early identification and protection of the optic nerve, provides space for the use of multiple surgical instruments, obviates a craniotomy and external incisions, and can be performed quickly with minimal morbidity. The technique of combined transconjunctival/intranasal endoscopic optic nerve decompression will be described and the experience with nine cases will be presented.

Diagnosis of laryngopharyngeal reflux disease with digital imaging

OBJECTIVE: The study goal was to assess the use of digital laryngeal videostroboscopy (LVS) in the detection of objective improvement of the larynx after 6 weeks of proton pump inhibitor (PPI) therapy and to evaluate a clinical grading scale for findings of laryngopharyngeal reflux disease (LPRD). STUDY DESIGN AND SETTING: We conducted a prospective analysis of digital LVS examinations from a tertiary referral center for laryngology by 3 independent blinded examiners. RESULTS: The mean score on the Laryngopharyngeal Reflux Disease Index for experimental patients was significantly higher than that for control patients (9.50 versus 2.92, P < 0.001), and posttreatment scores were significantly lower than pretreatment scores (7.35 versus 9.50, P < 0.001). Useful items on the grading scale for assessing the presence of LPRD and improvement in LPRD included supraglottic edema and erythema, glottic edema and erythema, and subglottic edema and erythema. Nonuseful items included the presence of pachydermia, granulomas, nodules, leukoplakia, and polyps. CONCLUSION: Objective improvement of signs of LPRD can be detected after 6 weeks of PPI therapy using digital LVS. The Laryngopharyngeal Reflux Disease Index is a useful valid clinical tool for following treatment response to PPI therapy.

The treatment of advanced juvenile nasopharyngeal angiofibroma

Fifteen patients with juvenile nasopharyngeal angiofibroma (JNA) were treated in the Department of Radiation Oncology, Baylor College of Medicine between 1973 and 1986. All patients underwent radiographic evaluation including CT scanning, selective digital subtraction angiography, tomograms, or MRI. Patients referred for definitive irradiation exhibited extensive tumor involvement. Eleven of 15 patients had middle cranial fossa involvement; cavernous sinus extension was observed in six patients. Ten patients were treated with primary radiation therapy; five patients had surgical resection initially and were referred for radiation therapy upon local recurrence. Follow-up ranges from 1 1/2-13 years. Four of the 5 patients who received 3200 cGy in 200 cGy fractions demonstrated tumor recurrence within 2 years after irradiation. All recurrences were ultimately controlled by either further irradiation and/or resection. No tumor recurrence was encountered among the patients treated at the higher tumor doses (36-46 Gy). No severe complications have been observed. Radiation therapy utilizing carefully tailored fields is an appropriate therapeutic approach to patients with extensive disease or intracranial extension. A total dose of greater than 40 Gy may allow improved local control for advanced lesions.

THE NEW TONGUE

Rehabilitation of major resections of the tongue has always posed a serious problem. This paper presents the feasibility and rationale of rehabilitating partial glossectomies by the use of the pectoralis major myocutaneous flap and the fabrication of a “new tongue” by the use of this flap. The criteria for these techniques in benign and malignant tumors of the tongue are outlined. The segmental innervation of the pectoralis major muscle from a variety of three to five nerve branches permits the development of a skin-muscle flap that may be transposed with its nerve supply intact or totally denervated, depending upon the status of the hypoglossal nerves and tongue in the operative field. This presents the possibility of transposing a skin-muscle flap into a glossal wound with a completely intact nerve supply where the new flap is under constant instruction in its new physiologic environment. It also presents the possibility of neurotization of the denervated section of the muscle flap by axones from the intact segment of tongue. A third possibility is the fabrication of a “new tongue” by the transfer of the hypoglossal nerves into the denervated segment of the peripheral aspect of the myocutaneous flap. This variety and combination of rehabilitative techniques introduces a new phase into the rehabilitation of the tongue.

Pectoralis myocutaneous flap for chin augmentation.

Radical resection of the anterior portion of the oral cavity, including a portion of the tongue, floor of the mouth, mandible, and neck, has always been, and remains, a perplexing problem in immediate rehabilitation of the area of the oral cavity and mentum. In the past, these deformities were classified as “Andy Gump.” Attempts at correction of this deformity are protracted and complex. The use of the pectoralis myocutaneous flap offers an improvement in the concept of management in that it supplies a skin lining for the oral cavity and augments the chin and neck in a single-stage procedure that may be combined with the primary operation.

Laryngectomy for fungal abscesses of the larynx.

m O m m F s nvasive fungal infections are known deadly compliations of immunosuppression. In the head and neck, isfiguring or debilitating procedures may be required. his often generates uncertainty as to the utility of roceeding in an already very ill child. We present the rst case described in the literature of a massive Asergillus subglottic abscess in a child with acute myloid leukemia treated with bone marrow transplantaion, in which a total laryngectomy was performed for ontrol of the fungal disease.

Does the sinus CT scan severity predict outcome in chronic sinusitis

Description of Symposium: Quinolones are the newest class of antimicrobials to be used in otolaryngology. Available agents include ciprofloxacin, ofloxacin, levofloxacin, trovafloxacin, sparfloxacin, gatifloxacin, and several others. They have some unique advantages: consistent activity against pneumococci that are resistant to other classes, activity against Pseudomonas aeruginosa, and no known associated ototoxicity. This panel will discuss the pros and cons of quinolone usage in sinus and ear disease, differentiate between the various agents, and discuss problems related to quinolone resistance. The thrust of the presentation will be on areas of appropriate usage. Topical agents and special cases, such as necrotizing external otitis, will also be discussed.