Stephen G. Rothstein

Extracranial Repair of Cerebrospinal Fluid Fistulas: Technique and Results in 37 Patients

Although neurosurgeons have traditionally preferred intracranial repair for the management of cerebrospinal fluid (CSF) fistulas, this approach is associated with the complications of a craniotomy, anosmia, and a high incidence of recurrent fistulas. Extracranial repair, on the other hand, produces no central nervous system morbidity, preserves olfaction, and is associated with a low incidence of recurrence. Although there have been several reports of extracranial repair of CSF fistulas by otorhinolaryngologists, this approach has received scant mention in the neurosurgical literature. We report here our experience with 37 patients with CSF rhinorrhea or otorrhea who underwent extracranial repair. The etiology of the fistula was postoperative in 22, traumatic in 6, and spontaneous in 9. The fistulas were repaired using one of four techniques: external ethmoid-sphenoid in 18 patients, transmastoid in 9, transseptosphenoid in 7, and osteoplastic frontal sinusotomy in 3. In 32 of the 37 patients (86%) the fistulas were successfully repaired with the initial procedure. Of the 5 patients requiring a second operation, the fistula was successfully closed in 4 for an overall success rate of 97%. Complications were few and consisted of a transient facial paresis in a patient undergoing transmastoid repair and one death from meningitis. The authors conclude that because of low morbidity and mortality and a high success rate in closing fistulas, extracranial repair is the preferred technique for the operative management of CSF rhinorrhea and otorrhea.

Otologic Disease in Patients with Acquired Immunodeficiency Syndrome

A 5-year retrospective study evaluating otologic disease in patients with acquired immunodeficiency syndrome (AIDS) was conducted at the New York University Medical Center-Bellevue Hospital Center. Twenty-six patients with documented otologic disease who met the Centers for Disease Control criteria for AIDS were identified and their charts were analyzed according to presenting complaints, physical examination, diagnostic modalities, pathologic condition, management, and outcome. A marked diversity of otologic diseases of varying severity was noted. The majority of patients complained of hearing loss and otalgia during their hospitalization for treatment of AIDS-related opportunistic infections. The most frequent diagnoses were otitis externa, acute otitis media, and otitis media with effusion. Sensorineural hearing loss frequently appeared to be related to ototoxic medications and neurologic infections.

Extracranial repair of cerebrospinal fluid otorhinorrhea

Forty-eight patients with cerebrospinal fluid leaks comprise this retrospective study. There were 39 traumatic and 9 spontaneous leaks. Nine patients were initially managed with bed rest and spinal drainage, but 3 patients in this group ultimately required surgical intervention for repair of their persistent leaks. Thirty-nine patients had surgery as initial therapy, with 33 extracranial repairs, 2 intracranial repairs, and 4 combined approaches. The extracranial approach was used in 36 of 42 patients, with an initial success rate of 86%.

Compliance With Anti-Reflux Therapy in Patients With Otolaryngologic Manifestations of Gastroesophageal Reflux Disease†

Objectives: The otolaryngologic manifestations of gastroesophageal reflux include sore throat, throat clearing, sensation of postnasal drip, hoarseness, and globus. This constellation of laryngeal and pharyngeal symptoms can be referred to as laryngopharyngeal reflux (LPR). Many patients with LPR are treated empirically and the results are often rewarding. The objective of this study is to evaluate compliance with antireflux therapy in this patient population.

Evaluation of malignant invasion of the carotid artery by CT scan and ultrasound

Carcinoma adherent to the carotid artery may be present in advanced head and neck cancers. Angiography, ultrasound, computerized tomography (CT), and magnetic resonance imaging (MRI) are available for the preoperative evaluation of the carotid artery. This study demonstrates that CT is not accurate in demonstrating malignant invasion of the carotid artery. Ultrasonography appears to be the best modality for assessing carotid artery invasion. Magnetic resonance imaging may prove helpful in this determination.

Reflux and vocal disorders in singers with bulimia

Dysphonia associated with bulimia has been described in the literature associated with vocal fold edema and polypoid changes. Laryngopharyngeat reflux (LPR) has been documented to cause reflux vocal fold pathology including edema and polypoid changes. We studied eight singers with bulimia and documented vocal fold pathology, including edema, posterior commissure hypertrophy, ventricular obliteration, and telangiectasia. Reflux was demonstrated in all eight. The results of this study showed that LPR may be a contributing factor to vocal disorders in singers with bulimia.

Squamous Cell Carcinoma in HIV‐Positive Patients Under Age 45

Eight patients 45 years of age and under (range, 29 to 45) with squamous cell carcinoma of the head and neck and infection with the human immunodeficiency virus are reported. Primary tumor sites include nasopharynx, oral cavity, oropharynx, and larynx. Probes for the human papillomavirus were positive in two of the patients. Therapy consisted of surgery followed by radiation therapy in five patients, surgery alone in one patient, and radiation therapy in the remaining two patients. Follow‐up ranged up to 2 years and revealed four deaths, three patients alive without disease, and one patient recently posttreatment with residual disease. The significance of the presence of the human papillomavirus in these individuals remains to be determined. The incidence of squamous cell carcinoma of the head and neck under age 45 is low, and whether there may be a higher incidence in HIV‐positive patients cannot be determined from this small series.

Clinical outcomes for the elderly patient receiving a tracheotomy.

Tracheotomies are routinely performed for severely ill and elderly patients with respiratory failure. This intervention is questioned, given the poor survival rate in this group. Outcomes analysis is performed after tracheotomy.

Squamous cell carcinoma in older patients without risk factors.

Ten patients over sixty years of age with no history of tobacco or alcohol use were treated for squamous cell carcinoma of the upper aerodigestive tract between 1979 and 1991. Nine of these ten patients were women with lesions confined to the oral cavity and oropharynx. Modes of treatment included surgery, radiation, or a combination of surgery and radiation. Followup from 1 to 10 years revealed two deaths from local and distant spread, and eight patients with no evidence of disease. Recurrences after treatment were aggressive and occurred within the same region as the primary lesion. Although most patients with upper aerodigestive squamous cell carcinoma are men with alcohol and/or tobacco exposure, this study demonstrates findings consistent with field cancerization in a group of older women with no risk factors.

Epiglottitis in AIDS patients

Adult epiglottitis in patients with acquired immunodeficiency syndrome has not been previously reported. A pale, floppy epiglottis with supraglottic edema, cervical lymphadenopathy, a normal to low white blood count without a shift to the left, and rapidly progressive airway obstruction characterize this entity. In this small series of patients, conservative medical management was not successful, and aggressive airway intervention with appropriate intravenous antibiotic therapy was necessary.