William H. Friedman

Current management of cerebrospinal fluid rhinorrhea.

Forty‐two patients with cerebrospinal fluid (CSF) rhinorrhea presenting over a 5 year period were analyzed as.to age, sex, etiology, anatomical and clinical findings, and methods of investigation and treatment. Eighty‐eight were traumatic in origin, with the most common anatomical sites being ethmoid, frontal and sphenoid sinuses, and the cribriform plate region. Meningitis and pneumocephalus were the most frequently associated clinical findings each present in 31% of the cases. Chemical analysis of the CSF for protein was positive in 88% of cases vs. 13% when the protein content was quantitatively analyzed. The demonstration and localization of CSF leaks were most effective using metrizamide and CAT scanning when they were active and by indium cisternography when they were small, intermittent, or questionable. The clinical management was divided into medical and surgical approaches with the advantages and disadvantages discussed.

Further evaluation of uvulopalatopharyngoplasty in the treatment of obstructive sleep apnea syndrome.

Since its introduction in 1981 uvulopalatopharyngoplasty (UPPP) has become an alternative surgical approach to permanent tracheostomy in treating obstructive sleep apnea (OSA). However, the criteria for selecting candidates for this procedure are unclear and the prediction of a positive response remains an enigma. This article presents the experience with UPPPs performed on 35 patients who had moderate to severe OSA. Criteria for patient selection included apnea severity, cardiopulmonary sequelae, and clinical symptomatology. All but two patients demonstrated clinical improvement, although there was considerable variability in the degree of response. Patients were classified as good or poor responders on the basis of the severity index (SI), which represents the number of apneas and hypopneas per hour of sleep resulting in oxygen saturation below 85%. A greater than 50% improvement in the SI was considered a good response. Twenty-three patients (65.7%) were good responders and the remaining 12 (34.3%) were poor responders. The need for permanent tracheostomy was obviated In 16 of 32 patients presenting with disabling daytime sleepiness or severe cardiopulmonary sequelae. Therefore it appears that UPPP is useful for treating most OSA patients.

The Degree to Which Accuracy of Preoperative Staging of Laryngeal Carcinoma has been Enhanced by Computed Tomography

In this retrospective study, the accuracy of preoperative staging by high-resolution CT and clinical evaluation (indirect-direct laryngoscopy) is compared to the postsurgical pathologic staging of laryngeal cancer. Forty-two patients who were admitted to St. Louis University Hospital between the years of 1978 to 1985 with diagnoses of laryngeal cancer were included. All patients received high-resolution CT scan of the larynx preoperatively and subsequently underwent total or partial laryngectomy. None of these patients received preoperative radiotherapy. The accuracy of the clinical vs. CT staging—as well as the accuracy of the staging by combination of the two modalities—was determined by comparison with the postsurgical pathologic staging. The accuracy was assessed separately for glottic, supraglottic, and transglottic carcinoma. The accuracy of CT staging for glottic carcinoma was 75%. However, clinical evaluation in this group of lesions was very reliable, offering 92.9% accuracy. The accuracy of CT staging increased in the supraglottic and transglottic lesions, to become superior to the clinical staging. With combined information gained by both examinations, the preoperative staging accuracy was 91.4% for supraglottic carcinoma and 87.5% for transglottic carcinoma. It is, therefore, recommended that high-resolution CT should be included in the preoperative staging of laryngeal cancer.

Nasopharyngeal Complications Following Uvulopalatopharyngoplasty

This report presents our experience with nasopharyngeal complications of UPPP in 85 patients undergoing the procedure from May, 1982 to January, 1985. Three patients developed nasopharyngeal stenosis and one patient developed permanent velopharyngeal insufficiency. Surgical management in two patients with nasopharyngeal stenosis resulted in adequate nasopharyngeal airway, while one patient still has a moderate stenosis following two surgical procedures. The patient with velopharyngeal insufficiency underwent Teflon® paste injection in the posterior pharyngeal wall. This resulted in complete alleviation of his nasal regurgitation.

The surgical treatment of snoring: A patient's perspective

An increasing number of loud snorers seek medical attention because of the social impact of snoring as well as its association with sleep apnea. Uvulopalatopharyngoplasty is reported to reduce or eliminate snoring in the majority of patients; however, little data are available to document the procedures success.

Five-Year Follow-up of the Effects of Bilateral Intranasal Sphenoethmoidectomy in Patients with Sinusitis and Asthma

Chronic sinusitis has been recognized to be a contributing factor to asthma in some patients. We report a 5-year follow-up study of 16 patients who had undergone bilateral sphenoethmoidectomy after not responding to aggressive medical management of underlying sinusitis. Sixty-two percent had subjective improvement of their asthma with 88% of the patients reporting a significantly reduced prednisone requirement. All patients had improvement of their nasal and sinus symptoms at 5 years. The improvement in the asthma reported at 2 years had for the most part persisted at 5 years.

Sphenoethmoidectomy: the case for ethmoid marsupialization

The authors report 510 sphenoethmoidectomics performed on 255 patients between 1969 and 1985. An overall polyp recurrence rate of 19.2% and less than a 1% complication rate are reported during that time. In patients followed jointly by the otolaryngologists and allergist, including 374 consecutive sphenoethmoidectomies on 187 patients who had this operation performed by the senior author, there was an overall polyp recurrence rate of 15% and a complication rate which was again less than 1%. Recent improvements in recurrence rates and diminished complication rates are attributed to better visualization and adherence to the concept of complete exenteration or marsupialization of the ethmoid labyrinth including middle turbinate resection in every case. Cooperation between the otolaryngologist and allergist is stressed, along with the realization that pulmonary and sinus diseases are frequently interrelated and may both be benefited by the performance of sphenoethmoidectomy in the patient with hyperplastic rhinosinusitis.

Staging of Chronic Hyperplastic Rhinosinusitis: Treatment Strategies

In 1990 we reported an initial prospective study of 100 patients using a four-stage system for classification of chronic rhinosinusitis. Between January 1988 and July 1992, we used this system in staging an additional 1814 patients, on whom 2980 intranasal sphenoethmoidectomies were performed. In this staging system a protocol trial of medication was given for 2 weeks, followed by axial and coronal computed tomography. Medication consisted of a second-generation cephalosporin antibiotic, usually cefuroxime; a 4-day burst of intraoral steroids, usually prednisone; and an antihistamine decongestant if not contraindicated. The stages of chronic hyperplastic rhinosinusitis included the stages described in the 1990 report (i.e., stage I, single-focus disease; stage II, discontiguous disease throughout the ethmoid labyrinth; stage III, diffuse disease responsive to medication; and stage IV, diffuse disease unresponsive to or poorly responsive to medication). The results of this study have shown that the computed tomography staging system based on computed tomography extent of disease after medical therapy is a simple, easily remembered, and very effective modality for the classification of chronic sinusitis. This system provides a rationale for discussing and planning surgery with patients and physicians and is a convenient reference for the reporting of end results. More importantly, a linear relationship between disease stage and outcomes is demonstrated. This statistically highly significant feature of the staging system provides a firm basis for the production of outcomes after various treatment strategies, particularly ethmoidectomy and the treatment of sinusitis.

Sphenoethmoidectomy: ITS Role in the Asthmatic Patient

Fifty patients who underwent intranasal sphenoethmoidectomy at the St Louis University Medical Center between July 1977 and April 1980 have been evaluated with respect to preoperative extent of disease and medication requirement as well as postoperative course and reduction in medication requirements, if any. These patients were followed jointly by the Departments of Allergy and Otolaryngology. Most of these patients were not allergic, and over half had intrinsic asthma. Fifteen of the 50 patients, all asthmatic, gave a history of aspirin sensitivity. Many had had previous nasal surgical treatment for polyps. Patients on large corticosteroid dosages had long-lasting reductions or elimination of their corticosteroid requirements in most cases. Similarly, most patients had long-lasting nasal airway improvement and reduction or elimination of recurring sinusitis. Antibiotics and antihistamine-decongestant preparations were sharply diminished in these patients. Although aspirin sensitivity was associated with some of the more severe asthmatic patients, it appeared not to be a factor in the responses to surgical treatment.

Evaluation of laryngeal cancer by computed tomography.

Six cases of laryngeal cancer have been examined by computed tomography. The findings were correlated with those obtained by laryngoscopy and in five cases by pathological examination of the surgical specimens. Computed tomography accurately delineated the extent of tumor involvement of the laryngeal and paralaryngeal soft tissues. The diagnosis of involvement of the laryngeal cartilages presents some problems, which are discussed.