Biomedical subjects
Publications and source records attributed to G D Becker.
The successful treatment of patients with midline granuloma requires prompt recognition of the cause as the therapy is quite specific. Nasal insufflation of cocaine is rarely mentioned as a cause. Two patients are described who used intranasal cocaine, leading to midline ulceration of the upper respiratory tract.
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To prevent ear infection, many physicians advise their patients to avoid water after insertion of tympanostomy tubes. This advice is a logical extension of the supposition that contaminated water entering the middle ear through the tube may cause an infection. While tympanostomy tubes have been in widespread use for over 30 years, very few prospective clinical trials have evaluated their use while swimming. This study evaluated 85 patients with tympanostomy tubes divided into three groups: swimming without earplugs, swimming with earplugs, and no swimming. The infection rates were 16%, 30%, and 30% in the three groups, respectively. We conclude that swimming without earplugs does not result in an increased incidence of middle ear infections.
In patients who are thought to have a perilymph (PL) fistula, careful inspection of the round and oval windows during exploratory tympanotomy may be normal. The decision must then be made either to terminate the procedure--knowing that the patient's symptoms will probably continue or deteriorate--or to repair both windows as if PL fistulas were present, risking further damage to the inner ear. From a series of 14 patients explored for possible PL fistulas, we report on 6 patients with preoperative diagnoses of PL fistula, based on history, physical examination, and audiometry. Symptoms resulting from trauma were present from 10 days to 23 years before surgery. During exploratory tympanotomy, no fistulas were evident; however, both the oval and round windows were repaired with tissue grafts. Follow up--for 1 to 5 years--revealed that vertigo was relieved in all patients. Postoperatively, one patient had a mild conductive hearing loss; yet no patient sustained a sensory neural hearing loss. We conclude that patch grafting of both the oval and round windows is a safe and effective method of treating suspected, but inapparent fistulas. Patient selection, surgical technique, and results shall be detailed.
Lymph node imaging has been helpful in managing patients with lymphoma, melanoma, and breast cancer. To evaluate 38 patients with head and neck cancers, 99mTc minicolloid was injected adjacent to the tumor and into a similar area on the uninvolved side. Lymphoscintigraphy of the neck was performed at 3- and 5-hour intervals after injection and bilateral cervical lymphatic drainage was observed. Each patient then underwent a neck dissection. The pathologic node findings were then correlated with the neck scans. Results confirmed that cervical lymphatic drainage is unpredictable in 50% of the patients once the channels are involved with metastatic disease. Lymphoscintigraphy is not a reliable method of detecting early metastatic cervical carcinoma.
Fourteen patients who experienced inner ear barotrauma (IEBT) while scuba diving were examined shortly after the episode and were followed up until symptoms resolved or stabilized. On the basis of these observations and a review of the literature, three types of IEBT are hypothesized that usually result from forceful autoinflation of the middle ear: (1) hemorrhage within the inner ear, (2) labyrinthine membrane tear, and (3) perilymph fistula through the round or oval window. Presenting symptoms, treatment regimens, and final results are detailed.
Despite the use of perioperative antibiotics, wound infection remains a major source of morbidity after contaminated head and neck cancer surgery. Accurate preoperative indentification of the patient likely to develop wound infection or prediction of the pathogenic organisms would allow a rational approach to antibiotic prophylaxis or initiation of therapy at the first sign of infection. This prospective study of patients undergoing contaminated head and neck cancer surgery evaluated cultures from hemovac lines in the prediction of the patient at high risk for wound infection and the bacteriologic findings in subsequent wound infections. Cultures were obtained from aspirates of the hemovac lines in 30 patients; 13% (four of 30 patients) developed a wound infection. Aerobic isolates were recovered in 100% (30 of 30 patients). Pathogens were isolated from 75% (three of four) and 73% (19 of 26) of patients with and without infection, respectively. Anaerobic bacteria were recovered in 8% (two of 26) of patients. There was a correlation between hemovac isolates and the patient's subsequent recovery from the wound infection in 50% (two of four) of the infected wounds. Cultures of hemovac lines in patients undergoing contaminated head and neck cancer surgery were not predictive of the high-risk patient or the bacteriologic findings in subsequent wound infections.
A composite resection for carcinoma of the upper aerodigestive tract was performed on 42 patients using a single transverse neck incision for the neck dissection, and an extension of this incision for inclusion of the primary lesion. This incision satisfies all the criteria that should be considered when designing a flap. Surgical exposure was adequate, no skin necrosis occurred, compatibility with reconstructive procedures was excellent, and resultant cosmetic deformity was minimal.
Only one detailed case of alternobaric (referring to alternating pressure changes) facial paralysis resulting from scuba diving has been reported in the world literature. This article describes the dive profile and clinical course of a commercial diver who developed facial paralysis after scuba diving on three different occasions. Probable pathophysiologies, identification of the diver at risk, treatment and prophylactic measures are reviewed. Additional cases from the literature due to scuba diving and flying are cited.
Prior to training, all scuba diving candidates must successfully complete a medical examination to determine their medical, physical, and psychological fitness for survival in a subaquatic environment. This article reviews the peculiarities of the diving medical examination and the reasons for them, suggests absolute, relative, and temporary disqualifications from diving, and outlines a sport diving questionnaire and medical examination.
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Posterior epistaxis from branches of the sphenopalatine artery can be rapidly and effectively controlled by a new ligation technique. The sphenopalatine artery or its branches are directly ligated as they exit the sphenopalatine foramen to enter the nose, completely avoiding the pterygomaxillary fossa. The vessels are exposed via a transantral approach, through the posterior portion of the medial antral wall. The mucoperiosteum of the lateral wall of the nose (medial antral wall) is preserved, elevated medially and posteriorly and used to tense the sphenopalatine vessels, bringing them into view and accessible for ligation at the foramen. Advantages of this technique include direct, specific ligation of the end vessels; ease and speed of operation; and avoidance of complications associated with the pterygomaxillary space. The technique was defined in multiple dissections of anatomic specimens and has been successful to date in 14 cases of severe posterior epistaxis.
A prospective study of patients undergoing major head and neck cancer surgery was undertaken to define the value of preoperative and intraoperative cultures in identifying the patient at "high risk" of wound infection and in predicting the bacteriology of wound infection. One or two days before surgery, the skin of the operative site on the neck, the oropharynx and anterior nares were swabbed. an intraoperative wound culture was obtained after the pharyngeal defect was closed and the wound irrigated with water. All cultures were processed for aerobes in the Anaerobic Bacteriology Research Laboratory at Wadsworth Hospital Center. Wound infections developed in 10 of 31 patients who received cefazolin prophylactically and 21 of 25 patients who received no perioperative antibiotics. Fifty-five percent of infected patients and 68% of noninfected patients demonstrated potential pathogens preoperatively. A potential pathogen isolated preoperatively or intraoperatively was subsequently recovered from 35% of infected wounds. The majority of infected wound cultures grew one or more additional pathogens. A poor correlation was also noted between preoperative nasal Staphylococcus aureus isolation and subsequent recovery from wound infections. We conclude that preoperative and intraoperative aerobic wound cultures are not predictive of the "high risk" patient or of the bacteriology of subsequent wound infection in major head and neck cancer surgery.
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A valid screening caloric test should decrease examination time, increase patient comfort and maintain a high degree of sensitivity in predicting bithermal (BT) caloric results. This prospective study of 362 consecutive electronystagmograms (ENG) compared right/left (R/L) difference results obtained using monothermal (MT) warm and cold irrigations alone with that of the (combined) BT tests. Comparing MT warm and cold irrigations, false negative (normal MT but abnormal BT test) results were obtained in 14% and 25% of irrigations, while false positive (abnormal MT but normal BT test) information was obtained in 22% and 15% of irrigations, respectively. False negative MT tests preclude detection of the abnormal BT test, while false positive tests require unnecessary completion of the BT caloric irrigations. This lack of diagnostic sensitivity limits the usefulness of the MT irrigation as a screening test.