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Biomedical subjects

R L Carrau

Publications and source records attributed to R L Carrau.

At least 19 recordsLinked to original sources
PubMed2001

Eagle syndrome produced by a granular cell tumor.

Eagle syndrome includes elicitation of pain on swallowing, turning the head, or extending the tongue. The syndrome is thought to be caused by irritation of the glossopharyngeal nerve, most commonly caused by its impingement against an elongated styloid process. We present a rare case of a granular cell tumor presenting as Eagle syndrome. Granular cell tumors orignate from Schwann cells and are most common in the subcutaneous tissue of the head, neck, and oral cavity, especially the tongue. A granular cell tumor is typically benign and solitary, rarely malignant. The differential diagnosis, diagnostic algorithm, and treatment are presented.

Adult↗
PubMed2001

Hydroxyapatite: an alternative method of frontal sinus obliteration.

Obliteration of the frontal sinus may be necessary for the treatment of chronic sinusitis, infectious complications, trauma, and benign and malignant neoplasms. Hydroxyapatite cement (HAC) is a relatively new material that is approved for the repair of cranial defects. HAC has been successfully used to obliterate the frontal sinus in 19 patients with few minor complications and the avoidance of donor site morbidity. Compared with other alloplastic materials, HAC has the advantages of easy use, biocompatibility, and osseointegration.

Adolescent↗
PubMed2001

Pituitary surgery.

This article focuses on surgical indications, perioperative management, and endoscopic approaches for pituitary surgery. Also discussed are sinonasal, neurologic, and endocrine complications, which may include bleeding, sinusitis, and synechiae; cerebrospinal fluid leaks and bleeding; and diabetes insipidus and panhypopituitarism, respectively.

Endoscopy↗
PubMed2001

Endoscopic and endoscopic-assisted surgery for juvenile angiofibroma.

OBJECTIVES/HYPOTHESIS: The mainstay treatment for juvenile angiofibromas is surgery. Endoscopic techniques have been applied to the resection of juvenile angiofibromas. The aim of the study is to establish the efficacy of endoscopic and endoscopic-assisted techniques for the removal of juvenile angiofibromas. STUDY DESIGN: Retrospective review. METHODS: Retrospective review was made of all patients with juvenile angiofibromas who were treated with endoscopic and endoscopic-assisted surgery from January 1994 to July 1999. RESULTS: Fifteen tumors in 13 patients were removed using endoscopic or endoscopic-assisted surgeries. In 11 patients, endoscopic surgery or endoscopic-assisted surgery (or both) was successful and the patients remained without evidence of disease at a median follow-up of 34 months. In two patients tumor persisted, which was detected during routine follow-up less than 6 months after the initial surgery. These tumors were managed with a second endoscopic or endoscopic-assisted surgery, and patients remained without evidence of disease. We encountered one postoperative complication, a progressive optic neuropathy that was successfully managed with endoscopic decompression. CONCLUSIONS: Endoscopic and endoscopic-assisted surgery is a feasible alternative or adjunct to traditional techniques.

Adolescent↗
PubMed2001

Detection, evaluation, and management of aspiration in rehabilitation hospitals: role of the otolaryngologist--head and neck surgeon.

CONTEXT: Reductions in the length of acute care hospitalizations have resulted in earlier transfer of patients with significant neurologic disease, such as head injury or stroke, to inpatient rehabilitation facilities. In many instances, these patients arrive at the rehabilitation hospital with multiple unresolved acute processes, including undetected or inadequately evaluated dysphagia. These patients may be at significant risk for the development of aspiration pneumonia, especially if elderly or debilitated. OBJECTIVE: To review the role of otolaryngologic consultation in the management of inpatients in two rehabilitation hospitals. DESIGN AND SETTING: Retrospective review of 1046 consultations performed by two otolaryngologists over a 4-year period at two long-term inpatient rehabilitation hospitals in the Pittsburgh, PA, metropolitan area. RESULTS: A total of 833 patients were evaluated. Three hundred were seen for a variety of common disease processes, including hearing loss, and cerumen removal. A total of 548 consultations were for recommendations regarding swallowing dysfunction. Fibre-optic endoscopic examination of swallowing function was performed in 478 patients. Two hundred consultations were for assistance in decannulation of patients who were transferred from the acute care hospital with an indwelling tracheostomy tube. CONCLUSIONS: The detection and evaluation of the aspiration risk of dysphagic patients in rehabilitation hospitals are enhanced by an onsite dysphagia team with access to instrumented measures of swallowing, especially videofluoroscopy or videoendoscopy. Otolaryngologic consultation can provide considerable benefit for many inpatients in rehabilitation hospitals, even those with apparent "minor" dysfunction. The otolaryngologist-head and neck surgeon is uniquely qualified to provide consultation in the management of those inpatients with complex clinical problems involving the upper aerodigestive tract. Consultation may be critical for some patients, assessing the cause and severity of dysphagia and assisting in the safe decannulation of those with indwelling tracheostomy tubes.

Deafness↗
PubMed2001

"Puffed-cheek" CT improves evaluation of the oral cavity.

BACKGROUND AND PURPOSE: Maneuvers that distend a lumen facilitate radiographic examinations. In evaluation of the upper aerodigestive tract, Valsalva and phonation maneuvers complement barium fluoroscopy. The current work investigates "puffed-cheek" CT to improve visualization of oral cavity tumors. METHODS: Seven patients (ages 17 to 86 years) underwent conventional and puffed-cheek CT. Five had squamous cell carcinoma, one had benign verrucous hyperplasia of the buccal mucosa, one had "cheek swelling," and one had a pulsatile cheek mass. Conventional contrast-enhanced axial CT scans (3-mm thick, no interslice gap) were obtained through the oral cavity and neck. Each patient then pursed the lips and puffed out the cheeks, and axial images were obtained through the oral cavity (puffed-cheek scans). RESULTS: Three patients had normal conventional CT scans whereas puffed-cheek scans clearly showed the mass. Conventional CT in three patients showed a mass inseparable from two mucosal surfaces whereas puffed-cheek images clearly showed which surface the tumor involved. Two patients had normal conventional and puffed-cheek CT studies; in one, the physical examination was also normal. The other patient was a teenager with orthodontic appliances that created artifacts on both conventional and puffed-cheek images. Conventional angiography in this patient revealed a facial artery aneurysm. CONCLUSION: The puffed-cheek CT maneuver is easily taught, and patients comply readily. Puffed-cheek CT scans provide a clearer and more detailed evaluation of mucosal surfaces of the oral cavity than do conventional scans. In selected patients, the puffed-cheek technique can supplement conventional CT studies.

Adolescent↗
PubMed2000

Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract: predictors of success.

INTRODUCTION: Cerebrospinal fluid (CSF) leaks may arise as a complication of endoscopic sinus surgery, trauma, or hydrocephalus, or they may occur spontaneously without any identifiable cause. Despite general agreement that CSF leaks should not be left untreated, their initial management, the surgical indications, and the technique of repair are controversial. OBJECTIVE: We undertook this study to ascertain whether a particular surgical technique or material was more successful for repair. Additionally, we tried to identify which specific characteristics of the patient, the CSF fistula, or the adjunctive treatment influenced the result of the repair. STUDY DESIGN: We completed a retrospective review of all patients undergoing endoscopic repair of a CSF leak at our academic hospitals. RESULTS: Forty-eight patients with 53 CSF fistulas were included in the study. Fifty sites were successfully repaired endoscopically on the first attempt. Three persistent leaks were repaired successfully on the second attempt. Location and size of the leak, cause, technique, and choice of material used for the repair did not significantly affect surgical outcome. However, the presence of hydrocephalus had a statistically significant negative influence on surgical outcome. All patients with increased intraventricular pressure required a ventricular shunt in addition to a second endoscopic repair. CONCLUSION: If the surgical technique is sound, endoscopic repair of CSF leaks is highly successful, independent of the choice of the material and technique used in the repair.

Adolescent↗
PubMed2000

Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis.

OBJECTIVES/HYPOTHESIS: Trauma and surgery are the most common causes of cerebrospinal fluid (CSF) rhinorrhea. Surgical repair is recommended for patients with CSF leaks that do not respond to conservative measures, traumatic CSF leaks that require transcranial surgery for associated brain injuries, and iatrogenic defects that are discovered intraoperatively. The purpose of our study was to ascertain the outcome after transnasal endoscopic repair of CSF leaks and to identify factors regarding the patient, CSF fistula, and treatment that may influence the results of the repair. METHODS: We performed a meta-analysis of all studies published in English between 1990 and 1999 that reported a minimum of five patients with CSF fistulae that were repaired using an endoscopic approach. We analyzed data that included type of graft and technique used during the repair, surgical complications, the use of packing, and the use of lumbar drains and antibiotics. The success rate was monitored and correlated with the other variables. The meta-analysis database was compared with and added to a database comprising our own patients. RESULTS: Fourteen studies comprising 289 CSF fistulae met the inclusion criteria. Endoscopic repair of CSF leaks was successful in 90% (259/289) of the cases after a first attempt. Seventeen of 30 persistent leaks (52%) were closed after a second attempt. Thus ultimately 97% (276/289) of the leaks were repaired using an endoscopic approach. The success rate of repairs using any of the reported techniques and materials was high and not statistically different. The incidence of major complications such a meningitis, subdural hematoma, and intracranial abscess was less than 1% for each complication. CONCLUSION: The endoscopic approach is highly effective and is associated with low morbidity. The literature supports the endoscopic approach using a variety of techniques and materials for the repair of CSF leaks.

Adolescent↗
PubMed2000

Selective neck dissection in the management of the clinically node-negative neck.

OBJECTIVE: To evaluate the efficacy of the selective neck dissection (SND) in the management of the clinically node-negative neck. STUDY DESIGN: Case histories were evaluated retrospectively. METHODS: The results of 300 neck dissections performed on 210 patients were studied. RESULTS: The primary sites were oral cavity (91), oropharynx (30), hypopharynx (16), and larynx (73). Seventy-one necks (23%) were node positive on pathological examination. The number of positive nodes varied from 1 to 9 per side. Of necks with positive nodes, 17 (24%) had extracapsular spread. The median follow-up was 41 months. Recurrent disease developed in the dissected neck of 11 patients (4%). Two recurrences developed outside the dissected field. The incidence of regional recurrences was similar in patients in whom nodes were negative on histological examination (3%) when compared with patients with positive nodes without extracapsular spread (4%). In contrast, regional recurrence developed in 18% of necks with extracapsular spread. This observation was statistically significant. Patients having more than two metastatic lymph nodes had a higher incidence of recurrent disease than the patients with carcinoma limited to one or two nodes. Recurrence rate in the pathologically node positive (pN+) necks was comparable to recurrence in those pathologically node negative (pNO) necks in the patients who did not have irradiation. CONCLUSION: SND is effective for controlling neck disease and serves to detect patients who require adjuvant therapy.

Adolescent↗
PubMed2000

The management of laryngeal fractures using internal fixation.

BACKGROUND: Laryngeal fracture is a rare injury with the potential to affect all functions of the larynx. Restoration of the laryngeal framework is critical for the rehabilitation of laryngeal function. OBJECTIVE: To ascertain the efficacy of adaptation plate fixation (APF) to repair the laryngeal skeleton. STUDY DESIGN: Retrospective review of the clinical data of all patients who underwent APF of laryngeal fractures from January 1989 to September 1999. RESULTS: Our series consisted of 16 men and 4 women presenting with laryngeal fractures caused by blunt (n = 16) or penetrating (n = 4) trauma. Most of these patients presented with severe fractures classified as category III (n = 6), IV (n = 10), or V (n = 1), according to the Schaefer-Fuhrman classification. All patients who required a tracheotomy (n = 13) were de-cannulated. Nineteen of the 20 patients recovered a social voice. The exception was a patient with aphasia secondary to head trauma No patient had aspiration problems. We encountered no complication associated with the use of APF. CONCLUSION: APF is an effective and well-tolerated method to repair laryngeal fractures.

Adolescent↗
PubMed1999

Laryngeal framework surgery for the management of aspiration.

BACKGROUND: During the past decade, laryngeal framework surgery has become the treatment of choice for the management of adductor paralysis of the vocal fold. The primary impetus for the use of this technique has been on the rehabilitation of voice. The purpose of this study was to ascertain the effectiveness of laryngeal framework surgery, including medialization laryngoplasty with silicone (MLS), with or without arytenoid adduction (AA), on eliminating aspiration, improving diet, and aiding in the subsequent decannulation of individuals with glottic insufficiency secondary to vocal fold palsy. METHODS: A retrospective chart review was performed on all patients initially seen with vocal cord paralysis who were treated with laryngeal framework surgery from June 1992 to April 1996. The study comprised 70 patients, including 31 women and 39 men, with a median age of 57 years. Clinical information was obtained regarding the etiology of the lesion, characteristics of the vocal cord deficit, history of aspiration, the presence of other neurologic deficits or concurrent pulmonary disease, treatment, and outcome. To determine the effectiveness of MLS, with or without AA, we assessed the final outcome regarding the presence and degree of aspiration, diet, history of aspiration pneumonia, and decannulation. RESULTS: Seventy patients underwent 77 MLS (three bilateral, four revisions), and 21 AA. Decreased aspiration was obtained in 96% of our patients. Seventy-five percent of those patients who had required a tracheotomy were decannulated. CONCLUSIONS: These results support the use of laryngeal framework surgery for the effective treatment of aspiration in selected patients initially seen with deficits of the glottic closure secondary to vocal fold paralysis or paresis.

Adult↗
PubMed1999

The role of skull base surgery for the treatment of adenoid cystic carcinoma of the sinonasal tract.

BACKGROUND: Adenoid cystic carcinoma (ACC) of the sinonasal tract is an aggressive malignancy associated with a poor 5-year survival rate. The role of skull base surgery for the treatment of patients presenting with sinonasal ACC and its impact upon their survival has not previously been evaluated. METHODS: A retrospective review of 35 patients with ACC of the sinonasal tract who were treated with surgery and radiation therapy at the University of Pittsburgh Medical Center was performed to evaluate patient outcome. RESULTS: Local recurrence of tumor following surgery and radiation therapy was observed in 36% of the patients originally treated at the University of Pittsburgh Medical Center. Fourteen percent of these patients developed a regional tumor recurrence, and 21% developed distant metastases. We did not identify any tumor-related factors that predicted patient outcome. Local recurrences were treated with salvage surgical excision, and, despite aggressive management, only 1 of 17 patients with local recurrence was considered cured (NED) at 24 months (follow-up after salvage surgery). Overall, disease-free survival was 46.4%, at a median follow-up of 40 months. CONCLUSIONS: ACC of the sinonasal tract is an aggressive malignancy. Skull base surgery has facilitated the gross total excision of advanced lesions that were deemed inoperable in the past, but has not resulted in an overall improvement in disease-free survival. Local recurrence portends a very poor prognosis, despite aggressive salvage regimens. Alternative therapies for local recurrences warrant further investigation. Prospective, randomized studies are necessary to evaluate the outcome of patients treated with aggressive multimodal treatment regimens, including chemotherapeutic regimens.

Adult↗
PubMed1999

The use of maxillary sinus endoscopy in the diagnosis of orbital floor fractures.

PURPOSE: The goal of the current study was to evaluate the ability to diagnose the presence of an inferior orbital wall fracture through the use of a transantral endoscopy technique at bedside. PATIENTS AND METHODS: Seven trauma patients with initial axial computed tomography (CT) scan findings consistent with an orbital floor fracture were studied. Before endoscopy, the patients underwent a coronal CT scan with 3-mm cuts for later comparison with the endoscopic findings. The surgeon performing the endoscopy procedure was blinded to the results of the coronal CT scan. Visual acuity, intraocular pressure, and measurement for enophthalmos were performed before endoscopy. The endoscopic procedure was performed at the bedside using local anesthesia. A trocar was used in the canine fossa to gain access to the maxillary sinus. A 30 degrees and then a 70 degrees endoscope were introduced through the trocar to evaluate the integrity of the orbital floor (ie, maxillary sinus roof). The degree of mucosal injury of the orbital floor and the presence of blood or orbital contents in the sinus were recorded. The ophthalmologic examination was repeated after completion of endoscopy. RESULTS: The endoscopic procedure was able to be completed in all patients. There was no change in the ophthalmologic examination in any patient as a result of endoscopy. In six of the seven patients studied, the endoscopic findings correlated with the need for surgical intervention to repair the orbital floor predicted on the basis of coronal CT scan. This was determined by the degree of injury to the orbital floor and the presence of hematoma, exposed bone, or fat. In the remaining case, endoscopy was not diagnostic for the presence of a fracture because only ecchymosis of the orbital floor was noted. CONCLUSIONS: The ability to perform endoscopy under local anesthesia at the bedside is useful in those trauma patients whose concomitant injuries may prohibit other diagnostic modalities.

Adolescent↗
PubMed1999

Squamous cell carcinoma of the sinonasal tract invading the orbit.

OBJECTIVE/HYPOTHESIS: The treatment of squamous cell carcinoma (SCC) of the sinonasal tract has evolved from routine exenteration of the orbital contents to sparing of the orbit when the SCC does not transgress the periorbita. Nonetheless, the influence of this change in treatment over the rate of local recurrence or survival has not been clearly elucidated. The objective was to ascertain whether orbital sparing surgery for the treatment of SCC of the paranasal sinuses influences the rate of local recurrence or survival. STUDY DESIGN: This is a retrospective study of patients presenting with SCC arising in the sinonasal tract, treated primarily at the University of Pittsburgh Medical Center from 1977 to 1990, including meta-analysis of the English literature regarding SCC of the sinonasal tract. METHODS: Review of medical records regarding demographics, histology, extension of tumor, pathologic results, type of surgery, adjunctive therapy, and outcome. Articles for meta-analysis were identified by Medline search and cross-referencing. RESULTS: Fifty-eight patients with orbital invasion, including bone and/or soft tissue invasion, were included in the study. Patients presenting with invasion of the bony orbit without soft tissue invasion were treated with maxillectomy and/or ethmoidectomy, sparing the orbital contents. Patients presenting with invasion of the orbital bones and soft tissues were treated with ethmoidectomy or maxillectomy, including orbital exenteration. At 3 years' follow-up, 52% of the patients whose orbit was exenterated were alive and without evidence of disease, compared with 59% of the patients whose orbit was spared. This difference was not statistically significant. Similarly, the rate of local recurrence was not statistically significant (P > .05). A meta-analysis of the literature revealed similar results. CONCLUSIONS: Our data suggest that sparing of the soft tissues of the orbit when the periorbita has not been transgressed by SCC does not downgrade the rate of cure or local control.

Carcinoma, Squamous Cell↗
PubMed1998

Repair of laryngeal fractures using adaptation plates.

BACKGROUND: There is a need to evaluate the effectiveness of laryngeal fracture repair using rigid adaptation plates. METHODS: A retrospective chart review of patients undergoing open repair of laryngeal fractures using metal alloy plates, from 1987 to 1995, was performed. Postoperative airway, deglutition, and voice were assessed. Postoperative follow-up ranged from 1 to 58 months (median, 27 months). All 10 patients sustained blunt or penetrating laryngeal trauma. After patients were resuscitated according to the ABC principles recommended by the American College of Surgeons, each underwent open repair of laryngeal fractures using rigid adaptation plates. RESULTS: Outcome was measured by perceptual analysis of the postoperative airway, swallowing, and voice, as well as biocompatibility. Ten patients underwent repair and stabilization of the larynx using adaptation plates. Nine patients sustained blunt trauma, and one patient sustained penetrating trauma. Voice was subjectively graded as good if it resembled the preinjury status, fair if it differed, and poor if it represented aphonia, whisper, or unintelligible speech. Airway was graded as good if it resembled preinjury status, fair if mild exercise intolerance or aspiration existed, and poor if the patient could not be decannulated. Nine patients had a good airway following repair, and six of seven patients requiring tracheotomy were decannulated. All patients tolerated the plates well and suffered no surgical complications. CONCLUSION: Repair of the laryngeal framework using adaptation plates provides adequate, immediate stabilization with restoration of function and is an alternative to traditional methods of repair.

Adolescent↗
PubMed1998

Intranasal endoscopic excision of a juvenile angiofibroma.

Intranasal endoscopic excision of a juvenile nasopharyngeal angiofibroma (JNA) was performed in a 13 year old white male. The patient remains disease-free 24 months after the operation. Although endoscopic surgical techniques have been applied to the therapy of some benign nasal tumors, such as inverting papilloma, endoscopic resection of a documented JNA has not been previously reported. This technique is reserved for tumors which are limited to the nasal cavity and paranasal sinuses with minimal extension into the pterygopalatine fossa.

Adolescent↗