_alp4_

TABLE OF CONTENTS _t2,_l_,_ _,_,_v_,_,VOL. 16, No. 3 (2001) s_._a_, Jw¢_ e_,_,_ e_

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Editorial Staff ,_-........................................

Guidelines for Authors

Original Studies

Risk Areas in Endoscopic Sinus SurgeD' A Review of 175 Computed

Tomography Scans of the Sinuses Among Patients with Nasal Polyposis

Emilio Romel G. Acosta, M.D., Gil M. Viccnte, M.D .................................................. 118-125

Clinical Efficacy of Gentamicin, Betamethasone, Toinaftate and Clinoquinol

in the Management of Acute Otitis Externa in Adults

Mildred B. Olvcda, M.D., Noel O. l-)e Guzman, M.D.,

Eduardo C. Yap, M.D., Howard M. l:;nriquez, M.D .................................................... 1.26-130

Surgical Innovation

Locally Produced Bioccramic Orbital Plate Used to Reconstruct OrbitalFloor Detect : A Preliminary Report

Rodcl Allan E. Gaft\ld, M.D., Edgardo del Rosario, M.D..

Karen Alcantara, M.l)..Jessica Albano M.D., .locelyn Sy, M.D.,

Jocelyn Reyes, M.D., Felix P. Nolasco, M.D ................................................................ 131-139

Le Fort I Osteotomy Down Fracture with Midline Palatal Split via a Midfacial

Degloving Excision of Juvenile Angiofibroma

Eutrapio S. Gt, evara..lr_. M.D.. Josefino G. Hernandez, M.D., Ramon Antonio

B. Lopa, M.D., Peter Jarin, M.D., Roberlo M. Pangan, M.D., DMD PhD ..................... 40-144

Case Report

Laryngeal Amyloidosis

Kennard Q. Felix, M.D., Joseph Arnold darvin, M.D., Virgilio de Gracia. M.D ............ 145-152

Paraganglioma Presenting as a Parotid Mass

Cecille Trisha B. Duran, M.D., Johanna M. Co, M.D., Felix P. Nolasco, M.D .............. 153-157

Guidelines for AuthorsTHE PHILIPPINE JOURNAL OF OTOLARYNGOLOGY

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All manuscripts and other editorial matter should be addressed to Charlotte M. Chiong,MD, Editor-in-chief. The Philippine Journal of Otolaryngology-Head and Neck Surgery,

Department of Otolaryngology, UP-PGH, Taft Avenue, Manila.

The Philippine Journal of Otolaryngology Head and Neck Surger

Founded in 198.1

Editor-in-chief Previous Editors

Charlotte M. Chiong, MD Angel E. Enriquez, MD- 1981 to 1988Eusebio E. Llamas, MD- 1989

Alfredo Q.Y. Pontejos, Jr., MD - 1990Joselito C. Jamir, MD - 1991 to 1998

Jose M. Acuin, MD- 1999 - 2000

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Jesus Randy O. Canal, MD

Managing EditorRhodora A. del Rosario-Ocampo, MD

Associate Editors

Roberto M. Pangan, MD, DMD, PhD, Oral and Maxillofacial SurgeryRuzanne M. Caro, MD, Clinical Epidemiology

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Eduardo C. Yap, MD, General Otolaryngology

Natividad A. Almazan-Aguilar, MD, OtologyCecilia Gretchen S. Navarro-Locsin, MD, Pediatric Otolaryngology

Ma. Clarissa S. Fortuna, MD, LaryngologyCesar V. Villafuerte Jr., MD, Facial Plastic Surgery

EDITORIAL ADVISORY BOARD

Joselito C. Jamir, MD, Laryngology and BronchoesophagologyGeneroso T. Abes, MD, Otology

Mariano B. Caparas, MD, Maxillofacial SurgeryEutrapio S. Guevara, Jr., MD, Facial Plastic Surgery

Adonis B. Jurado, MD, Pediatric Otolaryngology

Dominador M. Almeda, Jr., MD, Neurotology

Alfredo Q.Y. Pontejos, Jr., MD, Head and Neck Surgery

Editorial Assitant: Melody T. Francisco

PHILIPPINE JOURNAL OF OIOI.AP-2r'NGOLOGYIIEAD & NECK SURGERYVol. 16 No, 3 118,,125.©2002 PFllLIPPINE SOCIETY OF OTOLARYNGOLOGY HEAD & NECK SURGERY

RISK AREAS IN ENDOSCOPIC SINUS SURGERY:A REVIEW OF 175 COMPUTED TOMOGRAPHY

SCANS OF THE SINUSES AMONG PATIENTSWITH NASAL POLYPOSIS*

EMILIO ROMEL G ACOSTA, MD**GIL M. VICENTE, MD, FPSO-HNS***

ABSTRACT

OBJECTIVE

This study aims to determine the types and frequency of occurrence of anatomic variations of high-risk

areas in CT scans of the paranasal sinuses as they relate to sinus surgery among patients with nasal polyposis.

DESIGNDescriptive/Cross Sectional

SETTING

Tertiary Government Medical Center

SUBJECTS

Pre-operative computed tomography scans of the paranasal sinuses of patients with nasal polyposis

RESULTS

Among one hundred and seventy-fiveCT studies reviewed, eight types of variations relevant to endoscopicsinus surgery were noted. These were: asymmetric ethmoid roof (19.4%), deep olfactory fossa/high lateral lamellaof the cribriform plate (Keros III) (15%), Onodi cells (8.2%), dehiscent lamina papyracea (2.5%), extensive sphenoidpneumatization (1.1%), asymmetric sphenoid septum attached to the carotid canal (1.1%), dehiscent carotidcanal in the sphenoid sinus (0.5%), dehiscent optic nerve in the sphenoid sinus (0.2%). The anterior ethmoid artery(0.8%) and posterior ethmoid artery (1.4%) were also identified.

CONCLUSION

We reviewed the pre-operativeCT scans of 175 patientswith PNS disease (nasal polyposis) and noted thehigh-risk areas where injury may occur during surgery. These anomalies are identifiable in the pre-operative CTscan and should be used as a guide in planning and execution of safe endoscopic sinus surgery.

*1st Place, PSO-HNS Descriptive Research Contest, November 29, 2000, Punta Baluarte, Calatagan, Batangas

**Resident, Department of Otorhinolaryngology-Head and Neck Surgery, Jose R. Reyes Memorial Medical Center

***Chairman, Department of Otorhinolaryngology-Head and Neck Surgery, Jose R. Reyes Memorial Medical Center

J18

INTRODUCTION ogy (obstruction of the ostiomeatal unit/OMU) or mayinterfere with the planned surgery. These include sep-

Endoscopicsinus surgery, while offering ad- tal deviations, agger nasi cells, concha bullosa, para-vantages over conventional surgery of the paranasal doxically curved middle turbinates, uncinate variants,sinuses, is not without its hazards 1,_-,3,2°.Mosher, a giant ethmoid bullae, and Hailer cells 5.7.8surgical anatomist, in a presentation in 1929, stated Ohnishi et al1_,based on surgery done on 190that surgery in the ethmoids is one of the easiest patients, identified main high-risk areas in the ethmoidways to kill a patient _.This remains true today de- labyrinth where they think surgical complications arespite the advances in imaging, equipment and surgi- most likely to happen. These are:cal techniques. 1. lamina papyracea

Complications of endoscopic sinus surgery 2. roof of the ethmoid sinus nearthe(ESS) may be major or minor and may involve the anteriorethmoid arteryorbit, the brain, and major vascular structures (inter- 3. lateral lamella of the cribriform platenal carotid artery and cavernous sinus). Some of the 4. ethmoid roof near the posteriormore serious complications include blindness, men- ethmoid arteryingitis, intraorbital hemorrhage, intracranial injury, brain 5. the area between the sphenoid andabscess, and major epistaxis have been reported to posterior ethmoid sinuses.occur in 0_75% - 10% of cases 34_ Meyers et ale, also identified maxillary sinus

Complications happen partly because surgical hypoplasia, fovea ethmoidalis abnormalities, sphenoidlandmarks differ among patients. This is due to the sinus wall variations, and Onodi cells as anatomicfact that the paranasal sinuses (PNS) are subject to variants identifiable in CT scans that are relevant tovarying degrees ofpneumatization and differentiation 4. ESS. It is the objective of this paper to attempt toEndoscopy, while allowing excellent visualization of identify the aforementioned areas in pre-operative CTthe lateral nasal wall, is limited in its view of the fron- scans.tal sinus and recesses, maxillary sinus and ostia, Foreign literature focusing on anatomic featuresethmoid bullae, and posterior ethmoid and sphenoid and variations of the PNSsinuses _. The CT scan, with its capacity to allow as seen in CT scans abound. None however, hasprecise delineation ofextentofdiseaseand delicate been done for Filipino patients. This study aims tobony anatomy (Fig_ 1), plays an important role in ascertain the presence and prevalence of anatomic

providingthe surgeon a road map prior to ESS 5.a.19.21 variants relevant to ESS in CT scans of the PNS ofA careful examination of the pre-operative CT patients with nasal polyposis.

..... • ',.

•/.(:t::,_ ,", ._ , .. "

)...i:i_:::::i_"-...._i:.-.'_.::: ...!..[.r/,_...:....:.:.::......_:..I OBJECTIVES

.!_ [I t_'l[:.'i :.! Genera/.

•"i:_Z..........x,.._,!/k..i_",{i''-!::&:"'_ .,/i 1. To determine the types and frequency of• ": ..,_,_ .....' i I anatomic variations of the PNS relevant to ESS in CT

• ".-i";.il ...._ .... Specific..•..... ........ .... .... 1. To determine the frequency of the following

...... "_':,.:b anatomic variations among CT scans of the PNS ofi.?_£_ patients with nasal polyposis:

a. dehiscent lamina papyraceab. ethmoid roof variation- asymmetry, depth

FIGURE1.Linediagramof coronalsectionat the levelof the C. Onodi cellsostiomeatalunit(OMU).F= frontal,E=ethmoid,M =maxillarysinus,It = inferiorturbinate,Mt--middleturbinate,LP= lamina d. sphenoid sinus variations -papyracea,FE=foveaethmoidalis,O= orbit,largearrowhead pneumatization= cribriformplate,encircledarea= OMU: I = infundibulum, -carotid and optic nerve canal dehiscencearrow = maxillary sinus ostium leading into the hiatus -septum variationssemilunaris,dots: uncinateprocess. 2. TO identify the anterior and posterier ethmoid

arteries as they course through the ethmoid labyrinth.scan should be done and the surgeon should note 3. To discuss the significance of these variationsanatomic variations that may predispose patients to as they relate to risks of complications in endoscopiccomplications 4,7.9.1o.It is also important to look for sinus surgery (ESS)other variations that either contribute to the pathol-

119

SIGNIFICANCE Additionally, asymmetry of the ethmoid roofswas noted by comparing both sides in the same

1. Knowledge of the more common anatomic patient and measuring the difference (the total numbervariants would alert the sinus surgeon on what to in this case was 175 CT scans as each nasal cavitylook for/watch out for when doing their surgeries, was not evaluated independent of the other).

2_ Accurate identification of these variants The frequencies of occurrence of thewould potentially reduce the risks of intra- anatomic variants were computed as a percentageoperativecomplicationsby enhancing pre-operative of the total number of cases seen.planning of sinus surgery,

3. No such study has been done among localpatients.

4, To provide a springboardfrom which further RESULTS

studies may arise, The CT scans reviewed numbered 175for a totalof 350 nasal cavities or sets of paranasal sinuses.

METHODS The age range was from 6- 77 years old with a meanof 68.3. Most of the subjects were from the 2n_- 5th

I. DESIGN Descriptive/Cross-sectional decade of life, with a male:female ratio of 1.96:1 orII. SETTING Outpatient clinic of the approximately2:l. Thediagnosisofallsubjectswas

Otorhinolaryngologydepartmentofatertiaryhospital of nasal polyposis. The most commonly affectedIII. MATERIALS The pre-operative PNS CT sinuses were the maxillary and ethmoids, followed

scans of t75 patients diagnosed to have nasal poly- by the frontal and sphenoid sinuses.posis. These are previously unoperated upon cases. The anatomic variants seen (arranged from

IV. PROCEDURE The CT scans of the study anterior to posterior) were:population were systematically evaluated by the au_

thor according to the guidelines proposed by A. High-riskareasStammberger and by Mason et al. (see Appendi- 1. Dehiscent lamina papyracea 9 (2.5%)ces A and B). Emphasiswas given to the previously 2. Ethmoid roofenumerated variants deemed relevant to ESS. The

a. Keros typesCT scans were reviewed in two separate occasions ..-- I 12 (3.4%)to minimize intra-observervariability. II 284 (81%)

The presence or absence of normal III 54 (15%)landmarks and anatomic variants previously b. asymmetricenumeratedwere noted and tabulated. Each feature ethmoid roof : 34 (19.4%)was counted as one (1) feature independent of any right higher thanother variant present in the same subject. The left the left 8 (4.5%)and right halves were counted separately for a total left higher thanof 350 nasal cavities evaluated, the right 26 (14.9%)

The ethmoid roof height was obtained by 3. Onodi cell 29 (8.2%)measuring the distance from the cribriform plate of 4. Extensive sphenoidone side to the apex of the fovea ethmoidalis of the pneumatization 4 (1,1%)frontal bone of the same side. These were then 5. Carotid canal in sphenoid sinusgrouped according to Keros' classification (Fig 2). a. bulge in sinus,

"Q:.t;Z:.:_,:'_;--',. b. dehiscence 1 (0.2%)'"-_:__y_ "i *_rS :'_1'" no dehiscence 11(3.14%)

• _.._i '4 .. /ti) J..,_ 6. Optic nerve canal in sphenoid sinus"_".............. . ", I .___....... a. bulge in sinus,

_. _-• _ "- .. .,. _.-.J .. _. ..

no dehiscence 8 (2_2%)

'.._'...........•........ _7:_::._:J_ b. dehiscence 1 (0.2%)

........ t':_: _ [ 7. Sphenoid sinus septa_ ) • a. absent 42 (24%)

/ I , I"_,,.........'.-' i _ '-" ....... b. single, median 43 (24.6%)

" .... •.... c. single, asymmetric 77 (44%)FIGURE2. This schematicdrawingshowsthe threedifferent d. multiple/subseptations13 (7.4%)types of olfactory fossa accordingto Keros. In Type I the

e. septum attached toheightof thelaterallamellais from1-3mm.TypeIi =4 -7 mm,TypeIII=8- 16ram.(fromStammberger,FunctionalEndoscopic the carotid canal 4 (1.1%)SinusSurgery,1991)

120

B. Anterior ethmoid artery 3 (0.8%)Posterior ethmoid artery 5 (1.4%)

DISCUSSION.._

There is a great amount of variation in the ik,,.anatomy of the paranasal sinuses and the nasal If"cavity. Some of these are seen more frequently amongpatients with disease of the PNS 7. These variantsare thought to contribute to the pathogenesis/ FIGURE4.CoronalCTscans showing dehiscenceofthe laminapathology of PNS disease through their obstructive papyracea (arrows).effect on the ostiomeatal unit (OMU) and interferencewith normal drainage pathways. However, there EthmoidRoofappears to be a lack of consensus among examiners Keros 10.13in his dissections of 450 skulls,as to the definite clinical significance of these classified the olfactory fossae in 3 types based

on the distance between the cribriform plale and thevariations 5. More importantly, noting the presenceand relationshipsof these anatomicdivergences may roof of the ethmoid. The findings of the current studyserve as a surgical road map - delineating high-risk paralleled his in that type II was the most commonareas in the conduct of endoscopic sinus surgery. (81%), followed by type III (15%) and lastly, type I

(3.4%). Among these, type iii is at greatest risk for

High; riskareas intracranial injury. This is because the olfactory fossa• is deep and the lateral lamella of the cribriform plate

Laminapapyracea is high and thin lo Injuries are more likely toThis is the medial wall of the orbit and is also happen when the surgeon works medial to the superior

the lateral wall of the ethmoid sinus• It is a thin and attachment of the middle turbinate in the attempt to

quite fragile structure, which normally protrudes into avoid the lamina papyracea. As a consequence, thethe surgical field 11_Also, dehiscence may occur which, surgeon works more medially, reaching the area whereby itself, may not be significant but if the periorbita is the anterior ethmoid artery crosses through theviolated, damage to orbital contents (medial rectus ethmoid 3.9(Fig. 5).and superior oblique muscles, ciliary nerve, opticnerve) may occur 3,_1,12(Fig. 3). This may lead to orbital ....fat herniation, hematoma, emphysema, diplopia, and ........._._:.iL._. ,1._--._"_;_'-- I

blindness secondary to retinal artery compression and ,.,--_,k_,_ __.,_,,'U[ '/iJ Ioptic nerve ischemia or direct optic nerve injury 9. i:[_'_[_,_.',_

Meyers et al reported dehiscence of the lamina ti_,it ll_ ::'_,/I_ !_ I

papyraceain2of400 CTs they reviewed. In ourstudy, _f /j.t til tI ,_this was noted in 9 of 350 orbits (25%) (Fig. 4). _ _-_ .

_"'_,.?.., FIGURE5. Thisfigureshowsahighethmoidroofandthesite

] _:_:, ', _., of probablepenetrationof the laterallamellaof the cribriform_k_.%_!,:.#:,__ "_\._ wherethe ethmoidarterycrossesthrough.

f i,_i_iIl!_. ? _',. It is this region where the lateral lamella of the

_,_......... cribriform is said to be weakest _0. Thus, identificationilli ,._I_i__'.,._. ,,,,/ ,,..;:,........:, • ,. , .; of the ethmoid artery (anterior and posterior) in the

•:_-_/f!,"_;.I ethmoids is helpful in avoiding damage to the mostinjury-pronepartofthe roofofthe ethmoidsinus 11inthis series, the anterior ethmoid artery and its canal

FIGURE3. Orbitalfat herniationthrougha traumaticdefectin was seen coursing through the ethmoids below thethe laminapapyracea roof in 3 cases (0.8%) (Fig. 6) while the posterior

J ethmoid artery and its canal was identified in 5 cases(1.4%).

121

J

FIGURE 6. Coronal CT scans showing the anterior ethmoid

artery and its canal crossing through the ethmoid sinus FIGURE 7. Coronal CT scans showing asymmetric ethmoid(arrows). roof height.

The anterior vessel was seen a slice or two OnodiCells

(slice thickness = 2mm) from the most anterior part These are posteriorethmoidal cells that haveof the middle turbinate, approximately 2 mm below extended posterosuperiorly and/or laterally beyondthe fovea ethmoidalis. The posterior ethmoid artery the sphenoid sinus and may lie in close relationshipwas identified 2 - 3 slices from the beginning of the to the optic nerve 7,1_(Fig_ 12).vertical attachment of the middle turbinate. Careful

dissection around the arteries is necessary astransection could often result in retraction into the -'_'.'_" ....-

orbit with its consequent intractable intraorbital °. _ _ • ., :

'hemorrhage, _. (, __, ,,Injury to this may also result in CSF leaks "...'......'-'_'• _11___tYJll!li'_ ,"_,".....

(_1 - 1%) which may lead to meningitis or brain ;_.\ X_,abscess formation which has a mortality rate of 20- _.-& ,t_r.jt_ml,_.,:_,il_l

p t \30%1_.1_. ., _....

Asymmetry of the ethmoid roof is also saidto contribute to intracranial injuries 7,15Maniglia et " _a/4 noted that more CSF leaks occur on the rightside of a patient operated upon by a right-handed FIGURE12. Schematicillustrationshowing the relationship of

the optic nerve to the posterolateral wall of an Onodi cell andsurgeon. The authorsattributed thisto theawkward the sphenoid sinus. 1 = optic nerve bulging into an onodi cell;position of the surgeon, preventing adequate and 2 = optic nerve bulging into the sphenoid sinus (from

visualization of surgical landmarks. Another Stammberger,FunctionalEndoscopicSinusSurgery,1991)_contention is that asymmetry in roof height might bea factor_ Right-handed surgeons commonly start onthe left nasal cavity and this may lead to under- or The reported incidence of this structure rangesover-estimation of the height on the right. A difference from 3_4-14% 6. In this review, onodi cells were seenin height of the ethmoid roofs was noted by Dessi et in 29 cases (8.2%) with the optic nerve creating anaPs in 15 of 150 scans (10%) with the right fovea impression in 2 cases (0.25%). Knowing thislower than the left in 8.6%. In our study asymmetry relationship pre-operatively is of importance if theof the roof was seen in 34 cases (19.4%), with the sphenoid is to be approached via the ethmoid.right lower in 26 cases (14.7%) (Fig 7)_ Care, Searching forthe anterior wall of the sphenoid sinustherefore, must be taken not only in approaching the behind the furthermost point of the posterior ethmoid

lateral wall of the ethmoid labyrinth where the orbit might lead to injury to the optic nerve _0,_.lies, but along the roof as well.

122

Sphenoid Sinus (0.5%). In this series, the carotid was seen to makeSphenoid sinus pneumatization is quite an impressionon the sphenoid sinuswall in 11 cases

variable and protrusion of surrounding structures (3.14%) and was dehiscent in 2 (0.5%). The opticoccurs in different degrees 18(Fig. 8). Extensive nerve was protruding in the sinus in 9 cases (2.2%)aeration into the clinoids, dorsum sellae and pterygoid and uncovered in 1 case (0.2%) (Figs 9, 10).processes may predispose some of these structures

to injury during surgery 1-/_

Internal carotid al_ery. Right sphenoid sinus

Pituitary /

' ' "i.'i.".- • "5i ''_"r ,-_...,.' .j./.,..? ,.,,....,o., internal carotidwall of sphenoid

....5,.:7"_ _ery against

-.._ .......................:. :: ' "....7: .,,:.,"....... ,_ :..:

,\ '. .....:., ,

,, "; - ....._:,....-"j4_"4'.'?-''--_' ' FIGURE 9. Extensively pneumatized sphenoid. Note the im-/'q

pression of the carotid canals (straight arrows) and the opticnerves (curved arrows) into the sphenoid sinus.

][INpl'Cb;_iO[I (')f OpliC IICI'Vf3 optic nerve

againsi wnll of sphcnoid

,..A...,,. %. '_":: ' " ".,"..'..",., '7"_

FIGURE 8. Schematic drawing of coronal sections through the FIGURE 10. Axial CT scan showing the left optic nerve cours-spheoid sinus showing the various structures surrounding it, ing through the sphenoid sinus without any bony covering

(arrow).

The more important of these entities as they

relate to sinus surgery are the optic nerve and internal The direction and insertion of the septa incarotid artery. The former is seen adjacent to the the sphenoid sinus is also important. The intersinusposterosuperior wall of the sphenoid while the latter septum may be absent, single, or with subseptations/courses just below the nerve, in well pneumatized multiple, median or asymmetric. It may deviatesphenoids, these may project into the sinus covered laterally and insert into the bony canals of the carotidby a thin bony shell. The bony covering may be or the optic nerve _°.Grasping and torsion applied onnaturally dehiscent or be absent 6._1.Thus, injury tothese structures may happen in cases where the septum can thus result in carotid avulsion orsphenoidectomy needs to be done to production of an aneurysm _. In this study, the septum

Elwany et a118,in their dissection of 93 was seen to be attached to the carotid canal in 4cadaver heads, noted the following: cases (1.1%) (Fig 11). Meyer et al.8reported this

1. carotid artery impression seen in occurrence in 1%.of their cases.34 sinuses (18.2%) From the preceding, we see that variations

2. dehiscent carotid canal in 9 sinuses (4.8%) are myriad and add to the complexity of the pre-3. optic nerve impression in 54 sinuses (29%) operative evaluation and planning as well as in the

with no dehiscences_ conduct of sinus surgery. It is thus imperative that

Meyers ei al?, in their review of 400 CT scans these high-risk areas be identified prior to surgery inorder to avoid potentially disastrous complications.

noted bulging of the carotid artery in the sinus 15%of the time, bulging of the optic nerve in 3 cases(0.75%), and a freely coursing optic nerve in 2 cases

123

Nasal Cavity and Paranasal Sinuses. InCummings et al [eds]. Otolaryngology-HeadandNeck Surgery. 3rdEd. 1998. Mosby-YearBook, Inc. St Louis. pp.1065-1091

8. Zinreich, SJ, D. Kennedy,A. Rosenbaum, BGayler, A. Kumar, H. Stammberger.Paranasal Sinuses: CT Imaging

_._ Requirements for Endoscopic Surgery.Radiology, 1987; 163:769-775

9. Rao, V, & K EI-Noueam Sinonasallmaging.

._11__ Anatomy and Pathology. Radiologic Clinics_: of North America. September 1998.36(5):921-938.

FIGURE11. AxialCTshowinganasymmetricsphenoidseptum 10. Stammberger, H. Functional Endoscopicattachingto the carotidcanalon the right. Sinus Surgery. 1991. Mosby-Year Book, Inc,

St_ Louis, Missouri_ 529pp11. Ohnishi, T, T. Tachibana, Y. Kaneko, S.

CONCLUSION Esaki. High-RiskAreas in EndoscopicSinusSurgery and Prevention of Complications.

In summary, we reviewed the pre-operativeCT Laryngoscope. October 1993.103:1181-scans of 175 patients with PNS disease (nasal 1185.

.polyposis)and'_oted the high-riskareas whereinjury 12. Mattox, D.E., R. Delaney. Anatomy of themay occur during surgery. These anomalies are Ethmoid Sinus. Otolaryngologic Clinics' ofidentifiable in the pre-operative CT scan and should North America. February 1985.18 (1): 3-14_be used in as a guide in planning and execution of 13. Teatini G, G Simonetti, U Salvolini, W.safe endoscopic sinus surgery. Masala, F Meloni, S Rovasio, GL Dedoia.

Computed Tomography of the EthmoidLabyrinth and Adjacent Structures: Normal

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Otolaryngology - Head and Neck Surgery. ethmoid?Can the bony margins be identified precisely?

1990.103(5 pt 2): 863-868. To what extent does the roof of the ethmoid

20. Stankiewicz, JA. Complications of project over the cribriform plate?

Endoscopic Nasal Surgery: Occurrenceand Is theolfactory fossashallowo¢deep?

Treatment, American Journal of Rhinology. Dotheethmoidcellsextendsupraorbitally?Are the right and left sides symmetrical?1987.1:45-49. 5. What is the relationship of the posterior ethmoiclal cells to

21, Chow J, MF Mafee. RadiologicAssessment the sphenoid sinus?

preoperative to endoscopic sinus surgery. ArethereOnodicells?Is the optic nerve involved within them?

OCNA. 1989.22(4): 691-701 6. To what extend is the sphenoid pneumatized?Are the internal carotid artery and optic nerveprominent and is there a suspicion that their bonycover may be dehiscent?

APPENDIXA Is the clinoid process well pneumatized?Are the bony attachments over the carotid andthe optic nerve?

PREE-OPERATIVECONSIDERATIONS 7. If the patient had previous surgery:

(Stammberger 1991) What was removed?Can I identify the middle turbinate or its rem-

1. What is the condition of the ethmoid infundibulum? nants?Is it almost atelectatic? Is there evidence of a bony defect or scar for-

Is the uncinate immediately adjacent to the lamina marion in the lamina papyracea, the periorbitapapyracea or is the infundibulum wide? and/or the roof of the ethmoid, the dura, andAt what angle does the uncinate process stand cribriform plate?to the lamina papyracea?Will I be able to resect the uncinate process di-rectly at its anterior attachment, or is there a realrisk of injuring the orbit by carrying the knife too APPENDIX Bfar laterally because of the narrowness of theinfundibulum?

Would it be safer in the given case to resect the STEPS EMPLOYED IN READING PNS CT SCANSuncinate process in "strips" from its free poste- (Mason et a1,1998)rior margin .anteriorly?

2. What are the relationships of the uncinate process superi- 1, Orientate coronal cuts anterior to posterior, check sides;orly, particularly to the frontal recess? identify the ethmoid bulla

Is there a recessus terminalis? 2, Lamina papyracea - is it eroded? Middle turbinate present?Concha bullosa or paradoxical middle turlbinate?Can I see whether the frontal recess opens me-

dially or laterally into the uncinate process? 3. Frontal recess - site and size of agger nasi cells, insertionWhat is the position of the frontal sinus? of the uncinate process.Is it symmetrical? 4. Height of the skull base - asymmetry of the skull base and

3. Is the ethmoid bulla small or large? cribriform plate. Height of the posterior skull base -Is it pneumatized? from roof of maxilla to posterior skull baseis there a lateral sinus? 5. Sphenoid - degree of asymmetry of sphenoi_l intersinusWhat is the relationship of the medial wall of the septum. Onodi cell, carotid dehiscent, optic nerve.orbit to the middle turbinate? 6. Staging of pathology, plan procedure, features of atypical

Can it be distinguished, does it bulge unusually infection or neoplasia.

strongly against the ethmoid? From Mason, J.D.T, N.S.Jones, R.J. HugheS, & I.M. Holland.Are there bony defects from the previous op- A systematicappr°acht°theinterpretati°n°fc°mputedt°-erat ion? mograp/nysc.w_spriortoendoscopicsinussu-gery.TheJour-

nalofLaryngology at'_ O_/ogy. October 19qR 112:986-990,

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PIIILIPPINE JOURNAL OF OTOLARYNGOLOGY I{EAD & NECK SURGERYVol. 16 No. 3 126-130, _2002 PHILIPPINE SOCIETY OF OTOLARYNGOLOGY HEAD & NECK SURGERY

Clinical Efficacy of Gentamicin, Betamethasone, Tolnaftate, andClioquinol (Quadriderm) in the Management of Acute Otitis

Externa in Adults*

MILDRED B. OLVEDA, MD**NOEL O. DE GUZMAN, MD**

EDUARDO C, YAP, MD, FPSO-HNS***

HOWARD M. ENRIGUEZ, MD, FPSO-HNS***

ABSTRACT

OBJECTIVE: To determine whetherQuadriderm ointment iseffective in treating acute external ear infections

. To identify the common causative organism in the test population

. To assess the rapidity with which the clinical symptoms of acute otitis externaare controlled

. Todetermine whether weekly administration of the drug is sufficient to controlthe infection

° To.determinewhether Quadridermointment causes significant changes in thehearing threshold among patient included in the study

DESIGN: Descriptive.Study

SEI-IING: Multicenter ClinicalTrial

RESULTS: A total of 17 subjects (8 males and 9 females) were included in the study. Seven out of 14 patientsnoted resolution of symptoms as early as the second day of treatment while complete resolution was noted in all14patients at day 4. No signs of inflammationwas noted inall patientsduring their follow up onthe seventh day oftreatment, Noneof them requireda second instillationof the drug. Pseudomonasaeruginosa and Staphylococcusaureus are still the most common causative organism isolated from our subjects_ Post-treatment pure toneaudiogram revealed no significant changes in hearing thresholds inany of the subjects. There was no complaintofworsening of symptoms during the treatment period.

CONCLUSION: We conclude that Gentamicin Sulfate, Bethametasone propionate, Clioquinol and Tolnaftatecombination (Quadriderm Ointment) is an effective drug for the treatment of acute otitis externa inadults_

INTRODUCTION

Acute Otitis Externaalso know as "swimmer's therefore,can be regardedto as a mixed bacterialandear" or "jungle rot" accounts for a majority of fungal infection and management should be effectiveotolaryngologicvisits. This isespeciallytrue for tropical enough to target both.countries like ours because of the warm and humid In most cases, this is a fairly easily treatableclimate. Various factors have been implicated in its conditionbut the infection has a tendency to recur andcausation. It usuallybeginswith the breakdownof skin's at timesbecome chronic. Contemporary managementprotectivefunctionfollowedby infection.The commonly consists of cleansing the ear canal andadministrationreportedcausative microorganismsare Pseudomonas of topical antibiotics or antibiotic-steroidpreparations.aeruginosaandStaphylococcusaureusbutcertainother Usually treatment is done empirically without thebacteria are also implicated in its causation. Fungal benefit of culture since majority of patients with thisinfections oftentimes coexist. Fungal infections of the condition is already tormented by pain_ It is oftenear canal are commonly associated with ear canal impractical, time-consuming and difficult to make amoisturel warmth, and prior treatment of a bacterial precise diagnosis under such condition. Thus,infection with topicalantibiotictherapy. Otitis Externa, treatment used in this condition needs to be effective

*Free Paper Presentation,44th PSO-HNS Annual Convention, December 01,2000, Punta Baluarte, Calatagan, Batangas**Resident, Department of OtolaTyngology,Ospital ng Makati**'Consultant, Department of Otolaryngology, Ospital ng Makati

126

against a broad range of microorganisms. All patients who satisfied the above criteriaAntibiotics either singly or in combination with and have consented with the procedure are included

steroids or an antifu ngal agent in the form of drops or in the study. The patient's history is carefully reviewedsuspension are commonly used because of the ease taking note of the signs and symptoms.of application. Since otitis externa are often A system of grading pain/tenderness wascharacterized by diffuse involvement of the ear canal discussed and agreed upon with the patient:a topical drug preparation that will cover the areasinvolved would be ideal. Moreover, various studies Grade 0 no painhave shown that fungal growth does occur in patient Grade 1 mild: dull pain when tension istreated with antibiotic or antibiotic-steroid otic drops applied to straighten the canalin as early as the third day of treatment. Addition of Grade 2 moderate: pain with pressure onan antifungal agent is often warranted. However, most the tragus or pressure on theantifungal otic drops cause sensitization and may concha underneath the Iobuleeven add more insultto the already injured canal skin. Grade 3 severe: persistent pain evenCost of treatment is another factor here. without manipulation

GBTC cream combines betamethasone

valerate, an extremely active anti-inflammatoryagent; The ear canal is gently swabbed win a cottongentamicin sulfate, a highly effective broad-spectrum pledget to obtain specimen for culture and sensitivityantibiotic; tolnaftate, a non-sensitizing topical testing. Once specimen is already available for culturefungicidal agent; and clioquinol, a useful drug for the cleansing of the ear canal is done next.treatment of mixed dermatologic infections and gram Initial otoscopic examination is done by thepositive bacteria. This drug combination have been OPD Resident and findings were recorded in theproven to be highly effective than its individual patient's chart. The tympanic membrane is carefullycomponents in treating mixed dermatologicinfections, assessed for the presence of any perforation. AWhether this drug will prove effective in treating system of grading the edema of the ear canal isinflammatory conditions of the external ear (otitis formulated:externa) is the prime objective of this study.

Grade 0 no hyperemia, no edema1 hyperemia of the external

MATERIALS AND METHOD auditory canal skin2 minimal swelling of the canal

PATIENTS 3 moderate swelling but canalis still patent

Inclusion Criteria: 4 marked swelling with obliteration1. patients 18 years of age and above of the external auditory canal2. there should be an informed consent

3. patients with signs and symptoms A pre-instillation pure tone audiomel_/is done.consistent with acute otitis externa All patients are provided with a 10g tube of GBTC

4. patients with external ear infections of cream. The Resident then places around 1.0 cc ofnot more than 2 weeks the ointment in a syringe connected to an 18-gauge

5. no history of prior otitis externa treatment intravenous catheter. The cream is instilled inside

within 36 hours the ear canal starting at the tympanic end and is6. there should be no middle ear disease gradually drawn to fill the entire canal with the cream.

(i.e. otitis media) A checklist or form was given for the patientto fill up and record the progress of his/her symptoms

Exclusion Criteria: on a daily basis. A translation of the grading system1. patients below 18 years of age in the vernacular is given to ensure comprehension2. perforated tympanic membrane and compliance (Appendix A).

regardless of size Patient is asked to follow-up on the third day3_invasive otitis externa requiring of treatment for re-evaluation. Appearance of any new

systemic antibiotic therapy symptom or sign or progression of the symptoms4_self-medication therapy for otitis warrant termination of therapy. An alternative otic

externa prior to therapy within 36 hou rs preparation is given in this case. If no adverse effects5_known allergy to any of the component were noted patient was sent home and ask to follow-

drug up on the seventh day from the initiation of treatment.6. patients who was lost to follow-up during On the seventh day the remaining GBTC

the 1-month clinical trial period cream are suctioned out. Otoscopic re-evaluation

127

done A post4reatment pure tone audiometry is Table 1. Grading of Painlikewise done and results are compared with that of ................................. _..............................

PaLient • Day 1 . D_ty 2 . Oay 3 Day 4 Day _; Day 6 Day 7

pi ................................................... "...................................... " ........the initial otosco c results and pure tone audiogram. 1 . o o o o oIf patient is already asymptomatic and the ear canal _ . ! o o o o o oappears healthy treatment no further application of .........................................;................................................'..........3 4,4.-.i- _ ++ 4- i 0 0 0 0

GBTC cream is required. However, if there are still , + i o o _ o o o osigns and symptoms of inflammation a second i s...........+, , o ,0 ........ ° ...... o..... o.... 0instillation of the ointment is done. Any patient with ......6 ............-_ t o ........o....... o _' o _ osigns and symptoms of inflammation of ear canal is • : .+ o o o : o : o : ogiven a second, a third, and a fourth application of 8 _ o o o o _ o o

: 9 _ : 0 o _ 0 0 0 0the cream. At the end of one month treatment is _.................. _ .................................................................terminated regardless of the status of the ear canal, lo.... _-, .+ , + ,,: o o o o

Anypatientwh 0failedtofollow-upduringthe .....!1, _ _ + o _ o o o ..... 0.....12 ++ + 0 0 , 0 0 . O

specified date is automatically eliminated from the ................................................................................13 _ o _ o o o : o °study. Attention is given on any progression of 1, _,+ . + o _:0 0 0

symptoms or changes in pure tone audiogram, _s ++ o o _ o o o o........ !............................ . .........

16 _ 0 O " 0 0 0 0

• 17 . , ,,I-+ 0 0 O • 0 0 0

RESULTS

Table 2. Otoscopic FindingsA total of 17 patients were included in the

•Patient InitialP.E, ' weeki.... week2 . i monthPOst-"study consisting of 8 males (47 %) and 9 females .........................................; treatment(53 %). Theirage ranged from 28 to 64 years (mean=

31yrs). _ 1 ........._-........... o.......' .........o ..............0 " '! 2 4-+ o 0 o

:......... No.of patients ......... 3........ _-; ' ,o " o...... o ............................ 4...... _- 0 0 i 0 •• Male 8(47%) .........5...... + ...... 0 .......: ......o , .......o "

Female 9(53%) 6 44- 0 .... _ .....0 .... ..... 0............................... " 7 ............+ 0 ............ b '_....... 0 ........

TOTAL 17 _ 8............... o.......... 0 ' ....... 0.............................. 9 .......: _ : '0 ....... o .....................o '

All patients have ear pain as their presenting ".... i0 ...... 4-+.......... o......... 0.... :.... 0 ' "complaint: 5 with grade III pain, 8 with grade II pain _.........1_.... + .... _.........o............. 0 _ oand 7 with grade I pain (Table 1). Ten patients noted .......i2 ' ++ ........o ....... o ...._...... o............complete resolution of pain as early as day 2. In 3 ...........13..... + ......i ' " 0 .... i. • o.......... o.............patients pain persisted until day 3. On day 4 onwards 14 +++ , 0 0 0none of the subjects experienced pain. ....15 ...........¥ ,...... 0 i 0...... 0 ................

Initial otoscopic examination of the ear canal 16 ..... 4: :........0...... : ....0 ....: 0................showed moderate swelling ofthe canal in 2 patients. 17 _ ¥ " :...... 0 ........ o " :. ' o ........In 6 patients minimal swelling were noted while onlyhyperemia of the canal is apparent in the remaining 9 DISCUSSIONpatients (Table 2). On day 7 of treatment the ear

Otitis Externa (OE) represents a spectrumcanal of all 18 patients appeared to be healthy. Therewere no signs of inflammation such as pain, erythema of inflammaton/changes inthe external auditory canalnor swelling of the ear canal. None of them required typically of an infectious origin_ The external auditorya secondinstillationofGBTCcream, canal, with its protective and self-cleansing

mechanism intact, is usually quite resistant toCulture and Sensitivity results revealedinfectious process. It is only when a local insult ofPseudomonas aeruginosa as the primary offending

organism followed by Staphylococcus aureus which any nature results in disruption of the integrity of theaccounted for 50% and 38% of cultures, respectively, epitheliumthat infectious organism may gain access

to the underlying tissues and cause an inflammatoryProteus mirabilis was accounted for 12% of culture

reports. All three organisms are susceptible to responseofvaryingdegrees.gentamicin_ Bacterial pathogens isolated from subjects

with otitis externa generally includes PseudomonasNo significant changes in the pre- and post-therapy pure tone audiograms were noted. None of aeruginosa, Staphylococcus aureus, Streptococcusthe subjects complained of vertigo or tinnitus, species, and various gram-negative enteric bacilli,

while Staphylococcus epidermidis and diphtheroids

I28

/"

are among the most frequently recognizedcolonizers of dermatologic conditions of mixed etiology.71t is aof external auditory canal? Fungi and yeast may combination offouragentswith distinct pharmacologicalso cause otitis externa but these organisms usually effects: bethametasone 17-valerate, 0.1% gentamicincause superficial infections with less inflammation and sulfate, 1.0% tolnaftate and clioquinol. All fourswelling. Mixed bacterial and fungal infections are components have been used extensively in clinicalnot uncommon, and cultures from the canal are usually practice for many years, demonstrating their safetynot necessary in the typical case of otitis externa, and efficacy. To date, no serious systemic side effectsThe skin-lined external auditory canal may also be from local application ofthisdrug have been reported.affected by non-bacterialinflammatoryconditionsthat In this study, we tested whether GBTCcommonly involve the skin in other parts of the body. cream will prove effective and safe in treating infectionsOtitis externa, therefore, may also be regarded as a of the skin*lined external auditory canal. The easemixed dermatologic condition, with which ototopical antibiotics drops are applied

Pain is the most common complaint among into the external auditory canal cannot beour subjects followed by itchiness, fullness, or overemphasized. The cream form was used heredecreased hearing. Depending upon the initial since this form has lesser viscosity and is easier topresentation the patient may reveal different stages, instill than the ointment form of the drug. Moreover, itSenturia and colleagues have proposed a staging will eliminate the need for frequent instillation of thesystem that divides the disease process into drug and assure patient compliance.preinflammatory,acuteinflammatory(mild, moderate, Gentamicin sulfate is one of the activesevere) and chronic stages_ In our experience, patient components of GBTC. It is one of the most commonlycomes to the clinic during the acute inflammatory used antibioticearpreparation. Gentamicin,is knownstage of the disease usually in the mild to moderate for its ototoxic potential but is still widely usedrange because of its broad spectrum of activity and its low

Although otitis externa causes considerable cost. There are various animal studies that,prove itsdiscomfort it usually responds to ototopical antibiotic ototoxic effect. In humans, however, ototoxicity fromtherapy. The objectivesoftreatmentofotitisexterna ototopical medications is extremely rare.2 Mostareto resolvethe infection while promoting restoration cases of ototoxicity in humans occurred duringof the external auditory canal to its normal state. The prolonged treatment without medical control and inkey in the management is meticulous cleansing of patients with extensive tympanic membranethe external auditory canal and use of otic drops. Otitis perforation. _ The reason for this seemingExterna is usually treated empirically without the contradiction between evidentototoxicitiesin animalbenefit of cultures. Thus, a treatment used needs to models and clinical safety in humans revolves onbe broadly effective against the usual pathogen, interspeciesvariability of the round window anatomy. 8

The distribution of pathogen isolated in this Patients with tympanic membrane perforationstudy generally reflects the types of organism long were automatically excluded from this study.known to be associated with otitis externa. Although tympanicmembraneinvolvementlnacutePseudomonas aeruginosa and Staphylococcus otitis externa is common resultant ototoxicity fromaureus were the most common pre-therapy pathogen, systemic absorption through the skin is far less withProteus mirabilis was the third most common topical applicationofGBTCcrearn.. In thegtudy bypathogen isolated in our subjects. Lancasteret aPthey concluded that there is systemic

The_most common therapy for otitis externa absorption of gentamicin that would ultimately beis a topical agent containing antibiotics (usually an absorbed into the perilymph. This absorlDtion isaminoglycoside) and a corticosteroid. These decreased in otitis externa owing to the infiammation,medications are thought to reduce the inflammation edema, and thickening of the skin and tympanicand treat the underlying pathogen. However, these membrane. Absorption is even less if drugs are givenmedications require three to four administrations per at a lower concentration. GBTC contains on_ 0.1%day and as with other forms of medications, gentamicin sulfate in contrast to 0.3% gentamicincompliance decreases with the number of daily otic drops used in various ototoxicity studies.administration. Compliance may also be affected by The other components of Quadridermthe stinging or burning, which commonly occurs ointmentwhichincludel3ethamethasonepropionate,following administration of otic medications. 8 In the Tolnaftateand Clioquinol have long been proven to bestudy presented herein, GBTC cream is given on a effective and safe_ No ototoxic effect had beenweekly basis was used in 14 subjects with acute otitis reported yet in any of these drugs.externa. Each component of Quadriderm makes a

GBTC cream is a highly effective topical significant contribution to the efficacy of the productdermatologic agent in ointment form which provides in treating infections of mixed etiology. In fact, therea complete range of therapy in treating a large number is evidence to support the claim that there is a

129

synergistic interaction among the antimicrobial 5_ Senturia BH: Etiology efotitisexterna. Laryngo-components, with Quadriderm having greater scope1945; 55:227-293

antimicrobial activity than its individual active 6. Slack RW. A study of three preparations in theingredientsalone, treatment of otitis externa_ J Otolaryngot

In this study, the efficacy and safety of 1987;101:533-5

Quadriderm ointment in treating acute otitis externa 7. Verallo V. Efficacy of combination type ointmenthad been described_ in the treatmentof typical dermatoses_ J Phil Med

Assoc. 1975; 51:160-162

8. Roland PS: Clinical ototoxicity of topical antibi-CONCLUSION otic drops. Otolaryngol Head Neck Surgery

110_598-602 1994

We found that Gentamicin Sulfate, 9. LancasterJL, MontimoreS, McCormick M, HartBethametasonepropionate, Clioquinol and Tolnaltate CA. Systemic absorption of gentamicin in thecombination (GBTC cream) is a cost-effective and management of acute mucosal chronic otitisefficacious drug for the treatment of acute otitis media. Clin Otolaryngo1199 Sep;24(5):435-9externa in adults.

APPENDIXARECOMMENDATIONS Patient's Checklist

NAME:We recommend that a comparative study AGE:

be conducted on the clinical efficacy of standard SEX-ototopical antibiotic solutions versus that of GBTC ADDRESS:cream in treating acute otitis externa. LEGEND:

Grade 0 no pain (walang sakitWe also recommend that an ototoxicity

study GBTC cream be done utilizing Transient-evokedOtoacoustic Emissions to test for the ototoxic effect ..........i_ ............ _i_ ......................ot0scopi¢........to the inner ear. Tenderness Rndings

Lastly, we recommend that a study be (Sakit)conducted regarding its (GBTC cream) future use 1 .............................................................in the management of chronically draining post- 2mastoidectomy cavities. ' .........3.........................................................................................:

BIBLIOGRAPHY 6......... : ............................. !........................

7 _ i............................................................................ i

1. Abello P, Vinas JB, Vega J. Topical ototoxicity:review over a 6-year period.Acta Otorrinolanngol Grade I mild; dull pain when tension is

Esp 1998 Jun-Jul;49(5):353-6 applied to straighten the ear canal(bahagyang sakit kapag hinihila ang

2_ Bojrab D, Bruderly T, Abdulrazzek Y. Otitis tainga)externa_OtolaryngolClinNorth Am. 1996;29:761- Grade II moderate; pain when pressure is82 applied on the tragus or pressure

3. Cassisi N, Cohn A, Davidson T, Witten BR_Dif- ontheconchaunderneaththeIobule (masakit kapag pinisil

fuse otitisexterna: clinicaland microbiologicfind- angilalimngtainga)ings inthe course of multicenter study on a new GradeIII severe;persistentpainwithoutotic solution. Ann Otol Laryngol. 1977;39:1-16 manipulation(masakitkahithindi

4. Jones R, Milazzo J, Seildlin M. Ofloxacin otic ginagalaw ang tainga)solution for treatment of otitis externa in adults

and children. Arch Otolaryngol Head Neck Surg.1997; 123(11):1193-2000

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PI-tlLIPPINE JOURNAL OF O'fOLARYNGOLOGY ItEAD & NECK Sth:tGERY

V4 " 16 No. 3 13 I-139. _2002 PHILIPPINE SOCIETY OF OIOLARYNGOLOGY I-IEAD & NECK SURGERY

LOCALLY PRODUCED BIOCERAMICORBITAL PLATE USED TORECONSTRUCT ORBITAL FLOOR DEFECT:

A PRELIMINARY REPORT*

RODEL ALLAN E. GAFFUD, MD**

EDGARDO DEL ROSARIO, MD**KAREN ALCANTARA, MD**

JESSICA ABANO, MD**JOCELYN SY, MD** .....•

JOCELYN REYES, MD**FELIX P. NOLASCO, MD***

ABSTRACT

There has been a growing interest in the use of porous alloplastic implants for reconstructive surgeries.Porous polyethylene (Medpore) and hydroxyapatite are two of the more popular and successful orbital implantsthat revolutionized orbital reconstructive surgery. However due to tl-eir prohibitive cost, the authors in cooperationwith the Department of Science and Technology have explored the use of a locally manufactured low cost (P 25)synthetic bioceramic porous biphasic calcium phosphate as a prospective orbital implant material for orbital floorfracture reconstruction. The implant's composition of 77% tricalcium phosphate and 23% hydroxyapatite is similarto bone. The implant was used to reconstruct an orbital floor defect_ Implant behaviorwas monitored clinically andradiographically. Post-operatively, the implant was stable. There were no signs of migration, encapsulation norresorption. Neither was there any sign of local tissue infection_ The bioceramic biphasic calcium phosphateceramic implant has a great potential as bone graft substitute.

KEY WORDS: Orbital plate Implant, Porous Biphasic Calcium Phosphate, Calcium Phosphate hydroxyapatite,Osteoinduction, Osteoconduction, Biocompatibility

INTRODUCTION

Trauma or tumors can cause large gaps Paris 2 to metals and alloplastics. The early 60'swithin the skeletal system. A surgeon faced with ushered the introduction of alloplastics such asfilling-in .a large gap within the bone has several Supramid, Teflon, silicon and Methyl Metacrylate. Duealternatives: autog rafting, allografting and to its availability and ease of handling, it became thebiomaterials, surgeon's preference 3_The primary concern in the

Autografting or autogenous bone grafts have use of alloplastics, with its solid nonporous structure,traditionallybeen used as the reconstructivematerial is the late complications such as fistula formation,of choice since the 1950's. However, it has been infection, implant displacement, its propensity forcriticized for its disadvantages such as donor-site encapsulation and hemorrhagic cyst formation 4._,6.morbidity, increased operative time, unpredictable Such drawbacks initiated the birth of porousresorption and remodeling and sometimes donor alloplastics such as coralline hydroxypatite in 1986availability, and porous polyethylene"Medpor" in 1991. This new

AIIografting or using cadaver bone has several generation orbital implant substitutes are capable ofmajor disadvantages. These include immune inducing osteoconduction and osteoinduction.response rejection, possible acquiring of AIDS or other Numerous publications document their successfulinfectious diseases and difficulty in obtaining the use. However, their use is limited by their cost. It isspecimen due to religious beliefs and local customs 1 for such purpose that this study was done and it aims

to examine and introduce an effective, locally madeBiomaterials or bone substitutes have been low cost synthetic porous biphasic calcium phosphate

used for almost a century from cow horn to plaster of orbital plate implant man ufactured by the Department

*3rdPlace,PSOHNSPosterSessiononSurgicalInnovation,November30,2002,PuntaBaluarte,Calatagan,Batangas**Resident,Departmentof Otorhinolaryngology,EastAvenueMedicalCenter***Consultant,Departmentof Otorhinolaryngology,EastAvenueMedicalCenter

131

DISCUSSION micron is generally required to achieve bonyingrowth 1_.Our implant has an average pore size of

Developrnent ofa safe, affordable and effective 198 microns (fig 2). This pore size could very wellbone grafting substitute could potentially alleviate promote osteoconduction (as documented by themany problems associated with human bone graft histopathologic findings in our preliminary animalmaterials. Voluminous amount of time, money and studies).effort has been spent in search for this alternative Toth et al., studied interspinal bone fusion

Alternativesto autogenous bone grafts have, characteristicsof calcium phosphate and suggestedin recent years, included Calcium Phosphate that minimum amount of porosity to be set at leastceramics, osteogenic proteins and composites of 30% (to encourage vascularization as well as tothese two. Of the calcium phosphate ceramics, provide proper channels for scaffolding and bonehydroxyapatite [Ca10 (PO4) 6(OH) 2] has been conduction) _3.The porosity of our implant is 60%_ Instudied most extensively. Hydroxyapatite has the fact, this vascularization was noted as early as 1advantages of being biocompatible, architecturally month in our preliminary animal studies.similar to bone and osteoconductiv&. In a study by An ideal implant should resist migration.Passuti et al., hydroxyapatitewas also proven to have Therefore being vascularized helps in anchoring ofosteoinductive properties by its induction of the implant. Porosity also allows viable tissuemultinucleatedcells (bone precursors)aftergrafting it insinuation within the graft and limits its tendencyon a chick chorioallantoic membrane 9. Its drawback to encapsulate. In the findings of Harvey et al_, asincludes weak mechanical strength and brittleness_ well as several authors TM, micromotion at the boneIt is generally considered to be minimally resorbable_ implant interface does not inhibit bone ingrowth as

Tricalcium pl_osphate [Ca3 (PO4) 2] is a proven by their successful mandibular grafts_ Inbiocompatible osteoconductive resorbable ceramic that cases where stability is crucial, our implant tolerateshas the theoretical advantage of being a bone graft suture fixation. Wire or screw fixation of poroussubstitute that is gradually replaced by bone. calcium phosphates must be avoided since suchResorption rate of Tricalcium Phosphate varies fixation could fracture the implants. Furthermore,depending on porosity and has ranged from 30% - onlays beneath inadequate soft tissue coverage85% in 6 months 1°,1__It is advantageous to have an should be avoided. It could lead to tissue necrosisimplantthatresorbswith simultaneous bonyingrowth, and delayed complications like persistent post-thereby maintaining its original volume during the entire operative drainage, show-through of the onlay andsequence from implantationto complete replacement possible implant migration 1_.by bone. By combining the two ceramics, Theuniquechemicalcompositionofporoushydroxyapatite and calcium, phosphate, we could biphasic calcium phosphate bioceramics suits thetheoreticallyhave an implantwith superiorquatitythat inorganic component of human bone. In studiesis stable, not easily resorbed, almost the same in made by Aoki, subcutaneous implantation ofcomposition with natural bone and has the capacity bioceramic in rabbits showed resistance toofosteoinduction an oasteoconduction, degradation with a rate of 1 micron/year, which is

In our animal studies 4,histomorphic analysis 100-micron/100years 16.showed 30-40% ofthe biphasic calcium phosphate The mechanical properties of calciumimplant was covered with new bone formation at one phosphate ceramics are currently the limiting factormonth and 50 - 60% at three months. The authors in their widespread utilization. Table 1 gives us apostulate that the porous ceramic framework initially simplified view of the mechanical properties offunctions as an osteoconductive scaffolding which calcium phosphate implants and bone, althoughsubsequentlydegradesas remodelingoccurs.These relatively similar, bone have much more complexpropertiescouldcompensateoverthe hydroxyapatite mechanical constant. This could pose a problemmaterial that remains unremodelled even aftera long when it is utilized on weight bearing areas of theperiod of implantation, skeleton. However, several authors 17,18have used it

Pore size is thought to be a critical factor in on the mandible, knee and tibia and results wereosteoconductive potential of an implant. Adequate comparableto thoseimplants used inthe other non-

porosity leads to rapid invasion of the intertrabecular weight bearing areas. Much research is currentlyspaces ofthe biomaterial by loose connective tissue being conducted to improve its mechanical

whichwouldfhenproli{erate _oform woven bone and properties. In the dental field, the primaryapplicationlater deposition of lamellar bone which is similar to for ceramics include the filling of pockets andthe typical early stages of embryonic bone formation augmenting of deficient mandibular or maxillaryor of bone fracture healing_ Klawitter and associates ridges, either due to trauma, benign diseases orin their study showed that minimum pore size of 100 congenital defects 1.

137

The bioceramic porous biphasic calciumphosphate implant is a biocompatible onlay bone graft BIBLIOGRAPHYsubstitute. It is a lot cheaper (at P25) as comparedto the more expensive porous polyethylene"medpore" 1. Lavernia, C., Schoenvng, J. Calcium Phosphate(P8-10,000) and hydroxyapatite (P19,550). Ceramics as Bone Substitutes. Ceramics Bul-Unanswered questions relating to the present study letin 1991, VoI. 70, No. 1.include: 2. E.F. Von Recum: Handbook of Biometerials

1) Is the biphasiccalcium phosphateeventually Evaluation. NewYork, Macmillan PublishingCo.resorbed completely? 1986, pp 3 - 86.

2) Is the biphasic calcium phosphate entirely 3. Browning CW AIIoplastic Materials in Orbitalreplaced by new bone overtime with maintenance of Repair. AMJO 1967 Man. pp 63 - 995_the originalimplantvolume? 4. Coyle J.T. • Hemorrhage into an Intraorbital

3) What is the long-term fate of this new bone? Pseudocyst. Arch Ophthalmology 1997, Aug,Studies are currently underway in an attempt to 115(8) 1085.

answer these questions. 5. Giordano, MM, Kirchsner, RA, Wule, AE: Or-bital Floor Implant Migration Across the EthmoidSinuses and Nasal Septum. AMJO 1998 Dec;

CONCLUSION 126(6) pp 848-50.6. Mauriello, JA, Flanagan, JG, Reyter, RG: An

Our paper was able to show initially Unusual Late ComplicationsofOrbital Fracturebiocompatibility and structural characteristics of Repair. Ophthalmology l994;91(1)ppl02-06.porous biphasic calcium phosphate ceramic orbital 7_ Abano, J., Sy,,J., Reyes, Jocelyn: Locally Pro-plate in a human subject. Our orbital plate implant duced Bioceramic Orbital Plate: A Low Cost AI-provides a stable platform for orbital soft tissues and ternativeTo CommerciallyAvailable Orbital Plateis capable of inducing physiological bone formation Implants. Unpublished.and healing. It is also resistant to bioresorption. 8. Rosen, H, McFarlandM: The Biologic BehaviourBiphasic calcium phosphate offers the surgeon an of Hydroxyapatite Implanted into the Maxillofa-alternative to autogenous bone tissue and probably cial Skeleton. Plastic and Reconstructive Sur-is one of the best biologic alternative materials gery, 1990, May.available for maxillofacial surgery today. This study 9. Passuti N, Daculsi S, Basle M - "Clinical Im-demonstratethat a locally produced synthetic porous plants Materials." Advances in Biomaterials 9,biphasic calcium phosphate ceramic orbital plate has Edited by G. Heinke et al (Elsevier, Amsterdam,an excellent potential as low cost alternative to 1990), p255.commercially available orbital plate implant. 10. Eggli, P, Muller, S, Schenk, R : Porous Hydroxya-

patite and Tricalcium Phosphate Cylinders withTwo Different Pore Size ranges Implanted in the

RECOMMENDATION Cavellous Bone of Rabbits, Clinical Orthop Rel.Res232; 127, 1988

The authors plan to conduct long term 11. RenoojiW, Hoogendoora HA, etal: Bioresorptionstudies of clinical trials and a possible side by side of Ceramic Strontium-85-LabelledCalcium Phos-comparison on all available commercial implants. As phate Implants in Dog Femora. A Pilot Study towell as the possibility of using it on other sites. Quantitative Bioresorption of Ceramic Implants

of Hydroxyapatite and Tricalcium Orthophos-:TAELEi:Sirnpl_edoftheltl_c, hanioalPro[_ertJesoftile ....... phate in Vivo. Clinical Orthop 197; 272, 1985_

_iandC_rJunnla_'Pi_eS_ _rn i 12. Klawitter J, Bagwell, Weimtem A- An Evalua-tion of Bone Growth into Porous High Density

briJ C6_npresSi__e"(a_ Modul,_...... Polyethylene. J. Biomed Mater Res. 10; 311-1976_F_gphae ........................ : 13. Toth JM, AN HS, LimTH, et al:The Evaluation of• _ ............ 3-130mi* r_15psi Porous biphasic Calcium Phosphate ceramic for

F_ous ...... 1-1_Jpsi ....... anterior interbody fusion in a carpine mosel, SpineOct 1995 20 (20) 2203-2210

Caroelo_ ............ 6-9psi ............ 2psi " "......................... i........... 14. HolmesRE: BoneRegenerationWithinACoral-

. _ ............. 2o.....................psi line Hydroxyapatite Implant. Plastic and Recon-

........................................... structive Surgery, 1979, pp 626-33.,_s_-poJndsper_qua'eir,:h

138

15. Salyer K, Heill C: Poous Hydroxyapatite as an 19. BreitbartA, Staffenberg D: Tricalcium PhosphateOnlay Bone Graft Substitute for Maxillofacial and Osteogenin: A Bioactive Onlay Bone GraftSurgery. Plastic and Reconstructive Surgery, Substitute. Plastic and Reconstructive Surgery1989, pp 236-44. 1999 September, pp 699-708.

16. Aoki H, Ohgushi M, Okunuaga: Proceedings of 20. Basle F, Passuti D, Filmon H : Cellular Responsethe SecondlnternationalSymposiumOn Ceram- to Calcium Phosphate Ceramics implanted inics in Medicine, Herdilberg 1989 ( German Ce- Rabbit Bone, J of Materials Sevice, Materials inramic Society, Cologne, 1990 ), p_65. Medicine 4 ( 1993 ) 273-80.

17. Holmes PE, Hagler H: Porous Hydroxyapatite: 21. Jarcho M, Salsbury R, Thomas, M: SynthesisA Bone Graft Substitute in Mandibular Augmen- and Fabrication of B-Tricalcium Phosphate ( Ce-tation. A Histometric Study. J. Oral ramicsforPotentialProstheticApplications)jour-MaxillofacialSurgery 45: 421, 1987_ nal of Materials Science 14 (1979) 142-150.

18. KlawitterJS, Hulberg SF: ApplicatuionOf Porous 22. Cummings Charles; Otolaryngology Head andCeramics for the Attachment of Load Hearing In- Neck Surgery, third edition, Mosby pressternal Orthopaedic Applicatuions. J. Biomed 23_ Mathog M Textbookof Maxillofacialtrauma, 1985Mater. Res.5 ( Suppl 2, Pt 1 ) 161, 1971.

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PHILIPPINE JOURNAL OF OTOLARYN_OLOGY HEAD & NECK SURGERY

Vo}, 16No. 3 ]40.144. ©2002 Phr/LIPPINE SOCIETY OF OTOLARYNGOLOGY HEAD& NECK SURGERY

LE FORT I OSTEOTOMY DOWN FRACTURE WITHMIDLINE PALATAL SPLIT VIA MIDFAClAL

DEGLOVINGFOREXCISION OFJUVENILE ANGIOFIBROMA*

EUTRAPIO S. GUEVARA JR, MD***

JOSEFINO G. HERNANDEZ, MD***RAMON ANTONIO B. LOPA, MD***

PETER R. JARIN, MD**ROBERTO M. PANGAN, MD***, DMD, PHD

ABSTRACT

This is a report of a surgical approach to excise an extensive case of a Juvenile Angiofibroma in a 16 year

old male. The approach consists of a midfacial degloving followed by a Le Fort I osteotomy down fracture combined

with a midline palatal split. This technique facilitated an adequate access to a large nasopharyngeal angiofibroma

with excellent cosmetic and functional results.

INTRODUCTION CASE REPORT

Various approaches may be used for excision A 16 year old male consulted the Philippineof Juvenile Angiofibromas. This can range from General Hospital Emergency Room for epistaxisendoscopic to transantral approach either via midfacial (Figure 1). Review of history revealed nasal congestiondegloving or lateral rhinotomy that can be combined accompanied by recurrent massive epistaxiswith a transpalatal access (1,3,4,6). Presented with a occurring for a span of two years. Anterior and posteriormore extensive lesion, the surgical team decided Le rhinoscopy revealed a red smooth fleshy massfort l osteotomy with a midline palatal split through a occupying th.enasopharynx and oropharynx.The rest

of the otolaryngologic exam was essentially normal.gingivobuccal incision would be a more appropriateapproach that provided not only an ample access to CT Scan of the paranasal sinuses showed anthe mass but also resulted in no external scarring nor enhancing nasopharyngeal mass invading the leftfunctionaldeficienciesposboperatively, side of the sphenoid sinus with extension to the

oropharynx and posterior end of both nasal cavities(Figure 2a and 2b). The assessment was Juvenile

OBJECTIVE Angiofibroma and excision was immediatelyscheduled. No Angiography with embolization was

1_To describe and illustrate an approach for ordered due to financial constraints.excision of Juvenile Ang iofibroma (Le Fort i OsteotomyDown Fracture with Midline Palatal Split via MidfacialDegloving) SURGICAL TECHNIQUE

2_ To cite advantages and disadvantages of this The initial incision is a gingival incision alongalternativeapproachforJuvenileAngiofibroma the inferior free border of the alveolus from one

maxillary tuberosity to the opposite side(Figure 3).

*2ndPlace,PSOHNSPosterSessiononSurgicalInnovationContest,November30, 2000,PuntaBaluarte,Calatagan,Batangas**Resident,DepartmentofOtorhinolaryngology,Universityof thePhilippines-PhilippineGeneralHospital**Consultant,DepartmentofOtorhinolaryngology,Universityof thePhilippines-PhilippineGeneralHospital

140

:::::::: : :::::: ::::::::::: :: ::::::: :the:in¢ re:was mo:dified:_i_ie, the:: patent s:....: : e:d:e:ii:i :::Mucosawas ti::i:_,::n a::

:lane tO expc!se the:pyr for :::ar_ter Of:':_a Iof the maxilia

: ................:::: u:p _'0the: levei: Oi the hlferioI: orb tai :::: : : .........: : :: : _e._n(fi 8) T _e_lfer o -::O_:bta ne yes were

v sua _e:dand:p_eserve.d MudoS:aw'as a so e c vatec:: :::::: :: ::::ffomttie::al_terot r_asa sp ie,: ma× a}"y CresL nasa

:mass,: : :::!::::::

5. Mohsen Naraghi et al Le Fort I Ap-BIBLIOGRAPHY proach To The Advanced Angiofibroma:

Report of a Case with Intracranial Ex-

1. Agnaldo Graciano et al_ tension.. Tehran University of MedicineNasopharyngeal Angiofibroma: Tehran, Iran Free paper session 17Endoscopic Approach. Federal Nose 2000 and Beyond held at theUniversity of Sao Paolo, Sao Paolo, Omni Shoreham Hotel, Washington,Brazil. Free paper session 17 Nose D.C. USA

2000 and Beyond held at the Omni 6. Mohsen Naraghi Endoscopic Resec-Shoreham Hotel, Washington, D.C. tionofNasopharyngealAngiofibroma.USA Tehran University of Medicine Tehran,,

2_ Lenarz T. Keiner S. [Midfacial deglov- iran. Free papersession 17 Nose 2000ing: an alternative approach to the and Beyond held at the Omnifrontobasal area, the nasal cavity and Shoreham Hotel, Washington, D.C.the paranasal sinuses]_ [German] USA

Laryngo- Rhino- Otologie_ 71(8):381-7, 7_ Sailer HF et al. The Le Fort l osteotomy1992 Aug. as a surgical approach for removal of

3. Lund et al. Recurrence in Juvenile tumours of the midface_ Journal of

Angiofibroma Rhinology_28(2):97-102, Cranio-Maxillo-FacialSurgery_ 27(1):1-1990Jun. 6, 1999 Feb_

4. Mitskavichetal. IntranasalEndoscopic 8_ Tewfik TL et al Juvenile Nasopharyn-Excision of a Juvenile,. Angiofibroma. geal Angiofibroma. Journal of Otolaryn-Auris,Nasus,Larynx.25(1):39- gology.28(3):145-51,1999Jun_44,1998Jan.

144

PHILIPPINE JOURNAl. OF O-FOLAKYN(iOLOG'f I-II_iAI)& NECK SIJR.GERY

Vol. 16 No. 3 145-152 ©2002 ' -I L ' _ NE SO(" .T","OF OTOI.ARYNGOI.OGY HEarD & NECK SURGERY

LARYNGEALAMYLOIDOSIS IN A 40 YEAR OLD FEMALE*

KENNARD Q. FELIX, MD**JOSEPH ARNOLD DARVIN, MD**VIRGILIO R. DE GRACIA, MD***

ABSTRACT

Amy loidosis affecting the head and neck region is uncommon and is mostly in the form of localized amyloidosis_The larynx is considered to be the most common site of involvement and accounts for 0.2% to 0.5% of benignlaryngeal tumors. When the larynx is involved, treatment is directed in improving the voice and maintaining theairway.

In this paper, we are reporting a 40-year-old woman who complained of hoarseness for 7 years with a softtissue deposition on the left false cord. Biopsy of this soft tissue and histological examination revealed laryngealamyloidosis. Tracheostomy under local anesthesia and excision of the amyloid under general anesthesia weredone. However, after a month post=operatively, we noted a recurrence of the mass. Considering the rarity of thisdisease, this paper aims to emphasize on how important it is to recognize laryngeal amyloidosis in order to achievean appropriate diagnosis and plan therapy properly. Local surgical excision is the treatment of choice for laryngealamyloidosis.

INTRODUCTION

Laryngeal disease is associated with a systemic diseases2 Nonetheless, even whenamyloidvariety of signs and symptoms, several mechanisms is apparently restricted to the larynx, further work-were mentioned in the pathogenesis of these ups should be done to rule out the possibility of adiseases namely: infectious, inflammatory or systemiccause. Thetherapyofchoiceforidiopathic,neuromuscular_ 1 Relation between the severity of localized, or organ limited amyloid deposits withoutsymptoms and the morbidity associated with the underlying disease is local excision_process is often poorly correlated.

Hoarseness is one of the most commoncomplaintsamong ENT patients. Accurate diagnosisand treatment depend upon the early detection of the CASE REPORTvoice pathology_ The spectrum of these problemswould rangefroma benign lesiontoa life-threatening Patient is V. Q., 40 year old female fromproblem. Tanauan' Batangas admitted with a chief complainti

Localized laryngeal amyl0idosis is not a of hoarseness.

common laryngeal disease and accounts for about .. Hiistory started 8 years PTA, when she1% of all benign laryngeal tumors. 2The importance developed on and off hoarseness. Her voice wasofthislesion lies in its possible confusion with invasive desciibed to be rough in character. No othersquamous cell carcinoma. There is a risk of missing associaied signs and symptoms were noted exceptconcomitant systemic amyloidosis or exhaustively for occasional coughing for which she was giveninvestigating for this when it is not present because " unrecalled mucolytics. No consultation was done

Iof the inability to understand the nature of the disease, nor medications taken_

The larynx is the most common site of J7 years PTA, because of on and offi

involvement by any amyloid in the head and neck hoarseoessand relatives'advice, the patientsoughtand localization in the larynx is twice as frequent as consultwith an ENT specialistwho noted a "laryngealin any other part of the respiratory tract. 3The cyst" fo_ which she was given steroids for 1 week.-supraglottic larynx, especially the false vocal cords, On follo_-up, her voice was noted to have improvedis the region most often involved, but the true vocal thus he[ medicinewas discontinued. Howeveraboutcords and subglottis are not spared_ Laryngeal 2 months after, she was again noted to be hoarse

amyloidosis as a presenting finding, is generally a with no other associated signs and symptoms. Nolocalized process and is not associated withiiI

*FreePaperPresentation,44thPSO-HNSAnnualConvention,December01,2000,PuntaBaluarte,Calatagan,Batangas**Resident,Departmentof Otolaryngology,ManilaDoctorsHospital I***Consultant,DepartmentofOtolaryngology,ManilaDoctorsHospital

145

granuloma 1. As for our patient, she had no previous nose, eye, oral cavity, oropharynx, andhistory of hospitalization nor operation. All her 3 tracheobronchial tree with the supraglottic larynx atpregnancieswere delivered via spontaneous delivery, the level of the false cord as the most frequent site2.thus she has no history of endotracheal intubation. While this disease is not benign in its systemic form,

Contactulcerssecondarytogastroesophageal it usually behaves in a harmless fashion when it isreflux is a direct result of gastric contents irritating localized to one site.the laryngeal mucosa eventually causing chronic It can present in several forms as described ininflammation. This may be confounded by the the classification of Symmers2: primary amyloidosisoccurrence of vocal abuse secondary to reflux. The (localized or general); secondary amyloidosis (localizedirritation brought about by the reflux of the acid then or general); amyloidosis associated with multipleincites a persistent foreign body sensation in the myeloma; and hereditary or familial amyloidosis.throatwith a strong urge to cough or clear the throat. Primary amyloidosis is a plasma cell disorder whichAll of these taken togetherwould bring about injurious originates in the bone marrow, a systemic diseaseapproximation of the vocal processes of the arytenoids with no identifiable cause. The deposits in this type ofthereby causing the formation ofcontactulcers. Our disease are made up of immunoglobulin light chainpatient had a history of long-standing untreated proteins which may be deposited in any bodily tissuehyperacidity and this could have predisposed her to or organ. The secondary amyloidosis refers todeveloping gastro-esophageal reflux and in turn systemic amyloidosis and is caused by a chronicpossibly developing contact ulcers, infection or inflammatory disease such as rheumatoid

The most common presenting symptoms of arthritis, familial Mediterranean fever_ osteomyelitis orcontact ulcer is hoarseness. Patients with voice granulomatous ileitis. The deposits in this type of

abuse or reflux as the cause often have a long history disease are made up of a protein called AA protein. Aof hoarseness with periods of exacerbation and subclass of systemic amyloidosis occurs in patientsremission. Post-intubation ulcers are usually with multiple myeloma. The familial or hereditarycomposed of bilateral pedunculated, epithelialized amyloidosis is a rare form of the disease which is foundgranulation tissue often increasing in size which may in families or nearly every ethnic background. Thegive rise to respiratory compromise _, Treatment deposits are mostcommonly made up oftransthyretinmodalities are directed towards the causative protein which is manufactured in the liver, in the

etiologies_ However, when the history is strongly localized form, there is no evidence of systemicsuggestive of vocal abuse with no history of intubation amyloidosis and no underlying chronic disease_ Theor symptoms of gastro-esophageal reflux, voice absence of a systemic disease may very well qualify

therapy is the most effective. If ever granuloma our patient with the localized form of amyloidosis.develops, surgical removal is advised Although the presenting symptom of laryngeal

amyloidosis is usually hoarseness, other clinicalLARYNGEAL AMYLOIDOSIS manifestations may develop over time with further

Amyloidosisis a disorderof protein metabolism development of the disease 3. It is not unusual to havein which autologous proteins are deposited patientswhowillcomplainofdysphagia, dyspneawithintracellularlyas fibrils in different organs and results exertion, choking, occasional aspiration, and a fullnessin a wide range of clinical manifestations. These in the throat_ A number of patients would also haveamyloid materials are constantly deposited outside significant reflux esophagitis, this raises the possibilitythe cells and these compressed cells cannot work that acid reflux can be an etiologic factor _consideringproperly. Abnormalities will depend on the organ that amyloid deposits can result from some types ofsystem involved. Amyloidosis most often occurs as chronic inflammatory process 2. The clif_ical nature ofa primary disease or in association with plasma cell laryngeal amyloidosis has not been v_Jl-established,dyscrasia or inflammatory diseases. Less often it and the natural history of the disease remains amay be due to inheritance or be a concomitant controversy. A study made by Lewis etal1_revieweddevelopment of aging 3. These may be systemic or the clinicopathologic and immunohistochemicallocalized to one site. Systemic amyloidosis features of 22 cases of laryngeal amyloidosis. Theycommonly affects the heart, kidneys, nervous concluded that hoarseness was the most commonsystem, and gastrointestinal tract. A localized form symptom and that the most frequent site affected wasalso occurs but the amyloid in all types has similar the false cords. However, in the retrospectivestudy ofmorphologic, structural, and staining properties Kernereta113 among 141 patientswith biopsy-verifieddespite involvement of fundamentallydifferent protein amyloidosis, they concluded that the tongue and thecomponents. In the head and neck, almost all sites larynx were the most common sites of involvement.have been reported to be involved; these include the Nonetheless, both studies confirmed that localizednasopharynx, salivary glands, paranasal sinuses, amyloidosis is indeed common in the head and neck.

149

The only clinical presenting symptom of our patient the classical apple-green bire#ingence which was veryis hoarseness and the gross appearance suggests a evident with our patient_ Electron microscopy was

mucosally covered mass. Hence, differential notdone.

diagnosis varied from infectious to malignant. Once the diagnosis of laryngeal amyloidosis isFurthermore, on direct laryngoscopyand biopsy made, further work-up should be done to rule out the

the reading suggested a foreign-bodytype of reaction, possibility of a systemic disease. Some systemicIt is only after the sections were re-examined and causes that should be considered are multipleanalyzed that amyloidosis was considered, myeloma, tuberculosis, and rheumaticdiseases_ The

Laryngeal amyloidosis is almost always work-up should include a pulmonary evaluation,evaluated initially at the time of biopsy and their tuberculin skin testing, complete blood count, blood

urea nitrogen and creatinine levels, liver enzymeappearance may vary to a tumor-like nodule or as adiffuse infiltrates in the submucosa of the larynx studies, sedimentation rate, determination of Rhmimicking a carcinoma-like lesion. 2 The 4 patterns ! factor; urinalysis, antinuclear antibody values, and

serum and urine electrophoresis. 2Only a completelocation of amyloid deposition in the larynx are 1.blood count and chest x-ray were done for our patientrandom, amorphous masses, 2. vessel walls, 3.which revealed normal results_ All these have yet tobasement membranes of the submucous glands, andbe done at the time of this report. The rest of4. adipose tissue as hyaline rings. Our patient

presented with random, amorphous mass over the laboratorieswere not requested primarily because thefalse cord and left arytenoid, diagnosis of amyloidosis was not considered pre-

Laryngeal Amyloidosis is best evaluated by operatively_ Clinically, our patient did not show anydirect laryngoscopy at the time of biopsy. It is during signs and symptoms that would raise the suspicionthis time that one would assess the surface of a systemic disease.

involvement, but because amyloidosis is a The treatmentfor isolated laryngeal amyloidosissubmucosaldiseasewhich can only be defined better can be one of observation or surgery. Depending onby radiological scans. Aydin et al TMstated that axial the size of the lesion, one may opt to wait providedCT scan and MRI would offer the best clinical that it does not obstruct the airway. Other forms ofassessment of the disease and would also aid in treatment, such as radiation therapy have little or no

determining the timing of the surgery based on the effect on the disease. The best treatment options forgrowth and extent of the lesion. Short of radiographic isolated laryngeal amyloidosis is still surgery. Surgicalimaging to documentthe disease, videolaryngoscopy options ranges from microscopic laryngoscopy withcould be done. It is an office procedure that can be carbon dioxide laserorcold knife excision to externalusedtodocumentchangesand monitorany progress partial laryngeal resection. Endoscopic carbonof tumor growth. As for our patient, the dioxide laser is successful in treating localizedvideolaryngoscopic finding was instrumental in amyloidosiswith no evidence of recurrence for at leastdetermining the extent of the lesion viewed from a 2 years. 16This was refuted by Kennedy 2 et al whomagnified standpoint, its surface character and the claimed claimed that laser excision is often notpossibility of threat to the airway. It also aids us in complete and it almost always resulted in recurrence_monitoring the recurrence of her disease, which is Some authors advocated external approaches toevident 1 month post-excision. Forthis case however, handle large supraglottic amyloid deposits, namelydespite the videolaryngosopy imaging, laryngeal thyrotomy and supraglottic laryngectomy. Kennedyamyloidosis was not considered as a differential et al then proposed a conservative surgicaldiagnosis pre-operatively, management, a lateral supraglottic procedure through

The gold standard for the diagnosis of the upperthyroid lamina. This approach preventstheamyloidosis is a tissue biopsy staining positive with loss of internal supraglottic structure and interruptionCongo-red demonstrating apple-green birefringence at the anterior commissure that may have an effectunder polarized light microscopy 2. On electron on swallowing and voice respectively.microscopy a classical fibrillar appearance in the Localized amyloidosis can be successfullyextracellularmatrix is evident. Theinitialhematoxylin treated by surgery alone with little or no majorand eosin staining of the mass of the patient already sequelae. In spite of this, Chow et aP reported 1raised the suspicion of amyloidosis because of the mortality secondary to massive hemorrhage of upperpresence of hyaline and / or amyloid in the stroma_ respiratory tract as a complication of undiagnosedThat is why Congo-red staining was suggested localized laryngeal amyloidosis. This suggests thatbecause hyalinewould not absorb the stain compared early recognition of the disease would preventto amyloid which would give a salmon pink complications_appearance once viewed on light microscopy. Tracheostomy was done prior to the excisionFurthermore, on polarized light, amyloid would show biopsy because of the threat of airway compromise.

150

In a study by Noguchi et al stated that laryngealamyloidosis is fragile and hemorrhagic, and that because of the tendency to obstruct the airway and

massive bleeding may occur during intubation, possibly cause massive hemorrhage.The procedure intended for our patient pre- Amyloidosisin any form is a slowly progressive

operatively was only excision biopsy, which may be lesion that does not respond to nonsurgical treatment.the reason why recurrence was noted 1 month post- Thus management of localized laryngeal Amyloidosisoperatively, iflaryngealamyloidosiswasconsidered is by far no exception. Local surgical excision isthen, a more definitive management which is wide the treatmentofchoicefor laryngealAmyloidosisandexcision of the amyloid mass could have been done. laser excision is probably the best. However, one

should always consider the possibility of recurrence,Since amyloidosis is a very slow growing, recurrence

as exhibited by our patient. Thus properevaluationis expected and may only manifest after several years and documentation should be made before planningso long term follow-up is necessary. The most ideal to resect the mass. Based on literature review, thismanagement for complete resolution of localized paper also suggested treatment options in excisingamyloidosis with recurrence would be multiple the mass. And because of its tendency to recurexcision. Godbersen et aP suggested that removal even after complete excision is done, close monitoringof the amyloid tumors at intervals is more feasible is advised.than radical resection, because of the slow growth ofthese tumors. Prognosis of the disease depends on

both the size of the amyloid deposit and whether there BIBLIOGRAPHYis systemic involvement.

1. Fried MP. The Larynx: A MultidisciplinaryApproach 2_ded. 1996

CONCLUSION 2. Kennedy TL, Patel NM Surgical Manage-ment of Localized Amyloidosis. Laryngos-

Hoarseness as an initial presenting symptom copy. June 2000; 110:918-923should alarm an otorhinolaryngologist regarding the 3. NandapalanV, JonesTM, Morar P, ClarkAH,underlying disease which may be as benign as an Jones AS_ Localized amyloidosis ofthe pa-infectious process or as life threatening as a rotid gland: a case report and review of thecarcinoma. One should always consider that Iocalizedamyloidosisoftheheadandneck_inflammatory condition such as amyloidosis exist. Head Neck 1998 Jan; 20 (1):73-8

Laryngeal Amyloidosis usually indicates 4. Ramden H, TaraziA, Baroudy F, Laryngeallocalized disease with no systemic involvement. Tuberculosis presentation of 16 cases andEarly diagnosis and recognition of the disease, would review of Literature. J Otalaryngo11993; 22:lead to less morbidity and appropriate plan of 39treatment_ However because of the potential for an 5. Kerner MM, Wang MB, Angler, G, Calcaterraunderlying disease state such as multiple myeloma, TC, Ward PH. Amyloidosisofthe Head anda full medical evaluation for systemic disease should Neck : A Clinicopathologic Study of UCLAbe performed. Complete work-up should include Experience, 1955-1991.ArchiveOtolaryngolpulmonary evaluation, tuberculin skin testing, Head and NeckSurg 1995; 121:778-782complete blood count, blood urea nitrogen and 6. RaymondAK, SneigeN, BatsakisJG. Amy-creatininelevels, liverenzymestudies, sedimentation Ioidosis in the Upper Aerodigestive tracts_rate, determination of Rh factor; urinalysis, antinuclear Ann Otol Rhinol Laryngol 1992; 101: 794-antibody values, and serum and urine 796electrophoresis. Wethereforerecommendthatthese 7. BennetJDC, ChowdhuryCR. PrimaryAmy-laboratories be done when one makes a diagnosis of Ioidosis of the Larynx. J. Laryngology andamyloidosis, whether it is systemic or in localized Otol April 1994; t08 : 339-340form. 8. Cheung-ChowLT, ChowWH, Shum BS. Fa-

This case was presented in an effort to shed tal massive upper respiratory tractlight on the possibility of occurrence of amyloidosis haemorrhage: an unusual complication ofof the larynx in our local setting_ Although no local localized Amyloidosis of the larynx. J. ofdata was available to document its incidence, the Laryngol and Otol. Jan 1993; 107:51-53.numerous international studies on laryngeal 9. Godbersen GS, Leh JF, Rudent H,amyloidosis suggest that it is relatively common Hansmann, Lnke RP. Organ-Limited Laryn-accounting for about less than 1% of all laryngeal geal Amyloid deposits: Clinical, Morphologi-tumors. And once undiagnosed, this could be fatal cal, and Immunohistochemical results of Five

Cases. Ann Otol Rhinol Laryngol 1992;

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101:770_775 15. Motta M, Velona G, Trojsi R, Turconi C.10. Nadpalan V, Jones TM, Clark AH, Jones AS. Laryngeal Amyloidosis : a case report. Acta

Localized Amyloidosis of the Parotid gland: Acase Otorhinolaryngo[ Ital 1996 Oct; 16 (5): 455-report and review of the localized Amyloidosis of 459the head and neck. Head and Neck 1998 Jan; 16. Woo KS, Van Hasselt CA, Waldron J. Laser20 (1): 73-78 resection of localized subglottic Amyloidosis.

11. Torta V, Smiroldo AF, Segatta P, Dvomik G, Vidi J Otolaryngol 1990 Oct; 19 (5): 337-338I. Localized Amyloidosis of the larynx. Acta 17. Noguchi T, Minami K, Iwagaki T, Takara H,Otorhinolaryngolltal l996 Dec;16(6): 537-542 Sata T, Shigematsu A. Anesthetic

12. Lewis JE, Olsen KD, Kurtin PJ, Kyle RA. Laryn- management of a patient with laryngealgeal Amyloidosis : a clinicopathologic and ira- amyloidosis_ J clin Anesth 199 Jun; 11 (4):munohistochemical review. Otolaryngol Head 339-341Neck Surg 1992 Apr; 106 (4):372-377 18. Koufman.JA, Isaacson G. The Otolaryngologic

13. Kerner MM, Wang MB, Angler G, Calcattera, ClinicsofNorthAmerica Voice disorders, OctWard PH. Amyloidosis of the Head and Neck : A 1991; Vol. 24; Number 5ClinicopathologicStudy of the UCLA Experience, 19. Ferrara G, Boscaino A. Nodular amyloidosis1955_1991Arch Otolaryngol Head Neck Surg, Vol of the larynx. Pathologica 1995 Feb;121, 1995 July; 778-782 87(1):94-6

14. Aydin O, Ustundag E., Iser M, Ozkarakas H,Oguz A; Laryngeal Amyloidosis withlaryngocoete;, J Laryngol Otol 1999, April: 113(4): 361 - 366

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PHILIPPINE JOURNAL OF OTOLARYNGOLOGY HEAD & NECK SURGERY

Vol, 16 No. 3 153-157. _2002 PHILIPPINE SOCIETY OF OTOLARYNGOLOGY READ & NECK SURGERY

PARAGANGLIOMA PRESENTING AS A PAROTID MASS*

CECILE TRISHA B. DURAN, MD**

JOHANNA M. CO, MD**

FELIX P. NOLASCO, MD, FPSO-HNS***

ABSTRACT

OBJECTIVE: To present our experience on the clinical behavior of paraganglioma occurring in the head and neckarea as this tumor has rarely been encountered in the local setting. Early recognition of this tumor will facilitateimmediate and complete resection and minimize further complications.

DESIGN: A case report

SETTING: A tertiary-hospital in Quezon City, Philippines

PATIENT: A 17-year old male presenting with a 1-year history of a slowly enlarging left infra-auricular mass_

RESULTS: The patient underwent left total parotidectomy using a lazy-s incision to excise the superficial lobe withpreservation of the left facial nerve, and a transmandibular approach (lip splitting+mandibular swing) to excise thedeep lobe. Extensive dissection of the tumor tissue was done in the area of the left base of the skull, left lateralpharyngeal wall and around the left carotid sheath..

CONCLUSION: A high index of suspicion is needed to diagnose a paraganglioma in the head and neck area asmajority of these cases are asymptomatic, has an insidious growth and are multicentric in origin. Paragangliomaof the head and neck should also be considered in patients presenting with an infra-auricular mass. Delayedidentification leads to tumor enlargement with increased surgical risk to neurovascular structures and possibleincomplete resection. Surgical excision is the mainstay of therapy for paraganglioma of the hea and neck.

INTRODUCTION

Paragangliomas are neuroendocrine disease. 19Documented cases of paraganglioma ofneoplasms which originate from neural-crest cells the head and neckwith a clinical presentation similarcalled paraganglia that are located throughout the to that seen in our patient is uncommon, making

body. 1,sThe incidence of paragangliornain the head diagnosisdifficult. It is importantthat an earlyand neck region is low, accounting for only 0.012% recognition of this tumor be made so as to facilitateof all tumors in man? Paraganglioma of the head the immediate and complete resection of the tumorand neck can occur in such locations as the larynx, and minimize further complications.orbit, paranasal sinuses and the jugulotympanicareaalong cranial nerves IX and X, 7 howeverthe majorityof these tumors arise in the carotid bifurcation and CASE REPORTare known as "carotid body tumors"_ " The most

common presentation of a carotid body tumor is of Our patient is B_P.,a 17-year-old male, withan asymptomatic, slowly enlarging mass inthe upper a 1-year history of a slowly enlarging, non-tender, firm,portion of the neck, anterior to the slightly movable mass at the leftinfra-auriculararea,sternocleidomastoid muscle, just below the angle of with no associated signs and symptoms. The patient'sthe mandible. 1 This tumor is usually benign but is previous medical history and family history werewell known for local soft tissue and bone invasion. 8 unremarkable. Since our patient had no otherMalignancy is difficultto determine histologically and subjective complaints at that time, there was nois usually based on the presence of metastatic

*FreePaperPresentation,44thPSO-HNSAnnualConvention,December01,2000,PuntaBaluarte,Calatagan,Batangas**Resident,Departmentof Otolaryngology-HeadandNeckSurgery,EastAvenueMedicalCenter***Cor_sultant,Departmentof Otolaryngology-HeadandNeckSurgery,EastAvenueMedicalCenter

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attempt made to consult with a physician and the (Paraganglioma).Ourpatientappearedwell duringpatient continued with his regular activities. After a subsequent follow-up, however on the 5thmonthfew months, the patient complained of further post-op, a 2 x 3 x 3 cm. slowly enlarging, non-enlargement of the masswhich had extended to the tender mass was again observed in the left lateralpre-auriculararea, as wellas a sensationofdysphagia neckarea. A repeat chestx-ray (CXR) showed theupon intake of solid food. Persistence of the presence of multiple nodules in the right mid- anddysphagia alarmed our patient's parents prompting bilateral lower lung region, the largest of whichconsult at our medical institution. Upon clinical measured 2 cm. in its widest dimension. Tumorexamination, the mass was noted to bearound 5 x 6 residual and growth with possible metastasis wasx 3 cm. insize, andwas firm, non-tenderand slightly suspected. The patient was then advisedmovable. Further examination of the oral cavity radiotherapy butwas lost to follow-up.revealed a bulging left lateral pharyngeal wall withthe uvuladisplaced to the right. There were noother DISCUSSIONabnormal findings in the rest of the physical

examination. Paragangliomas arising from the carotidBased on the clinical findings, our primary bodies account for 60% of all head and neck

consideration was a Parotid New Growth, probably paragangliomas._They usuallyoccur in patients40benign. Our differential diagnoses included a to 60 years old,1,3making the appearance of thisBranchial cleft cyst, TB adenitis, and Lymphoma. tumor in our 17-yearold patient relatively unusual.Diagnostics done to confirm our initial impression Approximately 10%of all paragangliomas haveanincluded a Fine Needle Aspiration Biopsy (FNAB) autosomal dominant pattern of inheritance,"which revealedcytomorphologicfeatures consistent however our patient's past medical history andwitha pleomorphicadenomaandContrast-enhanced family medical history were unremarkable_ TheComputedTomography(CTScan)which revealedthe most common presentationof a paraganglioma inpresenceof a large, irregular soft tissue mass in the the headand neck area is that of anasymptomatic,left parotid space. The mass was noted to extend slowly enlarging mass atthe anterior border of theanterolaterally to the ipsilateral masticator space, sternocleidomastoid muscle that is mobile in themedially to the parapharyngeal space and lateralplanebutlimitedincephalocaudaldirecSon.21posteromediallytothe carotidspace. The left carotid They may grow large enough, as in our case, tosheathwas displaced posteriorlywith note of small, encroach into nearby structures causing a varietyrim-enhancing hypodense nodular structures in the of symptoms such as thedysphagia of our patient.left carotidspace. The CTScan Findingswas signed As this tumor enlarges, progressivesymptoms notout as a soft-tissue mass in the left parotid space only of dysphagia but also of odynophagia,with extensions and lytic erosions consistent with a hoarsenessand other cranialnerve (IX-XlI) deficitsparotid gland tumor as well as the consideration of may appear.21an enlarged lymph node in the left carotid space, Aside from a Parotid new growth, ourThe chest x-ray (CXR), complete blood count (CBC) differentialdiagnosesincludedBranchialcleft cysts,and urinalysis of our patient yielded normal results. TB adenitis and Lymphoma,2 mainly because of

Surgical management involved a left total the location and characteristics exhibited by theparotidectomy using a lazy-s incision to excise the mass, as well as the absence of other signs andsuperficial lobewith carefulpreservation of the facial symptoms. Allour otherconsiderationswere rulednerve,and a transmandibularapproach (lip splitting out by appropriate clinical examination and+ mandibular swing) to excise the deep lobe. The diagnosticwork-up.left submandibular and sublingual glands were Fine-needle Aspiration Biopsy (FNAB) isremoved. Intra-operativefindingsshowedthemass not useful in the diagnostic evaluation ofto extend until the base of the skull, left lateral paragangliomaof thehead andneck,2 althoughforpharyngeal wall, and the area of the patient's left tumors ofthethyroidand parotid, ithas a specificityexternalcarotid artery (ECA), leftinternaljugularvein of 88% - 89% and a sensitivity of 87% - 100%.12(IJV) and left internal carotid artery (ICA). Excision Fine needle aspiration cytology of a carotid bodyof the mass was done togetherwith transection and paraganglioma would usually reveal blood richligationof the patient's left ECA. Frozen sectionwas aspirate with poorto moderatecellularity, indistinctnot done and the specimens were sent for routine cell outline, and acinar formation.22 interestinglyhistopathologicexamination (permanent section), enough, the FNAB of our patient showed cells with

Ourpatienttoleratedtheprocedurewell,with features consistentwith a benign tumor of thenopost-operativecomplications,andwasdischarged salivaryglandandwas signedoutas Pleomorphiconhiseighthpost-opday.Theofficialhistopathologic Adenoma. Finalhistopathologicexaminationoftheexaminationwassignedoutasa CarotidBodyTumor tumor in our case (Figure 3) revealed features

," .: "t

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