Manometry and Electromyography of the Pharyngeal Muscles in Patients With Dysphasia To the Editor.\p=m-\Inote with interest the recent publication of "Manometry and Electromyography of the Pharyngeal Muscles in Patients With Dysphasia" in the August 1990 issue of the ARCHIVES.1 I find this a useful analysis of the disordered swallow in a mixed population of patients. I also applaud the authors' efforts to develop a simple and cost-effective preoperative assessment for dysphasia, with particular reference to the indication for cricopharyngeal myotomy. I would like to suggest a simpler clinical assessment than the simultaneous study described. It has been a useful technique, in my practice, to infiltrate the cricopharyngeous muscle unilaterally as a field block to test the preoperative effect of cricopharyngeal relaxation. This may, or may not, be performed using simultaneous fluoroscopy. It has been highly correlated with successful myotomy for those patients who achieve improved swallowing function for the duration of the anesthetic block.2 The upper esophageal sphincter is a complex, anatomic, and physiologic structure, and the authors' study helps to define the contributing components of this poorly understood, and yet crit¬
ically important,
area.
MARK I.
SINGER, MD Indianapolis, Ind
1. Elidan J, Shochina M, Gonen B, Gay I. Manometry and electromyography of the pharyngeal muscles in patients with dysphasia. Arch Otolaryngol Head Neck Surg. 1990;116:910-913. 2. Singer MI. Aspiration. In: Gates GA, ed. Current Therapy in Otolaryngology. Philadelphia, Pa: BC Decker; 1987.
In Reply.\p=m-\We would like to thank Dr Singer for his kind remarks. We appreciate Dr Singer's observation that improvement of a patient's swallowing function after cricopharyngeal myotomy is well correlated with his re-
sponse to local block of the
bination therapy of hydrochlorothiazide and triamterene as our diuretic of choice in the medical management of Meniere's disease in the absence of unstable diabetes or uncontrolled se¬ rum cholesterol levels and suggest that any patients receiving indapamide be carefully monitored for hy-
cricopharyngeal muscle before the operation. However, as mentioned in our article, at least part of the pressure in the upper high-pressure zone in the esophagus is due to elastic forces of the sur-
rounding tissues. Thus, there is
no
substitute for actual measurement of intraluminal pressure (and the electrical activity). It would be of interest to record these parameters before and after local infiltration, and eventually we will add this to our usual preoperative battery of tests. J. ELIDAN, MD Jerusalem, Israel
Indapamide to Treat
pokalemia.
HAYES H. WANAMAKER, MD JOHN M. FLANZER, MD HERBERT SILVERSTEIN, MD Sarasota, Fla
1. Gulya AJ. Meniere's disease: medical management. In: Gates GA, ed. Current Therapy in
Otolaryngology\p=n-\Headand Neck Surgery. Toronto, Ontario: BC Decker Inc; 1990;4:69-73. 2. Physicians'Desk Reference. 4th ed. Oradell, NJ: Medical Economics Books; 1990:1871.
Meniere's Disease
To the Editor.\p=m-\Diuretictherapy is
mainstay in the medical
Transseptal Fracture Displacement Approach for Treatment of Pituitary
a
treatment of
Meniere's disease.1 In our practice, as well as in many other large otologic practices, the drug of choice has been a fixed combination of hydrochlorothiazide and the potassium-sparing diuretic triamterene (Dyazide). Because of concern regarding the possible effect of this therapy on cholesterol and glucose metabolism, our internal medicine consultants recently advised us to switch our patients' therapy to indapamide (Lozol), a new oral antihypertensive/diuretic reported to have only a "slight"2 effect on serum potassium levels. Shortly after changing our patients' therapy to this medication, we began to receive numerous laboratory reports of hypokalemia, as well as calls from patients complaining of its characteristic symptoms (weakness, fatigue, and lethargy). In all cases, symptoms promptly resolved and potassium levels stabilized with resumption of therapy with hydrochlorothiazide and triamterene. We wish to alert the otolaryngologic community to the possible occurrence of hypokalemia with the use of inda¬ pamide. We have returned to the com-
Lesion
To the Editor.\p=m-\The transseptal transsphenoidal approach for pituitary surgery, although an excellent route, produces the common rhinological complication, septal perforation.1 Various authors have modified the technique to improve on exposure of the pituitary fossa, as well as to prevent cosmetic deformity, to avoid nasal septal perforation, to reduce operating time, and to facilitate technique. Some of the varied approaches that have been attempted are the external rhinoplasty approach,2 the transseptal approach,3 and the columellar flap technique.4 However, in all of these techniques, septal perforation continues to pose a problem. Our technique is a modification of the endonasal transseptal approach, wherein septal perforation is avoided.
Technique.\p=m-\Thepatient is anesthetized, positioned, and draped. A Killian's incision
is made on the left side after infiltration of the nasal septum. An anterior tunnel is made under the mucoperichondrium of the septal cartilage. As the dissection proceeds, the anterior tunnel is converted to a posterior tunnel by raising the mucoperichon-
Downloaded From: http://archotol.jamanetwork.com/ by a Michigan State University User on 06/09/2015
drium of the perpendicular plate of the ethmoid and vomer. An inferior tunnel is then made along the floor of the nose by elevating the mucosa of the floor of the nose. The anterior and inferior tunnels are con¬ nected by sharp dissection. The left side of the sphenoid rostrum is identified, and the transsphenoidal speculum is introduced be¬ tween the flap and septum on the left side, such that its tip reaches the sphenoid ros¬ trum. The speculum is gradually opened and the thin bony septum fractures to the right, exposing the anterior and inferior walls of the sphenoid sinuses. If there is any question regarding location, a lateral roentgenogram is taken. The surgical microscope is positioned and the mucosa over the ante¬ rior and inferior walls of the sphenoid sinuses is elevated. The sphenoid crest and rostrum are removed with a forwardgrasping forceps, thus entering one or both of the sphenoid sinuses. The opening is en¬ larged using Kerrison's rongeurs and the neurosurgical procedure is performed, af¬ ter which the transsphenoidal speculum is removed. The mucosal incision is sutured with absorbable sutures, the bony septum is repositioned with Ashe's septal forceps, and the nasal cavities are packed with medicated ribbon gauze.
Comment—From November 1989 until May 1990, endonasal transseptal
procedures were performed on 14 pa¬ tients requiring surgery of the pitu¬ itary gland. On follow-up, none of the patients developed septal perforation. One patient developed vestibulitis postoperatively, which healed with lo¬ cal application of neosporin ointment, because of the trauma of applying the transsphenoidal speculum. Since no part of the bony or carti¬ laginous septum is removed and a flap is elevated only on one side of the nasal septum, septal perforation is avoided. The procedure is technically simple, reduces operating time, and provides good visualization of the pituitary gland. ANAND JOB, MS, DLO SIDDARTHA GOSH, MS THOMAS JOSEPH, MS Vellore, South India
1. Kern EB. Transnasal pituitary surgery. Arch Otolaryngol. 1981;107:183-190.
2. Koltai PJ, Goldstein JC, Parnes SM, Price JC. External rhinoplasty approach to transsphenoidal hypophysectomy. Arch Otolaryngol. 1985; 111:456-458. 3. Escajadillo JR, de Gortari E. Transseptal approach for the treatment of pituitary lesions. Arch Otolaryngol. 1983;109:326-328. 4. Peters GE, Birmingham AL, Zitsch RP. Columellar flap for transseptal transsphenoidal hy-
pophysectomy. Laryngoscope. 1988;98:897-899.
Facial Palsy Following Local Anesthetic Infiltration for Middle Ear
Surgery To the Editor.\p=m-\Facial palsy following tympanomastoid surgery has recently been reported1 due to local anesthetic
effect. This has been attributed to the possible dehiscent facial canal in the middle ear. We have also seen patients with facial palsy following local anesthetic infiltration during middle ear surgery. We were, however, quite convinced of the integrity of the facial canal during surgery. The possible explanation is the effect of local anesthetic on the facial nerve at the level of the stylomastoid foramen. During parotid gland surgery, the facial nerve is identified as following the posterior belly of the digastric muscle and the external ear cartilage pointer. Hence, it is postulated that whenever local anesthetic is infiltrated near the mastoid tip for postaural or at the inferior osseocartilaginous junction for permeatal surgery, the local anesthetic seeps out to affect the facial nerve. Interestingly, in two patients there was a history of Bell's palsy that had recovered spontaneously. Hence, as a policy, it may be advisable to use adrenalin infiltration alone to raise the flap and achieve hemostasis in patients where the surgery is done under gen¬ eral anesthesia. In patients where sur¬ gery is done under local anesthesia, it is useful to check for facial palsy after infiltration, before performing the sur¬ gery.
R. RAMAN, MS, DLO ANAND JOB, MS, DLO Vellore, South India
1. Madden G. Facial palsy following tympanomastoid surgery. Arch Otolaryngol Head Neck
Surg. 1989;115:635.
Pseudocyst of the Auricle To the Editor.\p=m-\Thearticle by Cohen and Grossman1 on the "Pseudocyst of the Auricle" was very good. However, their conclusion that "corticosteroids do not play a role in the management of pseudocyst of the auricle" based on two cases,
one
by systemic
treatment
and another by intralesional injection, seems to be contrary to my experience with the latter. The technique used is to first cleanse the area with an antiseptic, then inject a local anesthetic with epinephrine into the skin overlying the swelling. A 22-gauge needle is then inserted into the pseudocyst and the fluid is aspirated. The first syringe is removed and a second syringe with the steroid is attached. The cavity is then flushed with triamcinolone acetonide suspension (10 mg/mL) (Kenalog 10) through the same needle that was left in place. The cavity is then aspirated once more to remove the excess steroid. Occasionally, pressure may have to be applied to the needle site after its withdrawal because of bleed¬ ing. This condition usually clears
promptly.
In the past 20 years, I have seen over half dozen of these patients and treated most of them with injection of steroid into the pseudocyst, with good results in all but one patient; that case having resulted in a thickened carti¬ a
lage. Another patient did require a second injection, with resolution. This technique met the following
outcome criteria of Cohen and Gross¬
"(1) resolution of the lesion with¬ and (2) structural and cosmetic preservation of the architec¬ man
out
recurrence
ture of the external ear."
WALTER K. W. YOUNG, MD Honolulu, Hawaii 1. Cohen PR, Grossman ME. Pseudocyst of the auricle: case report and world literature review. Arch Otolaryngol Head Neck Surg. 1990;116:1202\x=req-\ 1204.
Downloaded From: http://archotol.jamanetwork.com/ by a Michigan State University User on 06/09/2015
ically important,
area.
MARK I.
SINGER, MD Indianapolis, Ind
1. Elidan J, Shochina M, Gonen B, Gay I. Manometry and electromyography of the pharyngeal muscles in patients with dysphasia. Arch Otolaryngol Head Neck Surg. 1990;116:910-913. 2. Singer MI. Aspiration. In: Gates GA, ed. Current Therapy in Otolaryngology. Philadelphia, Pa: BC Decker; 1987.
In Reply.\p=m-\We would like to thank Dr Singer for his kind remarks. We appreciate Dr Singer's observation that improvement of a patient's swallowing function after cricopharyngeal myotomy is well correlated with his re-
sponse to local block of the
bination therapy of hydrochlorothiazide and triamterene as our diuretic of choice in the medical management of Meniere's disease in the absence of unstable diabetes or uncontrolled se¬ rum cholesterol levels and suggest that any patients receiving indapamide be carefully monitored for hy-
cricopharyngeal muscle before the operation. However, as mentioned in our article, at least part of the pressure in the upper high-pressure zone in the esophagus is due to elastic forces of the sur-
rounding tissues. Thus, there is
no
substitute for actual measurement of intraluminal pressure (and the electrical activity). It would be of interest to record these parameters before and after local infiltration, and eventually we will add this to our usual preoperative battery of tests. J. ELIDAN, MD Jerusalem, Israel
Indapamide to Treat
pokalemia.
HAYES H. WANAMAKER, MD JOHN M. FLANZER, MD HERBERT SILVERSTEIN, MD Sarasota, Fla
1. Gulya AJ. Meniere's disease: medical management. In: Gates GA, ed. Current Therapy in
Otolaryngology\p=n-\Headand Neck Surgery. Toronto, Ontario: BC Decker Inc; 1990;4:69-73. 2. Physicians'Desk Reference. 4th ed. Oradell, NJ: Medical Economics Books; 1990:1871.
Meniere's Disease
To the Editor.\p=m-\Diuretictherapy is
mainstay in the medical
Transseptal Fracture Displacement Approach for Treatment of Pituitary
a
treatment of
Meniere's disease.1 In our practice, as well as in many other large otologic practices, the drug of choice has been a fixed combination of hydrochlorothiazide and the potassium-sparing diuretic triamterene (Dyazide). Because of concern regarding the possible effect of this therapy on cholesterol and glucose metabolism, our internal medicine consultants recently advised us to switch our patients' therapy to indapamide (Lozol), a new oral antihypertensive/diuretic reported to have only a "slight"2 effect on serum potassium levels. Shortly after changing our patients' therapy to this medication, we began to receive numerous laboratory reports of hypokalemia, as well as calls from patients complaining of its characteristic symptoms (weakness, fatigue, and lethargy). In all cases, symptoms promptly resolved and potassium levels stabilized with resumption of therapy with hydrochlorothiazide and triamterene. We wish to alert the otolaryngologic community to the possible occurrence of hypokalemia with the use of inda¬ pamide. We have returned to the com-
Lesion
To the Editor.\p=m-\The transseptal transsphenoidal approach for pituitary surgery, although an excellent route, produces the common rhinological complication, septal perforation.1 Various authors have modified the technique to improve on exposure of the pituitary fossa, as well as to prevent cosmetic deformity, to avoid nasal septal perforation, to reduce operating time, and to facilitate technique. Some of the varied approaches that have been attempted are the external rhinoplasty approach,2 the transseptal approach,3 and the columellar flap technique.4 However, in all of these techniques, septal perforation continues to pose a problem. Our technique is a modification of the endonasal transseptal approach, wherein septal perforation is avoided.
Technique.\p=m-\Thepatient is anesthetized, positioned, and draped. A Killian's incision
is made on the left side after infiltration of the nasal septum. An anterior tunnel is made under the mucoperichondrium of the septal cartilage. As the dissection proceeds, the anterior tunnel is converted to a posterior tunnel by raising the mucoperichon-
Downloaded From: http://archotol.jamanetwork.com/ by a Michigan State University User on 06/09/2015
drium of the perpendicular plate of the ethmoid and vomer. An inferior tunnel is then made along the floor of the nose by elevating the mucosa of the floor of the nose. The anterior and inferior tunnels are con¬ nected by sharp dissection. The left side of the sphenoid rostrum is identified, and the transsphenoidal speculum is introduced be¬ tween the flap and septum on the left side, such that its tip reaches the sphenoid ros¬ trum. The speculum is gradually opened and the thin bony septum fractures to the right, exposing the anterior and inferior walls of the sphenoid sinuses. If there is any question regarding location, a lateral roentgenogram is taken. The surgical microscope is positioned and the mucosa over the ante¬ rior and inferior walls of the sphenoid sinuses is elevated. The sphenoid crest and rostrum are removed with a forwardgrasping forceps, thus entering one or both of the sphenoid sinuses. The opening is en¬ larged using Kerrison's rongeurs and the neurosurgical procedure is performed, af¬ ter which the transsphenoidal speculum is removed. The mucosal incision is sutured with absorbable sutures, the bony septum is repositioned with Ashe's septal forceps, and the nasal cavities are packed with medicated ribbon gauze.
Comment—From November 1989 until May 1990, endonasal transseptal
procedures were performed on 14 pa¬ tients requiring surgery of the pitu¬ itary gland. On follow-up, none of the patients developed septal perforation. One patient developed vestibulitis postoperatively, which healed with lo¬ cal application of neosporin ointment, because of the trauma of applying the transsphenoidal speculum. Since no part of the bony or carti¬ laginous septum is removed and a flap is elevated only on one side of the nasal septum, septal perforation is avoided. The procedure is technically simple, reduces operating time, and provides good visualization of the pituitary gland. ANAND JOB, MS, DLO SIDDARTHA GOSH, MS THOMAS JOSEPH, MS Vellore, South India
1. Kern EB. Transnasal pituitary surgery. Arch Otolaryngol. 1981;107:183-190.
2. Koltai PJ, Goldstein JC, Parnes SM, Price JC. External rhinoplasty approach to transsphenoidal hypophysectomy. Arch Otolaryngol. 1985; 111:456-458. 3. Escajadillo JR, de Gortari E. Transseptal approach for the treatment of pituitary lesions. Arch Otolaryngol. 1983;109:326-328. 4. Peters GE, Birmingham AL, Zitsch RP. Columellar flap for transseptal transsphenoidal hy-
pophysectomy. Laryngoscope. 1988;98:897-899.
Facial Palsy Following Local Anesthetic Infiltration for Middle Ear
Surgery To the Editor.\p=m-\Facial palsy following tympanomastoid surgery has recently been reported1 due to local anesthetic
effect. This has been attributed to the possible dehiscent facial canal in the middle ear. We have also seen patients with facial palsy following local anesthetic infiltration during middle ear surgery. We were, however, quite convinced of the integrity of the facial canal during surgery. The possible explanation is the effect of local anesthetic on the facial nerve at the level of the stylomastoid foramen. During parotid gland surgery, the facial nerve is identified as following the posterior belly of the digastric muscle and the external ear cartilage pointer. Hence, it is postulated that whenever local anesthetic is infiltrated near the mastoid tip for postaural or at the inferior osseocartilaginous junction for permeatal surgery, the local anesthetic seeps out to affect the facial nerve. Interestingly, in two patients there was a history of Bell's palsy that had recovered spontaneously. Hence, as a policy, it may be advisable to use adrenalin infiltration alone to raise the flap and achieve hemostasis in patients where the surgery is done under gen¬ eral anesthesia. In patients where sur¬ gery is done under local anesthesia, it is useful to check for facial palsy after infiltration, before performing the sur¬ gery.
R. RAMAN, MS, DLO ANAND JOB, MS, DLO Vellore, South India
1. Madden G. Facial palsy following tympanomastoid surgery. Arch Otolaryngol Head Neck
Surg. 1989;115:635.
Pseudocyst of the Auricle To the Editor.\p=m-\Thearticle by Cohen and Grossman1 on the "Pseudocyst of the Auricle" was very good. However, their conclusion that "corticosteroids do not play a role in the management of pseudocyst of the auricle" based on two cases,
one
by systemic
treatment
and another by intralesional injection, seems to be contrary to my experience with the latter. The technique used is to first cleanse the area with an antiseptic, then inject a local anesthetic with epinephrine into the skin overlying the swelling. A 22-gauge needle is then inserted into the pseudocyst and the fluid is aspirated. The first syringe is removed and a second syringe with the steroid is attached. The cavity is then flushed with triamcinolone acetonide suspension (10 mg/mL) (Kenalog 10) through the same needle that was left in place. The cavity is then aspirated once more to remove the excess steroid. Occasionally, pressure may have to be applied to the needle site after its withdrawal because of bleed¬ ing. This condition usually clears
promptly.
In the past 20 years, I have seen over half dozen of these patients and treated most of them with injection of steroid into the pseudocyst, with good results in all but one patient; that case having resulted in a thickened carti¬ a
lage. Another patient did require a second injection, with resolution. This technique met the following
outcome criteria of Cohen and Gross¬
"(1) resolution of the lesion with¬ and (2) structural and cosmetic preservation of the architec¬ man
out
recurrence
ture of the external ear."
WALTER K. W. YOUNG, MD Honolulu, Hawaii 1. Cohen PR, Grossman ME. Pseudocyst of the auricle: case report and world literature review. Arch Otolaryngol Head Neck Surg. 1990;116:1202\x=req-\ 1204.
Downloaded From: http://archotol.jamanetwork.com/ by a Michigan State University User on 06/09/2015
