Papers by Stephen Wetmore
Otolaryngology-Head and Neck Surgery, Apr 1, 1997
Management of patients with cerebrospinal fluid rhinorrhea (CSF) remains controversial. Most stud... more Management of patients with cerebrospinal fluid rhinorrhea (CSF) remains controversial. Most studies recommend either an endoscopic or an external extracranial approach, depending on the surgeon's preference. Eighteen patients with CSF rhinorrhea have been managed at our institution since 1990. The causes of the CSF rhinorrhea consisted of functional endoscopic sinus surgery (7), lateral rhinotomy with excision of a benign nasal tumor (3), spontaneous rhinorrhea (7), and secondary repair after intranasal ethmoidectomy (I). In 11 patients the CSF leak was recognized at the time of surgery; in 10 of these patients it was repaired during the primary surgery, whereas one patient underwent secondary repair after failure of conservative management of his CSF fistula. Seven patients underwent exploration for spontaneous CSF rhinorrhea. Four patients had computer tomography scans that showed the leak, and two patients had cisternography to localize the leak. One patient underwent magnetic resonance cisternography. Both of these leaks were identified with cisternography and were then confirmed intraoperatively. Repair methods included a pedicled septal mucosal flap (4), a free mucosal graft from the septum (7), and a middle turbinate (5). Two patients had obliteration of the sinus with muscle/fascia and fibrin glue. Eight patients were repaired endoscopically. The remainder underwent repair through external approaches. Seventeen patients (at a minimum I year follow-up) remain free from leakage. One patient required a second repair 8 months after surgery, latrogenic trauma remains the most common cause of CSF rhinorrhea. Management at the initial setting is the least morbid approach and is successful in 95% of cases. Whether an endoscopic or external approach is used depends on surgical expertise and experience. (Otolaryngol Head Neck Surg 1997;116:442-9.) ll~,terebrospinal fluid (CSF) rhinorrhea was first described by Galen in the second century AD. 1 He postulated that CSF was released into the nose by way of the pituitary and ethmoid regions. In 1899 Saintclair Thompson 1 reported the first series of patients with spontaneous CSF rhinorrhea. However, it was not until 1926 that Dandy 2 reported the first successful repair through an intracranial approach. Causes of CSF rhinorrhea before World War I were primarily nontraumatic because patients with sufficient head injuries to tear
Head & neck, Jul 1, 1995
Background. Carcinoma of the paranasal sinuses is rare. The majority of these originate in the ma... more Background. Carcinoma of the paranasal sinuses is rare. The majority of these originate in the maxillary sinus with primary ethmoid carcinomas occurring in up to 20% of cases. Adenocarcinomas comprise up to 50% of the ethmoid malignancy. The relative rarity of tumors originating in this areahas led to their inclusion in series that consist mainly of maxillary antral tumors. Methods. A retrospective chart review of all patients presenting with primary ethmoid adenocarcinoma at West Virginia University Hospitals between 1988 and 1993 was undertaken. Only patients whose epicenter was believed to be in the ethmoids were included in this analysis. CT scans, MRls, operative notes, pathology, and final outcome were all analyzed. Results. Eight patients with primary ethmoid adenocarcinoma were treated during this time span. The male to female ratio was 1:l with a mean age of 50 years. Symptoms had been present from 3 to 18 months (mean 8 months). All patients underwent craniofacial resection with 5 patients receiving postoperative radiotherapy. Pathologically 4 patients had cribriform plate erosion, 2 had dural involvement, and 1 had extension into the sphenoid sinus. With a mean follow-From the Departments of Otolaryngology Head and Neck Surgery (Drs.
Otolaryngology–Head and Neck Surgery, 1988
The presence of anterior and posterior nasal packs in patients with epistaxis is known to be asso... more The presence of anterior and posterior nasal packs in patients with epistaxis is known to be associated with cardiorespiratory problems and sometimes death, although the mechanism has not been well understood. To determine the incidence and severity of obstructive sleep apnea in patients with epistaxis treated with both anterior and posterior nasal packs, we obtained polysomnograms on twelve patients while the packs were in place. Ten of these patients demonstrated obstructive sleep apnea. The apnea index (apneas/hour sleep) ranged from 1 to 83, with a mean of 29; the hypopnea index (hypopneas/hour sleep) ranged from 9 to 33, with a mean of 20; and the lowest oxygen saturation (SaO2) ranged from 17% to 91%, with a mean of 77%. Ten patients returned for another polysomnogram after removal of the packs. These baseline studies showed improvement in the apnea index and in the lowest SaO2 in all patients, although four patients still demonstrated at least mild obstructive sleep apnea. Th...
Otolaryngology - Head and Neck Surgery, 1997
Management of patients with cerebrospinal fluid rhinorrhea (CSF) remains controversial. Most stud... more Management of patients with cerebrospinal fluid rhinorrhea (CSF) remains controversial. Most studies recommend either an endoscopic or an external extracranial approach, depending on the surgeon's preference. Eighteen patients with CSF rhinorrhea have been managed at our institution since 1990. The causes of the CSF rhinorrhea consisted of functional endoscopic sinus surgery (7), lateral rhinotomy with excision of a benign nasal tumor (3), spontaneous rhinorrhea (7), and secondary repair after intranasal ethmoidectomy (I). In 11 patients the CSF leak was recognized at the time of surgery; in 10 of these patients it was repaired during the primary surgery, whereas one patient underwent secondary repair after failure of conservative management of his CSF fistula. Seven patients underwent exploration for spontaneous CSF rhinorrhea. Four patients had computer tomography scans that showed the leak, and two patients had cisternography to localize the leak. One patient underwent magnetic resonance cisternography. Both of these leaks were identified with cisternography and were then confirmed intraoperatively. Repair methods included a pedicled septal mucosal flap (4), a free mucosal graft from the septum (7), and a middle turbinate (5). Two patients had obliteration of the sinus with muscle/fascia and fibrin glue. Eight patients were repaired endoscopically. The remainder underwent repair through external approaches. Seventeen patients (at a minimum I year follow-up) remain free from leakage. One patient required a second repair 8 months after surgery, latrogenic trauma remains the most common cause of CSF rhinorrhea. Management at the initial setting is the least morbid approach and is successful in 95% of cases. Whether an endoscopic or external approach is used depends on surgical expertise and experience. (Otolaryngol Head Neck Surg 1997;116:442-9.) ll~,terebrospinal fluid (CSF) rhinorrhea was first described by Galen in the second century AD. 1 He postulated that CSF was released into the nose by way of the pituitary and ethmoid regions. In 1899 Saintclair Thompson 1 reported the first series of patients with spontaneous CSF rhinorrhea. However, it was not until 1926 that Dandy 2 reported the first successful repair through an intracranial approach. Causes of CSF rhinorrhea before World War I were primarily nontraumatic because patients with sufficient head injuries to tear
Otolaryngology - Head and Neck Surgery, 2010
Hoarseness is an exceptionally common symptom that often will lead to a referral to an otolaryngo... more Hoarseness is an exceptionally common symptom that often will lead to a referral to an otolaryngologist. Although frequently self-limited, hoarseness can persist and lead to significant dysfunction as well as portend potentially life threatening illness. The otolaryngologist plays a unique role on the appropriate diagnosis and treatment of hoarseness, while considering the health care costs of care. Fortunately the directed history and physical examination will often yield the diagnosis, but this is not always the case. The role of more complex evaluation modalities such as laryngeal videostroboscopy and electromyography are not as straight forward. Even more complex is the treatment, such as for laryngopharyngeal reflux, or the timing of surgery in relationship to speech therapy. This subject has been the focus of much recent interest, and by having input in an open panel format, the practitioner will be offered guidelines to modern management based on the recent literature. Focused history and physical examination will be reviewed as well on the components of a thorough physical examination. The place of more sophisticated diagnostic modalities will be discussed as well as various treatment options whether they be medical, voice therapy, or surgical. Case examples will form the basis for discussion, with ample time for audience interaction. EDUCATIONAL OBJECTIVES: 1) Understand the elements of a history and physical examination of an adult patient with hoarseness. 2) Discern the appropriate role of ancillary diagnostic studies such as videostroboscopy and electromyography. 3) Comprehend, based on current information, treatment modalities such a medications, voice therapy, and surgery.
Archives of Otolaryngology–Head & Neck Surgery, 2008
To analyze the results of primary and revision endolymphatic sac surgery for the treatment of Mén... more To analyze the results of primary and revision endolymphatic sac surgery for the treatment of Ménière's disease in patients who failed medical therapy. Design: Retrospective medical chart review. Setting: Tertiary referral center. Patients: Fifty-one adult patients with Ménière's disease who failed medical therapy. Interventions: Endolymphatic sac to mastoid shunts were performed. Revision sac procedures were performed in patients who developed clinically significant recurrent vertiginous spells 5 months or longer after their original procedure. Main Outcome Measures: Frequency of major vertiginous episodes measured by the standards listed in the 1995 American Academy of Otolaryngology guidelines for evaluation of therapy in Ménière's disease. Results: Twenty-four months after primary sac surgery, 27 patients (53%) exhibited class A results (no vertigo), and 12 (24%) exhibited class B results (1%-40% of baseline). In 14 patients undergoing revision sac surgery, 5 (36%) showed class A results and 4 (29%) showed class B results. Patients who failed treatment with sac surgery more than 24 months after their primary procedure obtained better results than those who failed treatment less than 24 months after their initial sac procedure. In the 37 patients who had long-term follow-up (mean duration of follow-up, 88 months) after their last sac procedure, 57% exhibited class A results (21 cases) and 35% exhibited class B results (13 cases). Conclusions: Endolymphaticsacsurgeryprovidedimprove-mentinmajorspellsofvertigoin77%ofpatientsat24months aftersurgery.Revisionsurgeryprovidedimprovementin65% of cases. Results of revision surgery were better in those patients who developed recurrent symptoms more than 24 months after their original procedure compared with those of patients who failed treatment earlier.
Head & Neck, 1995
Background. Carcinoma of the paranasal sinuses is rare. The majority of these originate in the ma... more Background. Carcinoma of the paranasal sinuses is rare. The majority of these originate in the maxillary sinus with primary ethmoid carcinomas occurring in up to 20% of cases. Adenocarcinomas comprise up to 50% of the ethmoid malignancy. The relative rarity of tumors originating in this areahas led to their inclusion in series that consist mainly of maxillary antral tumors. Methods. A retrospective chart review of all patients presenting with primary ethmoid adenocarcinoma at West Virginia University Hospitals between 1988 and 1993 was undertaken. Only patients whose epicenter was believed to be in the ethmoids were included in this analysis. CT scans, MRls, operative notes, pathology, and final outcome were all analyzed. Results. Eight patients with primary ethmoid adenocarcinoma were treated during this time span. The male to female ratio was 1:l with a mean age of 50 years. Symptoms had been present from 3 to 18 months (mean 8 months). All patients underwent craniofacial resection with 5 patients receiving postoperative radiotherapy. Pathologically 4 patients had cribriform plate erosion, 2 had dural involvement, and 1 had extension into the sphenoid sinus. With a mean follow-From the Departments of Otolaryngology Head and Neck Surgery (Drs.
The Laryngoscope, 1986
Uvulopalatopharyngoplasty (UPPP) is an operation that is frequently performed for the treatment o... more Uvulopalatopharyngoplasty (UPPP) is an operation that is frequently performed for the treatment of obstructive sleep apnea (OSA). While UPPP usually eliminates or decreases snoring and often reduces excessive daytime sleepiness, the decrease in the number of episodes of apnea and hypopnea, and the improvement in oxygen saturation (SaO2) have been less predictable. We compared preoperative and postoperative polysomnography (PSG) in 27 patients with OSA and found that no single PSG parameter could accurately reflect the changes in respiration seen after UPPP. We suggest that a combination of indices including the apnea index, the apnea and hypopnea index, the frequency and severity of decreases in SaO2, and the lowest SaO2 be used to assess the effect of UPPP. Using this combination we determined that 30% of our patients were markedly improved, 33% were somewhat improved, and 37% were unimproved. To rely solely on the patient's subjective improvement often results in overestimating the therapeutic results of surgery, whereas to rely only on one PSG parameter may underestimate or overestimate the degree of improvement.
Annals of Otology, Rhinology & Laryngology
Objective: Determine the effect of complete malleus removal during canal wall up tympanomastoidec... more Objective: Determine the effect of complete malleus removal during canal wall up tympanomastoidectomy for cholesteatoma on ossiculoplasty success and rate of residual cholesteatoma. Methods: We reviewed the operative, audiogram, and clinical reports of patients who underwent canal wall up tympanomastoidectomy for cholesteatoma between 2009 and 2016 at a tertiary academic medical center with at least 8 months of follow-up after surgery. To control for extent of disease, we independently catalogued the subsites of the middle ear and mastoid that cholesteatoma involved from each operation. We performed multivariate logistic regression to determine the independent effect of complete removal of the malleus on the rate of residual disease and success of ossiculoplasty. Results: One hundred eighty surgeries were included in the analysis. For ossiculoplasty success, the adjusted odds ratio of complete malleus removal was 1.7 (95% CI, 0.43-7.0, P = .43), which was not statistically significant. For residual disease, the adjusted odds ratio of complete malleus removal versus not was 0.29 (95% CI, 0.074-1.1, P = .076), which approached but did not meet statistical significance. Conclusion: Though complete malleus removal does not independently decrease the rate of residual cholesteatoma, it may be a safe technique as it did not compromise ossiculoplasty success.
Otolaryngology - Head and Neck Surgery
and allowed to harden. After hardening, the material could be sculpted with a drill. Fascia and p... more and allowed to harden. After hardening, the material could be sculpted with a drill. Fascia and post-auricular periosteal flaps were used to cover the material in the EAC. Methods: Study Design: Retrospective review Setting: Academic otology practice. Twenty-one patients who had surgical repair of EAC or tegmen defects from 1998 to 2001 in whom carbonated calcium phosphate bone cement was used to reconstruct defects of the tegmen or EAC. The material was used to repair the EAC in 16 patients, including complete EAC reconstruction in five patients. Tegmen defects alone were repaired in four cases. Results: The structural integrity of the material and postoperative complications in these patients will be described in detail, along with modifications of the surgical technique based on these findings. Conclusion: The surgical technique is not technically difficult and the cement hardens within minutes of application. The mean follow-up was 2.5 years, with 11 patients followed for over three years. Post-operative infections requiring implant removal occurred in three patients (14%). Delayed healing was observed in five patients (22%), requiring implant removal in one patient. Aside from infected cases, the structural integrity of the material was excellent.
Otolaryngology -- Head and Neck Surgery, 2014
ABSTRACT Program Description: Dizziness and balance problems are very common in older adults. The... more ABSTRACT Program Description: Dizziness and balance problems are very common in older adults. These problems can be vexing to manage for the otolaryngologist given that symptoms are often nonspecific, and multiple vestibular and nonvestibular factors are typically involved. In this miniseminar sponsored by the Geriatric Otolaryngology and Equilibrium Committees, we will review the latest evidence on how vestibular function changes with age and how this affects mobility and falls risk in older adults. We will discuss a practical, evidence-based approach to identifying important vestibular and nonvestibular contributing factors (eg, benign paroxysmal positional vertigo in elderly patients, orthostatic hypotension, specific medications), and strategies for managing these factors.
Otolaryngol Head Neck Surg, 1997
C i s p l a t i n is a potent chemotherapeutic agent known to cause mild-to-moderate high-frequen... more C i s p l a t i n is a potent chemotherapeutic agent known to cause mild-to-moderate high-frequency sensorineural hearing loss (SNHL) in 11% to 100% of patients when administered intravenously (IV) in high doses. 1-5 Although intraarterial (IA) use is uncommon, that route of administration is used by the Brain Tumor Cooperative Group (BTCG) in some of their protocols. We describe a case of rapidly progressive bilateral SNHL after cisplatin was injected into a vertebral artery for the treatment of a malignant brain tumor. METHODS AND MATERIAL West Virginia University Hospital is one of several institutions enrolled in various BTCG protocols. For Protocol 89-1, patients with malignant brain tumors were randomly assigned to one of the following two arms: (1) radiation therapy with concomitant IA cisplatin and IV 1,3-bis-(2-chloroethyl)-l-nitrosourea (BCNU), or (2) radiation therapy with concomitant IV BCNU. The cisplatin is administered monthly at 60 mg/m 2 for six doses; BCNU is administered every 8 weeks at 200 mg/m 2 for 18 months. Hearing is monitored by obtaining audiograms before each dose of cisplatin.
Atlas of Operative Otorhinolaryngology and Head and Neck Surgery : Otology and Lateral Skullbase Surgery (Volume 1), 2013
Head & Neck
None of the consultants disagree with the initial plan to treat this T1N0 squamous cell carcinoma... more None of the consultants disagree with the initial plan to treat this T1N0 squamous cell carcinoma of the true vocal cord with radiotherapy. The consensus is that 10% to 20% of these lesions can fail conventional treatment. Dr. Rice cites incorrect radiotherapy ports, understaging, and extension into muscle or cartilage as the likely reasons for failure. He also believes that a patient who continues to smoke is at risk for persistent or recurrent disease. Drs. Wetmore and Singer add that some tumors are radioresistant for indefinable reasons. Although all the consultants agree that the differentiation between severe atypia and carcinoma in situ can be very difficult, Dr. Singer warns that the surgeon should not play a role in the histologic decision-making. He does not make a distinction between the two and suggests treating a lesion on the basis of its clinical behavior. Dr. Rice draws the line at treating T3 glottic carcinomas with radiotherapy. He states that the greater the tumor...
Transactions. Section on Otolaryngology. American Academy of Ophthalmology and Otolaryngology
Ontology & Neurotology
This section is a regular feature of The American Journal of Otology. Readers are invited to subm... more This section is a regular feature of The American Journal of Otology. Readers are invited to submit letters pertaining to specific patient problems to: Mark May, M.D., Facial Paralysis Center, Shadyside Hospital, Suite 210, 510 S. Aiken Ave., Pittsburgh, PA 15232. Dr. May is affiliated with the Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh School of Medicine, as Clinical Professor. (C) 1991, The American Journal of Otology, Inc.
The West Virginia medical journal
Mohs micrographic surgery has been highly successful in treating skin cancers that grow in a cont... more Mohs micrographic surgery has been highly successful in treating skin cancers that grow in a contiguous manner. The technique requires removal of involved tissue in thin layers and histographic mapping to pinpoint residual tumor. This process is repeated until all of the tumor is resected. This allows 100 percent of all margins to be examined and is very tissue conservative, attributing to its unsurpassed cure rates and excellent cosmetic results. Since it is done as an outpatient procedure under local anesthetic, it also is safe and efficient.
Cancer Treatment and Research, 1984
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 1993
Epistaxis is a common condition as well as a frequent otolaryngologic emergency, with up to 60% o... more Epistaxis is a common condition as well as a frequent otolaryngologic emergency, with up to 60% of people experiencing one episode in their lifetime and 6% seeking medical attention. Treatment is controversial, with many options being available. We retrospectively reviewed the hospital course and management of 65 patients who experienced epistaxis from January 1, 1986, to October 31, 1991, to compare medical and surgical treatment methods. Fifty-one patients were managed medically. Of these, 36 patients required one treatment (group 1), 10 required multiple treatments (group 2), and seven required multiple admissions (group 3). The mean lengths of hospitalization were 3.27, 4.90, and 5.57 days respectively. Fourteen patients were managed surgically. The preoperative stay of nine patients who underwent unsuccessful medical management at our institution (group 4) was 3.9 days, with an average postoperative stay of 7.3 days. The difference in length of stay was statistically significan...
Otolaryngology and head and neck surgery
Bullous myringitis is manifested by moderately severe otalgia associated with vesicles on the tym... more Bullous myringitis is manifested by moderately severe otalgia associated with vesicles on the tympanic membrane and medial external auditory canal wall. This disease occurs mainly in young adults, most commonly in winter, and is usually preceded or accompanied by an upper respiratory infection. A reversible sensorineural loss developed in three of 22 patients. Complement fixation antibody studies performed on ten patients failed to implicate Mycoplasma pneumoniae, influenza virus types A or B, or adenovirus as the causal agent.
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Papers by Stephen Wetmore