Revisiting closure options for heavily irradiated tissue following Mohs excision: A case report and review of literature.

INTRODUCTION: Squamous cell carcinoma is a cancer of the squamous cells of the epithelium, often treated with radiation therapy or surgical resection. Patients who undergo Mohs excision on the face are left with defects that require thoughtful reconstruction, especially if previously treated with radiotherapy. CASE PRESENTATION: We report a patient who suffered from squamous cell carcinoma of the skin overlying his right cheek. After receiving upwards of 10,000 cGY of radiotherapy, he underwent Mohs excision. Despite conventional therapy protocols, which would normally consist of a free-tissue transfer, a successful rhomboid flap was performed to cover the defect. DISCUSSION: Conventional reconstruction of a previously irradiated area would consist of using non-irradiated tissue. Data on whether such a large, heavily irradiated defect of the face could be repaired using a local flap is practically non-existent. CONCLUSION: This case demonstrates that a local flap can still be successful even with large facial defects and previously radiation therapy, sparing the patient from free-tissue transfer and its possible complications, while leaving the option of a free-tissue transfer available in case of flap failure. This case serves as a reminder that local flaps are still viable options for such defects.

Comparison of effectiveness of silicone gel sheeting with microporous paper tape in the prevention of hypertrophic scarring in a rabbit model.

OBJECTIVE: To determine the effectiveness of treating scars with microporous paper tape or silicone gel sheeting (SGS) in preventing hypertrophic scarring. METHODS: Forty hypertrophic scars were induced in a validated rabbit ear model. Wounds were randomized and bandaged for 30 days with either SGS (20 wounds), paper tape (20 wounds), or untreated controls (40 wounds). Two outcome measures of hypertrophic scarring included (1) histologic measurement of scar elevation index (SEI) and (2) blinded photograph analysis using a visual analog scale. RESULTS: In histologic comparison, no difference in mean (SE) SEI between treatment groups was seen (paper tape group, 1.32 [0.2]; SGS group, 1.41 [0.18]; control, 1.35 [0.23]; P = .51). In photographic analysis, both treatment groups were superior to the control group (P < .01), whereas no difference was seen between the SGS and paper tape groups (P = .88). CONCLUSIONS: Paper tape and SGS demonstrated equal effectiveness in the prevention of hypertrophic scarring on visual analysis, whereas histologic analysis demonstrated no difference in treatment groups from controls. The effectiveness of paper tape in preventing hypertrophic scarring in humans will require further laboratory and clinical investigation.

Pharyngeal wall differences between normal younger and older adults.

Previous research has demonstrated differences in pharyngeal size and constriction between normal younger and older adults. The distance between the larynx and the hyoid bone at rest is greater in older persons, as is the anteroposterior width of the pharynx when it is maximally expanded during swallow. In addition, pharyngeal clearing during swallow is reduced with aging. These observations suggest that the aging pharynx undergoes structural changes consistent with atrophy. The purpose of this investigation was to compare pharyngeal wall thickness at rest and when maximally constricted during swallow in younger and older adults. Videofluoroscopic swallow studies were performed on 178 normal adults. Measures of posterior pharyngeal wall thickness were determined at rest and during maximum constriction of the pharynx during a 20-ml bolus swallow. Data were subjected to analysis of variance and Student t test procedures to determine sex and age differences. We found no statistically significant differences between the men and women in either age group, and so we then pooled our data across sex. Mean pharyngeal wall thickness at rest was 0.39 cm (±0.09) in the younger group and 0.30 cm (±0.08) in the older group (p < 0.01). Pharyngeal wall thickness measured at the same point during maximum constriction was 1.08 cm (±0.34) in the younger group and 0.92 cm (±0.36) in the older adults (p<0.01). Our data suggest that the posterior pharyngeal wall is thinner and does not constrict to the same extent in older subjects compared with younger individuals. These findings contribute to our understanding of differences in pharyngeal strength, swallowing efficiency, and safety associated with aging.

Imaging findings of rhinocerebral mucormycosis.

BACKGROUND AND OBJECTIVES: The purpose of this study was to describe common radiographic patterns that may be useful in predicting the diagnosis of rhinocerebral mucormycosis. METHODS: We retrospectively evaluated the imaging and clinical data of four males and one female, 3 to 72 years old, with rhinocerebral mucormycosis. RESULTS: All the patients presented with sinusitis and ophthalmological symptoms. Most of the patients (80%) had isointense lesions relative to brain in T1-weighted images. The signal intensity in T2-weighted images was more variable, with only one (20%) patient showing hyperintensity. A pattern of anatomic involvement affecting the nasal cavity, maxillary sinus, orbit, and ethmoid cells was consistently observed in all five patients (100%). Our series demonstrated a mortality rate of 60%. CONCLUSION: Progressive and rapid involvement of the cavernous sinus, vascular structures and intracranial contents is the usual evolution of rhinocerebral mucormycosis. In the context of immunosupression, a pattern of nasal cavity, maxillary sinus, ethmoid cells, and orbit inflammatory lesions should prompt the diagnosis of mucormycosis. Multiplanar magnetic resonance imaging shows anatomic involvement, helping in surgery planning. However, the prognosis is grave despite radical surgery and antifungals.

Validation of the pharyngeal squeeze maneuver.

OBJECTIVE: The pharyngeal squeeze maneuver (PSM) is a surrogate measure of pharyngeal strength on endoscopy. The validity of this measure has not been reported. The purpose of this investigation was to evaluate the validity of the PSM. STUDY DESIGN: Case series with planned data collection. SUBJECTS AND METHODS: Simultaneous endoscopic and fluoroscopic swallow evaluations were performed on a cohort of individuals with dysphagia. The PSM was compared to a validated measure of pharyngeal strength, the pharyngeal constriction ratio (PCR). An elevated PCR indicates a weakened pharynx. RESULTS: The mean PCR for subjects with an intact PSM was 0.06 (+/- 0.08), compared to a mean PCR of 0.31 (+/- 0.20) for individuals with an absent PSM. The PCR was significantly higher, indicating a weaker pharynx, in persons with an absent PSM (P < 0.001). CONCLUSIONS: The PCR is elevated in persons with a diminished pharyngeal squeeze. These data suggest the pharyngeal squeeze maneuver is a valid surrogate measure of pharyngeal motor integrity.

Recent advances in presurgical molding in cleft lip and palate.

PURPOSE OF REVIEW: Although many protocols for treating infants with cleft lip and palate have been successful, the severely wide deformities often require a multidisciplined team approach. Maxillary appliances have been used for 50 years; however, nasal molding is a relatively recent development that has shown progress but not without stalwart criticism. RECENT FINDINGS: Presurgical nasal alveolar molding is an evolving technique in the treatment of cleft lip and palate. Used properly, molding can create improved nasal symmetry in unilateral cases and columellar lengthening in bilateral cases. Some regression of improvement is often seen in the following years due to differential growth patterns within the nasal subunits. The nasal septal and columellar deviation seen in unilateral cleft lip and palate can also be improved with a novel device. SUMMARY: Although traditional repair of the cleft lip and nasal deformity is often adequate, severely wide clefts are amenable to a variety of presurgical measures. Presurgical nasal alveolar molding in children with cleft lip and palate allows repositioning of the maxillary alveolus and surrounding soft tissues in hopes of reducing wound tension and improving results. These techniques can be extremely challenging but an excellent addition to a cleft lip and palate team's armamentarium.

Role of tumor necrosis factor-alpha in sensorineural hearing loss after bacterial meningitis.

HYPOTHESIS: Blockade of tumor necrosis factor-alpha with tumor necrosis factor-alpha antibody will reduce the extent of cochlear injury and hearing loss associated with Streptococcus pneumoniae meningitis. BACKGROUND: Inflammatory mediators play a significant role in the morbidity associated with bacterial meningitis, including hearing loss and labyrinthitis ossificans. Previous studies have shown the attenuation of hearing loss by the nonspecific blockade of such pathways. METHODS: Fifty Mongolian gerbils were divided into four groups. Auditory brainstem response testing was conducted to measure hearing thresholds. Streptococcus pneumoniae meningitis was induced in Groups 1 and 2. Group 2 was then given a single intraperitoneal injection of tumor necrosis factor-alpha antibody, whereas Group 1 received phosphate-buffered saline. Uninfected animals in Groups 3 and 4 were implanted with osmotic pumps that delivered a continuous 8-day intrathecal flow of either tumor necrosis factor-alpha (Group 4) or phosphate-buffered saline (Group 3). After 6 weeks, auditory brainstem response testing was repeated. The cochleas were harvested and analyzed histomorphometrically. RESULTS: Group 2 animals with Streptococcus pneumoniae meningitis that also received tumor necrosis factor-alpha antibody developed significantly less hearing loss than Group 1 animals with meningitis alone. The decrease in the average threshold at 4, 8, 16, and 32 kHz was 31, 30, 25, and 28 dB sound pressure level, respectively (p < 0.0092 for each). Furthermore, histomorphometric analysis showed significantly less damage to the organ of Corti, spiral ganglion, spiral ligament, and stria vascularis in Group 2. Conversely, tumor necrosis factor-alpha induced meningitis animals (Group 3) showed increased hearing loss compared with phosphate-buffered saline controls (Group 4), with p < 0.0001 at all frequencies. CONCLUSION: Tumor necrosis factor-alpha plays an important role in cochlear injury after bacterial meningitis. Blockade of tumor necrosis factor-alpha reduces postmeningitic hearing loss and cochlear injury. Induction of meningitis with intrathecal tumor necrosis factor-alpha also resulted in hearing loss and cochlear injury similar to bacterial meningitis.