Temporal bone giant cell tumour: report of a second primary giant cell tumour of the temporal bone and infratemporal fossa.

OBJECTIVE: To report a second primary giant cell tumour (GCT) of the temporal bone and infratemporal fossa. METHODOLOGY: Medical records were analyzed in the context of the available literature. RESULTS: A 30 year-old male developed a temporal bone GCT with infratemporal fossa extension 12 years after undergoing successful surgical treatment of a GCT of the femur. These tumours were histologically distinct, suggesting the development of a second primary GCT rather than metastatic disease. This case differs from prior reported cases by surgical approach. Complete removal was achieved but required resection of the zygomatic arch and dissection of all upper facial nerve branches. The patient is disease free after 3 years with acceptable functional and cosmetic results. CONCLUSION: Complete resection of GCTs of the temporal bone and infratemporal fossa is advocated. Surgical techniques that allow for visualization of the facial nerve and increase surgical access can enhance overall clinical success.

Microvascular transplantation and replantation of the rabbit submandibular gland.

BACKGROUND: Xerostomia is a devastating complication of radiation therapy. Previous research has demonstrated that submandibular glands may be removed from the neck and transplanted using microvascular techniques, with good gland survival. However, microvascular transplantation and replantation has never been attempted on a composite tissue such as a salivary gland. OBJECTIVE: To evaluate the ability of a rabbit submandibular gland to undergo 2 successive microvascular transplantations. SUBJECTS AND DESIGN: Study rabbits underwent a midline neck incision with dissection of a submandibular gland to its arterial and venous pedicle. Microvascular techniques were then used to transplant the gland to the femoral system of the right groin. The incisions were reopened later under surgical conditions. The transferred gland was examined for survival and patency of its artery and vein. Healthy glands were dissected and transferred to a suitable artery and vein within the neck, where they were again reanastamosed using microvascular surgical techniques. After additional time, the gland was again examined for survival and pedicle patency, then removed and evaluated for histopathological evidence of survival. RESULTS: Surgical technique evolved during the course of this work to avoid encountered pitfalls. After refining the technique, we have determined that the rabbit submandibular gland is able to withstand successive microvascular transplantation and replantation with good likelihood of long-term survival, according to histopathological criteria. CONCLUSIONS: The rabbit submandibular gland is able to undergo microvascular transplantation and replantation with evidence of long-term survivability and preserved function. The body's natural response to surgery and tissue transplantation makes replantation a technical challenge; however, methods delineated herein alleviate many of the potential pitfalls. Extending these results to humans, patients who are to undergo radiation therapy could have a disease-free gland removed from the neck, transferred outside of the field of radiation, and then returned to the neck at the completion of radiation therapy. This may enable them to maintain salivary gland function and maintain oral cavity function and comfort.

Central incisor width as a predictor of appropriate curette size in adenoidectomy.

As inadvertent eustachian tube injury during adenoidectomy can have serious short- and long-term implications, a simple anatomic correlate that could predict the optimal curette choice for adenoidectomy, especially in severely hypertrophic cases, is beneficial. This study evaluates the correlation of the distance between the lateral borders of the upper central incisors and the distance between the tori tubarius in the nasopharynx. One hundred one consecutive patients undergoing adenoidectomy at a pediatric tertiary care hospital were enrolled in this study. The patients ranged in age from 7 months to 15 years. No complications were noted in any of the procedures. During the operation, the distance between the central upper incisors was measured in millimeters, as was the inter-tubarius width (ITW). A multiple regression analysis was completed to assess the correlation between central incisor width and ITW. Age and inter-incisor width were positively correlated with ITW in a statistically significant manner (p = .007 and p = .006, respectively). The distance between the lateral borders of the upper central incisors predicts the distance between the tori tubarius in the nasopharynx. Therefore, an adenoid curette the window of which does not overlap the lateral aspects of the central upper incisors can be used relatively safely, even in fields with poor visualization.

Flexible esophagoscopy as part of routine panendoscopy in ENT resident and fellowship training.

We conducted a retrospective study to evaluate the use of flexible esophagoscopy as part of routine panendoscopy in an academic setting. We reviewed the results of 378 procedures that were performed over a 4-year period in an academic otolaryngology--head and neck surgery program for residents and fellows. Medical records were reviewed for early and late complications as well as for adequacy of the examination. We found no immediate or long-term complications associated with flexible esophagoscopy. Adequate examination was achieved in all but two cases (99%), both of which involved patients who had significant strictures related to radiation therapy and who were not able to be evaluated by rigid esophagoscopy. We conclude that flexible esophagoscopy is a safe and accurate means of evaluating the esophagus during a panendoscopic evaluation of the upper aerodigestive tract, and that it should be included in the diagnostic armamentarium of every otolaryngology--head and neck surgery resident and fellow.

Sphenoid sinus mucocele: a rare complication of transsphenoidal hypophysectomy.

Only seven cases of a sphenoid mucocele occurring after transsphenoidal hypophysectomy have been previously reported in the world literature. In this article, we report a new case, which occurred in a 67-year-old man. The sphenoid sinus mucocele developed 12 years following transsphenoidal hypophysectomy and adjunctive radiotherapy. The patient was successfully managed with incision and drainage. Although transsphenoidal hypophysectomy is a common operation, this particular complication appears to be rare or at least under-reported. Sphenoid sinus mucocele deserves consideration in the differential diagnosis of a sphenoidal parasellar mass in a patient who has undergone an earlier transsphenoidal hypophysectomy.

The optimum method for reconstruction of complex lateral oromandibular-cutaneous defects.

BACKGROUND: Ablation of large intraoral cancers can create extensive through-and-through defects of the lateral face, resulting in loss of external facial skin, the lateral and anterior mandible, and the lateral mouth. Repair requires reconstruction of the lips, mandible, and full-thickness cheek defects. Ideal reconstruction with vascularized composite free flaps requires adequate bone and sufficiently large, yet versatile, skin flaps capable of resurfacing extensive intraoral and external defects. METHODS: A series of 12 patients with large lateral facial-mandibular defects is reviewed. All patients were treated for squamous cell carcinoma except for 1 patient with osteoblastic sarcoma of the mandible. All patients underwent primary reconstruction with various free flap techniques, including 6 scapular free flaps, 2 iliac crest free flaps, 3 free fibula flaps, and 1 radial forearm flap. Attainment of reconstructive goals, free flap survival, and complication rates were assessed. RESULTS: All defects were successfully reconstructed in the primary setting. No flap failures occurred. One venous occlusion was successfully salvaged. No orocutaneous fistulas or postoperative hematomas were noted. CONCLUSION: The reconstructive options for extensive defects of the lateral face and jaw are reviewed with attention to the complex three-dimensional soft tissue requirements. The superiority of the scapular composite flap is emphasized because this single free flap provides two independent and versatile skin paddles of optimal thickness in addition to adequate bone stock.

Prevention of pharyngoesophageal spasm after laryngectomy with a half-muscle closure technique.

Because pharyngoesophageal spasm can limit successful voice restoration after total laryngectomy, 24 patients underwent a modified pharyngeal closure in an effort to avoid this problem. All patients underwent total laryngectomy with appropriate neck dissections and pharyngeal closure with a half-muscle closure technique in which only one side of the remnant constrictor muscles was used to reinforce the primary closure. Twenty-three patients underwent voice restoration. Twenty-two (96%) had a functional voice, and 1 patient (4%) had pharyngoesophageal spasm that required a secondary myotomy. One fistula (4%) occurred and resolved with conservative measures. Quantitative voice analysis demonstrated no significant differences between half-closure patients and control patients for fundamental frequency (96 Hz versus 101 Hz) or intensity (57 dB versus 64 dB). Extensive qualitative analysis by trained and naive listeners revealed no differences. This preliminary report indicates the half-muscle closure modification of the pharyngeal closure at primary laryngectomy may provide a simple and effective means of avoiding pharyngoesophageal spasm and maintaining an effective voice without increased complications.

Technical modifications of the latissimus dorsi pedicled flap to increase versatility and viability.

OBJECTIVE: Describe the elevation and insetting of the pedicled latissimus dorsi musculocutaneous flap. Review history of this flap's evolution and personal series of 68 consecutive cases since 1984. STUDY DESIGN: Retrospective review. SETTING: Tertiary, referral, academic center. METHODS: Retrospective review of 68 consecutive patient records in which the pedicled latissimus dorsi musculocutaneous flap was used to reconstruct head and neck defects. Overall flap survival and postoperative complications were used as outcome measures. RESULTS: Thirty-one women and 37 men underwent reconstruction with the latissimus dorsi pedicled flap between 1984 to 1998. The mean age was 61 years. Sixty-three cases followed postoncologic ablation and 5 cases addressed traumatic tissue loss. Forty-three patients had prior radiotherapy and 26 patients had undergone prior reconstructive surgery. The overall flap survival rate was 67/68 (98.5%), with one case of complete flap necrosis. Six cases of partial flap necrosis occurred. There were 8 other minor complications including fistula, wound dehiscence, hematoma and cerebrospinal fluid accumulation. Fifty-six donor sites were closed primarily resulting in 2 dehiscences and 17 seromatas. Three of 12 skin grafts to the donor sites were compromised. CONCLUSION: The excellent flap survival rate (98.5%) is the result of proper patient selection and adherence to three technical fundamentals: skin paddle design, pedicle dissection, and pedicle stabilization. The minimal donor site morbidity also demonstrated in this series supports the continued use of the latissimus dorsi pedicled flap for reconstruction of head and neck defects.

Straight midline mandibulotomy revisited.

OBJECTIVE: Describe recent experience with a simplified modification of the traditional mandibulotomy approach. STUDY DESIGN: Retrospective chart review. METHODS: Charts were reviewed retrospectively for 17 consecutive patients who underwent this approach over a 3-year period as a part of treatment for oral and oropharyngeal malignancies. RESULTS: No cases of bony nonunion, plate exposure, or other complications related to the mandibulotomy occurred in the postoperative phase. CONCLUSIONS: The modified straight midline mandibulotomy approach is simple and provides safe access for the treatment of oral and oropharyngeal tumors while minimizing postoperative morbidity.

Lateral thigh free flap for head and neck reconstruction.

OBJECTIVES: To present the technique of lateral thigh free flap reconstruction in the head and neck and review the use of this procedure in 58 head and neck defect reconstructions. STUDY DESIGN: Retrospective review in the setting of a tertiary, referral, and academic center. METHODS: Retrospective review of patient records in cases of lateral thigh free flap reconstruction for head and neck defects. Records were reviewed for patient age, gender, pathologic findings, type of reconstruction (pharyngoesophageal, glossectomy, oropharyngeal, or external soft tissue defects), recipient and donor-site complications, and flap failure. RESULTS: Fifty-eight patients underwent lateral thigh flap reconstruction from 1984 to 1997. Patient age ranged from 10 to 76 years. Thirty-nine patients were men, and 19 were women. Forty-three flaps were used for pharyngoesophageal reconstruction, nine for glossectomy defects, two for oropharyngeal defects, and four for external, soft tissue defects. All resections were for squamous cell carcinoma, except one case of recurrent hemangiopericytoma. One flap failure occurred from venous thrombosis (1.7%). Forty-two of 43 pharyngoesophageal defects were successfully reconstructed (97.6%). Five temporary salivary leaks were noted, but no frank fistulas occurred. One fistula occurred in the oropharyngeal reconstruction group. Four minor donor-site complications were noted (6.9%). CONCLUSION: This series demonstrates the low donor-site morbidity, as well as the reliability and versatility, of the lateral thigh free flap for head and neck reconstruction.

Effects of sound pressure levels on fundamental frequency in tracheoesophageal speakers.

The quality of tracheoesophageal (TE) voice after laryngectomy is dependent on numerous factors. The relative contribution of specific variables is not well described. To evaluate the modulation of fundamental frequency (F0) pitch in TE speakers after total laryngectomy and voice restoration, we instructed 11 TE speakers to complete a series of vocal tasks under standardized conditions. All patients underwent standard laryngectomy with appropriate neck dissection and full-course radiation therapy. Each speaker produced 4 sustained phonations at distinct levels. Sound pressure level (SPL) intensity and F0 measurements were taken for each level. Statistical analysis to assess the relative effect of SPL on F0 demonstrated a statistically significant effect. However, the knowledge of SPL allowed only a 9% greater prediction of F0, indicating that factors other than SPL are integral to the modulation of F0 by TE speakers. These data lend further support to the theory that TE voice is an active process incorporating the myoelastic properties of the pharyngoesophageal segment as well as the properties of aerodynamic flow.

Quality of life assessment in patients undergoing head and neck surgery as evaluated by lay caregivers.

OBJECTIVES/HYPOTHESIS: Rehabilitation following head and neck cancer surgery has steadily moved into the outpatient realm and become dependent on caregivers with no formal medical background (lay caregivers.) Satisfactory rehabilitation and quality of life (QOL) depend on successful relationships between patients and the lay caregivers. This study evaluates the QOL assessments of patients by themselves and their primary lay caregivers before head and neck surgery. STUDY DESIGN: Institutional Review Board-approved study using validated QOL assessment instrument. MATERIALS AND METHODS: The preoperative QOL status in 50 patients undergoing extensive head and neck surgery was evaluated using the self-administered Medical Outcomes Survey Short Form 36 (SF-36). The patient's primary lay caregiver (spouse, child, or friend) completed a similar questionnaire evaluating the patient's status. RESULTS: Thirty-three (66%) questionnaires were returned. Twenty-five (50%) questionnaire sets were successfully completed by both parties and employable for comparison. Sixty percent of the caregivers were within the 90% confidence interval of the patient's assessment for six or more of the eight parameters evaluated by the SF-36. Likewise, caregiver assessments for specific parameters were consistently congruent with patient evaluation, except for the parameters of bodily pain and general health, for which caregivers demonstrated a trend for overrating pain and underestimating general health. Caregivers of the same generation as the patient demonstrated significantly higher congruence (P = .007). Similarly, a trend for higher congruence was noted in patients with recurrent disease. CONCLUSIONS: The importance of the lay caregiver has increased in the era of greater outpatient rehabilitation. This pilot study indicates that QOL assessment by lay caregivers may be examined with existing instruments and highlights QOL parameters critical to both the head and neck surgery patient and his or her primary lay caregiver.

Quantitative and qualitative analysis of tracheoesophageal voice after pectoralis major flap reconstruction of the neopharynx.

Although tracheoesophageal voice restoration is accepted after reconstruction of the neopharynx with the pectoralis major myocutaneous flap, the character of such voice is not well described. Six patients reconstructed with the pectoralis major flap after laryngopharyngectomy underwent successful voice restoration with the Blom-Singer prosthesis. Voice was evaluated by a standardized protocol and compared with voices of control subjects treated with total laryngectomy and similar voice restoration. The patients with pectoralis major flaps produced similar intensity levels for soft voice (53.7 dB vs. 55.6 dB) and loud voice (61.3 dB vs. 65.3 dB) when compared with controls (p > 0.05). No significant differences (p > 0.05) were noted for fundamental frequency (F0) between patients with pectoralis major flaps and controls for soft (62.3 Hz vs. 85.4 Hz) and loud (109.8 Hz vs. 133.8 Hz) voice. Jitter was also comparable. Trained and naive listeners completed qualitative analyses for 10 parameters and judged that control patients had significantly better voice for most parameters. This finding demonstrates that dependable voice is attainable after pectoralis major flap reconstruction of the neopharynx. Although this voice does not differ significantly from voice after standard laryngectomy for acoustic parameters, perceptual analysis does reveal significant differences.