The impact of a skilled nursing facility on the cost of surgical treatment of major head and neck tumors.

BACKGROUND: The finite resources available for health care and the proliferation of managed care in the United States have forced the head and neck surgeon to critically evaluate the cost of tumor treatment. OBJECTIVE: To determine whether the cost of treating patients with head and neck tumors would be reduced if the patients were to spend a portion of what would otherwise be acute care hospital days in a hospital-based skilled nursing facility (HB/SNF). DESIGN: Retrospective cost-benefit analysis. SETTING: Tertiary referral center. PATIENTS: Twenty-four consecutive hospital admissions for definitive surgical treatment of head and neck tumors were retrospectively reviewed. The postoperative day on which the patient theoretically could have been transferred to the HB/SNF was determined. The charges and cost of each patient's actual hospital stay were compared with the theoretical counterparts had the patient been transferred to the HB/SNF on the determined day. MAIN OUTCOME MEASURE: Cost savings. RESULTS: The total hospital stay for the 24 patients was 524 days. One hundred eighty-two of those days could have been spent in the HB/SNF. The total charge and cost savings with the use of an HB/SNF were $201,045 and $84,238, respectively (15% of the total charge and cost). This represents an average charge and cost savings of $8377 and $3510, respectively, per patient. The difference was statistically significant (P<.005). CONCLUSION: An HB/SNF could reduce the cost of head and neck tumor treatment without compromising patient care.

Reconstruction of nasal alar defects.

OBJECTIVE: To evaluate aesthetic and functional results of reconstruction of the nasal alar subunit using free cartilage grafts with an interpolated cheek or forehead flap and a vascularized mucosal flap when required. SETTING: University-based facial plastic surgery practice. PATIENTS: A case series of 50 patients with primary alar defects undergoing nasal alar reconstruction. MAIN OUTCOME MEASURES: Observer's and patient's rating of the final results, patient's rating of breathing and level of self-consciousness, and medical record review of complications. RESULTS: Most aesthetic outcomes were excellent to good. Breathing from the reconstructed side can be returned to preoperative status in most of these patients. CONCLUSION: Staged reconstruction of the nasal ala using free cartilage grafts, interpolated cheek or forehead and mucosal flaps when necessary, result in a highly aesthetic and functional outcome in most patients.

Laryngeal function in postpolio patients.

Of the 250,000 survivors of the polio epidemics, approximately 25% experience progressive muscle weakness known as postpolio syndrome (PPS). Laryngeal function in postpolio patients previously has not been studied. This paper presents data detailing laryngeal function in a group of postpolio patients who had been evaluated for swallowing complaints. Nine patients underwent comprehensive history and physical exam, acoustical voice analysis, and laryngeal videostroboscopic endoscopy. Three patients underwent laryngeal electromyography (EMG) evaluation. Results indicated some degree of phonatory or laryngeal deficit in all subjects. Subjects with dysphagia also demonstrated vocal fold paralysis. EMG revealed decreased recruitment and increased amplitude, findings consistent with EMG studies in skeletal muscle in postpolio patients. Results suggest that postpolio patients who complain of swallowing difficulties are at risk for laryngeal pathology.

The fate of medialized cartilage in thyroplasty type I.

Thyroplasty type I is rapidly emerging as the preferred means of medializing a paralyzed vocal fold. We discuss our experience with the fate of a medialized cartilage window 9 months after an otherwise successful operation. Cartilage resorption over time resulted in degeneration of voice and in progressive aspiration. We recommend removing the cartilage window rather than medializing it, in the interest of stabilizing the degree of long-term vocal fold medialization.

Development of the statocyst in Aplysia californica. I. Observations on statoconial development.

The gravity receptor organs of gastropod molluscs, such as Aplysia californica, are bilateral paired statocysts, which contain dense statoconia within a fluid-filled cyst. Gravitational forces on the statoconia are sensed through their interaction with ciliated mechanoreceptor cells in the wall of the cyst. Larval Aplysia contain a single statolith within each statocyst; when the animals grow to a critical size, they begin producing multiple statoconia, a process that continues throughout life. The number of statoconia is highly correlated with animal weight but poorly correlated with age, indicating that stone production is related to total metabolism. The single statolith has an amorphous internal structure whereas the multiple statoconia have calcification deposited on concentric layers of membrane or matrix protein. The statolith appears to be produced within the cyst lumen but the multiple statoconia are produced within supporting cells between the receptor cells. Large adult animals have statoconia larger than those in early post-metamorphic animals which have just started producing multiple stones. The maximum statocyst diameter at which the receptor-cell cilia can suspend the statolith in the center of the cyst lumen is 45 microns; production of multiple stones begins when the cyst reaches this size. The mechanisms by which statoconia production is initiated and controlled are discussed.