Ventilación mecánica y traqueotomía. Protocolo de destete de ventilación mecánica y decanulación de la Unidad de Cuidados Respiratorios Intermedios de la Fundación Jiménez Díaz / Mechanical ventilation weaning protocol and decannulation of the Intermediate Respiratory Care Unit of the Fundación Jiménez Díaz

En este artículo se pretende presentar un protocolo de decanulación de pacientes procedentes de los Servicios de Cuidados Intensivos en los que el destete de ventilación mecánica ha sido imposible, saliendo de esta unidad con ventilación mecánica sobre traqueotomía. La aparición de unidades de cuidados intermedios respiratorios ha hecho posible ubicar en ellas a estos pacientes al ser unidades donde se maneja la vía aérea superior, la ventilación mecánica y la endoscopia respiratoria. Nuestro Servicio de Neumología dispone de una Unidad de Cuidados Intermedios y tiene amplia experiencia en el destete de ventilación mecánica y posterior decanulación de estos enfermos. No existe en la literatura ningún artículo que presente de manera global el manejo de estos enfermos, por ello presentamos el protocolo que seguimos en nuestra unidad y con el que obtenemos unos resultados muy favorables en este tipo de enfermos (AU)

This article presents a decanulation protocol procedure for difficult to wean patients from the intensive care units in whom mechanical ventilation weaning has not been possible, and left this units needing invasive mechanical ventilation and tracheotomy. The appearance of the socalled Intermediate Respiratory Units allow pulmonologists, specialized in critical care medicine to treat these patients as those units deal with upper airway management, artificial invasive and non invasive mechanical ventilation and respiratory endoscopy. Our Pulmonology service include an intermediate respiratory unit and have wide experience in weaning patients from mechanical ventilation and subsequent decanulation. At present, no article in the literature globally explains the management of these patients. We present the protocol we follow in our unit with which we have obtained very favorable results in this type of patient (AU)

[Classification of head and neck paragangliomas]. / Clasificación de los paragangliomas cervicocefálicos.

The terms glomus or chemodectoma arose with knowledge of the histological structure of these tumors; their paraganglionic cells, together with autonomic ganglion cells, form the paraganglia, and consequently the most appropriate term to describe these tumors is paraganglioma. Classification of these tumors varies according to the parameter chosen: patient age, secretory capacity or biochemical behavior, whether the tumor is isolated or syndromic, or benign or malignant, etc. Moreover, there are other classifications based on other features such as localization, extension, the recommended surgical approach, immunohistochemical characteristics of the tumor, whether the tumor is hereditary, etc. None of these criteria have been universally accepted. Thus, in the present article, the most important criteria will be described. By paying attention to their localization, extension and the recommended surgical approaches, the classification of these tumors has progressed and, at the same time, diagnostic imaging tests and surgical techniques have improved. This type of classification is of great interest from the clinical-surgical point of view and consequently the present article describes them in detail, especially in temporal and carotid body paragangliomas.

Clasificación de los paragangliomas cervicocefálicos / Classification of head and neck paragangliomas

Los términos glomus o quemodectoma surgen con el conocimiento de la estructura histológica de estos tumores; sus células paraganglionares, junto con las células autonómicas ganglionares, forman los paraganglios, por lo que el término paraganglioma resulta el más adecuado para referirse a ellos. La clasificación de estos tumores varía en función del parámetro elegido para su realización: edad del paciente, capacidad secretora o funcionalidad desde el punto de vista bioquímico, si son tumores aislados o sindrómicos, si son benignos o malignos, etc. Además, existen otras clasificaciones basadas en otros aspectos, como localización, extensión, abordajes quirúrgicos recomendados, características inmunohistoquímicas del tumor, carácter hereditario, etc. Ninguna de ellas ha sido aceptada de forma universal, así que procederemos a describir las más importantes en el siguiente capítulo. Atendiendo a la localización, extensión y abordajes quirúrgicos recomendados, la forma de clasificar estos tumores ha ido evolucionando, a la vez que han mejorado las técnicas diagnósticas de imagen y las técnicas quirúrgicas. Este tipo de clasificaciones es de gran interés desde el punto de vista clinicoquirúrgico, y éste es el motivo por el que serán más detalladas durante la exposición, sobre todo en los paragangliomas temporales y carotídeos (AU)

The terms glomus or chemodectoma arose with knowledge of the histological structure of these tumors; their paraganglionic cells, together with autonomic ganglion cells, form the paraganglia, and consequently the most appropriate term to describe these tumors is paraganglioma. Classification of these tumors varies according to the parameter chosen: patient age, secretory capacity or biochemical behavior, whether the tumor is isolated or syndromic, or benign or malignant, etc. Moreover, there are other classifications based on other features such as localization, extension, the recommended surgical approach, immunohistochemical characteristics of the tumor, whether the tumor is hereditary, etc. None of these criteria have been universally accepted. Thus, in the present article, the most important criteria will be described. By paying attention to their localization, extension and the recommended surgical approaches, the classification of these tumors has progressed and, at the same time, diagnostic imaging tests and surgical techniques have improved. This type of classification is of great interest from the clinical-surgical point of view and consequently the present article describes them in detail, especially in temporal and carotid body paragangliomas (AU)

Injertos cartilaginosos en rinoplastia / Cartilaginous grafts in rhinoplasty

Presentamos una revisión de 38 casos de rinoplastia de aumento con utilización de injerto cartilaginoso, realizada entre los años 1992 y 2001. El 83% de los casos eran hombres, y el 17% mujeres. La media de edad era de 31 años. En 33 intervenciones, el injerto se ha colocado en el dorso; en 4 casos se ha localizado en la punta, y en un caso se colocó un injerto en el dorso y otro en la punta. El injerto cartilaginoso utilizado con mayor frecuencia ha sido el cartílago septal en 28 casos, cartílago auricular en 3, alar en 5, y cartílago costal en 1 caso, y septal y alar en un caso en un mismo paciente. La movilización del injerto se evita mediante su fijación a piel por un punto de sutura reabsorbible que se retira en una semana. Solo un caso tuvo que ser reintervenido por proyección excesiva del injerto en el dorso. Se realizó un seguimiento postoperatorio a 25 pacientes; de ellos el 12% refería encontrarse mucho mejor, el 76% mejor y el 12% se encontraba igual. Los injertos cartilaginosos autólogos han dado buen resultado en rinoplastia, por su facilidad de obtención, y por ser un material moldeable y con un bajo índice de reabsorción (AU)

We present a revision of 38 cases operated on for augmentation rhinoplasty from 1992 to 2001, using a cartilaginous graft. 83% of our patients were men and 17% were female. The mean age was 31 years old. In 33 rhinoplasties, the graft was placed in the nasal dorsum; in 4 cases it was placed at the nasal tip and in one case reconstruction of the dorsum and the tip was performed. The most frequently used graft was septal cartilage, in 28 cases. Conchae cartilages were used in 3 cases, lower lateral cartilage in 5 cases, rib cartilage in one, and in another case, septal and lower lateral cartilage were used in the same patient. We stabilized the graft fixing it to the skin with a suture which is removed after a week. We did a postoperative follow-up on 25 of the patients. In terms of patient satisfaction, 12% of them felt that their nasal appearance had improved, 76% felt that there had been a great improvement, and 12% did not notice any change. Only one patient had to be reoperated on because of an overprojection of the graft in the nasal dorsum. We conclude that the use of autologous cartilaginous grafts offers important advantages in rhinoplasty; they are easy to be obtained, easy to mould and with a low index of resorption (AU)

Osteotomías laterales externas en rinoplastia para la corrección de las desviaciones de dorso óseo / External lateral osteotomies in rinoplasty for the corrections of nasal dorsal desviations

Se revisan 45 casos de septorrinoplastia para la corrección de desviaciones del dorso óseo, realizadas desde el año 1993 hasta el 2001, en las que se ha utilizado la técnica de osteotomías laterales por vía externas. El 67% de los casos eran hombres, y el 33 per cent mujeres. La media de edad era de 25 años. En todos los casos se realizó una septoplastia y se corrigió la desviación ósea mediante osteotomías mediales realizadas a través de una incisión intercartilaginosa y osteotomías laterales por vía externa. Se realizó un seguimiento postoperatorio a 35 pacientes. De ellos, el 78% refirió encontrarse subjetivamente mejor que previamente a la cirugía, y el 22% mucho mejor. Un paciente tuvo que ser reintervenido por presentar una fractura nasal traumática posteriormente a la rinoplastia. Consideramos que esta técnica ofrece importantes ventajas, con mayor control del trazo de fractura, menor incidencia de techo abierto y de escalón lateral, sin provocar secuelas cicatriciales (AU)

We present a revision of 45 patients with nasal deviation operated on between 1993 and 2001. Septorhinoplasties were done in all cases using the external lateral nasal osteotomies technique. 67% of our patients were male and 33% were female with a mean age of 25. In all cases a septoplasty was performed. To correct nasal deviation, medial osteotomies through an intercartilaginous approach and external lateral nasal osteotomies were done. We did a postoperative follow-up of 35 patients. In terms of patient satisfaction, 78% of them felt that their nasal appearance had improved after surgery, and 22% felt that they had a great improvement. One case had to be reoperated on because of a traumatic nasal fracture after surgery. We believe this technique offers important advantages, such as: an excellent control of the fracture line, fewer incidences of open roof and lateral step, without causing visible scars (AU)

[Inflammatory pseudotumor of paranasal sinuses]. / Pseudotumor inflamatorio de fosas nasales.

Inflammatory pseudotumor is a rare benign lesion of unknown etiology which was first described in the lung. In head and neck the areas most commonly involved are the orbit and paranasal sinuses, but they have been also described in the larynx, pterygomaxilar space, tonsils, ears, gingiva and other periodontal tissues. We present a case of a 64 years old male who presented a three months history of right nasal obstruction. Physical examination showed a big nasal tumor arising from the nostril. CT scan shows nasal fossa mass with a normal paranasal sinuses. Histology made the diagnosis of an inflammatory pseudotumor. The lesion was surgically removed trough a midface degloving approach. The patient has no signs of recurrence two years after surgery. Data about diagnosis, treatment and outcome of inflammatory pseudotumors is revised also in this paper.

Pseudotumor inflamatorio de fosas nasales / Inflammatory pseudotumor of nasal fossal

El pseudotumor inflamatorio es una neoplasia benigna muy poco frecuente que fue descrita en primer lugar en el pulmón. En cabeza y cuello es más frecuente en la órbita y senos paranasales, pero ha sido descrita en la región pterigomaxilar, laringe, amígdalas, oídos, mucosa gingival y otros tejidos periodontales. Presentamos un caso de un paciente de 64 años que refería una historia de tres meses de evolución de obstrucción nasal por fosa derecha; el examen físico mostraba una gran tumoración que emergía de la narina. El TC mostraba la masa en fosa nasal, sin afectación de los senos paranasales. El diagnóstico histológico fue de pseudotumor inflamatorio. Esta lesión se extirpó mediante un abordaje mediofacial tipo "degloving". El paciente no muestra signos de recurrencia dos años después de la cirugía. Describimos algunos datos sobre el diagnóstico, el tratamiento y la evolución de esta entidad. (AU)

Inflammatory pseudotumor is a rare benign lesion of unknown etiology which was first described in the lung. In head and neck the areas most commonly involved are the orbit and paranasal sinuses, but they have been also described in the larynx, pterygomaxilar space, tonsils, ears, gingiva and other periodontal tissues. We present a case of a 64 years old male who presented a three months history of right nasal obstruction. Physical examination showed a big nasal tumor arising from the nostril. CT scan shows nasal fossa mass with a normal paranasal sinuses. Histology made the diagnosis of an inflammatory pseudotumor. The lesion was surgically removed trough a midface degloving approach. The patient has no signs of recurrence two years after surgery. Data about diagnosis, treatment and outcome of inflammatory pseudotumors is revised also in this paper (AU)

[External lateral osteotomy in rhinoplasty for the correction of nasal dorsal deviations]. / Osteotomías laterales externas en rinoplastia para la corrección de las desviaciones de dorso óseo.

We present a revision of 45 patients with nasal deviation operated on between 1993 and 2001. Septorhinoplasties were done in all cases using the external lateral nasal osteotomies technique. 67% of our patients were male and 33% were female with a mean age of 25. In all cases a septoplasty was performed. To correct nasal deviation, medial osteotomies through an intercartilaginous approach and external lateral nasal osteotomies were done. We did a postoperative follow-up of 35 patients. In terms of patient satisfaction, 78% of them felt that their nasal appearance had improved after surgery, and 22% felt that they had a great improvement. One case had to be reoperated on because of a traumatic nasal fracture after surgery. We believe this technique offers important advantages, such as: an excellent control of the fracture line, fewer incidences of open roof and lateral step, without causing visible scars.

[Cartilaginous grafts in rhinoplasty]. / Injertos cartilaginosos en rinoplastia.

We present a revision of 38 cases operated on for augmentation rhinoplasty from 1992 to 2001, using a cartilaginous graft. 83% of our patients were men and 17% were female. The mean age was 31 years old. In 33 rhinoplasties, the graft was placed in the nasal dorsum; in 4 cases it was placed at the nasal tip and in one case reconstruction of the dorsum and the tip was performed. The most frequently used graft was septal cartilage, in 28 cases. Conchae cartilages were used in 3 cases, lower lateral cartilage in 5 cases, rib cartilage in one, and in another case, septal and lower lateral cartilage were used in the same patient. We stabilized the graft fixing it to the skin with a suture which is removed after a week. We did a postoperative follow-up on 25 of the patients. In terms of patient satisfaction, 12% of them felt that their nasal appearance had improved, 76% felt that there had been a great improvement, and 12% did not notice any change. Only one patient had to be reoperated on because of an overprojection of the graft in the nasal dorsum. We conclude that the use of autologous cartilaginous grafts offers important advantages in rhinoplasty; they are easy to be obtained, easy to mould and with a low index of resorption.

Vertical partial laryngectomy versus supracricoid partial laryngectomy for selected carcinomas of the true vocal cord classified as T2N0.

From an inception cohort of 204 patients with squamous cell carcinoma of the true vocal cord classified as T2N0 and a minimum of 3 years of follow-up, the authors compare the oncological and functional outcomes following vertical partial laryngectomy (group 1; 85 patients) and supracricoid partial laryngectomy (group 2; 119 patients). The 10-year actuarial survival estimate was 46.2% for group 1 and 66.4% for group 2. Survival was statistically more likely to be reduced (p = .019) in group 1 than in group 2. The 10-year actuarial local control estimate was 69.3% for group 1 and 94.6% for group 2. Local recurrence was statistically more likely to occur (p < .0001) in group 1 than in group 2. Salvage treatment resulted in an overall 94.1% local control rate and a 78.1% laryngeal preservation rate for group 1 and an overall 99.2% local control rate and a 94.9% laryngeal preservation rate for group 2. The 10-year actuarial nodal control estimate was 81.7% for group 1 and 93.7% for group 2. Nodal recurrence was statistically more likely to occur (p = .028) in group 1 than in group 2. The 10-year actuarial estimate for patients without distant metastasis was 84.6% for group 1 and 95.1% for group 2. Distant metastasis was statistically more likely to occur (p = .05) in group 1 than in group 2. The hospital mortality rate was 1.2% for group 1 and 0.8% for group 2. The incidence of permanent gastrostomy was 0% for group 1 and 2.4% for group 2. The incidence of permanent tracheostomy was 1.2% for group 1 and 2.4% for group 2. The incidence of completion laryngectomy due to functional problems was 1.2% for group 1 and 0.8% for group 2.

[Severe Frey syndrome after parotidectomy: treatment with botulinum neurotoxin type A]. / Syndrome de Frey sévère post-parotidectomie: traitement par la neuro-toxine botulique de type A.

Based upon an inception cohort of 30 patients with severe Frey's syndrome, after conservative parotidectomy, the technique and the results of intracutaneous injection of botulinum toxin type A are presented. The skin surface involved with Frey's syndrome was managed with intracutaneous injection of 2.5 international units of botulinum toxin type A per square centimeter. A minimum follow-up of 16 months was achieved. The only adverse side effect encountered was a temporary paresis of the upper lid noted in 2 patients. Frey's syndrome vanished within 2-5 days from the intracutaneous injection of botulinum toxin type A. Frey's syndrome was controlled in 53.2% of cases (17/30) after the initial injection of botulinum toxin type A. Five of the 13 patients with recurrence of Frey's syndrome elicited to undergo a watch and wait policy due to the lack of discomfort induced by the recurrence. The remaining eight patients with recurrence of Frey's syndrome were successfully managed with a secondary intracutaneous injection of botulinum toxin type A. Such preliminary data, together with the review of the literature suggests, that the intracutaneous injection of botulinum toxin type A should now be the first line treatment option in patients with severe Frey syndrome.

Local recurrence after vertical partial laryngectomy, a conservative modality of treatment for patients with Stage I-II squamous cell carcinoma of the glottis.

BACKGROUND: Based on an inception cohort of 103 patients who had local recurrence (Group I) and a witness group of 311 patients who achieved local control (Group II) after vertical partial laryngectomy for Stage I-II glottic carcinoma, the current retrospective study documented the consequences and management of local recurrence. METHODS: Three hundred two patients (97.1%) in Group II and all 103 patients (100%) in Group I were followed until death or for a minimum of 10 years. Statistical analysis of survival, lymph node control, and distant metastasis was based on the Kaplan-Meier product limit method. RESULTS: The 10-year actuarial survival estimate was 30.8% for Group I patients and 63.1% for Group II patients. Survival was statistically more likely to be reduced in Group I patients (P < 0.0001) than in Group II patients. The percentage of patients who died of their initial disease was 44.6% in Group I and 6.3% in Group II. The 10-year actuarial lymph node control estimate was 70.2% for Group I and 96.1% for Group II. Lymph node recurrence was statistically more likely to occur in Group I patients than in Group II patients (P < 0.0001). The 10-year actuarial estimate for patients without distant metastasis was 80.2% for Group I and 96.7% for Group II. Distant metastasis was statistically more likely to occur in Group I patients than in Group II patients (P < 0.0001). Salvage treatment was unsuitable for 4.7% of patients with local recurrence; for other patients, it yielded a 86.7% local control rate, a 21.4% laryngeal preservation rate, a 4.5% death rate, and an 11.2% rate of incidence of severe complications. CONCLUSIONS: Among patients with Stage I-II glottic carcinoma managed with vertical partial laryngectomy, local recurrence results in a reduced rate of survival as well as a high rate of necessity for salvage total laryngectomy.

Recurrent gustatory sweating (Frey syndrome) after intracutaneous injection of botulinum toxin type A: incidence, management, and outcome.

OBJECTIVE: To evaluate the duration of effectiveness of intracutaneous injection of botulinum toxin type A for gustatory sweating as well as the incidence, severity, management, and outcome of recurrent gustatory sweating. DESIGN: An inception cohort with a minimum of 18 months of follow-up. SETTING: A tertiary care center and university teaching hospital. PATIENTS: Thirty-three patients with severe gustatory sweating. INTERVENTION: Intracutaneous injection of 25 to 175 IU (mean, 86 IU) of botulinum toxin type A. MAIN OUTCOME MEASURES: Analysis of the effectiveness of the intracutaneous injection of botulinum toxin type A using the Kaplan-Meier actuarial life-table method; completion of the Minor starch-iodine test in patients without symptomatic recurrent gustatory sweating; and the patients' self-assessment of the severity of the recurrent gustatory sweating. RESULTS: The 1-, 2-, and 3-year actuarial estimate for symptomatic recurrent gustatory sweating was 27%, 63%, and 92%, respectively. In the 7 patients without symptomatic recurrent gustatory sweating, the Minor starch-iodine test revealed persistent gustatory sweating in 6, resulting in an overall 97% rate (32 of 33 patients) for recurrent gustatory sweating. No statistical relationship could be demonstrated between the duration of effectiveness, the incidence of recurrent gustatory sweating, the severity of recurrent gustatory sweating, and the following variables: age, sex, cause of gustatory sweating, skin surface involved, and dose of botulinum toxin type A injection. Within the group of 26 patients with symptomatic recurrent gustatory sweating, (1) the severity of the recurrent gustatory sweating was always reduced when compared with the severity of the initial gustatory sweating, and (2) the recurrent gustatory sweating always remained amenable to reinjection of botulinum toxin type A. CONCLUSIONS: The present series demonstrated a linear regression in the effectiveness of the intracutaneous injection of botulinum toxin type A in patients with gustatory sweating, while no factors appeared to be statistically related to the duration of effectiveness and/or the incidence of recurrent gustatory sweating. However, because the severity of recurrent gustatory sweating is reduced when compared with the severity of the initial gustatory sweating and because recurrent gustatory sweating remains amenable to reinjection of botulinum toxin type A, we believe that the intracutaneous injection of botulinum toxin type A should become the first-line treatment option in patients with gustatory sweating.

[Pharyngeal chordoma]. / Cordoma faríngeo.

Chordoma is a neoplasm arising from embryonal notochord remnants. It is infrequent and rarely located at the cervical level. The diagnosis is histological and immunohistochemical tests are required to differentiate it from other neoplasms. We report a case of pharyngeal chordoma treated with a transmandibular approach. The diagnosis, treatment, and prognosis of these tumors are reviewed.

[Acoustic rhinometry in a normal population]. / Rinometría acústica en la población normal.

Acoustic rhinometry is a new method for objectively studying the geometry of the nasal cavity which is based on sound-wave reflection. One hundred normal subjects were studied by acoustic rhinometry under baseline conditions and after decongestion of the nasal mucosa. The minimum cross-section, area distance from this point to the nostril, nasal cavity volumen, and variations in these parameters after decongestion gave useful information about the state of the nasal cavity under normal conditions.