Clinical Consensus Statement: Septoplasty with or without Inferior Turbinate Reduction.

OBJECTIVE: To develop a clinical consensus statement on septoplasty with or without inferior turbinate reduction. METHODS: An expert panel of otolaryngologists with no relevant conflicts of interest was assembled to represent general otolaryngology and relevant subspecialty societies. A working definition of septoplasty with or without inferior turbinate reduction and the scope of pertinent otolaryngologic practice were first established. Patients 18 years and older were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus. RESULTS: The group defined nasal septoplasty as a surgical procedure designed to correct a deviated nasal septum for the purpose of improving nasal function, form, or both. After 2 iterative Delphi method surveys, 20 statements met the standardized definition of consensus, while 13 statements did not. The clinical statements were grouped into 8 categories for presentation and discussion: (1) definition and diagnosis, (2) imaging studies, (3) medical management prior to septoplasty, (4) perioperative management, (5) surgical considerations, (6) adjuvant procedures, (7) postoperative care, and (8) outcomes. CONCLUSION: This clinical consensus statement was developed by and for otolaryngologists and is intended to promote appropriate and, when possible, evidence-based care for patients undergoing septoplasty with or without inferior turbinate reduction. A complete definition of septoplasty with or without inferior turbinate reduction was first developed, and additional statements were subsequently produced and evaluated addressing diagnosis, medical management prior to septoplasty, and surgical considerations, as well as the appropriate role of perioperative, postoperative, and adjuvant procedures, in addition to outcomes. Additionally, a series of clinical statements were developed, such as "Computed tomography scan may not accurately demonstrate the degree of septal deviation," "Septoplasty can assist delivery of intranasal medications to the nasal cavity," "Endoscopy can be used to improve visualization of posterior-based septal deviation during septoplasty," and "Quilting sutures can obviate the need for nasal packing after septoplasty." It is anticipated that the application of these principles will result in decreased variations in the care of septoplasty patients and an increase in the quality of care.

Long-term Functional Outcomes of Total Glossectomy With or Without Total Laryngectomy.

IMPORTANCE: The optimal reconstruction of total glossectomy defects with or without total laryngectomy is controversial. Various pedicled and free tissue flaps have been advocated, but long-term data on functional outcomes are not available to date. OBJECTIVES: To compare various total glossectomy defect reconstructive techniques used by multiple institutions and to identify factors that may lead to improved long-term speech and swallowing function. DESIGN, SETTING, AND PARTICIPANTS: A multi-institutional, retrospective review of electronic medical records of patients undergoing total glossectomy at 8 participating institutions between June 1, 2001, and June 30, 2011, who had a minimal survival of 2 years. INTERVENTION: Total glossectomy with or without total laryngectomy. MAIN OUTCOMES AND MEASURES: Demographic and surgical factors were compiled and correlated with speech and swallowing outcomes. RESULTS: At the time of the last follow-up, 45% (25 of 55) of patients did not have a gastrostomy tube, and 76% (42 of 55) retained the ability to verbally communicate. Overall, 75% (41 of 55) of patients were tolerating at least minimal nutritional oral intake. Feeding tube dependence was not associated with laryngeal preservation or the reconstructive techniques used, including flap suspension, flap innervation, or type of flap used. Laryngeal preservation was associated with favorable speech outcomes, such as the retained ability to verbally communicate in 97% of those not undergoing total laryngectomy (35 of 36 patients) vs 44% (7 of 16) in those undergoing total laryngectomy (P < .001), as well as those not undergoing total laryngectomy achieving some or all intelligible speech in 85% (29 of 34 patients) compared with 31% (4 of 13) undergoing total laryngectomy achieving the same intelligibility (P < .001). CONCLUSIONS AND RELEVANCE: In patients with total glossectomy, feeding tube dependence was not associated with laryngeal preservation or the reconstructive technique, including flap innervation and type of flap used. Laryngeal preservation was associated with favorable speech outcomes such as the retained ability to verbally communicate and higher levels of speech intelligibility.

Selectin blockade decreases postischemic recruitment of bone marrow stromal cells.

OBJECTIVES/HYPOTHESIS: Investigate the localization mechanisms of bone marrow stromal cells following transient ischemia-reperfusion injury in a murine flap model. STUDY DESIGN: Controlled laboratory study. METHODS: A cutaneous flap based on the inferior epigastric artery was elevated, and transient ischemia of 3.5 hours using a microvascular clamp was achieved. Fucoidan was injected intravenously 24 hours before the ischemic period. Following the period of ischemia, radiolabeled bone marrow stromal cells were injected intravenously, and radioactivity was determined postoperatively. RESULTS: Attenuation of the uptake of bone marrow stromal cells into postischemic tissue was observed in those mice treated with fucoidan as indicated by gamma counts measured in the flaps when compared with controls (P < . 001). CONCLUSIONS: Decreased uptake of radiolabeled bone marrow stromal cells into postischemic tissues pretreated with fucoidan indicates selectin-mediated bone-marrow stromal cell recruitment in a murine cutaneous flap model.

Establishment of a cutaneous flap animal model to study platelet and leukocyte dynamics after ischemia-reperfusion injury.

OBJECTIVES To study a cutaneous flap in an animal model for platelet and leukocyte dynamics after ischemia-reperfusion injury and to explain how such a model is relevant to the understanding of reconstructive flaps in a clinical setting. METHODS Cutaneous flaps based on the inferior epigastric artery were raised on C57BL/6 mice and were subjected to various periods of ischemia followed by reperfusion. We used intravital microscopy to observe and characterize platelet and leukocyte interactions within the microvasculature. RESULTS Platelet and leukocyte adherence to the microvasculature was greater after a longer reperfusion period in contrast to the adherence pattern seen after a shorter reperfusion period. Leukocyte rolling activity occurred at a greater rate after longer ischemia and shorter reperfusion periods, whereas the rate of platelet saltation occurred after shorter ischemia and longer reperfusion periods. CONCLUSIONS With the establishment of an animal model of cutaneous flaps to study cellular dynamics within the microvasculature after ischemia-reperfusion injury, further investigation into the cellular and molecular characteristics of such injury and the analysis of pharmacological interventions is warranted.

Cervical thoracic duct cyst: Importance of preoperative suspicion for appropriate management of left-sided neck mass.

Cervical thoracic duct cysts occur infrequently but are an important consideration when evaluating cystic supraclavicular masses. Only 22 cases have been reported to date. We review the clinical presentation, evaluation, and treatment of 2 cases of large thoracic duct cysts treated with surgical resection. A high suspicion of thoracic duct cyst based on location, radiographic findings, and fine-needle aspiration results is sufficient evidence for recommendation of surgical excision. However, enlarged cysts, as noted in our cases, can obliterate or attenuate the thoracic duct, making it difficult to identify intraoperatively. A high suspicion of thoracic duct cyst is important for identifying and ligating the duct to prevent complications such as chyle leak or chylothorax.

A unique case of infraorbital myxoid liposarcoma.

Liposarcomas of the head and neck are rare, owing to the paucity of adipose tissue in this region. We present what we believe is a unique case of a myxoid liposarcoma in the infraorbital region, which arose in a 38-year-old man. The patient had presented with a slowly growing mass under his left eye that had been present for about 3 months. A wide local excision was performed, and the tumor was removed in its entirety. The final pathology report identified the mass as a well-differentiated myxoid liposarcoma. The patient's postoperative course was uneventful, and at the 12-month follow-up, he exhibited no evidence of disease.

Intracerebral metastasis of a sinonasal teratocarcinosarcoma: a case report.

Sinonasal teratocarcinosarcoma (SNTCS) is a rare, malignant neoplasm that contains both mesenchymal and epithelial components. The mortality rate for this tumor is ∼60% within 3 years, with the average survival rate being 1.7 years. Usually, this neoplasm presents with symptoms of nasal obstruction and epistaxis. Neurological symptoms from intracranial extension and dural invasion are rare presentations for this neoplasm. We present the first known case of an intracerebral metastasis of a previously resected SNTCS.

Vascular anatomy of anterolateral thigh flap.

OBJECTIVES: To understand the vascular anatomy of the anterolateral thigh (ALT) free flap. To anatomically determine whether including a 2-cm cuff of vastus lateralis muscle (VLM) incorporates musculocutaneous perforators in the harvest of the ALT free flap. STUDY DESIGN: Anatomic study on human cadavers. METHODS: Twenty-seven cadaver thighs were dissected. Musculocutaneous perforators from the vascular pedicle of the ALT free flap were identified. The distance from the anterior border of the VLM to the point where perforators entered the muscle was measured. RESULTS: An average of four musculocutaneous perforators to the ALT free flap were identified per thigh. The distance from the anterior border of the VLM to the point where perforators entered the muscle ranged from 0.1 to 7 cm, with the mean distance being 1.80 cm. Sixty-four percent of perforators entered the VLM within 2 cm of the muscle's anterior border. At least one perforator entered the VLM within 2 cm of the muscle's anterior border per thigh. CONCLUSIONS: Most musculocutaneous perforators to the ALT free flap enter the VLM within 2 cm of the muscle's anterior border, thus providing for an anatomic basis for including a 2 cm cuff of VLM when harvesting the ALT free flap. By including a 2 cm cuff of VLM, tedious dissection of individual musculocutaneous perforators is unnecessary, thereby increasing the ease of dissection and expediting the harvest of the ALT free flap.

Follicular dendritic cell sarcoma of the tonsil: a case report and literature review.

We describe a case of follicular dendritic cell sarcoma (FDCS) of the tonsil in a 59-year-old woman. She was successfully treated with excision of the mass and postoperative radiation therapy. According to our review of the literature, only 25 cases of extranodal FDCS in the head and neck have been previously reported, including only 10 cases that involved a tonsil. We briefly review these earlier reports, and we discuss the diagnosis and management of FDCS.

Total laryngectomy and T3-T4 laryngeal cancer without other adverse histopathology.

OBJECTIVE: We sought to determine the postoperative management, incidence of tumor recurrence in the neck, and outcome in laryngeal cancer patients whose risk for tumor relapse is not clear. STUDY DESIGN AND SETTING: Thirty patients (27 of whom had transglottic tumors) met the study criteria (resected T3-T4 laryngeal cancer, histologically negative cervical nodes, and no other adverse histopathology). A group of 12 patients who underwent surgery alone was compared with a second group of 18 patients with similar characteristics but who received postoperative radiotherapy. RESULTS: Overall survival at five years was 50% in the surgery alone group and 61% in the combined therapy group (P=0.63). Among the 28 evaluable patients with a median follow-up of 44 months, the relapse rate in the neck was 25% in the surgery alone group and was 0% in the postoperatively irradiated group (P=0.07). Recurrences in the neck remained uncontrolled in two of the three patients at the time of death. CONCLUSION AND SIGNIFICANCE: Postoperative radiotherapy deserves consideration in selected cases of T3-T4 laryngeal cancer without adverse histopathology.

Predictive factors for posterior triangle metastasis in HNSCC.

OBJECTIVE: Surgical modifications sparing uninvolved structures such as the spinal accessory nerve have been implemented since the advent of the radical neck dissection in 1906. The increased morbidity to the spinal accessory nerve involved with the dissection of level V lymph nodes has led to much controversy. In this study, we examine the incidence of nodal metastasis to all nodal levels involved with upper aerodigestive squamous cell carcinoma and attempt to determine when level V dissection is indicated. STUDY DESIGN: Retrospective chart review. METHODS: A study of all radical and modified radical neck dissections was performed at Louisiana State University - Shreveport Health Sciences Center and Overton Brooks Veterans Administration Hospital between 1996 and 2003 for upper aerodigestive squamous cell carcinoma. Univariate and multivariate analyses were performed to determine which neck and patient factors were significantly associated with level V metastasis. RESULTS: Seventy-nine patients with a total of 94 neck dissections were analyzed. The prevalence of level V metastasis was 7.4% of the total neck dissections. Multivariate analysis found that positive lymph nodes involving levels II, III, and IV was the only independent significant factor for level V metastasis (P = .0003). CONCLUSION: Our study is in concordance with other studies in the literature, revealing a low prevalence of level V metastasis in upper aerodigestive squamous cell carcinoma. Unlike other studies, we have found if levels II, III, and IV lymph nodes are found to be positive, dissection of level V is warranted.

Otoplasty: an analysis of technique over a 33-year period.

OBJECTIVE: To compare the merits of otoplasty technique with a diverse patient population as experienced spanning a period greater 30 years. STUDY DESIGN: A review of a series of otoplasty cases that occurred in two distinctly different clinical settings during a 33-year period. METHODS: A retrospective analysis of 211 patients undergoing otoplasty from 1969 to 1982 in a military hospital setting was compared with 118 patients receiving otoplasty from 1982 to 2002 in a university/private practice setting. The patient population consisted of 180 adults and 149 children. RESULTS: Otoplasty patients in the military setting were primarily adults, whereas those in the university/private practice setting were primarily children. In the adult population, 98.9% of patients required use of lateral conchal cartilage resection combined with a mattress suture technique. In the pediatric population, all patients required use of a mattress suture technique and in 83.2% of selected cases limited lateral conchal cartilage resection was required. CONCLUSION: Otoplasty technique involving lateral conchal cartilage resection, mattress suture fixation, or a combination of both is applicable to diverse patient populations.