Association of Oesophageal Hypertension with Bradycardia Mediated Deglutition Syncope.

Swallow syncope is a rare form of situational syncope. We report a case of swallow syncope with invasive confirmation of esophageal hypertension (spasm) and invasive confirmation of a bradycardia mechanism. Awareness of this uncommon disorder is important as a treatable cause of syncope.

Discrete solvation layering in confined binary liquids.

The solvation force profiles of squalane/octamethylcyclotetrasiloxane (OMCTS) mixtures confined between Si3N4 tips and highly oriented pyrolytic graphite (HOPG) and hexadecane/OMCTS confined between alkanethiol-functionalized tips and freshly cleaved mica have been measured by atomic force microscopy. Measurements on HOPG reveal oscillatory behavior where discrete solvation layers of both squalane and OMCTS are observed in a single force curve. The large repulsive force of the first solvation layer (squalane) on HOPG indicates that it is strongly bound. Oscillatory behavior is also observed for hexadecane/OMCTS on mica excepting that the oscillations are found in the attractive regime. The OMCTS layers in this case are less ordered with slightly larger (approximately 1 A) periodicities. These results are in agreement with computer simulations for binary liquid mixtures but differ qualitatively from surface force apparatus experiments.

Management of vagus nerve injury afer carotid endarterectomy.

BACKGROUND: Inadvertent injury to the vagus nerve or its branches during carotid endarterectomy can result in adductor vocal cord paralysis (hoarseness) and cricopharyngeal dysfunction (dysphagia) with aspiration, known as "double trouble." This study describes our experience in the management of this complication in cases where conservative treatment failed. METHODS: All patients were examined by a vascular surgeon, a head and neck surgeon, and a speech therapist. Their examinations included comprehensive speech evaluation, video stroboscopy, video fluoroscopy, and methylene blue testing for aspiration. All patients underwent Teflon injections to medialize the paralyzed vocal cord and a cricopharyngeal myotomy to restore swallowing and alleviate aspiration. RESULTS: Fourteen patients, eight men and six women, were treated. The duration of dysfunction was 24 weeks in two patients, 6 weeks in four patients, 4 weeks in three patients, and 1 week in five patients. Five patients had severe dysfunction (defined as difficulty in swallowing both solid and liquid foods with more than 20% aspiration), seven patients had moderate dysfunction (defined as difficulty swallowing solid food with aspiration of less than 20%), and two patients had mild dysfunction (defined as difficulty in swallowing solids but with no aspirations). After the Teflon injections and myotomy, 13 of 14 patients had satisfactory outcomes, including normal voice and swallowing. CONCLUSIONS: Vagus nerve injury from a carotid endarterectomy can be a debilitating complication. Prevention, early recognition, and prompt correction of these injuries are important in the management of this complication.

Endoscopic CO2 laser cricopharyngeal myotomy.

Cricopharyngeal dysfunction due to various causes can lead to severe upper pharyngeal dysphagia with or without laryngeal penetration. Resurgence of Dohlman's endoscopic diverticulotomy for Zenker's diverticulum has been brought about by the development of the diverticuloscope, improved intravenous analgesia, and the advent of the laser. Recent use of videofluoroscopy for swallowing documents a frame-by-frame picture of swallowing with special focus on the cricopharyngeal function and its stages of malfunction. The "cricopharyngeal crescent" (cricopharyngeal bar) as termed by Jackson is visible during endoscopy and can be incised in layers under the operating microscope with the CO2 or contact Nd:YAG laser. This paper introduces the staging of cricopharyngeal dysfunction regarding its initiation and progression in correlation with its symptoms and videofluoroscopic pictures. It also reports the application of endoscopic laser cricopharyngeal myotomy for 44 patients with cricopharyngeal dysfunction besides 4 with Zenker's diverticulum. This procedure is found to be effective, safe, brief, and prompt in restoring swallowing.

Contact Nd:YAG laser excision of rhinophyma.

Rhinophyma, an excessive hyperplasia of the sebaceous glands of the nose, results in disfigurement, occasional nasal blockage and recurrent infection. This condition is considered to be the culmination of acne rosacea and can degenerate to a basal cell or squamous cell carcinoma. Various surgical methods have been used to treat rhinophyma, but most have resulted in complications and poor cosmetic outcomes. Wenig and Weingarten reported four cases of rhinophyma which were successfully treated with the contact Nd: YAG laser, and this article describes my experience in use of this modality to treat a 71-year-old patient at the Eye and Ear Clinic of Charleston.

Nd:YAG laser surgery of venous malformations.

Venous malformations are prevalent in the head and neck. These anomalies are difficult to eradicate by conventional methods due to excessive bleeding and imprecise excision. This article details how the success rate for treating low flow venous malformations was 100% in 24 patients who underwent Nd:YAG surgery.

Double cheek-cervical rotation flap for repair of facial defects.

Repair of extensive facial defects due to cancer surgery or trauma is a challenge to restore form, function, and facade. This article studies the advantages of using the double cheek-cervical rotation flap for immediate reconstruction of 10 patients with huge facial defects.

Endoscopic CO2 laser arytenoidectomy for postintubation glottic stenosis.

Extended endotracheal intubation for assistive respiration can lead to cricoarytenoid joint fixation and subsequent bilateral midline vocal cord fixation--thus, complete glottic stenosis. Endoscopic CO2 laser arytenoidectomy was performed on 10 patients for bilateral midline vocal cord fixation caused by prolonged translaryngeal endotracheal intubation because of central nervous system respiratory insufficiency resulting from various causes. Eight of these patients had concomitant cricopharyngeal myotomy for associated severe upper pharyngeal dysphagia. All of these patients had successful return of airway, voice, and swallowing functions. The advantages of the CO2 laser for endoscopic arytenoidectomy are its facility, hemostasis, precision, and minimal scarring.

Contact Nd:YAG laser for soft tissue surgery.

The contact Nd:YAG laser is an effective tool for head and neck soft tissue surgery for its precision, predictability, and touch technique. Understanding of its biophysics, precaution and application expedites operation, enhances surgical results and shortens hospitalization.

Cricopharyngeal myotomy with diverticulopexy for Zenker's diverticulum.

Prolonged cricopharyngeal dysfunction due to various causes can lead to severe dysphagia, aspiration, pneumonia, debilitation and subsequent pharyngoesophageal (Zenker's) diverticulum. This paper reports the successful use of cricopharyngeal myotomy with diverticulopexy for management of huge Zenker's diverticulum on five high-risk patients. The advantages of this method are immediate swallowing, short hospitalization, and avoidance of serious complication.

Pectoralis major myocutaneous flap in reconstruction of head and neck defects.

Immediate reconstruction of head and neck defects due to various causes is required to restore structure, function, and appearance. The pectoralis major myocutaneous flap (PMMF) is the ideal reconstructive tissue for its accessibility, versatility, reliability, and cosmeticity. This paper reports a 10-year experience on the use of the PMMF for restoration of extensive head and neck defects.

Laser tumor debulking.

When adequate tumor ablation is nonfeasible, debulking has become essential to palliate or to prepare patients for chemotherapy, radiotherapy or definite surgery. The CO2 and Nd:YAG lasers were used to debulk 120 head and neck cases, of which 118 were successfully debulked. The advantages of the laser as a debulker are its facility, rapidity, repeatability, coagulability, atraumaticity, precision, sterilization, and prompt healing; thus, tracheostomy and extended hospitalization were obviated. This paper describes the effectiveness and benefits of the CO2 and Nd:YAG lasers as tumor debulkers.

Metastatic renal cell carcinoma of the nasal septum.

Renal cell carcinoma tends to metastasize early to nearly all organs. In the head and neck region, the nasal cavities and paranasal sinuses are targets for its hematogenous spread. This is a case report of a renal cell carcinoma involving the nasal septum that presented as severe epistaxis after a nephrectomy for its primary and after a finger amputation for its metastatic site.

Carotodynia exposed: hyoid bone syndrome.

The hyoid bone syndrome, first described in 1954, is manifested by tenderness near the greater horn of the hyoid bone. In 1968, the syndrome was reported to be a form of insertion tendinosis, and injection of procaine HCl with corticosteroid at the tip of the greater horn was found to provide temporary relief of pain. I report 50 patients with the hyoid bone syndrome who had excision of the involved greater horn after one month of conservative medical treatment failed to relieve the pain. Operation promptly relieved pain in 45 (90%) of the patients. An understanding of the close relationship between the greater horn of the hyoid and the posterior pharynx and carotid sinus is important in detecting the hyoid bone syndrome.

Precaution and safety in carbon dioxide laser surgery.

The introduction of the carbon dioxide laser--(in 1972) by Strong and Jako as a surgical tool for removal of laryngeal papilloma--heralded a new period of surgical refinement and precision in otolaryngology and also led to adjustment and precautions in operating room setup and in the administration of anesthetics. This article recounts 8 years of experience in carbon dioxide laser surgery on 3500 head and neck patients. Techniques and precautions of administering anesthetics for laser surgery are presented. The management of a laser-ignited burn is also discussed.