The thoracoacromial/cephalic vascular system for microvascular anastomoses in the vessel-depleted neck.

OBJECTIVE: To review our experience with use of the thoracoacromial/cephalic (TAC) system in the free flap reconstruction of complicated head and neck defects. DESIGN: Case series. SETTING: Tertiary care referral center. POPULATION: A consecutive sample of 11 patients requiring free flap reconstruction of head and neck defects using the TAC system for microvascular anastomoses was identified by medical chart review. INTERVENTION: Free flap reconstruction of complicated defects of the head and neck using the TAC vascular system for microvascular anastomoses. MAIN OUTCOME MEASURES: Free flap survival and microvascular thrombosis. RESULTS: Of 11 patients using TAC anastomoses, all had complete survival of free flaps. No complications related to anastomotic failure were identified. CONCLUSIONS: The TAC system provides a reliable source of undisturbed vessels when cervical vessels are unusable or absent.

A patient- and observer-rated analysis of the impact of lateral rhinotomy on facial aesthetics.

OBJECTIVE: To determine, using patient- and observer-rated facial disfigurement measures, whether a lateral rhinotomy imparts significant aesthetic morbidity. DESIGN: Retrospective and subject-controlled study in a large, tertiary-referral, academic otolaryngology department. Twenty-one consecutive patients who had undergone lateral rhinotomy for the treatment of inverted papilloma were studied in the long-term. MAIN OUTCOME MEASURES: Scores on the following: (1) the novel Patient-Rated Facial Disfigurement Analogue Scale questionnaire and (2) the reliable and validated Observer-Rated Facial Disfigurement 9-Point Likert Scale. RESULTS: Patients rated their facial appearance as minimally altered and significantly less apparent to others. The observers in this study, a surgeon (J.C.I.) and a psychiatrist (M.R.K.), rated the patients' facial disfigurement as minimally visible. Patients seem to rate how apparent their appearance is to others in a similar fashion to observers. The observer-rated facial disfigurement scale used is valid and reliable. CONCLUSION: Patient- and observer-rated facial disfigurement measures suggest that a lateral rhinotomy does not impart significant aesthetic morbidity.

Reconstruction of the pediatric maxilla and mandible.

BACKGROUND: The creation of osseous defects in the upper and lower jaws in children is an uncommon occurrence. It is therefore likely that a head and neck reconstructive surgeon will accumulate only limited experience in restoring such defects. We have reviewed 7 pediatric bone-containing microvascular free flap reconstructions in 6 patients for reconstruction of the upper or lower jaws. Three patients were available for long-term follow-up to evaluate the effect of osseous free flap reconstruction on function and growth and development of the donor site. DESIGN: Retrospective review. SETTING: Academic tertiary referral center for otolaryngology. PATIENTS AND METHODS: Six pediatric patients ranging in age from 8 to 16 years underwent 2 fibular, 4 scapular, and 1 iliac free flap procedure for restoration of 2 maxillary and 5 mandibular defects from 1992 to 1997. Three of the 6 patients were available for long-term follow-up to assess the postoperative donor site function in an effort to determine the effect of this surgery on long-term donor site morbidity and development. RESULTS: Two patients were lost to follow-up, and 1 died secondary to complications related to distant metastatic disease. Three of 6 patients were observed for 2 years 6 months, 4 years, and 4 years 2 months, respectively. Two of the 3 patients who were observed long term have undergone full dental rehabilitation and currently maintain a regular diet and deny pain with mastication or deglutition. One patient did not require dental rehabilitation. All 3 patients demonstrate gross facial symmetry and normal dental occlusion. Assessment of the fibular donor site demonstrated normal limb length and circumference. The patients denied pain or restriction to recreational activity. Scapular donor sites demonstrated normal range of motion, strength, and shoulder stability. CONCLUSIONS: Free flap reconstruction of the pediatric maxilla and mandible requires harvesting bone from actively growing donor sites. We have found no evidence of functional deficit after bone harvest from the fibular or scapular donor sites. Patients demonstrate normal growth at the donor sites, and symmetry of the mandible and maxilla is preserved.

Use of the peritracheal fold in the dog tracheal transplantation model.

OBJECTIVE: To investigate the technical aspects of the canine model of human tracheal transplantation for potential application to reconstruction of extremely long tracheal defects (> 10 cm). DESIGN: In phase 1, long tracheal segments were skeletonized and pedicled with the thyroid glands, cranial thyroid arteries and veins, and internal jugular vein branches. The segments were elevated completely, attached to the vascular pedicle only, and replaced with primary tracheal anastomoses. In phase 2, long segments were elevated along with a diffuse soft tissue "blanket" that envelops the trachea and thyroid glands. Because this study was designed to primarily address, in situ, tracheal perfusion territories of a cranially located vascular pedicle, microvascular anastomoses were not conducted. SUBJECTS: Two small-bodied beagles (10-15 kg) and 5 large-bodied mixed-breed dogs (20-30 kg) were humanely killed 2 to 41 days after surgery, and anatomic and histological analyses were conducted. RESULTS: Unlike that of humans, the thyroid gland complex of dogs is not intimately associated with the trachea but is conjoined with a peritracheal soft tissue "fold." Within this fold, blood is transmitted to the trachea via a diffuse, segmental vascular plexus. In phase 1, pronounced tracheal necrosis occurred within 2 to 5 days. In phase 2, extremely long tracheal segments (10-12 cm), based only on a cranially located pedicle, were still viable at 2 to 6 weeks. CONCLUSIONS: Preservation of the "peritracheal fold" in the dog model of tracheal transplantation is critical to the onset and maintenance of vascular perfusion in a long tracheal segment. Furthermore, the use of large-bodied dogs is necessary to provide for a usable venous efflux component.

An objective analysis of the impact of lateral rhinotomy and medial maxillectomy on nasal airway function.

OBJECTIVE: The lateral rhinotomy and medial maxillectomy procedure, while known to interrupt nasal valve supports, has not previously been reported to adversely affect nasal airway function. The purpose of this study was to utilize state-of-the-art techniques to objectively analyze the impact of this procedure on nasal airway function. DESIGN: The study design was retrospective and subject controlled. METHODS: The study population was derived from an academic, tertiary-referral, otolaryngology-head and neck surgery department with an estimated catchment population of 4 million people. Subjects included 21 consecutive, long-term postoperative patients who had undergone lateral rhinotomy and medial maxillectomy for inverted papilloma. Objective measures included vestibular cephalometric measurements, airflow rhinomanometry, and acoustic rhinometry. RESULTS: Statistically significant results reveal that although lateral rhinotomy and medial maxillectomy are associated with alar collapse, both overall nasal airflow and valve areas are increased. CONCLUSION: Lateral rhinotomy and medial maxillectomy does not adversely affect nasal airway function. This appears to be the result of concomitant resection of the functionally dominant inferior turbinate. This suggests that lateral rhinotomy performed in conjunction with operations not requiring inferior turbinectomy, such as anterior craniofacial resection, may adversely affect nasal airway function.

Analysis of the recent cluster of invasive fungal sinusitis at the Toronto Hospital for Sick Children.

OBJECTIVE: The aim of this study was to review the eight histopathologically proven cases of invasive fungal sinusitis that occurred at the Toronto Hospital for Sick Children between 1985 and 1995, seven of which that clustered between March 1990 and February 1992. DESIGN: A retrospective review of the relevant cases and a review of the literature are presented. METHOD: A clinical review of this rare, life-threatening entity, occurring almost exclusively in severely neutropenic patients is presented and compared to the relevant clinical findings from an analysis of this series, the largest reported to date and first to document a significant clustering (p < .01). CONCLUSION: We conclude, based on epidemiologic evidence, that this clustering was directly related to the release of airborne fungal spores from dormant soil reservoirs disturbed during hospital construction. Therefore, we strongly advocate increased vigilance with respect to precautions against airborne pathogens wherever severely neutropenic hosts are treated.

Ligation of the common carotid artery for the management of a mycotic pseudoaneurysm of an extracranial internal carotid artery. A case report and review of the literature.

Although vascular involvement by deep neck space infections occurs very rarely today with the widespread use of antibiotics, they often pose a significant challenge to the modern otolaryngologist, who most likely will have had no previous experience with either the diagnosis or treatment of these potentially life-threatening infections. We describe the case of a young female presenting with fevers, dysphagia, and blood-tinged sputum, who was diagnosed by contrast-enhanced computerized tomography, to possess a mycotic pseudoaneurysm of her right extracranial internal carotid artery, for which ligation of her common carotid artery was required. We also discuss both the clinical findings which should lead one to suspect that a neck infection may be involving the extracranial carotid arteries, and the English literature, on the morbidity and mortality of ligating a common carotid artery.

Dangers of immunosuppressive therapy in hepatitis B virus carriers.

OBJECTIVE: To identify the risk of hepatic failure in hepatitis B virus (HBV) carriers given intermittent immunosuppressive therapy. DATA SOURCES: The key words "immunosuppression" and "hepatitis B" were used to search MEDLINE for relevant articles in English published from 1970 to 1990; the bibliographies of these articles were reviewed for additional publications. Also included were articles published in 1991. STUDY SELECTION: Articles were included if they documented the use of immunosuppressive drugs to treat chronic hepatitis B or another condition in patients at high risk for the HBV carrier state. RESULTS: Long-term immunosuppressive therapy has not improved the survival of patients with chronic hepatitis B. The withdrawal of such therapy from HBV carriers has resulted in a flare-up of potentially fatal hepatitis in 20% to 50%, regardless of whether underlying liver disease was present. The presence of replicating viral DNA in the serum of HBV carriers may identify those who are at high risk of the deleterious effects of immunosuppressive therapy. CONCLUSIONS: Long-term immunosuppressive therapy is not advised for liver disease in HBV carriers. For other conditions in such people continuous rather than intermittent therapy is safer. Patients at high risk for hepatitis B should be screened for this virus when immunosuppressive therapy is contemplated.