Frontotemporal reconstruction with hydroxyapatite cement and the radial forearm free flap.

BACKGROUND: Contemporary surgical reconstruction of extensive frontal and temporal bony and soft tissue defects requires the use of myocutaneous free flaps. These flaps are associated with donor site morbidity, lengthy operative time, and lack of rigid protection for the brain. To circumvent these problems, we introduce a new surgical technique for reconstruction of frontotemporal defects. OBJECTIVES: To evaluate and discuss hydroxyapatite and radial forearm free flap (RFFF) reconstructive options for patients with soft tissue and bony defects in the frontal and temporal regions after ablative cancer surgery. METHODS: Eight consecutive patients with extensive soft tissue and bony defects in the frontal and temporal regions underwent primary reconstruction with hydroxyapatite cement for replacement of bone, and the RFFF for soft tissue coverage. Patient follow-up ranged from 6 to 48 months. Outcome was determined in terms of immediate and delayed postoperative complications, donor site morbidity, and long-term aesthetic results. RESULTS: Excellent bony and soft tissue contour restoration was achieved in all patients. The bony and soft tissue volume was maintained throughout the follow-up period. One patient had a stroke. No other postoperative complications were encountered. Morbidity from RFFF harvest was minimum. CONCLUSIONS: The combination of hydroxyapatite cement and the RFFF is a viable alternative to the conventional myocutaneous free flap reconstruction of extensive frontotemporal defects. This technique provides excellent aesthetic results, provides rigid protection for the brain, produces minimal and well-tolerated donor site morbidity, and reduces operative time by avoiding intraoperative changes in patient position.

Laryngospasm: an atypical manifestation of severe gastroesophageal reflux disease (GERD).

OBJECTIVES: To present a potentially life-threatening manifestation of gastroesophageal reflux disease (GERD), laryngospasm. This review covers the diagnosis and management of eight patients treated by the authors. STUDY DESIGN: A retrospective analysis of 8 consecutive patients who were referred for the evaluation of unexplained laryngospasm. The medical therapy and lifestyle modifications of treatment are discussed. METHODS: The patient records were reviewed and tabulated for age, onset of symptoms, and history of GERD; the presence of an associated upper respiratory infection with persistent cough; and the development of syncope in the presence of laryngospasm. RESULTS: All 8 patients had initial control of laryngospasm. Three had complete control without relapse, 3 had initial control with rare relapse of mild laryngospasm, and 2 patients had initial control with frequent relapses. Six of the 8 had syncopal episodes as a consequence of the laryngospasm. All patients were initially treated with a proton pump inhibitor. Five of the 8 required the addition of an esophageal prokinetic agent to control the reflux and subsequent laryngospasm. Two patients are off all medications at the time of this writing and 4 of the 8 have had rare relapses after initial control of symptoms. Once control of the laryngospasm had been achieved, there were no subsequent episodes of syncope. CONCLUSIONS: Based on the data collected in these 8 individuals, patients with reflux disease (known or unknown) can develop severe laryngospasm and possible syncope. The key factor seems to be the association of a recent or concurrent upper respiratory infection that results in a protracted cough that is more severe when supine and at times violent. The cough increases the amount of the refluxate, which is the noxious insult to the larynx.

Third branchial cleft anomaly presenting as a retropharyngeal abscess.

Branchial cleft anomalies are congenital developmental defects that typically present as a soft fluctuant mass or fistulous tract along the anterior border of the sternocleidomastoid muscle. However, branchial anomalies can manifest atypically, presenting diagnostic and therapeutic challenges. Error or delay in diagnosis can lead to complications, recurrences, and even life-threatening emergencies. We describe a case of an infected branchial cleft cyst that progressed to a retropharyngeal abscess in a 5-week-old female patient. The clinical, radiographic, and histologic findings of this rare presentation of branchial cleft cyst are discussed.

Delayed facial paralysis after stapedotomy using KTP laser.

OBJECTIVE: Delayed facial paralysis after stapes surgery is uncommon and has been reported after traditional, nonlaser techniques for stapedotomy. The purpose of this paper is to inform the reader of the potential risk of delayed facial nerve paralysis associated with the use of the potassium titanyl phosphate (KTP) laser for stapedotomy. Etiologic mechanisms are discussed. STUDY DESIGN: The study was a descriptive study-case report. SETTING: The study was conducted at a university-based otologic practice. PATIENTS: Two patients with otosclerosis and delayed onset facial palsy 5 to 7 days after uncomplicated stapedotomy using the KTP laser were included in the study. INTERVENTION: Potassium titanyl phosphate laser stapedotomy was performed. Patients received treatment of facial palsy with a tapering course of oral steroids. MAIN OUTCOME MEASURE: House-Brackmann facial nerve grade scores were used. RESULTS: Improvement of House-Brackmann facial nerve scores from Grade VI to Grade I-II in one patient, and improvement from Grade IV to Grade I-II in the other was seen. CONCLUSION: The probable etiology of delayed facial palsy is viral neuritis from reactivation of dormant virus within the facial nerve, initiated by thermal stress of the KTP laser. Presentation and resolution of the facial palsy is similar to other types of delayed facial palsy resulting from nonlaser techniques of stapes surgery and other types of middle ear and neurotologic surgeries previously reported.

Extracranial repair of pediatric traumatic cerebrospinal fluid rhinorrhea.

OBJECTIVE: To examine the methods of extracranial repair of traumatic defects in the cribriform plate and ethmoid roof resulting in persistent cerebrospinal fluid (CSF) rhinorrhea in pediatric patients. DESIGN: Retrospective case series. SETTING: A single-institution, tertiary care, pediatric hospital. PATIENTS: Four children, ranging in age from 3 1/2 to 9 years, who sustained fractures in the cribriform plate or ethmoid roof. INTERVENTION: Transnasal endoscopic repair in 4 patients, with 2 patients also undergoing external ethmoidectomy because of the large bony defect and the need for further exposure for repair. MAIN OUTCOME MEASURES: Time free from CSF leaks or recurrence, meningitis, and other postoperative complications. RESULTS: All patients except 1 have been free of recurrent CSF leaks, meningitis, and other postoperative complications. The 3 patients who solely underwent the extracranial approach did not experience the complications of the traditional intracranial approach. CONCLUSIONS: In a select group of pediatric patients, the extracranial approach for the repair of CSF leaks is appropriate. Successful use of an extracranial approach in 3 of 4 patients supports this method.

Malignant clival chordoma with postoperative cutaneous metastases.

The authors report the case of a chordoma with malignant cytologic features, presenting as a mass lesion in the clival and infratemporal region at the level of the craniocervical junction in an 8-year-old female. Following gross resection of the mass, the patient subsequently developed distant subcutaneous and peritoneal metastases from the lesion. The rare histologic features, the surgical approach to the lesion, and the follow-up management of this unique case are discussed.

Gunshot wounds of the temporal bone: a rational approach to evaluation and management.

Gunshot injuries of the temporal bone are uncommon but are being seen more frequently with the increasing incidence of violent crimes and use of firearms. A retrospective analysis of 43 consecutive patients treated at our institution with this injury was undertaken to determine the clinical symptoms, associated injuries, and treatment outcome. This is the largest series from a single institution treated by a single group during a brief period of time. Most of these patients had injury to various structures within and around the temporal bone, including hearing loss (29), intracranial injury (23), facial nerve injury (22), vascular injury (14), and mandible fracture (6). Ocular trauma and paralysis of cranial nerves V and IX, X, XI, and XII were rare occurrences. A rational approach to the evaluation and management of these injuries will be discussed in detail to optimize outcome.

Brain stem compression secondary to adipose graft prolapse after translabyrinthine craniotomy: case report.

Three cases of fat graft prolapse into the cerebellopontine angle with clinical deterioration are presented. These patients had undergone translabyrinthine craniotomy for cerebellopontine angle tumors and had autologous abdominal fat strips placed to obliterate the dural defect and the mastoid cavity. Two patients suffered significant morbidity, and one patient died. Clinical presentation, computed tomographic scan findings, methods of treatment, and avoidance of this complication are discussed.

Anterior communicating artery aneurysm presenting as pulsatile tinnitus.

Objective tinnitus is caused by a vascular abnormality of the cervical region, skull base or intracranium. These lesions produce an abnormal flow lesion in the arterial or venus circulatory system of the brain, skull base or cervical region. This flow abnormality is perceived by the auditory system as pulsatile tinnitus. An aberrant carotid artery, a dehiscent jugular bulb or a glomus tumor are common causes. The cause of subjective tinnitus is often not found. Many serious vascular anomalies and tumors can present as pulsatile tinnitus. These include: arteriovenous malformations, atherosclerotic vascular disease, and intracranial tumors with elevated cerebrospinal fluid pressure. We recently diagnosed a patient with an anterior communicating artery aneurysm presenting with pulsatile tinnitus. An aneurysm presenting as pulsatile tinnitus is extremely uncommon. Only 8 have been identified in the literature. The clinician evaluating patients with tinnitus must be aware of this diagnosis. A complete evaluation should include an appropriate radiologic exam; either computed tomography or magnetic reasonance imaging.

Histiocytosis X of the head and neck in a pediatric population.

Despite an extensive literature, histiocytosis X is still a poorly understood disease and the origin remains unknown. To study the impact of recent therapeutic and diagnostic advances on this disease, 28 cases of histiocytosis X treated at Children's Hospital of Los Angeles, Calif, from 1976 through 1987 were reviewed. A classification system was developed that accurately described the clinical outcome in our patients. Type patients (n = 7) had monostotic disease, and type 2 patients (n = 15) had multiple tissue sites other than the viscera. The latter type was further divided into types 2A and 2B, depending on whether lesions were solely osseous (type 2A [n = 8]) or if soft-tissue sites were involved (type 2B [n = 7]). Type 3 patients (n = 6) had disseminated disease at the time of presentation, as defined by visceral involvement other than the liver. Type 1 patients were usually treated by surgical curettage alone and had an excellent prognosis. Type 2A patients required either surgery or radiation for symptomatic lesions. Type 2B patients were treated similarly. In addition, Type 2B patients received chemotherapy, a practice that is intensively debated in the literature. All the Type 2 patients survived with varying morbidity. Type 3 patients were all treated with chemotherapy but none of them survived. The majority of patients with histiocytosis X had otolaryngologic manifestations ranging from bony lesions to infectious complications. To conclude, the term histiocytosis X should be maintained to describe a spectrum of diseases. A simple classification system with three divisions gives reliable prognostic and therapeutic guidelines.

Unilateral acoustic neuromas in childhood without evidence of neurofibromatosis: case report and review of the literature.

A six-year-old female with a unilateral benign acoustic neuroma and no evidence of neurofibromatosis is presented. Review of the literature revealed only 16 cases of unilateral acoustic neuromas in children less than 15 years old. Children often do not appreciate hearing loss when compared with adults. As a result, they often present with larger tumors, thus adversely affecting outcome. The need for early diagnostic tests and a hearing-conservation surgical approach is emphasized. Routine follow-up imaging studies are crucial to rule out the development of a contralateral acoustic neuroma in neurofibromatosis-2 (NF-2).

Vestibular autorotation test asymmetry analysis of acoustic neuromas.

The vestibular autorotation test (VAT) measures the vestibulo-ocular reflex (VOR) response from 2 to 6 Hz, during 18 seconds of active head movements, while the patient attempts to fixate on a wall-mounted target. A new method of measuring eye velocity asymmetry from VAT data is presented, based on computer estimation of the 0th harmonics of discrete Fourier spectra over short segments of digital eye and head velocity records. Eye asymmetries greater than a 3% normal range are shown to be directionally correlated with the side of the lesions in patients with unilateral labyrinthectomies. Among patients with a diagnosis of acoustic neuroma, who were tested preoperatively with the VAT, nine of nine patients showed eye asymmetries greater than 3% toward the side of the neuroma. Those patients with acoustic neuromas who have sufficiently vigorous high-frequency head responses showed mean percentages of eye asymmetry that were linearly correlated with the size of the acoustic neuroma. These results suggest that VAT high-frequency asymmetry provides a useful method of diagnostic evaluation of the side and extent of unilateral peripheral lesions.

Inflammatory torticollis in children.

Acute torticollis is commonly seen in the pediatric emergency department. It often results from an inflammatory process that irritates the cervical muscles, nerves, or vertebrae. Posturing of the head occurs with unilateral spasm of the sternocleidomastoid muscle such that the child will position the head with the occiput rotated to the affected side and the chin rotated to the contralateral side. We recently treated 26 children who presented to the emergency department with acute nontraumatic torticollis. The most common causes were upper respiratory infection, sinusitis, otomastoiditis, cervical adenitis, and retropharyngeal abscess or cellulitis. Four patients had subluxation of the atlantoaxial joint as a result of the inflammatory process. Children with acute torticollis need careful evaluation for either overt or occult otolaryngologic infections. Computed tomography and magnetic resonance imaging are helpful in determining the cause of the acute torticollis and in ruling out rotatory subluxation of the atlantoaxial joint.

Cervicofacial actinomycosis in children.

Actinomycotic infections, once common in humans and cattle, are now rare causes of disease in man. This general group of organisms belongs taxonomically between the true bacteria and the fungi; however, the organisms behave clinically like true anaerobes. The organism, although phagocytized by the host cells, is not killed. Therefore, it is defined as a facultative intracellular parasite of the host. The protean manifestations of actinomycotic infections often mimic infectious processes, such as osteomyelitis or granulomatous disease, as well as neoplasia. It is therefore important for the surgeon to include actinomycosis in the differential diagnosis of cervicofacial masses in children as well as in adults. Being an anaerobe, the organism is difficult to culture and the diagnosis must be considered at the time of biopsy of a cervicofacial mass or when culturing a sinus tract. A case of a 12-year-old girl seen at Children's Hospital of Los Angeles prompted the review of our experience with this disease. In this child, actinomycosis presented as an expansile mass in the mandible. From 1956 to 1986, five children were treated for cervicofacial actinomycosis. Detailed case analysis, pathophysiology, clinical characteristics, and current treatment recommendations are presented.

Retrolabyrinthine transsigmoid approach to basilar trunk and vertebrobasilar artery junction aneurysms. Technical note.

A retrolabyrinthine transsigmoid approach was employed successfully in three patients with vertebrobasilar aneurysms. The major benefits of this technique include a relatively shallow depth of exposure, lack of brain stem retraction, and simplicity as compared to traditional and some recently proposed methods. All three patients have returned to their previous activities.