Refined mastoid reconstruction with the pedicled postauricular perichondrial flap.

Successful canal wall reconstruction after open cavity surgery may be compromised by both immediate (graft dehiscence and infection) or delayed (graft retraction, absorption, and extrusion) complications. Many of the healing problems following canal wall reconstruction are related to incomplete soft tissue coverage of the graft and limited blood supply. Under these conditions, we sought to increase graft viability with a broad-based perichondrial flap developed from the posterior surface of the auricle. The flap was used over a period of 3 years at a tertiary referral center in 36 cases of canal wall reconstruction in conjunction with composite grafts of cartilage and perichondrium. The patients ranged in age from 12 to 63 years and in all cases had undergone a canal down tympanomastoidectomy that was reconstructed either primarily or secondarily. The canal wall was successfully reconstructed in 35 of 36 ears. These results demonstrate a reduction in our dehiscence rate from 10 to 3% since the introduction of the perichondrial flap. With the perichondrial flap, we were consistently able to achieve better soft tissue coverage of the composite cartilage graft, eliminate lateral graft dehiscence, and encourage reepithelization of the canal. By implication, we believe this flap provides a source of nutritional support for the free cartilage graft as well as the overlying skin.

Cervical osteomyelitis after percutaneous transtracheal ventilation and tracheotomy.

BACKGROUND: Percutaneous transtracheal ventilation has proven useful in emergent airway management. METHODS: A report of a case is presented. Results. A 42-year-old woman who developed laryngospasm required emergency airway intervention She developed massive subcutaneous emphysema and required emergent cricothyroidotomy which was immediately converted to a tracheotomy. Although she was quickly decanulated, she developed late cervical osteomyelitis which resolved with intravenous antibiotic therapy. CONCLUSIONS: Cervical osteomyelitis has not been previously reported as a complication of percutaneous transtracheal ventilation or tracheotomy Contamination of the deep neck spaces facilitated by pressure dissection of the fascial planes may have led to this complication.

Composite autograft "shield" reconstruction of remnant tympanic membranes.

The authors present their combined experience with large cartilage-perichondrial composite grafts used to reconstruct total tympanic membrane perforations in 294 ears. Patients chosen for this procedure had failed earlier tympanoplasty surgery or were identified as poor candidates for conventional facial tympanoplasty because of the perforation size. Successful perforation closure was achieved in 97% of ears with chronic otitis media characterized by absence of the tympanic membrane, including portions of the anterior annular ligament. Hearing results in general were good, considering the advanced stage of the disease, which required the use of alloplastic ossicular prostheses (PORP and TORP) in 76% of ears. Hearing improvement was maximal at 2000 Hz regardless of the method of ossicular reconstruction. Closure of the air-bone gap at this frequency to within 10 dB was achieved in 87% of type I tympanoplasties, 73% of type III (PORP), and 70% of type III (TORP) tympanoplasties. Although cartilage autografts have also been promoted to reverse tympanic membrane atelectasis, the authors believe that the above preoperative conditions are strong indications for this grafting technique, which is described in detail.

Head and neck liposarcoma. A histopathologic reevaluation of reported cases.

Head and neck liposarcoma is an extremely rare tumor. As with all rare lesions there is a void in the literature regarding tumor activity and treatment response. It is difficult to make rational treatment plans and advise patients as to probable treatment response and prognosis. To obtain as much information as possible from available data we have reviewed the world literature and reevaluated the descriptive histopathologic findings and treatment response of reported cases. Seventy-six cases have been reported since 1911. We added another case and then reclassified the previously reported lesions according to a current histopathologic system (well-differentiated, myxoid, round-cell, and pleomorphic lesions). We assessed tumor activity and treatment response by histopathologic tumor type. Paralleling tumor activity in other anatomic regions, all patients with myxoid and well-differentiated tumors did well; all were alive at the end of follow-up, eight of eight and 11 of 11, respectively (average follow-up, 5.7 and 4.8 years). This is compared with a 50% mortality rate in the round-cell and pleomorphic groups by the end of 2 years, (two of three and six of 11 patients alive, respectively). The likelihood of recurrence correlated with extent of tumor removal, and metastatic disease was identified almost exclusively with the tumor of the round-cell and pleomorphic variants. Surgical excision remains the primary treatment modality, while radiation and chemotherapy appear to be of limited utility.

Comparison of surgical approaches to the skull base.

The surgical accessibility of many complex areas of the base of the skull has expanded rapidly in recent years, as has the literature on these procedures. Several routes to each anatomic region have been described, although little has been written or illustrated comparing and contrasting the different approaches to the skull base. Thirteen representative surgical approaches will be discussed, accompanied by diagrams of accessible anatomic regions. Key features of each procedure will be compared and contrasted. A uniform presentation will be used, showing the incision for each procedure as well as the accessible anatomic areas in three views. Modern imaging techniques permit CT and MR data to be viewed in similar projections, facilitating the choice of surgical procedures.

Conservation laryngeal surgery. A critical analysis.

Three hundred forty-two cases of laryngeal cancer were treated at the University of Michigan, Ann Arbor. One hundred ten supraglottic cancers and 150 glottic cancers were studied in depth. Conservation surgery was performed on 63 patients. Determinate two-year disease-free survival for glottic cancer was 90% in those irradiated primarily, 83% for those treated with vertical hemilaryngectomy, and 58% in the group that had total laryngectomy. Supraglottic cancers had a determinate survival rate at two years of 62% for those irradiated primarily, 80% for those treated with a supraglottic laryngectomy, and 62% when total laryngectomy was required. The cost of preserving the respiratory and sphincteric functions of the larynx in some cases amounted to the morbidity associated with a protracted hospital stay, altered deglutition, instances of a weak but functional voice, and the possibility of a permanent tracheostomy. Despite high recurrence rates of 30% to 40%, the overall determinate survival with salvage was an acceptable 80% for the conservation surgery group.

Intraoral ligation of the maxillary artery for posterior epistaxis.

Intraoral ligation of the maxillary artery for intractable posterior epistaxis has been used effectively in 14 consecutive patients, all of whom had failed conventional anterior and posterior packing techniques. Fresh cadaver material was dissected in order to define the anatomic relationships of the infratemporal portion of the maxillary artery, as well as to develop the surgical technique prior to clinical application. The results indicate that this technique is rapid, safe, versatile, and effective in the majority of patients that require surgical interruption of the blood supply to the nose. The results of this study and the surgical technique are discussed.