Botulinum toxin type b for the treatment of a sialocele after parotidectomy.

BACKGROUND: A 41-year-old male patient developed a sialocele after partial parotidectomy for a parotid pleomorphic adenoma. The sialocele was effectively treated by a single injection with botulinum toxin type B combined with multiple needle aspirations. METHODS: Ultrasound-guided infiltration of 2500 mouse-units of botulinum toxin type B in the residual parotid gland tissue under local anesthesia. Repeated needle aspirations were performed before and after the infiltration. RESULTS: Ten days after the injection, the patient was free of any discomfort. CONCLUSION: Botulinum toxin type B is effective in the management of postoperative sialocele after parotid gland surgery.

Stent migration to the ileum: a potentially lethal complication after Montgomery salivary bypass tube placement for hypopharyngeal stenosis after laryngectomy.

BACKGROUND: Montgomery salivary bypass tubes (MSBTs) have been used for decades in the treatment of stenoses and fistulae of the hypopharynx and the cervical esophagus. Generally, MSBT use is not associated with serious complications. Only a small number of cases with severe MSBT-associated complications have been reported in the literature. METHODS AND RESULTS: We report for the first time an MSBT migration to the ileum in a laryngectomized patient who underwent surgical pharyngocutaneous fistula closure with MSBT placement. The MSBT was removed surgically via laparotomy. The patient died 15 days later due to sepsis associated with peritonitis. CONCLUSION: To avoid potentially lethal complications associated with MSBT migration into the intestinal tract, we recommend secure fixation of the MSBT to a nasogastric tube.

Reconstruction of complex peripheral facial nerve defects by a combined approach using facial nerve interpositional graft and hypoglossal-facial jump nerve suture.

OBJECTIVES/HYPOTHESIS: To describe a modified facial nerve reconstruction technique for complex defects of the facial fan after parotid surgery that avoids synkinesis between upper and lower face. STUDY DESIGN: Retrospective case series. METHODS: Patients who had undergone radical parotidectomy with a large defect of the facial fan, reconstruction of the upper face by facial nerve interpositional graft, and reconstruction of the lower face by hypoglossal-facial nerve jump nerve suture were included in this series. RESULTS: Four patients underwent the modified combined approach after tumor resection and prior to postoperative radiotherapy in three of the four cases. Surgery was combined with an upper lid weight implantation. Regeneration of the face was successful in all cases within 12 to 16 months. Most important, the separated reanimation of the upper and lower face circumvented synkinesis of the upper and lower face. This factor was essential for good functional results. Using the hypoglossal jump technique instead of a classical cross-nerve suture technique prevented the sacrifice of ipsilateral tongue function. CONCLUSIONS: The presented method offers satisfactory results for facial reanimation and avoids synkinesis between the upper and lower face. Using the jump technique instead of a classic hypoglossal transfer as it was described originally for the combined approach avoids long-term sequelae for the tongue.

Diversity of treatment of T2N0 glottic cancer of the larynx: lessons to learn from epidemiological cancer registry data.

CONCLUSION: Neither elective selective neck dissection nor any conservative treatment option in pT2cN0 glottic cancer showed a significant advantage on survival. This should be the basis for future treatment standardization. Obligatory documentation of the R status and cause of death in the cancer registries will improve the data interpretation in the future. OBJECTIVES: Optimal adjuvant treatment of pT2cN0 glottic cancer is not well defined. The impact of neck dissection or radio(chemo)therapy for better outcome is unknown. METHODS: In a retrospective cancer registry study we analyzed the survival of 73 patients with pT2cN0 glottic cancer in Thuringia, Germany, treated surgically between 1996 and 2005. RESULTS: In all, 35 patients had undergone elective neck dissection, the remaining 38 patients had not. Histopathology revealed occult lymph node metastasis in three patients. Adjuvant radiotherapy was delivered to 17 patients and radiochemotherapy to 4. Overall, 52 patients received an adjuvant treatment. The 5-year recurrence-free survival rate was 60.8% and the 5-year overall survival rate was 56.5%. Multivariate but not univariate analysis revealed age >62 years (p = 0.05) and neck dissection (p = 0.033) as significant negative risk factors for tumor recurrence. Looking at overall survival, the site of primary surgery and radiotherapy were significant univariate risk factors, whereas multivariate analysis did not reveal any independent risk factor. No adjuvant treatment or combinations of adjuvant treatment resulted in better recurrence-free or overall survival (p = 0.253; p = 0.279).

Modern concepts in facial nerve reconstruction.

BACKGROUND: Reconstructive surgery of the facial nerve is not daily routine for most head and neck surgeons. The published experience on strategies to ensure optimal functional results for the patients are based on small case series with a large variety of surgical techniques. On this background it is worthwhile to develop a standardized approach for diagnosis and treatment of patients asking for facial rehabilitation. CONCLUSION: A standardized approach is feasible: Patients with chronic facial palsy first need an exact classification of the palsy's aetiology. A step-by-step clinical examination, if necessary MRI imaging and electromyographic examination allow a classification of the palsy's aetiology as well as the determination of the severity of the palsy and the functional deficits. Considering the patient's desire, age and life expectancy, an individual surgical concept is applicable using three main approaches: a) early extratemporal reconstruction, b) early reconstruction of proximal lesions if extratemporal reconstruction is not possible, c) late reconstruction or in cases of congenital palsy. Twelve to 24 months after the last step of surgical reconstruction a standardized evaluation of the therapeutic results is recommended to evaluate the necessity for adjuvant surgical procedures or other adjuvant procedures, e.g. botulinum toxin application. Up to now controlled trials on the value of physiotherapy and other adjuvant measures are missing to give recommendation for optimal application of adjuvant therapies.

Prognostic value of anterior rhinomanometry in diode laser turbinoplasty.

OBJECTIVE: To identify objective criteria predicting the success of diode laser-assisted turbinoplasty. DESIGN: Prospective before-and-after trial with follow-up of 8 weeks. SETTING: Outpatient department of a tertiary referral center. PATIENTS: Forty-one patients with nasal obstruction caused by hyperplastic inferior nasal turbinates. INTERVENTION: Active anterior rhinomanometry with and without decongestion was used to assess the patients both before and after diode laser-assisted turbinate surgery. Surgery was performed under local anesthesia in "contact mode" using a continuous diode laser. In addition, a questionnaire assessed the subjective postoperative benefit. MAIN OUTCOME MEASURES: Presurgical effect of topical decongestion was correlated with postoperative improvement of nasal airflow and patients' subjective satisfaction. RESULTS: Turbinoplasty significantly improved the mean (SD) nasal airflow by 37.1% (52.4%) (95% confidence interval [CI], 20.6%-53.7%), from 509.8 (189.2) cm³/s (95% CI, 450.1-569.5) to 660.9 (285.4) cm³/s (95% CI, 570.8-751.0) (P < .001). There was no significant correlation between patients' subjective satisfaction and improvement of nasal airflow postoperatively (r(s) = -0.01; P = .93). There was a strong correlation between the presurgical effect of topical decongestion and the improvement of nasal airflow by surgery (r(s) = 0.42; P = .01). The correlation was even stronger when the absolute values were adjusted by the preoperative nasal airflow baseline (r(s) = 0.55; P = .01). CONCLUSIONS: Rhinomanometry with topical decongestion has a high predictive value for the objective outcome of diode laser-assisted turbinoplasty. Thus, performing a rhinomanometry with topical decongestion and calculating the relative spread of decongestion can help to estimate the patients' benefit from diode laser-assisted turbinate surgery.

Electromyographic facial nerve monitoring during parotidectomy for benign lesions does not improve the outcome of postoperative facial nerve function: a prospective two-center trial.

OBJECTIVES/HYPOTHESIS: To analyze the benefit of electromyographic (EMG) neuromonitoring during primary surgery on benign parotid lesions for postoperative facial function compared to visual observation only. STUDY DESIGN: Prospective controlled clinical two-center trial. METHODS: Using an operation microscope, 100 parotidectomies in 96 patients were performed: 50 procedures with a continuous EMG monitoring plus visual facial observation (EMG group), and 50 procedures with only visual facial control (control group). The rate of postoperative facial weakness was detected. Patients with postoperative facial paralysis were followed up until total recovery or defective healing by repeated EMG examinations. RESULTS: Seventy-nine superficial and 21 total parotidectomies were performed. Histological analysis found pleomorphic adenoma in 38 patients, cystadenolymphoma in 39, and chronic parotitis in 18. Immediate postoperative facial paralysis was evident in 41 patients. Six patients had permanent paralysis; in this group definitive defective healing was detected by EMG in five cases. EMG was not classifiable in one case. Intraoperative EMG monitoring had no significant effect on immediate postoperative or definitive facial outcome (P =.23 and P = .45, respectively). The duration of superficial, but not of a total parotidectomy, was diminished in the EMG group (P = .02 and P = .61, respectively). This result was independent of the specimen's histology. CONCLUSIONS: EMG monitoring in parotid surgery in addition to visual facial observation did not diminish either the incidence of postoperative facial paralysis or the final facial outcome. Nevertheless, the duration of surgery for superficial parotidectomy could be reduced by using EMG monitoring.

The extent of thermal injury affects fractions of mononuclear cells.

BACKGROUND: The mononuclear cell (MNC) fraction contains a variety of cell types, including stem cells such as endothelial progenitor cells (EPCs). EPC can rapidly revascularise ischaemic areas, but their role in burns is unclear. AIM: This study investigates how thermal injury to the skin might influence mononuclear cells, CD34(+) cells and circulating EPC. METHODS: The study group comprised 17 people with burns and 17 age-matched controls. Blood samples were collected at five different time points during the first 5 days of hospitalisation. Clinical parameters and scores were documented as well as cell counts for MNC, CD34(+) cells and EPC. Counts were quantified by fluorescence-activated cell sorting. Serum was tested for vascular endothelial growth factor VEGF(165) by ELISA. RESULTS: All cell populations displayed significant, differing changes in counts and percentages after burn. These effects varied markedly over time and expressed different patterns if clinical scores were subjected to significance testing. EPC counts were significantly lowered in cases with fatal outcome. CONCLUSION: Burn affects the numbers of circulating MNC, CD34(+) and EPC. These time-dependent changes imply involvement of these cell groups in the trauma. EPC counts seem to be a predictive factor for outcome of cases of severe burn.