Complications of head and neck surgery in the elderly.

Many recent studies have documented that complications of head and neck surgery are no more common in the elderly than in younger patients. But few studies have addressed complication rates in a population undergoing reconstruction with microvascular free tissue transfer (MFTT). We compared outcomes of patients older and younger than 70 who underwent MFTT and found no significant difference in the incidence of surgical complications. However, older patients did experience more medical morbidity and more surgical mortality. Nonetheless, we conclude that MFTT should not be withheld from patients 70 years and older solely on the basis of their advanced age.

Tracheal transplantation: defining the vascular territory of the canine cranial thyroid artery.

The management of long-segment tracheal stenosis remains an unsolved clinical problem that has significant implications for the survival of some patients and the quality of life of others. However, recent advances in microvascular tissue transfer may allow tracheal transplantation to be used as a treatment option. Studies in dogs have demonstrated that the reanastomosis of the cranial thyroid artery (CTA) after the transplantation of a short segment of trachea sustains cartilage viability. However, the distal perfusion zone of the CTA within the canine trachea has not been described. Hence it is unclear what length of trachea can be safely harvested, with use of the CTA as the donor artery, without risking ischemia of the distal trachea. This study determined the perfusion territory of the CTA by use of latex or dye infusion via the thyroid branches of the CTA. Findings in five perfusion-fixed cadaver mongrel dogs (8 to 12 kg) were studied. In each dog, both common carotid arteries were dissected and the CTAs identified. The right CTA was ligated and the left common carotid artery was ligated cranial to the CTA. The left common carotid artery was perfused for 10 minutes under 100 mm Hg pressure with black india ink/saline solution (20:1000 ml) or with blue latex solution. Perfusion territories were determined by grossly and microscopically measuring the region of stain in the endolaryngeal and endotracheal airways. The results demonstrated that up to 18 ipsilateral rings of the canine trachea are perfused after injection of dye under physiologic pressure into the CTA. Contralateral staining was also noted, but to a lesser degree. These results suggest that the canine CTA may perfuse, on average, a 16- to 17-ring tracheal segment.

Characterizing the antigenic profile of the human trachea: implications for tracheal transplantation.

BACKGROUND: Tracheal transplantation may be a viable alternative in select situations of long-segment tracheal stenosis. Issues concerning human tracheal antigenicity and the requirement for systemic immunosuppression need to be addressed. This study examined the distribution of the major transplantation antigens on fresh human trachea. METHODS: Frozen sections of 10 human tracheas were examined for class I (HLA [human leukocyte antigen]-A, -B, -C) and class II (HLA-DR) histocompatibility antigens using mouse monoclonal antibodies in an indirect immunoperoxidase assay. The tracheal mucosa, perichondrium, cartilage matrix, and chondrocytes were examined and assigned a semiquantitative score for HLA class I and class II expression. RESULTS: The tracheal mucosa was strongly antigenic for HLA class I and class II antigens, whereas the perichondrium contained only scattered fibroblasts that were positive for both classes. The polysaccharide matrix was consistently devoid of class I or class II expression. The chondrocytes of all 10 specimens expressed diffuse class I positivity; only two specimens contained chondrocytes that expressed class II positivity. CONCLUSIONS: The human trachea contains "compartments" of highly antigenic tissue that are morphologically distinct from regions of lesser antigenicity.

Tracheal transplantation: superior and inferior thyroid artery perfusion territory.

OBJECTIVE: To determine the perfusion territories of the superior and inferior thyroid arteries in humans. Tracheal transplantation is a potential option for management of long-segment tracheal stenosis. However, the maximum length of vascularized trachea that can be reliably transplanted has not been established. STUDY DESIGN: The tracheal vascular territory of individual superior and inferior thyroid arteries was determined separately in 10 humans postmortem. METHODS: India ink was infused unilaterally under controlled pressure into the superior (n = 5) and inferior (n = 5) thyroid arteries of cadaveric tracheas. Tracheas were sectioned longitudinally and the caudalmost extent of mucosal dye staining was determined via microscopic assessment. RESULTS: The tracheal perfusion territory of the superior thyroid artery was two to five rings (1.7 +/- 0.5 cm) and the inferior thyroid artery, nine to 13 rings (6.5 +/- 1.1 cm). In both cases, the tracheal mucosa on the contralateral side was stained to the same caudal level. CONCLUSIONS: The inferior thyroid artery was shown to perfuse the trachea maximally to the 13th ring (8.1 cm). As such, the unilateral inferior thyroid artery would serve as a suitable vascular component for long-segment tracheal transplantation in humans.

Complications of microvascular head and neck surgery in the elderly.

OBJECTIVES: To evaluate the complications of head and neck reconstruction using microvascular free tissue transfers (MFTTs) performed in an elderly population and to determine whether these complications are more common than in a younger population. SETTING: Tertiary referral center. PATIENTS AND DESIGN: Retrospective, consecutive chart review of patients older than 70 years who underwent MFTT in the past 5 years (group 1). The complications in this population were compared with those in a second group (group 2) of consecutive patients younger than 70 years who were matched according to the site of the primary tumor. MAIN OUTCOME MEASURES: Surgical and medical complications. RESULTS: The median age for group 1 was 74 years and for group 2, 55 years. The overall complication rate for group 1 was 48%, compared with 57% for group 2. In group 1, surgical morbidity was less common and medical morbidity was more common than in group 2. Mortality rate was 6% for group 1 and 0% for group 2. The types of complications were similar for both groups. There was no difference in complication rates when complications were classified by site of the defect, patient status determined by American Society of Anesthesiologists classification, or use of preoperative radiation. The overall success rate of MFTT was 100% for group 1 and 94% for group 2. CONCLUSIONS: Microvascular free tissue transfers for head and neck reconstruction can be safely performed in the elderly. An age older than 70 years does not increase the rate of surgical complications following head and neck reconstruction with MFTT. Medical complications, however, are more common and are equally divided between bronchopulmonary and cardiovascular effects.

Botulinum toxin decreases salivation from canine submandibular glands.

The objective of this study was to determine whether botulinum toxin types A and D reduced the production of saliva from the submandibular glands of 18 dogs. The left submandibular glands of 8 dogs were injected with increasing doses of botulinum type A toxin (range 10 to 70 units), and the left glands of 10 dogs were injected with botulinum type D toxin (50 or 100 units). The right gland of each dog was injected with equivalent volumes of saline solution to serve as control. Six days after the injection, the lingual nerve was electrically stimulated for 10 minutes (3 mAmp, 20 Hz). The resulting volume of saliva was collected and weighed. Overall, the glands injected with types A or D toxin produced significantly less saliva than comparable glands injected with saline solution. Six of 8 dogs injected with type A toxin showed a significant decrease in saliva production (range 10.1% to 19.2%, one-sided p value = 0.0375) when compared with the controls. Nine of 10 dogs injected with type D toxin demonstrated a highly significant reduction in saliva production (total average decrease = 60%, two-sided pvalue = 0.001) when compared with the controls. We concluded that intraglandular injections of botulinum toxin types A and D significantly reduced the production of saliva from canine submandibular glands. The potential applications of intraglandular injections of botulinum toxin are discussed.

Clinical and molecular pathology of aggressive Schneiderian papilloma involving the temporal bone.

BACKGROUND: Inverting papilloma is a benign but locally aggressive sinonasal tumor that rarely involves the middle ear or temporal bone. METHODS: A report of a case and the molecular pathology of the tumor is presented. RESULTS: A 35-year-old woman with a history of recurrent inverting papilloma of the left paranasal sinuses was found to have evidence of extension through the eustachian tube and extensive involvement of the temporal bone. Surgical management resulted in the patient being disease-free at 14 months. Molecular pathology studies of the resected tumor suggest an association with human papillomavirus. CONCLUSIONS: Direct extension of the sinonasal tumor through the eustachian tube may represent the pathologic mechanism involved in the development of inverting papilloma involving the middle ear and temporal bone.

Staged repair of cervical tracheoesophageal fistulae.

Acquired, nonmalignant tracheoesophageal (TE) fistulae are most often iatrogenic or trauma induced. When a cervical TE fistula is complicated by tracheal stenosis or malacia, a single-stage repair of the fistula and tracheal defect is usually advocated. Complications of this single-stage repair, which occur in 25% to 50% of patients, are secondary to either excess tension at the tracheal anastomosis or the presence of inflammation at the time of tracheal anastomosis. Complications include recurrent tracheal stenosis, pneumonia, or a recurrent TE fistula. This report describes the senior author's techniques of reconstructing the trachea when tracheal stenosis complicates a TE fistula. These techniques are illustrated in two case reports of patients with postintubation TE fistulae. Current methods of tracheal reconstruction in this setting are reviewed. The incidence of postoperative complications may decrease if tracheal reconstruction is delayed until the fistula is successfully closed.

Rhinorrhea is decreased in dogs after nasal application of botulinum toxin.

At this time no effective long-term therapy exists for the excessive secretion of vasomotor rhinitis. Because rhinorrhea is under parasympathetic control, it was theorized that botulinum toxin--a powerful and long-acting cholinergic blocker that has been successful in the treatment of dystonia--might be useful in blocking the cholinergic control of rhinorrhea. Four male mongrel dogs were studied. Fifty units of type A botulinum toxin was soaked into sterile gauze, which was then packed into the left nasal cavity of each dog for 1 hour. Saline-soaked gauze was similarly introduced into the right nasal cavity to serve as control. Six days later, rhinorrhea was produced by inserting a bipolar needle electrode into the sphenopalatine ganglion and electrically stimulating for 10 minutes (6 mA, 50 Hz). Nasal secretions were collected with a suction catheter placed in the nasal vestibule. Three of four dogs exposed to the toxin showed a 41% average decrease in rhinorrhea (specifically 53%, 41%, and 30%). One dog showed a 10% increase in secretion after exposure to the toxin. We conclude that topically applied botulinum toxin reduced neurally evoked rhinorrhea by an average of 41%. Because some secretion is mediated by noncholinergic neurotransmitters such as vasoactive intestinal peptide, topical application of an anticholinergic substance has limitations. However, because all the nasal parasympathetic nerves appear to originate from cholinergic synapses in the sphenopalatine ganglion, direct injections of toxin into this ganglion may possibly allow complete blockade of all cholinergically mediated rhinorrhea.

Inverted papilloma: a report of 112 cases.

Inverted papilloma is a benign sinonasal tumor which is locally aggressive and has a significant malignant potential. This report updates the experience of the two senior authors, who have treated 112 patients with inverted papilloma at the Mount Sinai Medical Center over a 20-year period. As clinical examination often underestimates tumor extent, preoperative radiographic assessment is of paramount importance in guiding selection of surgical therapy. Complete en bloc excision via lateral rhinotomy and medial maxillectomy was the method of treatment in the majority of patients (84%). In selected patients with limited disease, or in patients who refused en bloc excision, conservative therapy employing intranasal or transantral ethmoidectomy was performed. The recurrence rates for the two groups were 14% and 20%, respectively. Recurrent disease developed throughout the paranasal sinuses, with the maxillary antrum and ethmoid labyrinth constituting the major sites. In two patients presenting with anterior skull base erosion, craniofacial resection was undertaken to eradicate disease. The latter cases underscore the aggressive nature of the tumor if left untreated. The overall rate of squamous carcinoma in this series was 5%. Given the predilection for local recurrence, multicentricity, and the possibility of malignancy, the authors continue to recommend lateral rhinotomy and medial maxillectomy as the standard therapy for the majority of cases. Management principles as well as a review of the literature are discussed.

Large thyroglossal duct cyst with laryngeal extension.

BACKGROUND: A thyroglossal duct cyst typically presents as a long-standing neck mass that becomes symptomatic when inflamed. Hoarseness is an uncommon complaint, and its association may suggest encroachment on and destruction of the larynx. Following removal of the cyst with the Sistrunk procedure, the larynx may need to be reconstructed. METHODS: A case is reported of a patient who was initially seen with hoarseness and a long-standing midline neck mass. Computed tomography (CT) demonstrated a large cystic neck mass that eroded the thyroid cartilage and encroached on the pre-epiglottic space and right paraglottic space. Although the clinical impression was that of laryngeal neoplasm, the CT diagnosis was that of a cyst. At surgery, a thyroglossal duct cyst was found and successfully removed with the Sistrunk procedure. Because the thyrohyoid membrane and thyroid perichondrium were preserved, the glottis did not require reconstruction. This case is presented and the literature of thyroglossal duct cysts that extend into the larynx is reviewed. CONCLUSIONS: The clinical and radiographic criteria that suggest encroachment of a thyroglossal duct cyst on the larynx are reviewed. The management and indications for laryngeal reconstruction are discussed.

Quantifying how location and dose of botulinum toxin injections affect muscle paralysis.

Despite the widespread use of botulinum toxin to treat muscle dystonias, no method exists to quantify muscle paralysis in either human or nonhuman models. In this study we examined how the location, dose, and volume of botulinum injection affects paralysis in the rat tibialis anterior muscle. Paralysis was quantified by electrically stimulating the nerve to the tibialis anterior and then staining sections of the muscle for glycogen. The areas of glycogen-containing fibers represented regions of botulinum action. The results showed that the most important injection technique is to inject botulinum directly into the motor endplate region of a muscle. Injections only 0.5 cm from the motor endplate resulted in a 50% decrease in paralysis. Increases in dose increased paralysis, however, some of that increase was simply due to the increased volume of injection. Thus, delivering toxin in small volumes near the MEP band of a muscle should produce the most effective paralysis.

Long-term morbidity and mortality in patients undergoing surgery for unilateral vocal cord paralysis.

Fifty-six patients who had undergone surgery for unilateral vocal cord paralysis (UVCP) were reviewed retrospectively. The etiologies; indications for surgery; timing of onset, diagnosis and surgery; complications; and survival rates are presented. Forty patients had neoplasms of which 32 were malignant and 8 were benign. UVCP was due to direct tumor involvement in 16 cases and surgical trauma in 21 cases. Mean survival for patients who presented with UVCP which was due directly to a malignancy was 5 months versus 22 months for those patients with UVCP due to surgical trauma during resection of malignancies. Mean survival for lung cancer patients was 5 months versus 24 months for patients with other malignancies. The etiology and manner of presentation of UVCP are important prognostic indicators which should be considered when planning surgical intervention for UVCP.

Quantifying the spread of botulinum toxin through muscle fascia.

Botulinum toxin was recently approved for treating several head and neck dystonias. Paralysis of neighboring muscles is the major complication of its use. Spread of toxin from the injected muscle has been suggested as an etiology. This study examines how botulinum toxin crosses muscle fascia by a novel method of quantifying muscular paralysis. Botulinum toxin (0.2 to 10 U) was placed onto the fascia of rat tibialis anterior (TA) muscles (n = 6). Toxin was also placed on dose-matched muscles that had their fascia surgically removed (n = 6). Twenty-four hours later, the nerve to the tibialis anterior was electrically stimulated to deplete the muscle fibers of glycogen. Toxin-paralyzed fibers retained their glycogen and appeared purple on periodic acid-Schiff (PAS) stain. Botulinum toxin easily passed through muscle fascia even at subclinical doses. The presence of fascia reduced the spread of botulinum toxin by 23%. These results suggest that spread of botulinum toxin can be prevented only by delivering small doses to the center of a target muscle.