Non-vascularized Fibular Cortex Grafts with Osteocutaneous Free Fibula Transfer: A Novel Technique in Midface Reconstruction.

OBJECTIVES: To present a method to reconstruct the midface using the fibula as both a microvascular free flap and as a free cortex graft. METHODS: 22-year-old male presented with bilateral maxillary odonotogenic myxoma. Bilateral total maxillectomy defects were reconstructed using an osteocutaneous fibula free flap. The nasomaxillary buttresses were augmented using free cortex grafts to provide additional soft tissue projection and lateral nasal support. RESULTS: The patient received dental implants at 10 months postoperatively and resumed a normal diet. His midface height, nasal and maxillary projection were adequate. At 36 months post-treatment he has no evidence of disease recurrence or resorption of the free bone grafts. CONCLUSION: The fibula free flap can be used to provide additional support to a patient's reconstruction by means of free cortex grafts. The patient has had successful restoration of pyriform aperture, nasal projection, mastication, and dental restoration using a single donor site.

Original report of bilateral carotid body tumors with 2 rare concomitant anatomic findings, an ectopic parathyroid gland and cervical thymus, with literature review.

BACKGROUND: Carotid body tumors are uncommon neoplasms with unique epidemiology and management demands. Cervical embryology is complex. Developmental abnormalities can result in ectopic displacement of native tissues. METHODS: We present the case of a 21-year-old female with bilateral carotid body paragangliomas who presented to our clinic seeking excision of the symptomatic right-sided tumor. RESULTS: The patient was successfully treated with surgical excision. Two rare anatomic variants were identified in her surgical specimen: a carotid sheath parathyroid gland and ectopic thymus tissue. CONCLUSIONS: This patient represents an unreported combination of pathologic and anatomic phenomena. The paraganglioma resulted from a familial genetic mutation that is well studied in this patient's ethnic population (Dutch), and the literature on this topic is reviewed herein. The 2 anatomic variants likely represent a single, embryologic glitch that will carry no physiologic sequelae. The clinical application of this ectopic anatomy and the common embryologic origins are discussed.

Endoscopic resection of juvenile nasopharyngeal angiofibroma.

Juvenile nasopharyngeal angiofibromas remain rare tumors representing approximately 0.05% of head and neck tumors. The typical presentation is a male teenager with recurrent epistaxis and nasal obstruction. These tumors were traditionally approached via external and/or intraoral incisions, but many are amenable to endoscopic removal. Preoperative embolization of major feeding vessels to these tumors by interventional radiology has resulted in significantly less blood loss and facilitated endoscopic resection. The following chapter discusses endoscopic resection of juvenile nasopharyngeal angiofibromas and outlines pertinent anatomy while covering important surgical techniques. Appropriate patient selection, anesthesia considerations, surgical preparation and techniques, and postoperative care are discussed. A case presentation is included with preoperative imaging and an accompanying video to demonstrate these surgical techniques.

Effects of antithrombogenic agents on microvenous anastomoses in a rat model.

OBJECTIVE: To compare venous thrombosis rates among animals treated with aspirin, clopidogrel bisulfate, and ketorolac tromethamine using an anastomotic "tuck" model. DESIGN: Single-blind randomized animal study. SETTING: An animal laboratory at a tertiary care academic referral center. SUBJECTS: Forty-two retired Lewis breeder rats divided into 3 equal groups. INTERVENTIONS: Before surgical intervention, 1 group received aspirin (10 mg/kg) through gavage; 1 group, clopidogrel bisulfate (5 mg/kg) through gavage; and the final group, ketorolac tromethamine (3 mg/kg) through intramuscular injection. Each rat was then anesthetized, and the femoral veins were prepared bilaterally. A 180° venotomy was made, and the vessels were anastomosed with the tuck model set-up for anastomotic failure. The vessels were checked for patency every 15 minutes for 2 hours after clamp removal. MAIN OUTCOME MEASURES: The rate of venous thrombosis and the time to thrombosis. RESULTS: In both the aspirin and clopidogrel groups, 2 of 28 vessels (7%) were thrombosed. Thrombosis occurred in 3 of 28 vessels (11%) in the ketorolac group (P = .86). All thromboses in the aspirin and clopidogrel groups took place at 7.5 minutes after clamp removal. In the ketorolac group, the mean time to thrombosis was 7.5 minutes (range, 0-22.5 minutes). There was no difference in time to thrombosis among the 3 groups (P = .86). CONCLUSION: Using a microvenous tuck model set-up for anastomotic failure, we found no difference in the rate of thrombosis or the time to thrombosis in rats pretreated with aspirin, clopidogrel, or ketorolac.

Free flap survival despite early loss of the vascular pedicle.

BACKGROUND: Early success of microvascular free tissue transfer is dependent upon the patency of the primary vascular pedicle. In time, neovascularization from the recipient bed and surrounding wound margins into the graft may be sufficient to maintain flap viability. The time necessary for successful neovascularization to occur is unclear. Most believe that prior radiation therapy will delay this process. METHODS: This case report describes a patient, status postchemoradiotherapy, who underwent composite resection with anterolateral thigh free flap reconstruction for a new base of tongue squamous cell carcinoma. On postoperative day 9 the vascular pedicle thrombosed secondary to abscess formation. RESULTS: Despite early loss of the arterial and venous pedicle, the flap survived completely. CONCLUSION: After microvascular free tissue transfer, neovascularization sufficient to maintain flap viability independent of the primary vascular pedicle may occur by postoperative day 9. This early revascularization can also occur despite a history of radiotherapy.

Migration of ingested foreign bodies into the thyroid gland: literature review and case report.

OBJECTIVES: We review the literature on the migration of ingested foreign bodies into the thyroid gland to analyze trends in patient presentation, evaluation, and management. Additionally, we present a case of an intrathyroidal foreign body from our own experience. METHODS: We searched the Medline database using key words "foreign bodies" and "thyroid gland," and present a new case report of an ingested foreign body that migrated to the thyroid gland. RESULTS: Our search generated 11 relevant articles with 15 total patients. All patients were female; 10 foreign bodies were fish bones, 2 were chicken bones, and 3 were wire bristles. The most common presenting symptoms were throat pain (67%) and dysphagia (47%). Computed tomography was the most sensitive test (100%), although cervical radiography also had high sensitivity (79%). Endoscopy was substantially less sensitive (38%). All patients required neck exploration. CONCLUSIONS: Radiographic evaluation has a high likelihood of detecting foreign bodies in the thyroid gland, and a computed tomographic scan is doubly useful because it assists in preoperative planning. Endoscopy has limited utility in cases of extraluminal migration, but should still be performed to evaluate soft tissue that is poorly visualized on a computed tomographic scan. Unless the foreign body can be removed endoscopically and there are no complications from migration or perforation, the definitive treatment is surgical.

Effects of synchronous nasal surgery on posttonsillectomy hemorrhage.

OBJECTIVE: To evaluate the effects of synchronous nasal surgery on the rate of posttonsillectomy hemorrhage. DESIGN: Retrospective medical record review. SETTING: Military tertiary referral center. PATIENTS: Adult patients identified in our surgical database from June 1, 2000, through September 31, 2005, who had undergone tonsillectomy or uvulopalatopharyngoplasty with tonsillectomy (UPPPT) either alone or with synchronous nasal surgery. MAIN OUTCOME MEASURES: The rate of posttonsillectomy hemorrhage was reviewed in all patients who underwent tonsillectomy or UPPPT at our medical center, and an investigation was conducted to determine whether synchronous nasal surgery altered this rate. RESULTS: A total of 1010 patients were included in this study, with a rate of posttonsillectomy hemorrhage of 5.5%. A total of 204 patients underwent synchronous nasal surgery. No significant difference was found between the hemorrhage rate in patients who underwent tonsillectomy or UPPPT alone and those who underwent synchronous nasal surgery (6.0% and 3.9%, respectively; P = .30). When these patients were further divided into those undergoing UPPPT and those undergoing synchronous nasal surgery, no significant difference in hemorrhage rate was found (6.2% and 2.0%, respectively; P = .06). CONCLUSIONS: Synchronous nasal surgery does not appear to increase the rate of postoperative hemorrhage in patients who undergo tonsillectomy alone or in those who undergo UPPPT. This information may help persuade physicians to perform synchronous surgical procedures instead of staging surgical procedures. In this regard, the patient requires only 1 anesthetic and 1 postoperative course without the risk of increased postoperative hemorrhage.

The effects of smoking on the rate of postoperative hemorrhage after tonsillectomy and uvulopalatopharyngoplasty.

OBJECTIVE: To evaluate the rate of posttonsillectomy hemorrhage and any change that smoking causes in patients who undergo tonsillectomy. DESIGN: Retrospective chart review. SETTING: Military tertiary referral center. PATIENTS: The study included 1036 adult patients who underwent tonsillectomy either alone or in conjunction with another procedure. MAIN OUTCOME MEASURES: The rate of postoperative hemorrhage was reviewed in all patients who underwent tonsillectomy at our medical center, and an investigation was conducted to determine whether smoking caused any alteration in this rate. RESULTS: A total of 1010 patients were included in the study, with a total bleeding rate of 6.7%. There was a significant increase in the rate of bleeding in all patients when they were divided into smokers and nonsmokers (10.2% and 5.4%, respectively; P = .01). The large difference was found by subset analysis to be attributable to a marked increase in postoperative hemorrhage in the patients who underwent uvulopalatopharyngoplasty (10.9% in smokers vs 3.3% in nonsmokers; P = .006) and remained significant when they were further subdivided by sex. Men who underwent tonsillectomy alone also bled significantly more than women (11.2% and 5.4%, respectively; P = .02). All other subsets analyzed did not reach statistical significance. CONCLUSIONS: Smoking does appear to increase the rate of posttonsillectomy hemorrhage in patients who undergo uvulopalatopharyngoplasty with tonsillectomy, but not in those who undergo tonsillectomy alone. This modifiable risk factor may help clinicians further counsel their patients before surgery, but further study is needed to ascertain that these findings apply to a broader patient base.

An unusual case of adult airway obstruction from a lymphovenous malformation.

Lymphatic, venous, and mixed lymphovenous malformations are low-flow lesions that are present at birth and grow proportionately with the patient. We describe an unusual presentation of a lymphovenous malformation in an adult. A 19-year-old man presented to the emergency department with complaints of recent upper respiratory tract symptoms, increasing left-sided sore throat, voice change, odynophagia, dysphagia, and occasional subjective fevers and blood-tinged sputum. Examination revealed the presence of a left peritonsillar bulge consistent with a peritonsillar abscess; however, findings on needle aspiration were negative. The patient was admitted for intravenous steroid and antibiotic therapy. Within 24 hours, his airway became compromised, and he underwent an awake tracheotomy and biopsy, which showed a lymphovenous malformation. Magnetic resonance imaging the following day revealed a large, poorly circumscribed, heterogeneous left parapharyngeal mass consistent with a vascular malformation. With continuation of the steroids and antibiotics, the lesion regressed, and the patient was subsequently decannulated. At the 1-year follow-up, he exhibited no clinical symptoms, and he was in good health off steroids.

Head and neck endocrine surgery in children: 1997 and 2000.

OBJECTIVES: To characterize children undergoing parathyroid, thyroid, and thyroglossal duct cyst surgery in 1997 and 2000 using a nationally representative discharge database to determine whether rates and outcomes of these surgical treatments vary by age, sex, and health care system attributes. DATA SOURCE: The 1997 and 2000 Kids' Inpatient Database, available through the Agency for Healthcare Research and Quality. STUDY SELECTION: All patients 18 years and younger undergoing head and neck endocrine (HNE) procedures were included. DATA EXTRACTION: The sampling scheme of this database allowed for calculation of national and regional estimates using Stata 7.0. DATA SYNTHESIS: An estimated 2077 and 1871 inpatient pediatric HNE procedures were performed nationally in 1997 and 2000, respectively. Most were performed at general (nonpediatric) teaching hospitals. There were an estimated 1102 thyroglossal duct cyst excisions, making this the most common HNE procedure and diagnosis. Thyroid lobectomy was the second most common HNE surgical treatment. Thyroid malignant neoplasm (usually treated by total thyroidectomy) was the second most common diagnosis. Neck dissections were performed in 32% of patients with thyroid malignant neoplasm. These HNE procedures accounted for more than 28 million dollars in hospital charges in 1997 and nearly 38 million dollars in 2000. CONCLUSIONS: Surgical treatment trends for pediatric HNE procedures remained stable between 1997 and 2000. Thyroglossal duct cyst excision and thyroid lobectomy are the most common procedures. There were regional differences in the rates of most HNE surgical treatments. In addition, hospital charges increased between 1997 and 2000.

Counseling patients on surgical options for treating acoustic neuroma.

The selection of surgical approach for the removal of AN is a complex one, depending on factors related to specific tumor anatomy, patient characteristics, and the familiarity and skill level of the skull base team.Overall, the literature supports that surgical outcomes are acceptable in regard to tumor removal, patient safety, and complication rates. The inconsistent reporting methods in the current literature make it difficult to assess logically the rates for hearing preservation, facial nerve outcome, and complications as controlled for tumor size and other preoperative patient characteristics. The best conclusions would be from prospective surgical trials controlling for patient factors, size of the tumor, and experience of the skull base team. In the absence of such studies, formal meta-analyses may help clarify specific differences among approaches.

Pediatric admissions and procedures for lymphatic malformations in the United States: 1997 and 2000.

OBJECTIVE: To describe the incidence of discharges for lymphatic malformation (LM) and the various treatments rendered for this condition in a nationwide sampling of pediatric discharges from 1997 and 2000. DATA SOURCE: The 1997 and 2000 Kid's Inpatient Database (KID), available through the Agency for Healthcare Research and Quality (AHRQ). DATA EXTRACTION: The sampling scheme of this database allowed for calculation of national and regional estimates using STATA 8.2. DATA SYNTHESIS: There were an estimated 3200 admissions for the treatment of pediatric LM in 1997 and 2000 combined. These admissions were most common in urban teaching institutions (69% in 1997 and 81% in 2000). The mean age at admission was 3.7 years, while the median was 1 year. The most common procedure performed in these children was surgical excision of the malformation. Over half of these were done in children under age 2. Airway endoscopy was the second most common procedure. Sclerotherapy was infrequently performed. The estimated national hospital charges for these admissions were $26 million in 1997 and $35 million in 2000. CONCLUSIONS: This analysis reveals a national perspective on the total number of pediatric admissions for LM and their associated inpatient procedures. Treatment trends for pediatric LM have remained relatively stable between 1997 and 2000, but hospital charges have increased.

Remission of chronic inflammatory demyelinating polyneuropathy following adenotonsillectomy.

Patients with chronic inflammatory demyelinating polyneuropathy (CIDP) experience proximal- and distalextremity weakness, sensory loss, and often hyporeflexia or areflexia. CIDP is associated with a variety of concomitant medical illnesses, which often manifest weeks before the onset of muscle weakness and paresis. We describe what we believe is the first reported case of an association between CIDP and recurrent acute adenotonsillitis, which we observed in an 11-year-old girl. Following adenotonsillectomy, the patient's CIDP went into remission and her overall physical condition improved with physiotherapy.