Barotrauma of the ears and sinuses after scuba diving.

The pathophysiology, differential diagnosis, and currently available management of barotrauma affecting the ears and sinuses after scuba diving are reviewed, along with medical standards for resuming scuba diving after barotrauma has resolved.

Management of large Mohs defects.

This study was performed to determine the appropriateness and relative merits of closing Mohs defects of the head and neck at the time of surgery or after surgery, in contrast with allowing defects to heal spontaneously. For 185 patients who had large Mohs wounds of the head and neck (scalp, nose, cheek, forehead, lip, chin, ear, or neck) that healed spontaneously and who underwent postoperative reconstruction as required, we recorded wound location, size, and depth. We then evaluated the cosmesis and functional result periodically and > or = 6 months after operation by chart review, interview, or both. We found that large wounds of the scalp, neck, and ear (except through-and-through defects) often heal spontaneously with acceptable cosmesis. Large defects of the nose usually require prompt reconstruction. Large defects of the central cheek, lip, and chin usually heal spontaneously with poor cosmesis. However, we often reserve surgery for an unacceptable cosmetic result, because repairing a small scar is often less complex than reconstructing a large Mohs defect. We conclude that spontaneous healing of selected Mohs wounds of the head and neck can result in satisfactory cosmesis and function, thus obviating or minimizing the need for complex surgical repair. Surgeons can select management of Mohs wounds effectively and efficiently by accurately predicting the final cosmetic and functional result of spontaneous healing, thus reserving surgery for unfavorable cosmetic or functional results.

Neurological consequences of scuba diving with chronic sinusitis.

Sinus barotrauma from scuba diving is relatively common, usually self-limiting, and often the result of transient nasal pathology. We describe serious neurological sequelae occurring in two scuba divers who had chronic sinusitis We suggest guidelines for evaluating and treating divers who have chronic sinusitis. Divers with nasal or sinus pathology should be aware of the potentially serious consequences associated with scuba diving even after endoscopic sinus surgery to correct this condition.

Secondary intention healing of exposed scalp and forehead bone after Mohs surgery.

For Mohs surgical wounds that show exposed bone (ie, bone denuded of periosteum), healing by secondary intention may be preferable to surgical reconstruction. To determine the appropriateness of secondary intention healing, we reviewed surgical outcome in 205 patients with Mohs wounds of the scalp and forehead that had healed by secondary intention. Of these patients, 38 had Mohs wounds showing exposed bone. The mean area of exposed bone was 1074 mm(2); the mean area of exposed soft tissue was 1575 mm(2). The mean time for wounds with intact periosteum to epithelialize was 7 weeks; the mean time for bare bone to epithelialize was 13 weeks. All wounds healed without infection or tissue breakdown. We conclude that secondary intention healing of scalp and forehead wounds showing exposed bone is a safe and effective method of wound management after Mohs surgery.

Spontaneous healing of Mohs wounds of the cheek: a cosmetic assessment.

BACKGROUND: Facial defects after Mohs surgery may be closed at the time of surgery, shortly thereafter, or allowed to heal spontaneously. Selection of appropriate management options requires accurate prediction of the final cosmetic result. OBJECTIVE: To determine the relative merits of treatment options for facial defects resulting from Mohs surgery. METHODS: We prospectively and retrospectively analyzed outcomes for 132 wounds of the cheek resulting from Mohs surgery and allowed to heal spontaneously. The cheek was delineated into topographic areas and the wound location, size, and depth were recorded. Patients were observed intermittently, and a final evaluation of cosmesis was made after > or = 6 months. RESULTS: Most wounds in the nasolabial fold and preauricular areas healed with excellent results and half the wounds in the medial area of the cheek healed with good or excellent results. Central and mandibular areas of the cheek healed unpredictably, and results were unsatisfactory for most of these wounds. CONCLUSION: Final cosmetic results of Mohs surgery in the cheek area can be predicted on the basis of location, size, and depth of the wound, enabling physicians to knowledgeably select the most suitable treatment option.

Mohs wounds of the forehead: healing by secondary intention.

Accurate prediction of the course of wound healing allows patients with Mohs surgical wounds on the face to be objectively selected either for surgical repair or for spontaneous healing. Parameters affecting wound healing--location, depth and size of wound--were documented at intervals for 135 patients who had full-thickness defects in the forehead after Mohs surgery, which were left to heal by secondary intention. Quality of cosmesis was determined at least four months after surgery. Final cosmetic result was predictable on the basis of wound location, size and depth. Allowing selected Mohs surgical wounds to heal spontaneously offers optimal cancer surveillance, simplified wound care and elimination of reconstructive procedures along with their associated costs and potential complications.

Healing by secondary intention of auricular defects after Mohs surgery.

OBJECTIVE: To evaluate secondary intention healing of full-thickness skin defects of the auricle. Immediate reconstruction of full-thickness skin defects after cancer surgery is an accepted surgical method used to preserve function and to minimize cosmetic deformity. However, healing by secondary intention offers the advantages of optimal cancer surveillance, simplified wound management, and avoidance of reconstructive procedures with their associated costs and potential complications. Accurate prediction of the course of wound healing would allow a rational approach to selection of patients for surgical or nonsurgical repair. DESIGN: We observed 133 patients with full-thickness auricular defects (helix, antihelix, concha, pretragal and tragal area, lobule, and posterior aspect) after Mohs surgery and documented a variety of parameters affecting wound healing, including the location, depth, and size of the wound and use of antibiotics. Patients were examined at intervals and determination was made regarding cosmesis at least 6 months after surgery. RESULTS: All wounds healed by secondary intention within 10 weeks. Analgesics were generally not required. Antibiotics were arbitrarily used in 13% of the patients. Three infections occurred with no permanent disfigurement. CONCLUSIONS: The location of the wound in the auricular subunit is predictive of the cosmetic result. Exposed cartilage is not a contraindication for secondary intention healing. Prophylactic antibiotics are not routinely required when exposed cartilage is present. The results of secondary intention healing are often more cosmetically pleasing than those of surgical repair.

Outcome analysis of Mohs surgery of the lip and chin: comparing secondary intention healing and surgery.

Wounds of the lip and chin resulting from microscopically controlled (Mohs) surgery are often repaired immediately. However, wounds allowed to heal by secondary intention have the advantage of optimal cancer surveillance, simplified wound care, and avoidance of the costs and potential complications associated with reconstructive procedures. Accurate prediction of the course of wound healing would allow a rational approach to selection of surgery or healing by secondary intention. The authors evaluated 105 patients with defects of the lip and chin after Mohs excision for cancer who healed by secondary intention. Forty-six patients treated surgically were followed for comparison. The lip and chin were divided into subunits and the wound location, size, and depth were recorded. Patients were followed at intervals and a final determination regarding cosmesis was made after 6 or more months. It is concluded that the final cosmetic result can be confidently predicted on the basis of location by subunit, size, and depth of the wound.

Collagen-assisted healing of facial wounds after Mohs surgery.

Allowing selected full-thickness skin defects to heal by secondary intention offers the advantages of optimal cancer surveillance, simplified wound management, and avoidance of reconstructive procedures with their associated costs and potential complications. The topical use of bovine collagen has been suggested as a method of enhancing wound closure and final cosmetic appearance. This study evaluated the effect of bovine collagen on wound healing in patients undergoing facial Mohs surgery using the fresh-tissue technique. A total of 111 consecutive patients were assigned to a collagen or no-collagen group. Wound care was identical except for the weekly addition of bovine collagen to the wound of patients in the collagen group. Evaluation was at weekly intervals until the wound epithelialized, then bimonthly for at least 6 months. There was no difference in the rate of wound epithelialization or final cosmetic appearance. This study provides no evidence that the topical use of bovine collagen in a facial wound after Mohs surgery enhances wound epithelialization or the final cosmetic appearance.

Uvulopalatopharyngoplasty for snoring: long-term results.

Uvulopalatopharyngoplasty (UPPP) has become a widely practiced procedure in the management of snoring. In a number of studies, all based on short-term follow-up, snoring was reduced or eliminated in 75% to 95% of patients. Because a decline in the initial success rate was casually observed, a formal analysis of the initial and long-term results of UPPP for snoring was made in the present study. From 1985 to 1989, 69 patients with severe habitual snoring were retrospectively analyzed. A scoring system was devised for snoring, and each patient was interviewed regarding the effects of UPPP on his or her snoring 16 to 75 (mean 44) months after surgery. In 60 (87%) of 69 patients, snoring was initially significantly reduced or totally eliminated. After 13 months the success rate dropped to 46% (32 of 69 patients). Most failures occurred between 6 and 12 months of surgery, after which time the success rate remained relatively stable. The authors' conclusion that the long-term success rate of UPPP for snoring declines significantly with time has obvious implications regarding presurgical patient counseling.

Temporal bone pathology in scuba diving deaths.

Scuba diving has long been associated with otologic injuries; however, little is known about temporal bone pathology in diving-related deaths. We examined 18 temporal bones from 11 divers who died, primarily from complications of rapid ascent. Bleeding into the middle ear and mastoid air cells was nearly universal. Inner ear damage included hemorrhage around Reissner's membrane and the round window membrane and rupture of the utricle and saccule. Most of the observed inner ear damage was not surgically treatable.

Inner ear barotrauma in scuba divers. A long-term follow-up after continued diving.

Divers who suffer inner ear barotrauma are usually counseled to permanently avoid diving, reasoning that the injured inner ear is at increased risk of further damage. Twenty patients who suffered inner ear barotrauma while diving, but continued to dive against medical advice, were assessed on an interim basis for 1 to 12 years. As difficulty equalizing the ears during the barotraumatic event was a universal finding, prior to resuming diving, all patients were reinstructed on methods of maximizing eustachian tube function. No further deterioration of cochleovestibular function was noted. Based on these preliminary results, we conclude that recommending no further diving after inner ear barotrauma may be unnecessarily restrictive.

Nonsurgical repair of perinasal skin defects.

Immediate reconstruction of full-thickness skin defects after cancer surgery is a commonly accepted surgical principle used to preserve function and minimize cosmetic deformity. Healing by secondary intention, however, offers the advantages of optimal cancer surveillance, simplified wound management, and avoidance of reconstructive procedures with their associated costs and potential complications. Accurate prediction of the course of wound healing, and thereby the final functional and cosmetic result, would allow a rational approach to selection of patients for surgical or nonsurgical repair. We observed 282 patients with full-thickness perinasal (glabella, medial canthus, dorsum, sidewall, tip, ala, philtrum, alar base, and nasolabial fold) skin defects after Mohs' surgery and documented a variety of parameters affecting wound healing, including location, depth, and size of the wound. Patients were examined at intervals, and a final determination regarding cosmesis and function was made at 6 months or later. We conclude that the most important considerations in predicting the final functional and cosmetic result include location by subunit, followed by size and depth of the wound.

Extended single transverse neck incision for composite resections: does it work?

Since Crile's original description of neck dissection in 1906 (Crile GW: JAMA 47:1780-1786, 1906), a variety of neck incisions has been described, suggesting that none is sufficiently versatile to satisfy the criteria necessary for the ideal neck flap. Single transverse neck incisions (STNI) for complete neck dissections have been performed since the 1950s but are not as commonly used as trifurcate incisions. A criticism of the STNI is that the perceived difficulty exposing the surgical field may compromise removal of disease and impair normal surgical technique, resulting in a higher incidence of recurrent neck disease and postoperative complications. One hundred nine patients with squamous cell carcinoma of the head and neck were operated using the STNI. There was no incidence of skin necrosis or carotid artery hemorrhage. Fourteen percent developed fistulae and 12% developed wound dehiscences. Recurrence in the operated neck was not identified. Cosmesis was considered good in all patients. We conclude that STNI does not result in an increased incidence of postoperative complications or recurrent neck disease compared with standard trifurcate incisions.

Quantitative bacteriology of intraoperative wound tissue in contaminated surgery.

This study was designed to evaluate the predictive value of quantitative bacteriology of intraoperative wound tissue in identifying the patient likely to develop wound infection, as well as its subsequent flora. Forty-one patients undergoing contaminated cancer surgery of the head and neck were studied. Intraoperatively, a sample of wound tissue was cultured and anaerobic and aerobic bacterial isolates quantitated. The wound infection rate was 22% (9 of 41). There was no significant correlation between intraoperative tissue bacterial density and subsequent wound infection, or contaminating and infecting bacteria.

Quantitative bacteriology of closed-suction wound drainage in contaminated surgery.

This study was designed to evaluate the predictive value of quantitative bacteriology of closed-suction postoperative wound drainage in identifying the patient likely to develop wound infection as well as its subsequent flora. Forty-one patients undergoing major cancer surgery of the head and neck were studied. Postoperatively, closed-suction wound drainage was cultured, and anaerobic and aerobic bacterial isolates were quantitated. The wound infection rate was 20% (8/41). No trend toward increased rate of wound infection with increased numbers of bacteria colonizing the wound was observed. Additionally, there was no consistent correlation between species of bacteria isolated from closed-suction wound drainage and recovery from subsequent wound infection. Quantitative bacteriology of closed-suction wound drainage after contaminated head and neck cancer surgery does not accurately predict which patients were likely to become infected, or the probable bacteriology of subsequent wound infection.

Midline granuloma due to illicit cocaine use.

The successful treatment of patients with midline granuloma requires prompt recognition of the cause as the therapy is quite specific. Nasal insufflation of cocaine is rarely mentioned as a cause. Two patients are described who used intranasal cocaine, leading to midline ulceration of the upper respiratory tract.