Volume rejuvenation of the facial upper third.

The next three articles in this issue take a unique approach to discussing volumetric restoration. Robert Glasgold has provided an assessment for each facial region and five different renowned authors (TK, SPS, RF, SML, and EFW) have been asked to speak on a particular volumetric product, of which they are considered an expert, as it applies to the different regions of the face. The articles are broken into the following: (1) upper third which corresponds to the upper eyelid, brow, temple, and forehead; (2) middle third which will cover lower eyelid, cheek, and perioral area; and (3) lower third which discusses the marionette, prejowl, and jawline. Our hope is that by placing differing opinions of experienced authors, organized by facial region together, the reader will have the opportunity to more readily compare the options. The contributing authors and their product area are as follows: Theda Kontis, MD-hyaluronic acid; Steve Smith, MD-calcium hydroxyl appetite; Rebecca Fitzgerald, MD-poly-L lactic acid; Sam Lam, MD-polymethyl methacrylate; and Edwin Williams, MD-Autologous Fat Transfer. If the author included general comments on the product, they are included in the article on the upper face only and are not repeated. Please note that other individuals may also have significantly assisted in the production of these articles, but those listed above are the senior authors.

Volume management of the middle third-lower orbit/midface.

This is the second of the three articles discussing volumetric rejuvenation of the face. The previous article, Volume Rejuvenation of the Facial Upper Third, focused on the upper one-third of the face while this article focuses on the middle one-third, primarily the lower eyelid, cheek, and perioral area. Again, the authors (RG, TK, SPS, RF, SL, and EFW) from the upper face article have provided a summary of rejuvenation utilizing a product of which they are considered an expert. Robert Glasgold has provided volumetric analysis of the region as an introduction.

Volume rejuvenation of the lower third, perioral, and jawline.

This is the third and final article discussing volumetric rejuvenation of the face. The previous two articles, Rejuvenation of the Upper Third and Management of the Middle Third, focused on the upper two-thirds of the face while this article focuses on the lower face, including the marionette area, jawline, and neck. Again, the authors of the previous two articles have provided a summary of rejuvenation utilizing a product of which they are considered an expert. Robert Glasgold has provided volumetric analysis of the region as an introduction.

Extensive bilateral arteriovenous malformations of the mandible successfully controlled by combined endovascular and transcutaneous angio-embolization: case report and review of the literature.

We report a unique case of extensive bilateral arteriovenous malformation (AVMs) in a child's mandible, discuss treatment options and review literature. A healthy 8 year-old girl presented with bright blood of unknown source found on her pillow. Three large AVMs involving the symphyseal region and bilateral mandibular bodies were found on angiography. Due to the extent of surgical resection required, the patient underwent a series of endovascular and transcutaneous angio-embolization. In cases of extensive intraosseous AVMs, serial embolization procedures can be successful in controlling episodes of hemorrhage and allow for bone remineralization. A multidisciplinary approach by otolaryngologists and neurointerventional radiologists can optimize the results.

Vitamin D deficiency as a potentially modifiable risk factor for thyroid cancer.

BACKGROUND: Vitamin D, classically involved in calcium homeostasis, has garnered recent interest for its potential role in cancer prevention and therapy. Although few risk factors have been established in the development of well-differentiated thyroid carcinoma, some would argue that no clear modifiable risk factor exists. Our study is one of the first to explore the relationship between vitamin D deficiency and thyroid cancer. METHODS: This retrospective cohort study was done at a university-affiliated thyroid cancer centre. In 2010, 212 patients undergoing thyroidectomy had their preoperative 25-hydroxyvitamin D(3) levels recorded in addition to the final pathologies of their resected thyroid nodule. The patients were stratified based on vitamin D status; vitamin D deficiency (VDD), reflecting levels under the established threshold of 37.5 nmol/L; and vitamin D sufficiency (VDS), reflecting levels above it. The primary outcome of malignancy rate was used to compare the proportion of malignant nodules in the VDD versus the VDS groups. RESULTS: The malignancy rate rises when comparing the VDS and VDD groups, from 37.5 (33 of 88) to 75% (9 of 12), respectively, corresponding to a relative risk of 2.0 (p  =  .03, 95% CI 1.07-2.66). CONCLUSION: This is the first study to demonstrate the inverse relationship between VDD and well-differentiated thyroid carcinoma. Larger prospective studies are needed to replicate these results. Should this happen, VDD may be the first modifiable risk factor for thyroid cancer.

Vitamin D deficiency and the risk of hypocalcemia following total thyroidectomy.

OBJECTIVE: To determine whether patients with vitamin D deficiency (VDD) are at increased risk for hypocalcemia following total thyroidectomy. METHODS: A retrospective study of 246 consecutive patients undergoing thyroidectomy at a McGill University teaching hospital was conducted. Patients who had subtotal thyroidectomy or concomitant parathyroidectomy or whose laboratory tests were incomplete for analysis were excluded, as were pediatric patients. The remaining 139 patients had preoperative 25-hydroxyvitamin D [25(OH)D], corrected calcium, and parathyroid hormone (PTH) measured. Postoperatively, PTH and serum calcium were measured to assess for hypocalcemia. Low vitamin D (LVD) was defined as 25(OH)D ≤ 70 nmol/L (≤ 28 ng/mL), which includes vitamin D insufficiency, 25(OH)D > 35 nmol/L (> 14 ng/mL) but ≤ 70 nmol/L (≤ 28 ng/mL), and VDD, 25(OH)D ≤ 35 nmol/L (≤ 14 ng/mL). Adequate vitamin D (AVD) corresponded to levels > 35 nmol/L (> 14 ng/mL), whereas optimal vitamin D (OVD) levels corresponded to levels > 70 nmol/L (> 28 ng/mL). RESULTS: The rate of postthyroidectomy hypocalcemia in OVD patients was 10.4% (8 of 77) compared to 3.2% (2 of 62) in LVD patients (odds ratio  =  0.29, p  =  .10). There was no hypocalcemia in the 9 VDD patients, meaning that all hypocalcemic episodes occurred in patients with AVD (7.7%; 10 of 130). The mean preoperative PTH levels for LVD patients was 4.65 pmol/L (43 ng/L) compared to 4.18 pmol/L (38.9 ng/L) for OVD patients (p  =  .073). CONCLUSIONS: In this series, preoperative LVD did not predict early postthyroidectomy hypocalcemia. On the contrary, it showed a trend toward protective effect. Adaptive changes in the parathyroid glands, such as hypertrophy, hyperplasia, or the ability to secrete more hormone secondary to prolonged VDD, may contribute to this phenomenon. A large prospective study is needed to better understand the relationship between preoperative vitamin D levels and postoperative hypocalcemia.

The presence of unilateral tonsillar enlargement in patients diagnosed with palatine tonsil lymphoma: experience at a tertiary care pediatric hospital.

OBJECTIVE: There is a significant debate over the need for tonsillectomy to rule out lymphoma in cases of unilateral tonsillar enlargement. Several publications have suggested that the presence of unilateral tonsillar enlargement in children was an ominous sign of the possibility of underlying lymphoma. More recently, some authors have recommended that routine tonsillectomy in this context is not indicated given the low incidence of tonsillar lymphoma in the pediatric population and the high cost associated with this procedure. The aim of this study is to determine whether or not children diagnosed with tonsillar lymphoma originally presented with unilateral tonsillar enlargement. METHODS: We queried the tumour board registry records at a pediatric tertiary care institution from 1949 to January 2006 for all cases of tonsillar lymphoma. We examined the clinic, pre-operative and operative notes as well as the pathology results and noted the presenting signs and symptoms with a specific interest in the presence of unilateral tonsillar enlargement. RESULTS: Our query returned six patients with a diagnosis of palatine tonsil lymphoma. All six identified patients presented at their first visit with clinically apparent asymmetry of the tonsils. In all six cases B symptoms were absent at the first visit. CONCLUSIONS: We conclude that even though the majority of patients who have unilateral tonsillar enlargement will not have tonsillar lymphoma, most patients with tonsillar lymphoma will have unilateral tonsillar enlargement as one of their presenting signs. Therefore, despite the low incidence of this malignancy in children, careful close follow-up of these patients is warranted until the diagnosis has been ruled out given the potentially devastating consequences of missing this diagnosis or prolonging the time to treatment. Moreover, a low level of suspicion should warrant a tonsillectomy.

Factors affecting unanticipated hospital admission following otolaryngologic day surgery.

BACKGROUND: Day surgery constitutes an important part of modern otolaryngology practice. However, high rates of unplanned admissions remain an issue. OBJECTIVE: To determine the incidence, reasons, and predictive factors for unanticipated admission after ambulatory otolaryngologic surgery. METHODS: A retrospective review of all cases of unplanned admission following otolaryngology day surgery at a tertiary care centre over a 4-year period from 2000 to 2004. Data relating to patient demographics, physical status, surgical procedure, perioperative complications, and reasons for hospital admission were recorded. A case-control analysis of these parameters with nonadmitted day surgery patients was used for comparison. RESULTS: During the above period, 1106 patients underwent otolaryngologic day surgery, of whom 74 (6.7%) required admission. Fifty-seven percent of the patients were male, and the average age was 48.9 years. The three most common procedures with unplanned admission were open neck biopsy (27%), functional endoscopic sinus surgery (20.3%), and panendoscopy (16.2%). The reasons for admission could be divided into airway monitoring (37.7%), postoperative bleeding (28.6%), the need for supportive or pain management (19.5%), anesthetic complication (5.2%), cardiovascular complication (3.9%), clerical error (3.9%), and suspicion of a cerebrospinal fluid leak (1.3%). Risk factors for admission were determined to be an American Society of Anesthesiologists' class of 3 or greater, open neck surgical procedures, and a length of surgery of 60 minutes or greater. Minor factors included the use of general anesthesia, male gender, advanced age, and living far from a hospital. CONCLUSIONS: This study suggests strategies to reduce the rate of unplanned admission by means of careful preoperative assessment and planning, patient selection, careful scheduling of higher-risk patients, and appropriate postoperative observation and management.