Feasibility of purely endoscopic intramedullary fixation of mandibular condyle fractures.

The investigators of this study hypothesized that fractures of the mandibular condyle can be repaired using short-segment intramedullary implants and purely endoscopic surgical technique, using a basic science, human cadaver model in an academic center. Endoscopic instrumentation was used through a transoral mucosal incision to place intramedullary implants of 2 cm in length into osteotomized mandibular condyles. The surgical maneuvers that required to insert these implants, including condyle positioning, reaming, implant insertion, and seating of the mandibular ramus, are described herein. Primary outcome was considered as successful completion of the procedure. Ten cadaveric mandibular condyles were successfully repaired with rigid intramedullary internal fixation without the use of external incisions. Both insertion of a peg-type implant and screwing a threaded implant into the condylar head were possible. The inferior portion of the implant remained exposed, and the ramus of the mandible was manipulated into position on the implant using retraction at the sigmoid notch. The results of this study suggest that purely endoscopic repair of fractures of the mandibular condyle is possible by using short-segment intramedullary titanium implants and a transoral endoscopic approach without the need for facial incisions or punctures. The biomechanical advantages of these intramedullary implants, including improved strength and resistance to mechanical failure compared with miniplates, have been recently established. The combination of improved implant design and purely endoscopic technique may allow for improved fixation and reduced surgical- and implant-related morbidity in the treatment of condylar fractures.

Strength of titanium intramedullary implant versus miniplate fixation of mandibular condyle fractures.

OBJECTIVE: To test the strength of internal fixation of mandibular condyle fractures repaired with titanium miniplates versus titanium intramedullary implants. STUDY DESIGN: Prospective laboratory experimentation in urethane mandible models and human cadaveric mandibles. SETTING: Materials testing laboratory at an academic medical center. METHODS: Osteotomies of the mandibular condyle were created in 40 urethane hemimandible models and 24 human cadaveric specimens. Half of the samples in each group were repaired with traditional miniplates, and the other half were repaired with intramedullary titanium implants. Anteroposterior and mediolateral loads were applied to the samples, and the displacement was measured with reference to the applied force. RESULTS: Titanium intramedullary implants demonstrated statistically significant improved strength and stiffness versus miniplates in the urethane model experimental groups. Despite frequent plastic deformation and mechanical failures of the miniplates, a 1.6-mm-diameter titanium intramedullary pin did not mechanically fail in any of the cases. Intramedullary implantation failures were due to secondary fracture of the adjacent cortical bone or experimental design limitations including rotation of the smooth pin implant. CONCLUSION: Mechanical implant failures that were encountered with miniplate fixation were not seen with titanium intramedullary implants. These intramedullary implants provide stronger and more rigid fixation of mandibular condyle fractures than miniplates in this in vitro model.

Pitfalls in endoscopic treatment of mandibular subcondylar fractures.

OBJECTIVES: The facial trauma surgeon should be able to list indications for endoscopic treatment of mandibular condyle fractures and discuss the limitations and complications of the technique. BACKGROUND: The ideal treatment of mandibular subcondylar fractures continues to be debated. Acceptable results are often obtained with conservative measures such as mandibular maxillary fixation followed by elastics. On the other hand, an open approaches result in potential risk injury to the facial nerve. These 2 arguments have cautioned many surgeons from open treatment of condylar fractures. Recent advances in endoscopic techniques have made the mandibular condyle more accessible with less risk to the facial nerve. As with any new technique, endoscopic treatment of mandibular subcondylar fractures is not without its own limitations and complications. METHODS: This was a retrospective case series. RESULTS: Three patients with mandibular subcondylar fractures with complications following endoscopic treatment were reviewed. There were a total of 4 condylar fractures (1 patient had bilateral fractures). There was 1 incidence of temporary facial nerve paresis, 1 failure of hardware positioning, 1 screw placement into the mandibular foramen, 2 condyles where adequate reduction of the fracture was impossible, and 1 failure to secure a screw into the proximal fracture segment. CONCLUSIONS: Endoscopic management of mandibular subcondylar fractures is a novel treatment with novel types of complications. Although promising, endoscopic treatment of mandibular subcondylar fractures should be approached prudently to avoid potential pitfalls.

The value of otolaryngologists' services in America: a national survey.

OBJECTIVE: To evaluate the perceived monetary value of physician services within the general population and to foster academic discussion about the finances of clinical practice in the setting of recent health care reform. STUDY DESIGN, SUBJECTS, AND METHODS: National survey of 409 members of the general population and review of Centers for Medicare and Medicaid Services data. RESULTS: The perceived monetary values of office visits were comparable to the actual physician reimbursements. However, the average perceived value associated with surgical treatments was significantly higher than the true Medicare reimbursement amount. For example, survey participants said that a reasonable price for a doctor to be paid for performing a tonsillectomy is $955.58, whereas the national average Medicare reimbursement is $257.74. Furthermore, 59% of respondents also believe that insurers, Medicare, and Medicaid pay doctors more than the respondent's perceived value for each service. CONCLUSION: The current patterns of Centers for Medicare and Medicaid Services reimbursement reveal a trend of declining payments for physician services. A survey of a sample of the general population indicated that most people believe that their doctors are paid far more than they actually are. It is important for otolaryngologists and head and neck surgeons to understand and discuss the economic forces that continue to shape our practices, and it is vital that we all play an active role in the discussions surrounding the evolution of the American health care system.

Resident physicians' perspectives on health care reform.

OBJECTIVE: To investigate the perspectives of resident physicians, in otolaryngology and other specialties, with respect to various health care reform proposals. Also, to determine if these opinions vary between residents training to become general medical doctors versus surgeons and specialists and between those with various levels of educational debt. STUDY DESIGN AND PARTICIPANTS: Survey of resident physicians across the United States. METHODS: Opinions of participants were measured on a 5-point Likert scale. RESULTS: Of the 1576 respondents, the majority agreed that tort reform and electronic medical records would improve quality of care and help contain health care costs. However, few residents agreed that bundling of services (BOS), hospital-acquired conditions penalties (HACP), and quality-based reimbursement (QBR) would improve the quality of care. Specialists and surgeons, in comparison to generalists, were (1) less likely to agree that BOS, HACP, or QBR would improve the quality of care; (2) more likely to agree that tort reform would help contain health care costs; and (3) more likely to believe that BOS, HACP, or QBR would decrease physician compensation. Higher educational debt burden was also an independent predictor of increased skepticism about health care reforms effects on physician compensation. CONCLUSIONS: Residents in general medicine and surgery/specialty training programs agreed that tort reform and electronic medical records would help improve the quality of health care and help contain costs. However, both groups expressed strong concern that certain elements of the Patient Protection and Affordable Care Act would not achieve these goals.

Miller fisher syndrome presents as an acute voice change to hypernasal speech.

The authors describe a 38-year-old man who presented with hypernasality, perioral and acroparesthesia, dyspnea, and dysphagia. Further evaluation revealed a diagnosis of Miller-Fisher syndrome (MFS). MFS is a variant of Guillain-Barré syndrome previously described in neurology and critical care journals; however, there is a paucity of work concerning this disease in the otolaryngology literature. An acute change in voice usually occurs secondary to inflammatory processes as seen after intubation and infection, but can occur as part of a more complex disease entity such as Guillain-Barré or Miller-Fisher syndrome. As such, clinicians should consider this in their evaluation of rhinolalia aperta.

Pi-bonded quinonoid transition-metal complexes.

Coordination of the carbocyclic ring of hydroquinones to electrophilic transition-metal fragments such as Mn(CO)3+ and Rh(COD)+ produces stable pi-bonded eta6-complexes that are activated to facile reversible deprotonation of the -OH groups. The deprotonations are accompanied by electron transfer to the transition metal, which acts as an internal oxidizing agent or electron sink. With manganese as the metal, the resulting eta5-semiquinone and eta4-quinone complexes have been used to synthesize one- two- and three-dimensional polymeric metal-organometallic coordination networks. With rhodium as the metal, the pi-quinonoid complexes have been demonstrated to play a unique role in multifunctional C-C coupling catalysis and in the synthesis of new organolithium reagents. Both classes of pi-quinonoid complexes appear to have significant applications in nanochemistry by providing an excellent vehicle for templating the directed self-assembly of nanoparticles into functional materials.

Prestorage leukoreduction prevents accumulation of matrix metalloproteinase 9 in stored blood.

OBJECTIVES: Transfusion of aged stored blood is associated with many neutrophil proinflammatory effects. The mechanism of these effects remains to be elucidated. The purpose of this study was to determine whether matrix metalloproteinases accumulate in packed red blood cells during storage and are responsible for some of the neutrophil proinflammatory events, and to determine whether prestorage leukoreduction prevents accumulation of matrix metalloproteinases and attenuates proinflammatory effects of stored packed red blood cells. DESIGN: Laboratory study. PARTICIPANTS: Healthy human volunteers. INTERVENTIONS: Units of blood were drawn from healthy volunteers. Half of each unit was filtered for leukoreduction, removing 99.9% of leukocytes. At biweekly intervals, aliquots were removed from packed red blood cell units, and the plasma fraction was isolated for assays. Plasma was assayed for specific molecules or incubated with isolated neutrophils, with or without a matrix metalloproteinase 9 inhibitor. MAIN OUTCOME MEASURES: Concentrations of matrix metalloproteinases 2 and 9 and tissue inhibitor of metalloproteinase 1; matrix metalloproteinase 9 activity; and neutrophil apoptosis. RESULTS: Concentrations of matrix metalloproteinase 9 and tissue inhibitor of metalloproteinase 1 but not matrix metalloproteinase 2 increased over time. This accumulation was abolished by leukoreduction. Matrix metalloproteinase 9 accumulated in an active form. Both leukoreduction and matrix metalloproteinase 9 inhibition reversed stored packed red blood cell-induced, delayed neutrophil apoptosis. CONCLUSIONS: Storage of packed red blood cells for 14 days or more is associated with increases in the concentrations of matrix metalloproteinase 9 and tissue inhibitor of metalloproteinase 1, with the enzyme in excess of its inhibitor. Prestorage leukoreduction prevents this accumulation. Delayed neutrophil apoptosis related to packed red blood cell plasma appears to be due, in part, to matrix metalloproteinase 9. Leukoreduction can help prevent the effects of matrix metalloproteinase 9 on neutrophil apoptosis.