Forehead flap in nasal reconstruction.

We establish criteria for anesthetic forehead flap reconstructions and evaluate the effect of mathematical models and computer simulation of the operation in preoperative and perioperative planning. We study a case series of 13 patients in an academic tertiary referral medical center. Most patients had nasal defects after Mohs' surgery for tumor ablation. Patients were followed up for 2 years after reconstructive surgery. Three patients underwent midline forehead flap nasal reconstructions, and 10 patients underwent paramedian forehead flap nasal reconstructions. We used patient satisfaction and physician evaluation of aesthetic form and function restoration as the main outcome measures. There were no major complications. Minor complications included short-term pincushioning in all patients, scar contracture that resolved after 8 months in one patient, and forehead necrosis after primary closure of the upper forehead in one patient. Computer simulation correlated two-dimension flap design to the transposition process. We conclude that the forehead flap is the optimal reconstructive modality for resurfacing large nasal defects. The paramedian forehead flap is superior to the midline forehead flap for nasal reconstruction, especially for distal tip reconstructions. Mathematical models and computer simulation of the reconstructive procedure that relate the two-dimensional flap design to the transposition process reveal subtle geometric relationships of the flap transposition that facilitate the design of the optimal flap for reconstruction.

Obstructive sleep apnea syndrome and acromegaly.

Obstructive sleep apnea syndrome is a complex disorder that has been associated with a variety of abnormalities of the upper airway, including tonsil and adenoid hypertrophy, nasal obstruction, retrognathia, and macroglossia. The cause of the airway obstruction in acromegaly is believed to be related to osseous and soft-tissue changes surrounding the upper airway, which lead to narrowing and subsequent collapse during sleep. We describe the results of treatment in seven patients with both sleep apnea and acromegaly. Four patients were treated by transsphenoidal hypophysectomy alone with a resolution of sleep apnea syndrome. One underwent hypophysectomy followed by postoperative radiation therapy, which reduced his apnea. Three patients underwent unsuccessful uvulopalatopharyngoplasty. Successful treatment of the primary disorder, in this case acromegaly, resulted in improved breathing during sleep in five patients. This series would suggest that acromegalic patients with sleep apnea should be treated for their pituitary tumor to reduce growth hormone before consideration of surgery to enlarge or bypass the upper airway.

Computer-assisted instruction in otolaryngology: the use of a database for examination review.

A database of questions and answers has been developed to assist residents in reviewing current topics in otolaryngology-head and neck surgery. Each question/item has an associated answer, general category, specific category, and reference that allows cross-referencing on the computer system. The user can search the database for categories of interest and obtain a specific subset of questions. This allows an efficient means of knowledge acquisition and review for Board examinations. Additional data entry is also facilitated to expand the database as desired. Currently there are more than 2300 items in the database.

Pharyngoesophageal intubation injuries: three case reports.

The hypopharynx and cervical esophagus are particularly vulnerable to intubation trauma. Contributing factors include hasty intubation by inexperienced personnel; the use of curved, beveled endotracheal tubes containing stylets; malpositioning of the head, and the application of cricoid pressure. Iatrogenic pharyngoesophageal perforations may go unsuspected until characteristic signs and symptoms are recognized. These include cervical pain, fever, dysphagia, leukocytosis, subcutaneous emphysema, and pneumomediastinum. We present three cases that illustrate important points in recognizing, evaluating, and treating pharyngoesophageal perforations. The third case presents a chronic cervical esophageal perforation with secondary pseudodiverticulum, requiring resection of the pseudodiverticulum and a primary sternocleidomastoid muscle flap repair of the cervical esophageal defect. To our knowledge, this technique has not previously been reported.

Cervicofacial actinomycosis in children.

Actinomycotic infections, once common in humans and cattle, are now rare causes of disease in man. This general group of organisms belongs taxonomically between the true bacteria and the fungi; however, the organisms behave clinically like true anaerobes. The organism, although phagocytized by the host cells, is not killed. Therefore, it is defined as a facultative intracellular parasite of the host. The protean manifestations of actinomycotic infections often mimic infectious processes, such as osteomyelitis or granulomatous disease, as well as neoplasia. It is therefore important for the surgeon to include actinomycosis in the differential diagnosis of cervicofacial masses in children as well as in adults. Being an anaerobe, the organism is difficult to culture and the diagnosis must be considered at the time of biopsy of a cervicofacial mass or when culturing a sinus tract. A case of a 12-year-old girl seen at Children's Hospital of Los Angeles prompted the review of our experience with this disease. In this child, actinomycosis presented as an expansile mass in the mandible. From 1956 to 1986, five children were treated for cervicofacial actinomycosis. Detailed case analysis, pathophysiology, clinical characteristics, and current treatment recommendations are presented.

Traumatic innominate pseudoaneurysm rupture during laryngeal dilatation.

Endotracheal hemorrhage from the innominate artery is, fortunately, a rare problem encountered by the otolaryngologist. We present a patient with a tracheal-innominate artery fistula secondary to delayed rupture of a traumatic innominate artery aneurysm. The differential diagnosis of innominate artery hemorrhage is discussed, as is the management of this potentially lethal event. We propose, as the treatment of choice, cessation of hemorrhage through the use of a cuffed endotracheal tube, followed by ligation of the innominate artery using cardiopulmonary bypass. These techniques were used in this patient with a successful outcome.

Frontal sinus fracture following osteoplastic frontal sinus obliteration.

A patient who sustained frontal sinus fracture and who earlier had undergone an osteoplastic fat obliteration procedure is described. The literature is reviewed and recommendations are made for management of this and other cases of frontal sinus fractures with posterior table involvement.