Anesthetic Considerations for Oral, Maxillofacial, and Neck Trauma.

Blunt, penetrating trauma to the ear, nose, and throat, and related structures are striking. Injuries may range from simple soft tissue wounds to complex injuries of the face, neck, and brain. Proximity of the cervical spine and airway complicate anesthetic management. A multidisciplinary approach is required. Airway control has highest priority in initial care. Management of airway, breathing, and circulation need to be tailored to the patient. Decisions regarding airway management, ventilation strategies, monitoring, and fluid and blood administration should be based on the patient's condition, clinical setting, and the available personnel, expertise, and equipment.

Poorly differentiated plasmacytoid squamous cell carcinoma: Case report of a rare malignancy.

Plasmacytoid squamous cell carcinoma is an especially aggressive variant of squamous cell carcinoma that has previously been described in the literature as a variant of oral cancers and most extensively, in vulvular [3], transitional cell, and urothelial carcinomas [2,13,15-20]. In this case report, we present a 36-year-old man with 6 to 8 weeks of a progressively enlarging mass over the lateral third of his clavicle, acromion process, and deltoid. The mass was resected, and the supraclavicular defect was reconstructed using an anterolateral thigh free flap. Final pathology determined the specimen was an invasive poorly differentiated squamous cell carcinoma with spindle cell and plasmacytoid features of cutaneous origin. Plasmacytoid squamous cell carcinomas have previously been described in the oral cavity, but in no other subsite of the head and neck. This article describes the patient's case and provides a literature review of the available reports related to plasmacytoid variant of squamous cell carcinoma.

Necrotizing epiglottitis treated with early surgical debridement: A case report.

OBJECTIVE: Necrotizing supraglottitis is a rare but potentially morbid infection most often seen in immunocompromised patients. All reported cases have utilized intravenous antibiotic therapy as the mainstay of treatment and many have had associated morbidities. METHODS: We describe a case of a 50-year-old previously healthy female who presented with necrotizing epiglottis and was treated with immediate surgical debridement followed by directed antibiotic therapy. RESULTS: Our patient rapidly recovered with no further invasive interventions. On follow up she had no further complications or functional deficits. CONCLUSIONS: Although uncommon, providers should be aware of the potential benefits of early debridement when treating patients with similar pathology. Early surgical intervention should be considered to avoid local tissue loss, airway interventions, and long-term sequelae.

Facing the facts on prophylactic antibiotics for facial fractures: 1 day or less.

BACKGROUND: To evaluate the role of initial prophylactic antibiotics on facial fractures, outcomes were compared between a short course (≤24 hours) of antibiotics to those who received an extended course (>24 hours). METHODS: Adults admitted (2010-2015) to a Level I trauma center intensive care unit with at least one facial bone fracture and major injuries isolated to the head and neck were included. Our primary analysis compared infectious complications of the head or neck (H/N infection) between patients given short or extended courses of antibiotic prophylaxis. Multivariate logistic regression and analysis of propensity score matched pairs were performed. RESULTS: A total of 403 patients were included, 85.6% had blunt injuries and 72.7% had their facial fracture managed nonoperatively. The H/N infection rate was 11.2%. Two hundred eighty patients received a short course of antibiotics and 123 patients received an extended course. Median Injury Severity Score was 14 in both groups (p = 0.78). Patients receiving an extended course of antibiotics had higher rates of H/N infection (20.3% vs. 7.1%, p < 0.001). Factors associated with development of H/N infection included younger age, penetrating injury, open fracture, upper face or mandible fracture, fractures in multiple facial thirds, vascular injury, hypertension, and extended antibiotic course. Multivariate logistic regression identified younger age (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.96-1.00; p = 0.02), multiple facial third fractures (OR, 4.9; 95% CI, 2.4-10.2; p < 0.001), and penetrating mechanism (OR, 3.1; 95% CI, 1.5-6.4; p = 0.003) as independent predictors of H/N infection, but not antibiotic duration. Propensity score-matched analysis found no differences in H/N infection between short and extended antibiotic courses (11.4% vs. 12.5%; p = 1.0). Subgroup analyses demonstrated no differences in H/N infection between short or extended antibiotic courses by injury pattern, mechanism, or treatment (operative or nonoperative). CONCLUSION: These results lead us to believe that we should limit antibiotics to 24 hours or less upon admission for facial fractures. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Extracranial ligation of ethmoidal arteries before resection of giant olfactory groove or planum sphenoidale meningiomas: 3 illustrative cases with a review of the literature on surgical techniques.

OBJECT: There are several surgical techniques for reducing blood loss-open surgical and endoscopic-prior to resection of giant anterior skull base meningiomas, especially when preoperative embolization is risky or not technically feasible. The authors present examples of an institutional experience using surgical ligation of the anterior and posterior ethmoidal arteries producing persistent tumor blush in partially embolized tumors. METHODS: The authors identified 12 patients who underwent extracranial surgical ligation of ethmoidal arteries through either a transcaruncular or a Lynch approach. Of these, 3 patients had giant olfactory groove or planum sphenoidale meningiomas. After approval from the institution privacy officer, the authors studied the medical records and imaging data of these 3 patients, with special attention to surgical technique and outcome. The variations of ethmoidal artery foramina pertaining to this surgical approach were studied using preserved human skulls from the Hamann-Todd Osteological Collection at the Museum of Natural History, Cleveland, Ohio. RESULTS: The extracranial ligation was performed successfully for control of the ethmoidal arteries prior to resection of hypervascular giant anterior skull base meningiomas. The surgical anatomy and landmarks for ethmoidal arteries were reviewed in anthropology specimens and available literature with reference to described surgical techniques. CONCLUSIONS: Extracranial surgical ligation of anterior, and often posterior, ethmoidal arteries prior to resection of large olfactory groove or planum sphenoidale meningiomas provides a safe and feasible option for control of these vessels prior to either open or endoscopic resection of nonembolized or partially embolized tumors.

Temporal bone fracture: evaluation and management in the modern era.

Temporal bone fractures occur from high-energy mechanisms, typically but not limited to motor vehicle accidents. However, as the automotive industry continues to introduce improved safety measures, violence and falls account for a larger proportion of cases. Given the great forces involved, temporal bone fractures rarely occur in isolation and initial evaluation must focus on the fundamental ABCs of Advanced Trauma Life Support with special attention to Glasgow Coma Scale, intracranial injury, and cervical spine injury. Subsequent evaluation relies on physical examination, high-resolution CT, and electrodiagnostic testing to address the neurotologic consequences of temporal bone fracture, including cerebrospinal fluid leak, facial nerve injury, and injury to the peripheral hearing and balance organs. Management algorithms must address immediate (eg, ABCs, neurosurgical issues), short-term (eg, cerebrospinal fluid leak, facial nerve injury, hearing loss), long-term (eg, facial nerve injury, hearing loss, vestibular injury), and delayed (eg, encephalocele, cholesteatoma, late meningitis) issues. This article reviews the current state of temporal bone fracture evaluation and management with special attention to mechanisms of injury, clinical presentations and emergency evaluation, and diagnostic workup, including the evolution of radiographic fracture classification systems and electrodiagnostic testing. Discussion of treatment approaches address management of immediate, short-term, long-term, and delayed complications.