Current trends in craniofacial reconstruction.

Reconstruction of the head and neck continues to pose a variety of difficult functional and aesthetic challenges to the plastic surgeon. While the surgical treatment for midfacial and skull base tumours continues to advance, the three-dimensional reconstruction predicaments continue to increase in complexity. Reconstructive strategies of the head and neck require the restoration of intricate skeletal architecture and large volumes of both internal and external soft tissue envelopes that can withstand adjuvant therapies. Vascularized bone grafts in combination with microsurgical techniques is the current trend of most reconstruction and has replaced local and pedicle flaps as the preferred modality for large defects. This article will focus on concise areas of difficulty in craniofacial reconstruction, including mandibular, midfacial, scalp and base of skull reconstruction. As our goals now move from flap survival to refinement, more complex and innovative reconstructions are executed. The problems with each modality are examined, and the frontiers of head and neck reconstruction are explored. With the potential combination of virtual surgery and tissue engineered biotechnology, we may someday be able to expand our reconstructive capabilities beyond free tissue transfer.

Adenotonsillar surgery in morbidly obese children: routine elective admission of all patients to the intensive care unit is unnecessary.

Morbidly obese children undergoing adenotonsillectomy, often with co-morbid obstructive sleep apnoea, may be considered at a higher risk of postoperative respiratory compromise. This retrospective study aimed to assess the frequency and severity of postoperative respiratory complications in these patients and to identify preoperative risks factors for such morbidity. Medical and nursing chart review of all consecutive elective post-adenotonsillectomy admissions of morbidly obese children (defined as >95th centile for body mass index adjusted for age and gender) to our intensive care unit over a 30-month period was performed. A total of 26 morbidly obese children were identified. The majority (14/26) had an uncomplicated recovery following surgery. Of those cases that required postoperative intervention, 10 patients required supplemental oxygen with or without suctioning and/or repositioning alone, whilst two required continuous positive airway pressure therapy. No patient required re-intubation. An oxygen saturation nadir of < 70% and the presence of more than one central apnoea, noted on preoperative overnight polysomnography, were associated with postoperative respiratory complications requiring intervention. Although the intervention group were younger, more obese and had a higher respiratory disturbance index, none of these factors were statistically significant. Routine admission to the paediatric intensive care unit of all morbidly obese children undergoing adenotonsillectomy may be unnecessary, once a suitable high level of nursing is available in an alternative setting, to administer simple positional and suctioning intervention and to perform regular patient observation. Special consideration should be given to the postoperative nursing environment for those patients with a SaO2 nadir < 70% noted preoperatively, indicating the presence of a significant central disease component.

Meatoplasty keloid: a rare lesion treated with an unusual surgical approach.

Keloid scarring is a benign hyperproliferation of fibrous tissue occurring at a wound healing site. Keloid formation related to the ear is generally the result of ear-piercing, mainly causing cosmetic disfigurement. We present an unusual case of keloid formation at a previous meatoplasty incision scar in a 10-year-old Caucasian with a modified radical mastoid cavity. This lesion prevented the cavity from self-cleaning and obstructed microscopic evaluation of the cavity. Treatment was successfully performed by surgical excision, with closure of the defect using supra-keloid skin flaps, followed by serial steroid injection therapy.

Parotid lymphomas - clinical and computed tomographic imaging features : otolaryngology

Objective. To review the clinical presentation and computed tomography (CT) imaging characteristics of all parotid lymphomas diagnosed at the study institution over a 7-year period. Design. Retrospective chart review of parotid lymphomas diagnosed between 1997 and 2004. Subjects. A total of 121 patients with parotid lesions were identified. After retrospective chart review; a total of 10 patients with histologically proven parotid lymphoma were included in the study; 8 of whom had CT scans available for assessment. Results. Ten patients with histologically proven lymphoma of the parotid gland were identified from among 121 patients with parotid neoplasms; an incidence in this series of 8.3. All lymphomas were of nonhodgkin's type. All patients presented with a painless unilateral parotid swelling. Most patients had a short history of less than 4 months' duration; of whom 3 presented with a rapidly evolving swelling of less then 1 month's duration. No patient had a background of SjA gren's disease or any other autoimmune disorders. The commonest finding noted on CT was of a unilateral; single mass of relative soft-tissue homogeneity with poorly defined; indistinct tumour margins. Associated loco-regional lymphadenopathy was identified in 2 cases; 1 clinically and another radiologically; multiple ipsilateral lesions were noted in 2 cases. No cases of contralateral disease were observed. Conclusion. Lymphoma has a clinical presentation similar to other neoplasms arising within the parotid gland. A unilateral; non-tender swelling was a universal finding. A history of less than 4 months may suggest the possibility of lymphoma. CT scanning is a useful adjunctive investigation to determine the site and extent of the disease; loco-regional nodal status and contralateral gland and neck status. Multifocality and associated adenopathy are associated with; but not exclusive to; parotid lymphoma. Although poor tumour boundary definition on CT imaging is a strong predictor of malignancy; no pathognomonic finding specific for lymphoma has been identified. The potential diagnosis of parotid lymphoma should be considered in all patients who present with a parotid mass

Systemic ototoxicity: a review.

BACKGROUND: Systemic ototoxicity is a significant cause of vestibulocochlear morbidity in sub-Saharan Africa. It may result in permanent hearing impairment and/or balance problems. OBJECTIVES: To review the literature pertaining to the ototoxic potential of three frequently prescribed systemic medications in the sub-Saharan setting; quinine, furosemide and aminoglycoside antibiotics. The pathophysiology, clinical manifestations and risk factors and risk minimisation strategies regarding the ototoxicity associated with these drugs are presented in order to highlight this problem and reduce the incidence of adverse outcomes. DATA SOURCES: The biomedical literature was systematically reviewed. This included a search of the National Library of Medicine's PubMed database (http://www.ncbi.nlm.nih.gov/ entrez/query.fcgi?db=PubMed). The search was limited to the English language literature and used the following search terms: ototoxicity; aminoglycosides; quinine; furosemide; gentamicin; vestibular toxicity; auditory toxicity; and Africa. STUDY SELECTION: Studies and reviews directly addressing clinical ototoxicity, experimental studies and studies regarding ototoxicity in sub-Saharan Africa were reviewed. The authors formed a consensus opinion regarding the most relevant articles considering factors including evidence level. DATA EXTRACTION: Systematic data extraction was undertaken from relevant studies. CONCLUSIONS: Quinine, furosemide and aminoglycosides are potentially ototoxic. High doses, prolonged treatment and intravenous administration increase this risk. The clinical condition of the patient may further predispose patients to ototoxic damage. Lack of monitoring facilities and efficacious, cost effective alternatives increase the risks of ototoxicity in the African setting. Clinicians must be aware of these risks and those patients at increased risk, and be vigilant in recognising their clinical manifestations.