Manually provided temporary maxillomandibular fixation in the treatment of selected mandibular fractures

OBJECTIVE

To report the occlusal outcomes of manually provided temporary intraoperative maxillomandibular fixation (MMMF) for the open repair of selected mandibular fractures. STUDY DESIGN/SUBJECTS AND METHODS: A retrospective chart review of the patients who underwent open reduction and internal fixation of mandibular fractures with MMMF was performed.

RESULTS

Twenty-six patients underwent open reduction and internal fixation with MMMF. Postoperative data were available for only 16 patients who kept their follow-up appointments. With the exception of one patient who experienced minimal cross-bite in the right molar region, all of the patients had their original normocclusion.

CONCLUSION

Preliminary results of MMMF suggest that satisfactory postoperative occlusal outcomes may be obtained without the use of wire-based maxillomandibular fixation methods in selected mandibular fractures.

The effects of laser irradiation on Trichophyton rubrum growth

The effects of various laser wavelengths and fluences on the fungal isolate, Trichophyton rubrum, were examined in vitro. Standard-size isolates of T. rubrum were irradiated by using various laser systems. Colony areas were compared for growth inhibition on days 1, 3, and 6 after laser irradiation. Statistically significant growth inhibition of T. rubrum was detected in colonies treated with the 1,064-nm Q-switched Nd:YAG laser at 4 and 8 J/cm(2) and 532-nm Q-switched Nd:YAG laser at 8 J/cm(2). Q-switched Nd:YAG laser at 532- and 1,064-nm wavelengths produced significant inhibitory effect upon the fungal isolate T. rubrum in this in vitro study. However, more in vitro and in vivo studies are necessary to investigate if lasers would have a potential use in the treatment of fungal infections of skin and its adnexa.

Combining use of resin models with external fixation in mandibular reconstruction

OBJECTIVE

To obtain accurate occlusion in mandibular reconstruction when the tumor is exophytic, which makes prebending the plate impossible.

DESIGN AND SETTING

Use of computed tomography-based resin models and external fixation devices is combined in a tertiary academic center. The exophytic part of the tumor on the model is burred off, and the reconstruction plate is bent on the model before surgery. Temporary external fixation is applied before resection, and a precontoured plate is applied following segmental resection before the release of external fixation.

RESULTS

Six patients underwent mandibular reconstruction by using this technique, and all of the patients retained a class 1 occlusal relationship without need for additional intraoperative plate contouring.

CONCLUSION

Computer-generated resin models of the mandible combined with intraoperative temporary external fixation allow the maintenance of preoperative occlusal status.

The effects of intense pulsed light (IPL) on blood vessels investigated by mathematical modeling

BACKGROUND AND OBJECTIVES

Intense pulsed light (IPL) sources have been successfully used for coagulation of blood vessels in clinical practice. However, the broadband emission of IPL hampers the clinical evaluation of optimal light parameters. We describe a mathematical model in order to visualize the thermal effects of IPL on skin vessels, which was not available, so far.

STUDY DESIGN/MATERIALS AND METHODS

One IPL spectrum was shifted towards the near infrared range (near IR shifted spectrum: NIRSS) and the other was heavily shifted toward the visible range (visible shifted spectrum: VSS). The broadband emission was separated in distinct wavelengths with the respective relative light intensity. For each wavelength, the light and heat diffusion equations were simultaneously solved with the finite element method. The thermal effects of all wavelengths at the given radiant exposure (15 or 30 J/cm2) were added and the temperature in the vessels of varying diameters (60, 150, 300, 500 microm) was calculated for the entire pulse duration of 30 milliseconds.

RESULTS

VSS and NIRSS both provided homogeneous heating in the entire vessel. With the exception of the small vessels (60 microm), which showed only a moderate temperature increase, all vessels exhibited a temperature raise within the vessel sufficient for coagulation with each IPL parameter. The time interval for effective temperature raise in larger vessels (diameter >60 microm) was clearly shorter than the pulse duration. In most instances, the vessel temperature was higher for VSS when compared to NIRSS.

CONCLUSIONS

We presented a mathematical model capable of calculating the photon distribution and the thermal effects of the broadband IPL emission within cutaneous blood vessels.

The Sensitivity and Specificity of High-Resolution Imaging in Evaluating Perineural Spread of Adenoid Cystic Carcinoma to the Skull Base

OBJECTIVE

To evaluate the sensitivity and specificity of computed tomography (CT) and magnetic resonance imaging (MRI) in detecting perineural spread (PNS) of adenoid cystic carcinoma of the head and neck to the skull base.

DESIGN

Adenoid cystic carcinoma of the head and neck frequently exhibits PNS across the skull base. Failure to detect PNS before treatment can have significant negative consequences on the planning and outcome of therapy. High-resolution CT, MRI, or both are used to evaluate the presence of PNS; however, their accuracy in detecting perineural involvement has not yet been determined.

PATIENTS

Twenty-six consecutive patients with adenoid cystic carcinoma, who were treated with cranial base resection, were included in this study. The surgical resection specimens of all patients were thoroughly examined by 1 pathologist for the presence of PNS along cranial nerves or their named branches. A total of 38 nerves were examined, and PNS was defined as the presence of tumor in the perineural or endoneural space. The results of the preoperative imaging studies (CT and/or MRI) were then reviewed retrospectively by 1 head and neck radiologist, who was unaware of the pathology report. Radiological evidence of PNS was considered to be present on CT, MRI, or both if nerves showed evidence of thickening (regardless of enhancement), contrast enhancement (regardless of size), or widening of their bony foramina or canals.

RESULTS

Histopathologic evidence of PNS was present in 25 (66%) of 38 named nerves. The sensitivity and specificity of CT in detecting PNS were 88% and 89%, respectively. Magnetic resonance imaging had a higher sensitivity (100%) and specificity (85%).

CONCLUSIONS

Perineural spread across the skull base is a frequent occurrence in patients with adenoid cystic carcinoma of the head and neck. Magnetic resonance imaging has a higher sensitivity and specificity than CT in detecting PNS along the base of the skull.

Reconstruction of the retracted nasal alar margin

Disruption of the integrity of nasal alar subunit as a result of previous ablative surgery or trauma may cause severe retraction or notching. This article presents a technique of successful reconstruction of the severely retracted alar margin due to prior ablative surgery or trauma by utilizing a turn-in flap brought from the nasal skin adjacent to the alar defect for inner lining, an auricular cartilage graft for alar margin support and a two-stage nasolabial flap for skin coverage.

Bisphosphonates and jaw osteonecrosis: the UAMS experience

BACKGROUND

Over the past year at least 10 case series and several case reports on osteonecrosis of the jaw (ONJ) have been published with most found in the oral surgery literature. This clinical entity is largely unknown to head and neck surgeons.

METHODS

Retrospective chart review.

RESULTS

A total of 479 charts were reviewed, identifying 25 individuals meeting inclusion criteria. Mean age was 63.4 (standard deviation, 9.9) years; 40% were female. Multiple myeloma was the most common comorbidity. Twenty-five patients were treated with bisphosphonates for 4.4 years (range, 1 to 8 years); most commonly pamidronate before ONJ diagnosis. Forty-two percent (10) took steroids within the month before diagnosis. Fifty-two percent (11) underwent dental work before developing ONJ.

CONCLUSION

These data reflect the importance of awareness of the possibility of ONJ with bisphosphonate therapy.

Effect of Vascular Endothelial Growth Factor on Skin Graft Survival in Sprague-Dawley Rats

OBJECTIVE

To examine the effect of exogenous vascular endothelial growth factor (VEGF) on skin graft survival in Sprague-Dawley rats.

DESIGN

Dorsal full-thickness skin grafts were harvested from 18 Sprague-Dawley rats. To simulate human full-thickness skin grafts, the panniculus carnosus muscle was removed from the undersurface of each graft. The recipient beds were delivered subfascial injections of recombinant human VEGF or isotonic sodium chloride solution in 12 animals before replacement of the grafts (6 in each group). Grafts were replaced without injections in 6 sham control animals. Using planimetry, grafts were analyzed for necrosis along epidermal and dermal surfaces on postoperative day 7. Results were compared between groups. To determine the role of the panniculus carnosus muscle in graft survival, 12 Sprague-Dawley rats underwent the same procedure with an intact panniculus carnosus muscle and with subfascial injections of VEGF or physiologic isotonic sodium chloride solution (6 in each group). Analyses were performed on postoperative day 14. The mean microvascular density was determined in each graft after staining with anti-factor VIII antibody.

RESULTS

The mean percentage of dermal necrosis in VEGF-treated skin grafts (10.0%) was significantly lower than that in saline-treated grafts (26.7%) or in control grafts (18.9%). Reduced, but not significant, epidermal necrosis was found in VEGF-treated rats vs saline-treated rats. No difference was found in VEGF-treated grafts vs saline-treated grafts when the panniculus carnosus muscle was left intact. Increased microvascular density was observed in VEGF-treated grafts vs saline-treated grafts, which did not reach statistical significance (P = .17).

CONCLUSION

Exogenously administered VEGF may improve the outcome of full-thickness skin grafts by decreasing dermal necrosis.

Comparison of Biomechanical Properties of Alloderm and Enduragen as Static Facial Sling Biomaterials

BACKGROUND

Static slings are one of the most commonly used surgical rehabilitation methods in the management of chronic facial paralysis. Acellular human cadaveric dermis (Alloderm; Life Cell Corp., Branchburg, NJ) is used for this purpose; however, it has variable stretching properties that may necessitate additional "tuning-up" procedure(s). Acellular porcine dermis (Enduragen; Tissue Sciences Laboratories, plc., Aldershot, U.K.) was recently introduced as a biologic implant and it is compositionally similar to Alloderm. However, no data currently exist regarding its biomechanical properties and potential use as an alternative implant to Alloderm in static facial sling procedures.

OBJECTIVE

The objective of this study was to compare the biomechanical properties of Alloderm and Enduragen for static facial sling procedures in the management of the paralytic face.

STUDY DESIGN

This study consisted of an in vitro prospective study in an academic medical research setting.

METHODS

Same size and thickness Alloderm and Enduragen samples were tested with MTS 858 Bionix materials test system for load-to-failure, displacement under increasing and constant stress, and stiffness.

RESULTS

Enduragen showed significantly less elongation under increasing stress and at the beginning of constant stress. Load-to-failure and stiffness were significantly higher in Alloderm; however, both biomaterials have adequate stiffness and load-to-failure for a static facial sling procedure.

CONCLUSIONS

Enduragen may serve as another potential static facial sling material, because it stretches significantly less than Alloderm under stress. Clinical experience is needed with Enduragen to determine its potential use as a static facial sling material.

Quality of Life for Patients Following Total Laryngectomy vs Chemoradiation for Laryngeal Preservation

BACKGROUND

The incorporation of chemotherapy and radiation, either sequentially or concurrently, has been increasingly used for organ preservation in patients with advanced laryngeal cancer. Traditional outcome measures of clinical response such as locoregional control and survival have been similar for patients treated with chemoradiotherapy and those treated with total laryngectomy (TL). The impact of concurrent chemoradiotherapy for laryngeal preservation on the overall quality of life (QOL) of patients has not been clearly evaluated, particularly in direct comparison with TL.

OBJECTIVE

To compare the QOL of patients treated with concurrent chemoradiotherapy with those treated with TL.

DESIGN

Nonrandomized, retrospective, cross-sectional study.

SETTING

Academic tertiary care referral center.

METHODS

The study included 42 patients with advanced stage III or IV cancer of the larynx, who were treated with either concurrent chemoradiotherapy or TL with postoperative radiation therapy. Patients had to be without evidence of recurrence and to have completed therapy at least 3 months prior to inclusion in the study. Quality of life was measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) in tandem with the head and neck module (EORTC QLQ-H&N35).

RESULTS

On the core questionnaire (QLQ-C30), there were no statistically significant differences in the overall QOL score between the 2 groups. Functional subscale analysis revealed a trend for patients in the surgery and radiotherapy group to experience greater difficulties with social functioning (P =.18) relative to the chemoradiation group. On the QLQ-H&N35, surgery patients reported significantly greater difficulties with sensory disturbances (smell and taste, P =.001), use of painkillers (P =.049), and coughing (P =.004). On the other hand, chemoradiation patients reported significantly greater problems with dry mouth (P =.02).

CONCLUSIONS

Both chemoradiation and TL affect, albeit differently, the QOL of patients treated for advanced cancer of the larynx. Although these differences can be detected by functional and subscale analysis, the overall QOL scores of both groups seem similar.

Surgical reconstruction in patients with cancer of the head and neck

Reconstructive surgical techniques have greatly changed the treatment approach for patients with cancer of the head and neck. These techniques provide head and neck surgeons the flexibility of performing tumor resection without concerns about the repair of the final defect and significantly increase the quality of life in patients who have undergone ablative surgery by providing better cosmetic and functional outcome after cancer resection. Reconstruction of the defects after ablative surgery for head and neck cancer includes various options, and each option has its own advantages and disadvantages. Techniques for head and neck reconstruction are summarized in this article along with recent advances in their application.

Complications, salvage, and enhancement of local flaps in facial reconstruction

Complications are part of every surgical procedure and their occurrences are inevitable if the surgeon performs enough operations during his/her lifetime. Learning how to prevent complications and how to manage them when they occur are as important as learning how to perform any given surgical procedure. This is especially true in facial reconstruction with local flaps, as complications threaten not only the functional restoration of the integrity, but also the cosmetic appearance of the patient. This article describes common complications and their underlying mechanisms seen in facial reconstruction with local flaps as well as their treatment or prevention, when possible.

Is glutathione-S-transferase-pi expression a reliable predictor of chemoradiation response in cancer of the head and neck?

PURPOSE

Concurrent radiation and chemotherapy is being evaluated as an alternative treatment to surgery for patients with advanced squamous cell carcinoma of the head and neck, because organ preservation maybe possible without compromising survival. However, the response to concurrent chemoradiation treatment varies from patient to patient, and there is currently no available molecular predictor of response for this particular treatment modality. There is some evidence to indicate that glutathione S-transferase-pi (GST-pi), which is one of the drug detoxifying enzymes, may decrease the effectiveness of platinum-based chemotherapy in the treatment of a variety of tumor types. This study was performed to investigate whether GST-pi expression was correlated with response to concurrent chemotherapy and radiotherapy in patients with advanced squamous cell carcinoma of the head and neck.

MATERIALS AND METHODS

Diagnostic biopsy specimens of 36 patients who underwent concurrent chemoradiotherapy for the treatment of advanced squamous cell carcinoma of the head and neck were examined for GST-pi expression by using immunohistochemistry with polyclonal antihuman GST-pi antibodies. GST-pi expression scores were compared among responders and nonresponders.

RESULTS

Although the staining rate with antiGST-pi was slightly lower in the responder group in comparison with the nonresponders (82% vs 100%), the difference was not statistically significant.

CONCLUSION

GST-pi expression is unlikely to be a valuable predictor of response to concurrent chemotherapy and radiation treatment in patients with advanced squamous cell carcinoma of the head and neck.

Genetic deletions of glutathione-S-transferase as a risk factor in squamous cell carcinoma of the larynx: a preliminary report

PURPOSE

To test whether genetic deletions of glutathione-S-transferase (GST) are associated with squamous cell carcinoma (SCC) of the larynx. GST are a group of detoxifying enzymes that may help reduce the risk of developing cancer in response to environmental carcinogens. Polycyclic aromatic hydrocarbons, found in high concentration in cigarette smoke, are known carcinogens especially for SCC of the larynx. Individuals with absolute or relative deficiency of the GST enzyme system may therefore be at a higher risk of developing laryngeal carcinoma.

MATERIALS AND METHODS

Genotyping for GST-M1 and GST-T1 was performed using polymerase chain reaction (PCR) assay on fresh frozen tissue specimens of 20 patients with SCC of the larynx and on 20 control subjects with a similar smoking history. Because this assay results in the absence of a PCR product in individuals expressing the GST-M1/GST-T1 null genotype, oligonucleotide primers that amplify a portion of the albumin gene were included in a multiplex PCR as a positive control for DNA quality and PCR conditions. The chi-square test was used for statistical analysis.

RESULTS

GST-M1 gene was deleted in 80% of patients with laryngeal SCC and in 50% of control subjects (P <.05). No statistically significant difference was observed in the incidence of GST-T1 gene deletion in patients with SCC of the larynx and control subjects.

CONCLUSION

GST-M1 gene deletion was significantly associated with SCC of the larynx and may produce a risk for this particular disease.

Coping with head and neck cancer during different phases of treatment

BACKGROUND

Little is known about how patients cope with head and neck cancer despite its devastating impact on basic functioning. This study examined coping patterns among patients at different phases of illness.

METHODS

Participants were 120 patients with advanced disease, who were grouped according to the following phases of illness: (1) pretreatment, (2) on treatment, (3) <6 months after treatment, and (4) >6 months after treatment. Coping was assessed with the COPE questionnaire, and outcome measures assessed general distress (Profile of Mood States) and illness-specific distress (Impact of Events Scale).

RESULTS

Use of specific coping responses differed among the groups. Denial (p <.05), behavioral disengagement (ie, giving up or withdrawing, p <.05), suppression of competing activities (ie, focusing exclusively on the illness, p <.01), and emotional ventilation (p <.10) were most characteristic of patients who were receiving or had recently completed treatment. There were no differences in flexibility of coping or overall effort expended, but patients who were on treatment or who had recently completed treatment used the greatest number of strategies. Generally, denial, behavioral disengagement, and emotional ventilation were associated with greater distress.

CONCLUSIONS

Results suggest that phase of illness may be important in shaping patients' responses to life-threatening illness.

Glabellar frown lines as a reliable landmark for the supratrochlear artery

OBJECTIVE

Preservation of the supratrochlear vascular pedicle (SVP) during use of the paramedian forehead flap can be accomplished by the aid of Doppler imaging; however, a reliable surface landmark may be invaluable in cases where Doppler examination fails. Our observations showed that the most prominent glabellar frown lines (GFLs) are very close to the SVP; however, the actual relationship of these structures remains unclear.

STUDY DESIGN

The relationship between GFLs and the SVP was investigated in 19 volunteers by the aid of Doppler imaging and in 8 cadaver heads by dissection. The distance between the GFLs and the SVP was measured.

SETTING

The study took place at an academic tertiary-care facility.

RESULTS

The SVP was located just at the GFLs in almost 50% of the cases and an average of 3.2 mm lateral to GFLs in the remaining cases.

CONCLUSION

GFLs may serve as reliable surface landmarks in the use of the paramedian forehead flap where Doppler imaging was not helpful.

Extended lateral rhinotomy incision for total maxillectomy

An extended lateral rhinotomy incision for total maxillectomy, which avoids postoperative lower eyelid complications, is described. Advantages of the extended lateral rhinotomy incision for total maxillectomy are discussed in comparison with the classic Weber-Fergusson incision.

The submental island flap in head and neck reconstruction

BACKGROUND

The submental island flap (SIF) is a new alternative in the reconstruction of various head and neck defects. We present our preliminary experience in the use of this flap and describe the surgical technique.

METHODS

Nine patients underwent reconstruction with the SIF between January 1998 and July 1999. The SIF has been used for the reconstruction of the cervical esophageal stenosis in 2 patients, floor of mouth and tongue defects in 6 patients, and a hemilaryngectomy defect in 1 patient.

RESULTS

With the exception of one partial flap loss caused by arterial insufficiency, no flap failures were observed. All the donor site defects but one were closed primarily. One patient who underwent reconstruction of a hemilaryngectomy defect underwent revision surgery because of intractable hair growth on the transferred skin paddle. Marginal mandibular nerve function was intact in all the cases.

CONCLUSIONS

When combined with the reported experience of other surgeons, our preliminary experience showed that the SIF was an excellent alternative in the reconstruction of head and neck defects because of its reliability, versatility, and relative ease of application.

Neural cell adhesion molecule expression in adenoid cystic carcinoma of the head and neck

OBJECTIVE

To investigate whether there is a correlation between neural cell adhesion molecule (NCAM) expression and perineural spread in patients with adenoid cystic carcinoma of the head and neck (ACCHN).

STUDY DESIGN

Retrospective review of medical records and immunohistochemical staining of specimens from 37 patients treated at the University of Arkansas in Little Rock from 1987 to 1997.

METHODS

Sections from paraffin-embedded specimens were examined for the presence of NCAM using monoclonal anti-NCAM antibody by avidin-biotin-peroxidase immunohistochemical staining. NCAM staining was scored in each specimen and correlated with the data obtained from patient charts.

RESULTS

Twenty-five of 37 specimens (68%) showed histopathological evidence of perineural spread. All 37 specimens (100%) stained positive for NCAM, regardless of perineural spread status.

CONCLUSION

Our results suggested that the use of NCAM expression as a predictor of perineural spread is highly unlikely.

Correlation of neural cell adhesion molecules with perineural spread of squamous cell carcinoma of the head and neck

Perineural spread (PNS) is a poor prognostic factor associated with increased risk of local recurrence and nodal metastasis and reduced survival of patients with squamous cell carcinoma of the head and neck (SCCHN). There is some evidence to indicate that neural cell adhesion molecules (NCAMs) may play a role in PNS of a variety of tumor types. We performed this study to investigate whether NCAM expression can be used as a predictor of PNS in SCCHN. The surgical specimens of 66 patients with SCCHN were evaluated with monoclonal IgG antibody immunoperoxidase staining for NCAM. Of the 41 specimens with PNS, 38 (93%) showed evidence of NCAM expression. In contrast, only 9 specimens (36%) without PNS expressed NCAMs. The difference in NCAM expression between the study and control groups was statistically significant (P < 0.01).

Assessing quality of life in patients with head and neck cancer: cross-validation of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Head and Neck module (QLQ-H&N35)

OBJECTIVE

To evaluate the reliability and validity of a new, disease-specific quality-of-life measure for patients with head and neck cancer: the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire--QLQ-H&N35.

DESIGN

Cross-sectional study using questionnaire data and medical chart review.

SETTING

Academic tertiary care otolaryngology clinic.

PARTICIPANTS

One hundred twenty ambulatory patients, including 30 patients with advanced head and neck cancer in each of the following stages of treatment: (1) prior to treatment, (2) during active treatment, (3) within 6 months of completing treatment, and (4) more than 6 months after completing treatment. In addition, (5) a comparison group of 40 patients without malignant disease was included (total sample, N = 160).

MAIN OUTCOME MEASURES

Scores on EORTC Quality of Life Core Questionnaire (QLQ-C30) and head and neck module (QLQ-H&N35), Profile of Mood States, and Impact of Events Scale.

RESULTS

The QLQ-H&N35 demonstrated acceptable reliability (internal consistency). It successfully discriminated between cancer patients and the comparison group, and among subgroups of cancer patients at different phases of treatment (construct validity). The instrument was sensitive to the effects of radiation treatment and to site of disease. Its low-to-moderate correlations with the EORTC core questionnaire indicated that the QLQ-H&N35 provided unique information (discriminant validity). Scores were significantly associated with a number of demographic variables.

CONCLUSION

Results support the use of this disease-specific measure to assess quality of life among patients with advanced head and neck cancer.

Intracranial extension of inverted papilloma: An unusual and potentially fatal complication

BACKGROUND

The purpose of this article is to define the outcome of intracranial extension of inverted papilloma and outline a rationale for management of this rare clinical presentation.

METHODS

A review of patients with intracranial extension of inverted papilloma reported in the literature (18 patients), or treated in our institution (3 patients ) was performed. The data of these 21 patients were consolidated with regard to clinical presentation, treatment, and outcome. Nine patients, including 1 of our cases, had coexisting squamous cell carcinoma and therefore were excluded from the analysis. Twelve patients with "pure" inverted papilloma formed the basis of this study.

RESULTS

The majority of patients (83%) with intracranial inverted papilloma had recurrent disease. Patients with extradural disease had a survival rate of 86% with an average follow-up of 4.4 years. Eighty-six percent of these survivors were treated with craniofacial resection. In contrast, 75% of patients with intradural inverted papilloma were dead of disease with an average follow-up of 9.3 months regardless of the treatment modality.

CONCLUSIONS

Intracranial extension of inverted papilloma is mostly associated with recurrent disease. Intracranial extradural inverted papilloma can be effectively controlled with craniofacial resection. Intracranial intradural involvement of inverted papilloma has a poor prognosis regardless of treatment. Aggressive treatment of intranasal inverted papilloma may be the most important factor in preventing intracranial presentation.

Modification of the inner flange of the Paparella type II ventilation tube for easier insertion

A simple modification of the inner flange of the Paparella type II ventilation tube is described to provide easier and faster insertion.

Modification of the tracheal flange of the Provox voice prosthesis for easier insertion

Prosthetic voice restoration with tracheoesophageal puncture has become the preferred method of speech rehabilitation of laryngectomized patients. Indwelling prostheses seem more advantageous because they do not necessitate frequent removal, cleansing, and insertion for the maintenance. The Provox system (Atos Medical AB, Horby, Sweden) is one of the most widely used prosthetic systems because it has several technical advantages over the other systems; however, the disproportion between its wide tracheal flange and the narrow puncture can make insertion somewhat difficult. We present a simple modification on the tracheal flange of the Provox voice prosthesis, which facilitates its insertion.

Development and implementation of a clinical pathway for patients undergoing total laryngectomy: impact on cost and quality of care

BACKGROUND

The current health care climate demands the provision of quality patient care in a cost-effective manner. Clinical pathways define the essential components of care that are provided to patients with a specific diagnosis to achieve a desired outcome within a predetermined period. Development and implementation of clinical pathways streamline the provision of quality care in the most cost-effective manner.

OBJECTIVES

To develop a clinical pathway for patients undergoing total laryngectomy and to evaluate its impact on the cost and quality of care provided to these patients.

SETTING

A tertiary care academic medical center.

PATIENTS AND METHODS

A total of 45 patients were included in the study. The clinical pathway was implemented for 15 patients, while the other 30 patients were treated without the implementation of the pathway guidelines.

MAIN OUTCOME MEASURES

Length of hospital stay, readmission rate, and hospital variable costs.

RESULTS

The clinical pathway affected all cost outcome measures. Length of stay decreased by 2.4 days (29%; P=.001), and the average hospital variable cost decreased from $3992 to $3419 per case. This represents a 14.4% reduction in cost associated with pathway implementation (P=.02). The standardization of care eliminated unnecessary variation and repetition in resource usage, resulting in overall cost reduction. Pathway implementation resulted in a lower readmission rate (7% [1/15]) than that of patients treated prior to protocol implementation (23% [7/30]).

CONCLUSION

Implementing a carefully developed clinical pathway may reduce cost without compromising the quality of care for patients undergoing total laryngectomy.