Auricular reconstruction with a postauricular myocutaneous island flap: flip-flop flap

Surgical defects of the concha-helix part of the ear larger than 2 cm may pose a reconstructive challenge. Split- or full-thickness skin grafts or local flaps may be used, and a number of these have been described. Yet cosmetic results are often unsatisfactory. Our experience with a postauricular myocutaneous island flap is described. Eleven patients (12 ears), aged 48 to 89 years, underwent the procedure under local anesthesia following excision of conchal bowl malignant tumors that included the cartilage underlying the skin. The surgical technique is described in detail. Few complications were encountered, and cosmetic results were excellent. In four ears, resection margins extended into the ear canal, and that portion was allowed to heal satisfactorily by secondary intention. We recommend the use of this flap for practical, safe, and early good cosmetic results.

DentaCT for evaluating mandibular and maxillary invasion in cancer of the oral cavity

We used a retrospective analysis of charts, imaging studies, and histologic findings when available in 17 patients with cancer of the oral cavity to define the value of DentaCT or multiplanar reformation software in assessing bony involvement by malignant tumors of the oral cavity. From two academic tertiary-referral medical centers, the 17 patients had a mean age of 63 years and suspected maxillary (2) or mandibular (15) invasion. All patients had conventional computed tomography scanning and multiplanar reformation scans with several additional imaging studies obtained. Two patients demonstrated no bony involvement by imaging and histologic studies. Twelve of the remaining 15 patients had surgically documented bony involvement also correctly detected by DentaCT. DentaCT was found to be a valuable tool in defining extent of bony invasion by tumor. Although not compared to other imaging modalities, our experience supports the use of DentaCT where available for this purpose.

Postintubation arytenoid subluxation

Arytenoid subluxation (AS), ie, malpositioning of the arytenoid cartilage with abnormal but existent contact between the joint surfaces, is an uncommon entity, and fewer than 70 cases have been reported, 26 of which were in a recently published series. Usually, AS is the result of upper airway instrumentation, and only a few cases were reported to occur with external trauma to the neck. Some predisposing factors and possible mechanisms have been suggested, but the reason for its occurrence remains obscure. Hoarseness and, to a lesser degree, dysphagia, odynophagia, cough, and sore throat may be indicative of AS. Diagnosis is established by the clinical course, laryngoscopy, and computed tomography. Electromyography and strobovideolaryngoscopy are additional diagnostic measures described. We report 7 cases of postintubation AS of long standing. Three of these patients had prior unilateral vocal cord paralysis, formerly undescribed as a possible contributing factor for AS. The pertinent literature is reviewed and treatment options are discussed.

[Nevoid basal-cell carcinoma syndrome in a patient with cleft lip and palate]

In a 48-year-old man with the nevoid basal-cell carcinoma, Gorlin-Goltz syndrome was diagnosed. There were multiple, facial, basal-cell carcinomas, multiple, odontogenic keratocysts of the mandible, rib malformations, and a wide nasal bridge, common characteristics of the syndrome. Cleft lip and palate, seen in this patient, has been described in only 5% of those with this syndrome.

Functional endoscopic sinus surgery: experience with the first 100 patients

Retrospective analysis of the data on the first 100 rhinosinusitis patients who had undergone functional endoscopic sinus surgery (FESS) is presented. High rate of good-excellent results (79%) and low rate of complications (17%, all minor) are satisfactorily comparable to those reported from other centers.

Clozapine for tardive dyskinesia in adolescents

Thousands of adolescents use neuroleptic drugs over extended periods of time for a wide range of mental disorders. One of the most severe adverse effects of neuroleptic drugs is tardive dyskinesia (TD), for which no successful treatment is currently available. Clozapine is a known atypical neuroleptic drug with few extrapyramidal side effects. It has been suggested that clozapine may be beneficial for the treatment of tardive dyskinesia in adolescents. However, the efficacy of the drug in adolescents is unknown. This report describes the beneficial effect of clozapine on tardive dyskinesia in two adolescents with schizophrenia.

Acute suppurative parotitis and parotid abscess in children

Acute suppurative parotitis and parotid gland abscess are infrequently encountered among children. Fourteen children were diagnosed in the Sheba Medical Center as suffering from these infections and their clinical features are described. Discussion reveals neither significant differences nor predominating factors to differentiate between these two entities.

Care of the terminal head and neck cancer patient in the hospice setting

The ratio of incidence to mortality is somewhat less than 3:1 for head and neck cancer, and the 5-year relative survival rate is 50%. Despite the high mortality rate, few reports have focused on patients with terminal head and neck cancer. A growing number of these patients end their lives in a hospice facility. A retrospective analysis was undertaken of 67 patients with terminal head and neck cancer who were admitted to the Tel Hashomer Hospice between 1988 and 1992. Patient data were reviewed and analyzed, and the particular characteristics of this population were defined. This study found that terminal head and neck cancer patients seem to receive better support in a hospice than in a general hospital or some family settings.

The indication for tonsillectomy in children following peritonsillar abscess

The clinical course of 19 consecutive children treated for peritonsillar abscess (PTA), in the Chaim Sheba Medical Center, between 1988-1992 was retrospectively reviewed. The abscess was drained through an incision (12 children) and by needle aspiration (7 children), under local (11 children) or general (8 children) anesthesia. One child suffered from recurrent bouts of tonsillitis after the abscess resolved and eventually underwent tonsillectomy. Two others, with a pre-PTA history of recurrent tonsillitis (T+) underwent interval tonsillectomy. Recurrent PTA did not develop in any of the 16 non-operated children. The involvement of mainly older children can explain both the low rate of the pre-PTA history of T+ and the number of children whose abscess could be drained under local anesthesia. Tonsillectomy should be indicated in cases of recurrent PTA or in children with a pre-PTA history of T+. The need for general anesthesia for draining the abscess in young children does not seem, in itself, to warrant a routine hot tonsillectomy.

Matutinal vertigo--a chronobiological phenomenon

Matutinal vertigo, characterized by vertiginous attacks occurring in the morning, has been noted in a significant percentage of patients with vestibular disorders and is considered to be precipitated by the patient's movements preparatory to arising from bed. Chronobiological studies of the variations of positional nystagmus in 10 patients with acute vertigo revealed rhythms of circadian periodicities in eight. The acrophases (i.e. computed peak hour), of nearly 40% of the circadian rhythms were found between 02.00 and 07.00 hours. Chronobiological characteristics of the vestibular system are postulated to play a part in the development of this clinical phenomenon.

Acute mastoiditis--revisited

The clinical course and causative organisms were studied in 18 patients with acute mastoiditis, 13 of whom (72%) had no previous history of middle ear disease. Their age ranged from 5 months to 21 years, and duration of middle ear symptoms immediately prior to admission ranged from 1 to 45 days (average 9.7 days). None had undergone a myringotomy prior to admission, while 13 (72%) had been receiving antibiotic treatment for acute otitis media. Three were admitted with intracranial complications. Bacteria were isolated in 10 of the 16 patients in whom samples were available for bacterial culture, and included Streptococcus pneumonia (2), Streptococcus pyogenes (2), Staphylococcus aureus (2), Staphlococcus coagulase negative (2), Klebsiella pneumonia (1), and Pseudomonas aeruginosa (1). Of the 17 patients treated by us, 11 received surgery. Acute otitis media, secretory otitis media, acute mastoiditis, subacute mastoiditis and masked mastoiditis create a continuum. Antibiotic treatment for acute otitis media cannot be considered as an absolute safeguard against acute mastoiditis. When antibiotics are prescribed for acute mastoiditis before culture result is available, an anti-staphylococcal agent should be included. At least some patients with acute mastoiditis develop a primary infection of the bony framework of the middle ear cleft. The prevalence of the intracranial complications in acute mastoiditis is still high and may appear soon after or concomitant with the first sign of acute mastioditis.

Peritonsillar abscess: repeated needle aspiration versus incision and drainage

The study evaluates the management of peritonsillar abscess (PTA) by comparing needle aspiration versus incision and drainage of the abscess. Twenty-four of 86 patients treated by needle aspiration underwent a single aspiration, and 38 had 2, 19 had 3, and 5 had 4 aspirations before the abscess resolved. A significant amount of pus, up to 8, 5, and 3 mL, respectively, was detected in the subsequent aspirations. Recurrent PTA was noted in 20 patients (23.26%). In 9 of these patients (10.47%) the recurrent episode occurred immediately (in less than 1 month) and was considered residual disease. Seventy-four patients were treated by incision and drainage, and none had an immediate recurrence. Only 3 (4.05%) patients developed a late recurrent episode. The difference in the recurrence rate between the two groups is statistically significant. A history of recurrent tonsillitis prior to abscess formation did not show a significant influence on the recurrence rate. A high incidence of streptococcal infections was noted in both groups, with anaerobes detected in only 15% of samples. There was a good response to penicillin-resistant organisms. Although needle aspiration is a tempting modality for treating PTA in community clinics, one should be aware of the risks of a higher incidence of residual and recurrent disease in comparison to incision and drainage, as well as the need for repeated aspirations.

The effect of prostaglandins E2 and F2a on brain and tracheal ciliary activity

Prostaglandins E2 and F2a have a mild stimulatory effect (+11% to 18% from baseline) on the in vitro ciliary beat frequency in tracheal rings, which contain mucus-producing cells, and in brain slices, which are devoid of mucus. Results are compared with previous studies and the merits of the used experimental models are discussed.