First branchial cleft anomalies involving the tympanic membrane and middle ear

First branchial cleft anomalies may involve the tympanic membrane or middle ear. A complete otologic examination must be performed in any patient with a suspected first branchial cleft anomaly. A surgeon treating such a defect must be prepared to perform both the excision of the lesion and reconstructive otologic surgery.

The use of the stomach in repairing tracheal leaks after resection of the oesophagus for carcinoma

A 44-year old male with carcinoma of the upper third of the oesophagus and invasion of the trachea recently underwent surgical treatment at our institution. After oesophageal resection tracheal and main bronchial leaks were unsuccessfully closed with pleural patches. The stomach was subsequently used to seal the remaining leaks. The post-operative recovery was uneventful and the patient was discharged after a hospital stay of 41 days.

[Left ventricular-right atrial shunt due to infective endocarditis--report of a case]

Acquired left ventricular-right atrial shunt is a very rare cardiac disease. Infective endocarditis, cardiac operative procedures, and thoracic trauma were reported as origins. We report a case of a patient with left ventricular-right atrial shunt due to infective endocarditis. A 53-year-old male who had aortic regurgitation due to infective endocarditis developed suddenly severe congestive heart failure. Two-dimensional and pulsed doppler echocardiography demonstrated left ventricular-right atrial shunt. Emergency operation was done. The fistula was found through the atrioventricular membranous septum. The position from the left view was just below the commissure between the right coronary cusp and non coronary cusp and the opening position from the right view was just above the septal leaflet of tricuspid valve. Aortic valve replacement and direct closure of fistula were done and patient's recovery was uneventful. Case reports of left ventricular-right atrial shunt due to infective endocarditis have been rarely seen, most of which were followed by poor prognosis. Surgical intervention in acute phase is recommended.

[Aortobronchial fistulae as late complications following the surgical correction of aortic isthmus stenosis]

Three patients (2 men, aged 39 and 52 years, one woman, aged 47 years) developed hemoptysis 3-19 years after surgical resection of coarctation of the aorta. Digital subtraction angiography in the two men was suspicious of an aortobronchial fistula. An emergency thoracotomy revealed the diagnosis in the woman: she died during the operation of intractable arterial bleeding, the initial operation having been atypical (insertion of a graft extending across the isthmus to the ascending aorta). The 52-year-old man died of left heart failure after pneumonectomy (for massive bleeding into the left lung). An aneurysm sack at the aortic isthmus was resected and a vascular graft implanted in the 39-year-old man. There have been no further hemoptyses. These cases emphasize the need for including aortobronchial fistula as a cause of hemoptysis.

Cochlear fistula found in a naturally healed tympanic cavity

A cochlear fistula found in a naturally healed mastoid cavity is reported. The patient is a 53-year-old Japanese woman who was complaining of unsteadiness. She had a long history of otorrhoea in childhood. Her tympanic and mastoid cavities were widely open and were covered by thin epithelium. The posterior wall of the ear canal was missing. She had no hearing in the ear but responded to electrical promontory testing. Exploratory surgery was indicated at which fistulae of the basal turn of the cochlea and the horizontal semicircular canal were found. These fistulae were sealed by pieces of bone and muscle.

[Urological complications in renal transplantation]

1,224 renal transplant patients were studied. 50 kidneys were obtained from living related donors. The mean age of the recipients was 34.6 years (16.8 to 67.6 years) Ureteric reimplantation was initially performed by uretero-ureteric anastomosis (19%), then into the bladder according to the Leadbetter-Politano technique (69%) and subsequently according to the Lich-Gregoire extra-vesical technique (10%). A cutaneous ileostomy or reimplantation into the renal pelvis was performed in the remaining 2% of cases. The risk of one or more urological complications was 11.2% (137/1,224) and 7.9% when only those patients requiring surgical intervention were taken into account. These complications were classified into 3 categories: strictures (60.6%), fistulae (35.8%) and stones (6.6%). The frequency of urological complications was lower with the Lich-Gregoire technique (4.1%) which we have currently adopted. The renal transplant was lost in 6.1% of cases directly related to a urological complication. The presence of urinary tract fistulae had an unfavourable influence on graft survival due to detransplantations. Whenever possible, our preferred approach consists of percutaneous and/or endourological techniques as first-line treatment followed by second-line surgical treatment in the event of failure of the percutaneous approach.

A simple technique for closure of a palatal fistula using a conchal cartilage graft

A simple technique for closure of a palatal fistula using a conchal cartilage graft as a substitute for nasal lining flaps is reported. This graft simplifies the repair of the palatal fistula and protects the suture line of the oral covering flaps from recurrence.

Clinical spectrum of bronchogenic cysts of the mediastinum and lung in the adult

Bronchogenic cysts are closed sacs considered to be the result of an abnormal budding of the respiratory system. They are lined by ciliated epithelium and have focal areas of hyaline cartilage, smooth muscle, and bronchial glands within their walls. They are seldom seen in the adult, and most are thought to be asymptomatic and free of complications. During a 20-year period, 86 patients underwent resection of a bronchogenic cyst of the mediastinum (66 patients) and lung (20 patients). There were 47 women and 39 men whose ages ranged from 16 to 69 years. Seventy-two percent of patients (67% with mediastinal cysts and 90% with cysts of the lung) were symptomatic at the time of operation, and the majority had two or more symptoms. Despite extensive investigations, which in some cases included computed tomographic scanning (n = 12) and angiography (n = 22), a positive diagnosis was never made preoperatively even if it was suspected in 57% of patients. In nearly all patients, the operative approach was that of a posterolateral thoracotomy. All but two mediastinal bronchogenic cysts could be locally excised, but all bronchogenic cysts of the lung required pulmonary resection (lobectomy, 13; limited resection, 6; pneumonectomy, 1). Major operative difficulties were encountered in 35 patients, all of whom were symptomatic preoperatively. Thirty-three patients had a complicated cyst; the complications consisted of fistulization (n = 16), ulcerations of the cyst wall (n = 13), hemorrhage (n = 2), infection without fistulization (n = 1), and secondary bronchial atresia (n = 1). Overall, 82% of patients had a bronchogenic cyst that was either symptomatic or complicated or both.(ABSTRACT TRUNCATED AT 250 WORDS)

Repair of a cerebrospinal fluid perilymph fistula primarily through the middle ear and secondarily by occluding the cochlear aqueduct

A 35-year-old man had a 5-year history of fluctuating hearing loss in his only hearing ear. History and diagnostic tests indicated a perilymph fistula, a diagnosis subsequently confirmed by exploration. Primary and secondary repairs temporarily ameliorated symptoms. A spinal fluid to middle ear fluid pathway was identified by radioactive tracer. A patent cochlear aqueduct indicated on computed tomography scan was found and repaired through a posterior cranial fossa approach. Hearing was preserved, remaining relatively stable during the 2-year follow-up period.

[Myocutaneous latissimus dorsi sliding flap in reconstruction of the lower thoracic wall in chronic fistula caused by cystic echinococcosis of the liver]

We report the successful treatment of a 47-year-old man who had a 22-year history of chronic discharge from a hepatic echinococcal cyst. Before treatment in our unit there had been 8 previous attempts to control the fistula. By means of a right thoracoabdominal incision (with resection of the 7th and 8th ribs) it was possible to perform a cystectomy with subsequent marsupialisation of the residual cyst wall to the skin. However, after 2 weeks subsequent treatment with maximal Albendazol therapy there was still a big persistent cavity which required further débridement. This resulted in resolution of the infection and allowed a definitive closure of the big cavity and the thoracoabdominal wall using a myocutaneous latissimus dorsi flap. The patient's subsequent course has been uneventful with no recurrence of the fistula.

Use of the Branemark implant in the cleft palate patient

This paper describes the clinical and surgical management of a patient presenting with a unilateral alveolar cleft and associated oronasal fistula. After orthodontic expansion of the maxilla, a secondary osseous graft was placed. A single Branemark implant was subsequently utilized to allow for prosthetic restoration of the dental arch. Through case presentation, a detailed course of treatment is outlined that effectively restores the anatomy, integrity, and function of both the alveolar and dental arches.

Perilymphatic fistula: surgical experience in the United States

One survey sent to 6953 individual otolaryngologic practices and 106 departments of otolaryngology at teaching hospitals in the United States, and a more limited survey of 75 patients operated on for perilymphatic fistula (PLF) at the House Ear Institute, addressed aspects of managing PLF: surgical incidence, reliability of diagnostic test, preoperative observations, and disability after surgery. Of surgeons sampled, 93% estimated incidence of PLF surgery to be less than or equal to 1 per 1000 otolaryngologic outpatient visits. The most reliable diagnostic indicators were history, symptomatology, and tympanometric and electronystagmographic fistula tests. About 72% of surgeons reported less than 4 weeks' average delay before surgery. Most surgeons and patients (greater than or equal to 70%) rated length of disability before return to work, exposure to noise, travel by airplane, swimming, and heavy lifting, at several weeks to several months. Diving was the most restricted activity. Results suggest that incidence of surgery and disability with PFL in the United States is very limited.

[Successful surgical treatment of aortic regurgitation with coronary artery fistula due to blunt chest trauma--a case report]

A Successful repair of aortic regurgitation with coronary artery fistula due to blunt chest trauma is reported. A 17-year-old boy was involved in a motor cycle accident, but there were neither open chest trauma nor rib fracture. On admission diastolic regurgitant musical cardiac murmur was noted. Color doppler echocardiogram showed severe aortic regurgitation. But any cardiac murmur had nerve been noticed before. CAG showed a fistula from the acute marginal branch of the RCA to the RV. But no shunt existed on calculation. The aortic valve was explored under cardiopulmonary bypass. There were a tear in the LCC and a fissure in the RCC. Otherwise the valve tissue appeared normal. The valve was excised and replaced with a integral of 21 mm Björk-Shiley valve prosthesis. The fistula was left because there were no abnormal findings on the RCA and no significant shunt. The patient is up and well 1 year and 10 months after operation. This is the first report of aortic regurgitation with coronary artery fistula due to blunt chest trauma.

[The role of a new method for occlusion of fistula tracts]

Digestive fistulae have a quite variable clinical presentation, depending on their origin and topography. Even when very small, they can cause considerable mechanical or metabolic derangement. Surgical correction often implies an operation with important consequences. The injection of an occlusive emulsion can, in a certain number of cases, close off the fistulous tract with minimal inconvenience. We have injected several invalidating fistulae between the digestive or respiratory tract and the skin with Ethibloc. Total occlusion of the fistulae was accomplished after one or more injections. The emulsion is resorbed after around 10 days, leaving a scar. The inclusion of radio-opaque material allows intraoperative control of injection. This technique widens the therapeutic modalities applicable to a difficult medical condition. When confronted with advanced inflammatory or neoplastic disease, for example, Ethnibloc injection can be considered if the tissue quality is sufficient. Gross infection or tissue necrosis are, in our experience, relative contraindications; the occlusive emulsion cannot adhere and is rapidly evacuated by the fistula.

Cleft palate fistulas: a multivariate statistical analysis of prevalence, etiology, and surgical management

A retrospective, multivariate statistical analysis of 129 consecutive nonsyndromic patients undergoing cleft palate repair was performed to document the incidence of postoperative fistulas, to determine their cause, and to review methods of surgical management. Nasal-alveolar fistulas and/or anterior palatal fistulas that were intentionally not repaired were excluded from study. Cleft palate fistulas (CPFs) occurred in 30 of 129 patients (23 percent), although nearly a half were 1 to 2 mm in size. Extent of clefting, as estimated by the Veau classification, was significantly more severe in those patients who developed cleft palate fistula. Type of palate closure also influenced the frequency of cleft palate fistula. Forty-three percent of patients undergoing Wardill-type closures developed cleft palate fistula versus 10, 22, and 0 percent for Furlow, von Langenbeck, and Dorrance style closures, respectively. The fistula rate was similar in patients with (30 percent) and without (25 percent) intravelar veloplasty. Age at palate closure did not significantly affect the rate of fistulization; however, the surgeon performing the initial closure did not have an effect. Thirty-seven percent of patients developed recurrent cleft palate fistulas following initial fistula repair. Recurrence of cleft palate fistulas was not influenced by severity of cleft or type of original palate repair. Following end-stage management, a second cleft palate fistula recurrence occurred in 25 percent of patients. Continued open discussion of results of cleft palate repair is recommended.

Successful use of a vascularized intercostal muscle flap to seal a persistent intrapleural cerebrospinal fluid leak in a child

The diagnosis and management of a persistent intrapleural-dural cerebrospinal fluid fistula following excision of a large mediastinal ganglioneuroma with intraspinal extension is reported. Use of a vascularized intercostal muscle flap to close the dural fistula was curative in this 4-year-old patient.

[Diagnostic and therapeutic problems of aorto-enteric fistulas caused by aortic prostheses. 5 surgical cases of which 4 were successful]

The clinical characteristics, surgical treatment and therapeutic results, were surveyed in 5 cases of aorto-enteric fistulas observed in 650 abdominal aortic reconstructive operations in ten years. The fistula concerned the duodenum in two cases, the jejunum in one and the ileum in two cases. Two patients were treated by removal of the prosthesis and an axillofemoral bypass, one by an axillofemoral shunt only and the two others by repair of the graft. One patient died a few days after the operation, another eighteen months later. The prognosis of aorto-enteric fistulas after aortic reconstructive surgery is often bleak. It should be improved by an early diagnosis, supported by anamnestic history and an upper endoscopy. An aggressive surgery, whose modalities are discussed, gives maximum chances of success.

[Aorto-enteric fistulas. Report of 12 cases]

Aorto-enteric fistulae are primary or secondary. The primary variant is the rupture of an aortic aneurysm into the gastro-intestinal tract. The secondary fistulae are complications of reconstructive aortic surgery. We report our experience with 12 aorto-enteric fistulae (2 primary and 10 secondary) treated from 1971 to 1989. All patients presented with gastro-intestinal bleeding and the fistula was to the duodenum (3), jejunum (8) or appendix (1). In the secondary patients, a mean of 5 years had elapsed since the aortic replacement. In addition to closure of the enteric defect, three types of treatment were applied: excision of the old prosthesis, infrarenal aortic closure and axillo-bifemoral bypass (5); insertion of a new graft (3) and local repair (3). A patient was not treated due to a triple carcinoma. Hospital mortality was 50%. We conclude that the diagnosis of aortoenteric fistula is difficult and that the mortality is high. The operative management remains imperfect and a subject of controversy. Prevention and early detection request more attention than in the past.

Esophagocutaneous fistula after anterior cervical spine surgery and successful treatment using a sternocleidomastoid muscle flap. A case report

An esophagocutaneous fistula following anterior cervical fusion is rare. A 61-year-old man had cervical myelopathy because of ossification of the posterior longitudinal ligament of the cervical spine. Anterior decompression of the cervical spine and anterior fusion with strut bone grafting were performed. A second anterior fusion was done because the graft was dislodged after the patient fell out of bed one month after surgery. An esophagocutaneous fistula occurred three months after the second anterior surgery. One of the causes of this esophagocutaneous fistula was considered to be a pressure necrosis of the esophagus because of to projection of the bone graft. Conservative treatment, which consisted of wound drainage and intravenous administration of antibiotics, was tried but was unsuccessful. A good result was achieved by cancellous bone grafting, closure of the esophageal fistula, and transposition of a sternocleidomastoid muscle flap to the interspace between the esophagus and the cervical spine.

Surgical management of perilymph fistulas. A new technique

A wide range of recurrence rates (21% to 47%) for perilymph fistula repairs have been reported in the otology literature. An improved surgical technique developed at the Portland (Ore) Good Samaritan Hospital and Medical Center Neurotology Department was used to repair perilymph fistulas in 58 patients from October 1986 to October 1988. Our recurrence rate was reduced from 27% in a 1982-1985 study to 8% in our study. At 1 year postoperatively, improvements in disequillibrium, dizziness, and vertigo were comparable with results of older surgical techniques. Functional outcomes were also good: 83% of patients returned to normal activities of daily living, and 71% also returned to school or resumed gainful employment outside the home.

[Case of primary aorto-jejunal fistula caused by gram-positive cocci]

A 46 year-old man was transferred to our department with a pulsating abdominal mass and back pain. On arrival he suddenly developed hematemesis. CT suggested the presence of an infrarenal aortic aneurysm and the jejunum was filled with contrast medium. An emergency operation was done. We found an aorto-jejunal fistula at the branching point of the renal artery. We directly sutured the aortic wall laceration and the jejunum wall in two layers. Then we resected infrarenal pseudoaneurysm as completely as possible, with replacement by a Dacron Y-shaped prosthesis. Culture of the aortic wall showed gram-positive cocci, but the species could not be identified. Gram stain of the aortic wall also showed infection by gram-positive cocci. The patient is alive and well 3 months after surgery.

Problems and complications associated with maxillectomy, mandibulectomy, and oronasal fistula repair

Many oral tumors can be effectively treated by partial maxillectomy or mandibulectomy. These techniques involve excision of the tumor as well as the underlying bone. These procedures are described here and emphasis placed on the management of potential complications. Useful techniques for repairing oronasal fistulas are also described.

Closure of tracheocutaneous fistula with perichondrial flap following cricothyroidotomy

A method for closure of large tracheocutaneous fistulas occurring in the cricothyroid membrane is described. Though an infrequent complication, large defects in this area can be successfully repaired with this technique.