Access to the central skull base via a modified le fort I maxillotomy: the palatal hinge flap

We describe a modification of the standard Le Fort I maxillotomy in favor of a unilateral palatal hinge flap. Used in combination with a partial medical maxillectomy, submucous resection of the nasal septum, and contralateral inferior turbinectomy, this approach provides direct access to the entire nasal cavity, ipsilateral maxillary antrum, pterygopalatine fossa, nasopharynx, clivus, and first two cervical vertebrae. Use of the palatal hinge serves both to maintain palatal vascularity and eliminates the need for intermaxillary fixation. Facial incisions are avoided through a midfacial degloving approach. A variety of other surgical techniques used to access the central skull base are critically reviewed and compared with this new technique.

Diagnostic accuracy of fine-needle aspiration and frozen section in nodular thyroid disease

OBJECTIVE

To assess the diagnostic accuracy of fine-needle aspiration (FNA) and frozen section (FS) in nodular thyroid disease.

SETTING

Tertiary care academic medical center.

STUDY DESIGN

Retrospective review of 139 consecutive patients undergoing surgery for nodular thyroid disease. FNA and FS sensitivity, specificity, and accuracy were calculated with respect to permanent section histology.

RESULTS

Among 63 patients with an FNA interpreted as either benign (n = 38) or malignant (n = 25), FNA was accurate (sensitivity 89%, specificity 97%, accuracy 94%). FS identified only one case of carcinoma missed by FNA. Among 76 patients with a "suspicious" FNA, FS was reasonably accurate (sensitivity 67%, specificity 100%, accuracy 89%), but was deferred in 50% of cases.

CONCLUSION

Given high FNA accuracy, more selective use of FS is suggested.

SIGNIFICANCE

The study results will assist with intra-institutional patient counseling and intraoperative decision-making with respect to FNA and FS results in patients with nodular thyroid disease.

Posterior scalping flap revisited

OBJECTIVE

To report our experience in a case series of 5 posterior scalping flaps.

DESIGN

Retrospective review of a case series.

SETTING

A tertiary academic care otolaryngology-head and neck surgery referral center.

PATIENTS

Five patients having undergone posterior scalping flap reconstruction of cutaneous midface defects.

METHODS

Reconstruction was performed for 4 cheek defects, 1 of which included the lateral third of the upper and lower lips, and 1 combined midfacial and lateral nasal wall defect.

RESULTS

All 5 patients had excellent cosmetic and functional results. The only complication was a single case of partial-thickness distal flap necrosis.

CONCLUSION

The posterior scalping flap offers a reliable source of skin with appropriate color and texture and minimal donor-site morbidity.

Videolaryngostroboscopy following vertical partial laryngectomy

Phonation after partial laryngeal ablative surgery has not often been examined. Videolaryngostroboscopic recordings made after vertical partial laryngectomy (VPL) were retrospectively reviewed and correlated with patient historical and operative factors. Among VPL patients (n = 42), the most common site of vibration during phonation was the contralateral false vocal fold (17/42 patients or 40.5%), followed by the contralateral arytenoid mucosa (10/42 or 23.8%) and the contralateral true vocal fold (8/42 patients or 19.0%). There was no overall difference in vocal quality judgment with respect to site of vibration (ANOVA, p = .373). Vocal quality scores were similar with use of the pyriform mucosal flap versus other reconstructive methods (Student's t-test, p = .568). This study highlights the fact that reconstruction of a new vibratory source after VPL is important for voice production. Because VPL patients infrequently demonstrated true vocal fold vibration, alternative sites (ie, false vocal fold, arytenoid mucosa) must be considered as new phonatory sources after VPL.

Slow tonic muscle fibers in the thyroarytenoid muscles of human vocal folds; a possible specialization for speech

Most of the sounds of human speech are produced by vibration of the vocal folds, yet the biomechanics and control of these vibrations are poorly understood. In this study the muscle within the vocal fold, the thyroarytenoid muscle (TA), was examined for the presence and distribution of slow tonic muscle fibers (STF), a rare muscle fiber type with unique contraction properties. Nine human TAs were frozen and serially sectioned in the frontal plane. The presence and distribution pattern of STF in each TA were examined by immunofluorescence microscopy using the monoclonal antibodies (mAb) ALD-19 and ALD-58 which react with the slow tonic myosin heavy chain (MyHC) isoform. In addition, TA muscle samples from adjacent frozen sections were also examined for slow tonic MyHC isoform by electrophoretic immunoblotting. STF were detected in all nine TAs and the presence of slow tonic MyHC isoform was confirmed in the immunoblots. The STF were distributed predominantly in the medial aspect of the TA, a distinct muscle compartment called the vocalis which is the vibrating part of the vocal fold. STF do not contract with a twitch like most muscle fibers, instead, their contractions are prolonged, stable, precisely controlled, and fatigue resistant. The human voice is characterized by a stable sound with a wide frequency spectrum that can be precisely modulated and the STF may contribute to this ability. At present, the evidence suggests that STF are not presented in the vocal folds of other mammals (including other primates), therefore STF may be a unique human specialization for speech.

Upper aerodigestive tract liposarcoma: report on four cases and literature review

OBJECTIVE

To report on the clinical behavior, histopathology, treatment, and prognosis of laryngeal, hypopharyngeal, and cervical esophageal liposarcomas.

STUDY DESIGN

Retrospective reviews of pathology files and hospital records at a tertiary care hospital and a retrospective search of the English-language literature.

METHODS

Cases of upper aerodigestive tract (UADT) liposarcoma with adequate histopathologic documentation and clinical information were included for review.

RESULTS

Four cases of UADT liposarcomas were identified. The literature review revealed 26 cases of laryngeal liposarcomas, 7 cases of hypopharyngeal liposarcomas, and 6 cases of esophageal liposarcomas: the mean age at presentation was 55.8 years, the male:female ratio was 5:1, and 60% of the patients presented with dysphagia. Eighty-six percent of tumors had low-grade histologic findings. The recurrence rate after primary resection was 50%. Recurrence correlated with surgical procedure rather than with histologic subtype; 94.7% of recurrences happened after simple excision. Distant metastases occurred in three patients; two of them died of the disease.

CONCLUSIONS

The literature supports that UADT liposarcomas are rare and usually of low-grade histologic type. The rate of metastatic disease and tumor-related mortality is low. However, high recurrence rates have been noted, particularly when less radical surgery is employed.

Transverse infrahyoid approach to bilateral glottic tumors

Glottic exposure and entry for vertical partial laryngectomy procedures has traditionally been through the subglottis. Although this approach is generally satisfactory for the resection of unilateral vocal cord lesions, it may be unsafe in cases in which tumors extend across the midline and/or subglottically. In these instances, we prefer the superior transverse infrahyoid approach to the glottis, which transects the petiole of the epiglottis and reflects the contents of the preepiglottic space posterior and superior. This improved visualization of the larynx has permitted precise tumor excision without sacrifice of uninvolved segments of the vocal cords. This procedure has been performed 35 times over a 15-year period at our institution for the resection of bilateral glottic tumors, with and without subglottic extension. In none of the cases in which it has been employed was there a positive surgical margin.

Human vocalis contains distinct superior and inferior subcompartments: possible candidates for the two masses of vocal fold vibration

It is not understood how different parts of the thyroarytenoid muscle contribute to vocal fold vibration. This study investigated the medial part of the thyroarytenoid muscle, the vocalis compartment, for anatomic differences that might suggest functionally distinct areas. Twenty human vocal folds were frontally sectioned and stained with hematoxylin and eosin. A single section from the middle of each vocal fold was magnified, and the muscle fascicles of the most superficial 25% of the vocalis compartment were then examined. In all 20 specimens the vocalis compartment could be separated into 2 plainly distinct subcompartments: the inferior vocalis compartment was composed of a single large muscle fascicle that contained densely packed muscle fibers of similar size; the superior vocalis compartment was composed of multiple small fascicles in which the muscle fibers were loosely arranged and varied greatly in size. On average, the inferior vocalis subcompartment composed 60% of the medial surface of the thyroarytenoid muscle. The superior subcompartment composed the remaining 40% of the medial surface, but also continued past the vocal ligament to make up the superior surface of the thyroarytenoid muscle. It is concluded that 2 distinct entities make up the vocalis compartment of the thyroarytenoid muscle. Their anatomy is so markedly different it suggests that they may function independently. One possibility is that they reflect the 2 masses observed in the superior and inferior aspects of the vocal fold during vibration.

Botulinum toxin decreases salivation from canine submandibular glands

The objective of this study was to determine whether botulinum toxin types A and D reduced the production of saliva from the submandibular glands of 18 dogs. The left submandibular glands of 8 dogs were injected with increasing doses of botulinum type A toxin (range 10 to 70 units), and the left glands of 10 dogs were injected with botulinum type D toxin (50 or 100 units). The right gland of each dog was injected with equivalent volumes of saline solution to serve as control. Six days after the injection, the lingual nerve was electrically stimulated for 10 minutes (3 mAmp, 20 Hz). The resulting volume of saliva was collected and weighed. Overall, the glands injected with types A or D toxin produced significantly less saliva than comparable glands injected with saline solution. Six of 8 dogs injected with type A toxin showed a significant decrease in saliva production (range 10.1% to 19.2%, one-sided p value = 0.0375) when compared with the controls. Nine of 10 dogs injected with type D toxin demonstrated a highly significant reduction in saliva production (total average decrease = 60%, two-sided pvalue = 0.001) when compared with the controls. We concluded that intraglandular injections of botulinum toxin types A and D significantly reduced the production of saliva from canine submandibular glands. The potential applications of intraglandular injections of botulinum toxin are discussed.

Complications of microvascular head and neck surgery in the elderly

OBJECTIVES

To evaluate the complications of head and neck reconstruction using microvascular free tissue transfers (MFTTs) performed in an elderly population and to determine whether these complications are more common than in a younger population.

SETTING

Tertiary referral center.

PATIENTS AND DESIGN

Retrospective, consecutive chart review of patients older than 70 years who underwent MFTT in the past 5 years (group 1). The complications in this population were compared with those in a second group (group 2) of consecutive patients younger than 70 years who were matched according to the site of the primary tumor.

MAIN OUTCOME MEASURES

Surgical and medical complications.

RESULTS

The median age for group 1 was 74 years and for group 2, 55 years. The overall complication rate for group 1 was 48%, compared with 57% for group 2. In group 1, surgical morbidity was less common and medical morbidity was more common than in group 2. Mortality rate was 6% for group 1 and 0% for group 2. The types of complications were similar for both groups. There was no difference in complication rates when complications were classified by site of the defect, patient status determined by American Society of Anesthesiologists classification, or use of preoperative radiation. The overall success rate of MFTT was 100% for group 1 and 94% for group 2.

CONCLUSIONS

Microvascular free tissue transfers for head and neck reconstruction can be safely performed in the elderly. An age older than 70 years does not increase the rate of surgical complications following head and neck reconstruction with MFTT. Medical complications, however, are more common and are equally divided between bronchopulmonary and cardiovascular effects.

Oromandibular reconstruction using microvascular composite flaps: report of 210 cases

OBJECTIVE

To review the experience of 1 microvascular surgeon during an 11-year period in performing 210 vascularized bone-containing free flaps for oromandibular reconstruction.

DESIGN

Retrospective medical records review of patients who underwent primary and secondary oromandibular reconstruction with the use of vascularized bone free flaps.

SETTING

Academic medical center.

PATIENTS

A total of 201 patients underwent 210 composite free-flap reconstructions of the mandible for various disorders and with a range of bony and soft tissue defects.

INTERVENTION

All patients underwent the microvascular transfer of vascularized bone flaps from the ilium, fibula, or scapula. In selected cases, 2 simultaneous free flaps were transferred to achieve an optimal bone and soft tissue reconstruction. Endosteal dental implants were used in 81 patients, with a total of 360 fixtures placed during these 11 years.

MAIN OUTCOME MEASURES

The success of microvascular free tissue transfer, dental implant extrusion, and short- and long-term complications at the recipient and donor sites.

RESULTS

Of the 210 mandibular reconstructions that were performed, 202 were successful in reestablishing mandibular continuity. Reexploration for vascular-related complications was done in 16 patients, 8 of whom were successfully treated, yielding an overall success rate of 96%. The overall success rate for endosteal dental implants was 92%. The implant success rate was 86% when the bone in which the fixtures were placed was irradiated postoperatively. The success rate was 64% in the 14 fixtures that were placed into previously irradiated bone.

CONCLUSIONS

The success of the use of vascularized bone free flaps in restoring continuity to the mandible is clearly demonstrated in this series. There was an acceptable incidence of donor- and recipient-site complications that resulted in minimal long-term morbidity. The careful selection of a donor site(s) for oromandibular reconstruction allows for an optimal restoration of bony and soft tissue defects. Dental implants can be safely used in oromandibular reconstruction with a high level of success. Placing these implants during the initial surgery shortens the duration for achieving dental rehabilitation and enhances the success of the implants when postoperative radiotherapy is administered.

Reconstruction of the laryngopharynx after hemicricoid/hemithyroid cartilage resection. Preliminary functional results

OBJECTIVE

To evaluate the use of a sensate radial forearm free flap and free cartilage graft for reconstruction of the laryngopharyngeal defect that results from resection of pyriform sinus carcinoma that extends to the apex of the pyriform sinus and includes the hemithyroid and hemicricoid cartilages.

DESIGN

Case series review of 6 patients treated during a 2 1/2-year period with an average follow-up of 23 months. Factors evaluated included oncologic outcome, as well as functional outcome with regard to the onset and quality of the airway, speech, and deglutition.

SETTING

Mount Sinai School of Medicine, New York, NY, an academic, tertiary referral center.

PATIENTS

Six men ranging in age from 51 to 73 years underwent a partial laryngopharyngectomy that included the hemicricoid and hemithyroid cartilages as well as the ipsilateral thyroid lobe and either unilateral or bilateral lymph node dissections for squamous cell cancer that involved the apex of the pyriform sinus.

INTERVENTION

These extensive laryngopharyngeal defects were reconstructed with a sensate radial forearm flap that resurfaced the endolarynx, restored the depth of the pyriform sinus, and reconstructed the remainder of the hypopharynx. In the final 4 patients, a free costal cartilage graft was used to restore the infrastructure of the larynx.

OUTCOME MEASURES

The status of the margins, the incidence and site of recurrent cancer, the quality of speech, and the times to decannulation and removal of the gastrostomy tube.

RESULTS

Three recurrences developed, with 1 each at the primary site, in the neck, and systemically. All but 1 patient who had completed radiotherapy by the last follow-up had been decannulated, and all but 1 patient regained the ability to maintain nutrition by mouth. Complications were limited to pharyngocutaneous fistulae requiring surgical closure in 3 patients early in the series.

CONCLUSIONS

Functional reconstruction of extensive laryngopharyngeal defects can be achieved with a sensate radial forearm flap and a cartilage graft, with favorable functional results and acceptable morbidity, thus expanding the limits of conservation laryngopharyngeal surgery.

Reconstruction of massive defects in the head and neck: the role of simultaneous distant and regional flaps

BACKGROUND

Massive defects resulting from excision of advanced head and neck tumors may not be amenable to reconstruction using a single technique of tissue transfer. Sixteen patients undergoing reconstruction using simultaneous free flaps and pedicled regional flaps are presented.

METHODS

Regional flaps included the pectoralis major, deltopectoral, cervical visor, paramedian forehead, cervicofacial, and nape of neck flaps. Microvascular tissue transfers included the radial forearm, iliac crest, parascapular/latissimus dorsi, rectus abdominis, fibula, and lateral thigh free flaps.

RESULTS

Most defects involved both aerodigestive mucosa and external cutaneous skin. Mucosal reconstruction was carried out using the soft-tissue component of the free flaps, whereas vascularized bone was used for mandibular reconstruction. Regional flaps were used to reconstruct skin of the face and neck.

CONCLUSIONS

When planned and applied in a stepwise fashion, simultaneous free flaps and regional flaps are complimentary for the reconstruction of complex wounds in the head and neck.

Management of bilateral glottic tumors

OBJECTIVE

To compare the rates of cure and complication and the time to decannulation and deglutition in patients undergoing resection of bilateral glottic tumors.

DESIGN

A 22-year, nonrandomized, prospective, retrospective analysis.

SETTING

Two academic tertiary care referral centers.

PARTICIPANTS

Seventy-two patients with bilateral glottic carcinoma were treated using bilateral hemilaryngectomy. Depending on the size of the tumor and the extent of thyroid cartilage resection, patients underwent 1 of 3 methods of reconstruction: group 1, placement of an anterior commissure stent (34 patients); group 2, epiglottic laryngoplasty (15 patients); and group 3, staged posterior thyroid alar transposition laryngoplasty (23 patients).

INTERVENTION

Resection and reconstruction of 72 larynges with bilateral glottic tumors using the bilateral hemilaryngectomy procedures.

MAIN OUTCOME MEASURES

Acceptable rates of cure and complication, intervals to decannulation and deglutition, and quality of speech.

RESULTS

High rates of tumor control and cure, low rates of recurrence and complication, acceptable time to decannulation and deglutition, and adequate quality and intelligibility of speech.

CONCLUSIONS

Bilateral vocal cord carcinoma can be treated surgically with a high degree of tumor control and cure. The use of all 3 methods maintained laryngeal function with regard to tracheal decannulation, oral alimentation, and speech intelligibility.

Staged repair of cervical tracheoesophageal fistulae

Acquired, nonmalignant tracheoesophageal (TE) fistulae are most often iatrogenic or trauma induced. When a cervical TE fistula is complicated by tracheal stenosis or malacia, a single-stage repair of the fistula and tracheal defect is usually advocated. Complications of this single-stage repair, which occur in 25% to 50% of patients, are secondary to either excess tension at the tracheal anastomosis or the presence of inflammation at the time of tracheal anastomosis. Complications include recurrent tracheal stenosis, pneumonia, or a recurrent TE fistula. This report describes the senior author's techniques of reconstructing the trachea when tracheal stenosis complicates a TE fistula. These techniques are illustrated in two case reports of patients with postintubation TE fistulae. Current methods of tracheal reconstruction in this setting are reviewed. The incidence of postoperative complications may decrease if tracheal reconstruction is delayed until the fistula is successfully closed.

Sinonasal hemangiopericytomas: a clinicopathologic and immunohistochemical study of seven cases

BACKGROUND

Sinonasal hemangiopericytoma (SNHPC) is a rare lesion usually of low-grade malignant potential. Aggressive and metastatic cases are uncommon, and experience using adjuvant therapy on these cases has been limited. Tumor-induced osteomalacia has a very rare association with SNHPC. Further, the diagnosis of SNHPC remains one of histologic-pattern recognition. Traditionally, immunohistochemistry has aided in excluding other diagnoses; only vimentin has been consistently expressed by the tumor spindle cells of HPC. Recent studies have shown that Factor XIIIa is also expressed by HPC, (as well as tumors of fibrohistiocytic differentiation) and hence may be yet another helpful positive marker in establishing an immunohistochemical profile.

METHODS

We identified 7 patients at this institution with SNHPC from 1990 to 1994. Immunohistochemistry was performed on seven formalin-fixed paraffin-embedded tumors utilizing antibodies to factor XIIIa as well as antibodies to vimentin, factor VIII, muscle-specific antigen, cytokeratin, and S-100.

RESULTS

All 7 patients were initially seen with nasal obstruction or epistaxis and underwent surgical resection. The period of follow-up was from 3 months to 14 years (mean 54 months) for 7 patients. Three patients had recurrent disease after 3, 5, and 10 years. The first 2 were known to have been originally treated by polypectomy. One patient required adjuvant radiotherapy for metastatic disease and local extension. One patient was initially seen with tumor-induced osteomalacia which dramatically improved following resection of the lesion. The immunohistochemical profile revealed strong expression of vimentin in 7/7 cases, and of factor XIIIa in 4/7 cases; tumor cells did not express the other markers studied.

CONCLUSIONS

Adequate surgical resection with negative margins appears to be the appropriate therapy for SNHPC. Our 1 case associated with tumor-induced osteomalacia was reversible after surgical excision of the tumor. The immunohistochemical results suggest that the pattern of vimentin and factor XIIIa positivity, as well as lack of expression of other markers, is consistent with the diagnosis of HPC, which still remains in the domain of histopathology.

Cranial neuropathy secondary to perineural spread of cutaneous malignancies

Skin cancers of the head and neck are common lesions that rarely metastasize or invade cranial nerves. Perineural spread, when present, typically involves cranial nerves V and VII, because of their extensive subcutaneous distributions. Partial or complete facial palsy, facial hypesthesia, and/or pain may occur months to years after excision of a cutaneous malignancy and is often the first manifestation of regional metastasis. Too often, a history of facial skin cancer is not elicited in the evaluation of patients who present with fifth and/or seventh cranial nerve neuropathies. The initial yield from computerized tomography and magnetic resonance imaging is often limited, leaving most patients with the diagnosis of Bell's palsy. The authors herein present their experience with the diagnosis and management of seven patients who developed a fifth or seventh cranial nerve neuropathy an average of 13.4 months following "complete" excision of a regional skin cancer.

Rhinorrhea is decreased in dogs after nasal application of botulinum toxin

At this time no effective long-term therapy exists for the excessive secretion of vasomotor rhinitis. Because rhinorrhea is under parasympathetic control, it was theorized that botulinum toxin--a powerful and long-acting cholinergic blocker that has been successful in the treatment of dystonia--might be useful in blocking the cholinergic control of rhinorrhea. Four male mongrel dogs were studied. Fifty units of type A botulinum toxin was soaked into sterile gauze, which was then packed into the left nasal cavity of each dog for 1 hour. Saline-soaked gauze was similarly introduced into the right nasal cavity to serve as control. Six days later, rhinorrhea was produced by inserting a bipolar needle electrode into the sphenopalatine ganglion and electrically stimulating for 10 minutes (6 mA, 50 Hz). Nasal secretions were collected with a suction catheter placed in the nasal vestibule. Three of four dogs exposed to the toxin showed a 41% average decrease in rhinorrhea (specifically 53%, 41%, and 30%). One dog showed a 10% increase in secretion after exposure to the toxin. We conclude that topically applied botulinum toxin reduced neurally evoked rhinorrhea by an average of 41%. Because some secretion is mediated by noncholinergic neurotransmitters such as vasoactive intestinal peptide, topical application of an anticholinergic substance has limitations. However, because all the nasal parasympathetic nerves appear to originate from cholinergic synapses in the sphenopalatine ganglion, direct injections of toxin into this ganglion may possibly allow complete blockade of all cholinergically mediated rhinorrhea.

Inverted papilloma: a report of 112 cases

Inverted papilloma is a benign sinonasal tumor which is locally aggressive and has a significant malignant potential. This report updates the experience of the two senior authors, who have treated 112 patients with inverted papilloma at the Mount Sinai Medical Center over a 20-year period. As clinical examination often underestimates tumor extent, preoperative radiographic assessment is of paramount importance in guiding selection of surgical therapy. Complete en bloc excision via lateral rhinotomy and medial maxillectomy was the method of treatment in the majority of patients (84%). In selected patients with limited disease, or in patients who refused en bloc excision, conservative therapy employing intranasal or transantral ethmoidectomy was performed. The recurrence rates for the two groups were 14% and 20%, respectively. Recurrent disease developed throughout the paranasal sinuses, with the maxillary antrum and ethmoid labyrinth constituting the major sites. In two patients presenting with anterior skull base erosion, craniofacial resection was undertaken to eradicate disease. The latter cases underscore the aggressive nature of the tumor if left untreated. The overall rate of squamous carcinoma in this series was 5%. Given the predilection for local recurrence, multicentricity, and the possibility of malignancy, the authors continue to recommend lateral rhinotomy and medial maxillectomy as the standard therapy for the majority of cases. Management principles as well as a review of the literature are discussed.

Comprehensive management of the eye in facial paralysis

OBJECTIVE

To determine guidelines for the management of paralyzed eyelids following facial palsy, including surgical indications, timing, and type of procedure(s).

DESIGN

Prospective analysis of 60 patients diagnosed as having complete facial palsy. Follow-up ranged from 18 to 36 months.

PATIENTS

All subjects had a complete unilateral facial palsy of various origins. Ages ranged from 6 to 81 years.

INTERVENTIONS

Forty patients underwent evoked electromyography and blink reflex testing of the facial nerve. Twenty additional patients had a known fifth-degree nerve injury that did not require testing.

MAIN OUTCOME MEASURE

Lack of interval improvement in clinical results of examination and/or evoked electromyography, coupled with length of time from injury, were used to determine surgical candidacy. All patients with fifth-degree nerve injury were considered surgical candidates, with clinical examination results of eyelid function used to determine which procedure(s) to be performed.

RESULTS

Of the 60 patients evaluated with facial palsy, 43 patients required surgical restoration of eyelid function. Forty-one patients required gold weight implants; 18 of these also required shortening of the lower eyelid. Two additional patients underwent eyelid shortening without gold weight implantation. Seventeen patients were treated only with corneal lubricants and moisturizers. No gold weights extruded; there were no infections. Two patients required revision of their lower eyelid surgery owing to progressive laxity. Four patients have had their gold weights removed an average of 9.5 months following insertion.

CONCLUSIONS

The degree of neural injury and its associated regeneration time, determined clinically and by evoked electromyography, are useful factors to assist in patient selection, surgical timing, and type of procedure(s) necessary to fully rehabilitate the upper and lower eyelids following facial paralysis.

Rigid fixation of vascularized bone grafts in mandibular reconstruction

OBJECTIVE

To evaluate the nature of complications and complication rates with the use of three different reconstruction plates for the rigid fixation of vascularized bone grafts in oromandibular reconstruction.

DESIGN

We conducted a case series of 95 patients over a 6-year period, with a minimum follow-up of 6 months and a maximum follow-up of 66 months.

SETTING

Academic tertiary referral medical center.

PATIENTS

Forty-eight patients had vascularized bone grafts fixated to native mandible with AO stainless steel reconstruction plates; 25 patients, with AO titanium plates; and 22 patients, with titanium hollow screw reconstruction plates (THORPs). Types of vascularized flaps, mandibular defects to be reconstructed, and use of radiation therapy were similar among the three groups.

INTERVENTION

The surgical approach involved oromandibular reconstruction with a vascularized bone graft rigidly fixated with a reconstruction plate.

OUTCOME MEASURES

Clinically and radiographically noted complications and resultant treatment.

RESULTS

In the grafts fixated with AO stainless steel reconstruction plates, three plate fractures, seven instances of loose screws, eight plate exposures, and two cases of nonunion occurred. No cases of plate fracture or nonunion occurred in the titanium or THORP groups. One titanium plate and two THORPs were exposed during the study period. One instance of loose screws occurred in the titanium group; none in the THORP group. Seventy-four percent of those complications occurred within 12.4 months (the mean follow-up time of the THORP group). The incidence of complications in the stainless steel group was significantly greater than that in the titanium or THORP groups. No statistically significant increase in the rate of complications was noted when radiation therapy was used as a component of treatment.

CONCLUSIONS

To our knowledge, this is the first study to compare three different reconstruction plates for fixation in vascularized bone reconstruction of the mandible. AO THORPs are now used almost exclusively to rigidly fixate vascularized bone grafts because of their advanced design and their potential for osseointegration and because fewer screws are necessary to attain adequate fixation than with conventional AO reconstruction plates.

The human communicating nerve. An extension of the external superior laryngeal nerve that innervates the vocal cord

OBJECTIVE

A second source of motor innervation for the thyroarytenoid (TA) muscle, other than the recurrent laryngeal nerve, has been suggested by clinical and experimental observations. Early anatomists noted what appeared to be small nerves connecting the cricothyroid and TA muscles; however, these observations were disputed by later anatomists and subsequently forgotten.

METHOD

In this study, we processed 27 human hemilarynges with Sihler's stain, a technique that clears soft tissue and counterstains nerve. In addition, four communicating nerves (CNs) were frozen sectioned and stained for acetylcholinesterase, a marker for motor neurons.

RESULTS

In 12 (44%) of the 27 specimens, a neural connection was found that exited the medial surface of the cricothyroid muscle and then entered into the lateral surface of the TA muscle. In general, this CN was composed of two parts: an intramuscular branch usually combined with the recurrent laryngeal nerve or terminated within the TA muscle directly and an extramuscular branch that passed through the TA muscle and terminated in the subglottic mucosa and around the cricoarytenoid joint. All four CNs tested positive for acetylcholinesterase. Specifically, the CNs contained an average of 2510 myelinated axons, of which 785 (31%) were motor neurons.

CONCLUSION

The results suggest that when the CN is present, it supplies a second source of motor innervation to the TA muscle and extensive sensory innervation to the subglottic area and cricoarytenoid joint. In addition, the CN may be the nerve of the fifth branchial arch, a structure that has never been identified (to our knowledge).

Craniofacial resection. An analysis of 73 cases

OBJECTIVE

To determine the morbidity and mortality associated with a large series of patients undergoing craniofacial resection at one institution. The series is also analyzed with respect to pathology, disease recurrence, and role of adjuvant therapy.

DESIGN

Retrospective review with a mean follow-up of 3 years (range, 6 months to 8 years).

SETTING

Tertiary care, urban referral center.

PATIENTS

The study included 73 consecutive patients (39 male and 34 female). Ages ranged from 13 to 78 years with a mean of 53.1 years. All patients had benign or malignant tumors of the paranasal sinuses.

MAIN OUTCOME MEASURES

Morbidity associated with craniofacial resection was categorized as follows: early (within 30 days of surgery) or late (> 30 days); neurologic, ocular, or infectious.

RESULTS

Overall morbidity rate was 63%, and the mortality rate was 2.7%. Of the patients who had complications develop, 26 had development of major morbidities and there were two mortalities. The most common complications were transient alteration in mental status (15 patients), diplopia (11 patients), cerebrospinal fluid leak (10 patients), and osteomyelitis of the frontal bone flap (eight patients).

CONCLUSIONS

Craniofacial resection is an effective surgical treatment for paranasal sinus tumors. The mortality rate is acceptable and morbidity appears directly related to experience with the procedure. Infectious complications were the most devastating.

A modified design of the buried radial forearm free flap for use in oral cavity and pharyngeal reconstruction

OBJECTIVE

We present a new design for the radial forearm flap that includes a small monitor segment that is connected to the primary skin paddle by a fascial subcutaneous segment of tissue. This design modification permits buried flaps to be easily monitored and provides vascularized tissue coverage of the flap vessels as well as the great vessels in the neck. Immediate augmentation of the radical neck deformity can be achieved.

SETTING

This study was conducted at a referral center.

PATIENTS

Fifteen patients with squamous cell cancer of the pharynx and tongue base were included in this study. The defects in these patients were judged to be best reconstructed with a radial forearm free flap.

RESULTS

All free flaps in this series survived. There was one case, described in detail, in which the fascial subcutaneous portion of the flap was exposed to salivary contamination. The flap vessels remained well protected and flap viability was unimpaired.

Simultaneous interstitial radiotherapy with regional or free-flap reconstruction, following salvage surgery of recurrent head and neck carcinoma. Analysis of complications

OBJECTIVE

Reports on complications following brachytherapy offer conflicting views on the benefit of locoregional flap coverage of the implanted tumor bed. This study reviews complications following pedicled and free-flap coverage of brachytherapy sources after salvage surgery for recurrent head and neck carcinoma.

DESIGN

Retrospective chart review.

SETTING

Academic tertiary referral center.

PARTICIPANTS

Fifteen patients with advanced, radiorecurrent carcinomas of the head and neck, treated between 1988 and 1992.

INTERVENTION

All patients underwent surgical resection and implantation of the tumor bed with iridium 192 after-loading catheters (13 patients) or iodine 125 seeds (two patients). The average dose of interstitial radiotherapy supplied was 50.24 +/- 45.19 Gy (mean +/- SD). Coverage of the implanted tumor bed was achieved with regional myocutaneous flaps in 10 patients and microvascular free flaps in five patients.

OUTCOME MEASURE

All wound and healing complications were identified. Patients were followed up for a minimum of 3 months.

RESULTS

No significant complications were encountered. No flap, pedicled or free, demonstrated any degree of necrosis. Four minor complications developed in the group of patients who underwent reconstruction with pedicled myocutaneous flaps. One orocutaneous fistula developed in a patient in whom a radial forearm was used to reconstruct a posterior pharyngeal wall defect.

CONCLUSIONS

An expectation of increased postoperative morbidity should not interfere with the decision to proceed with multimodality salvage therapy of patients with advanced, recurrent head and neck tumors. The advantages of free tissue transfer in the reconstruction of head and neck defects are not compromised when the flaps are simultaneously utilized to provide coverage for brachytherapy sites.

Sinonasal esthesioneuroblastoma with intracranial extension: marginal tumor cysts as a diagnostic MR finding

PURPOSE

To determine whether the MR finding of cysts along the intracranial margin of sinonasal esthesioneuroblastomas can be considered to suggest this tumor.

METHODS

MR scans of 54 patients who had sinonasal lesions with intracranial extension were examined specifically for cysts along the intracranial margins of the lesions.

RESULTS

Only 3 of the 54 patients had these cysts, and all 3 of these patients had esthesioneuroblastoma. Surgical pathologic findings of one specimen showed the cyst to be marginally located within the tumor.

CONCLUSION

If cysts are seen on MR along the intracranial margin of a sinonasal mass, this finding highly suggests esthesioneuroblastoma.

New approach for operative management of vascular lesions of the infratemporal internal carotid artery

Direct operative management of aneurysms of the internal carotid artery is associated with significant morbidity. Preauricular surgical approaches to this area can result in violation of the inner ear, temporomandibular joint, or mandibular ramus, and cranial nerves V, VII, IX, X, XI, and XII. A new technique for saphenous vein bypass of the infratemporal and petrous internal carotid artery, using a postauricular curvelinear groove drilled in the mastoid cortex, is described. Proximally, the reverse vein graft is anastomosed to either the internal or external carotid artery, whereas the distal anastomosis is to the horizontal petrous internal carotid artery. The latter is accessed through a small pterional craniotomy. The internal carotid artery is then ligated between points of anastomosis, thus isolating the lesion and eliminating dissection in the infratemporal fossa. The posterior location of the vein graft also avoids potentially infected areas adjacent to the oropharynx, nasopharynx, and soft tissues of the face. Use of the external carotid artery decreases carotid cross-clamp time and minimizes graft length, and creation of a bony canal protects the graft from subsequent compression and kinking.

The innervation of the human posterior cricoarytenoid muscle: evidence for at least two neuromuscular compartments

Recent work has demonstrated that the dog posterior cricoarytenoid (PCA) muscle is composed of three neuromuscular compartments: a vertical, an oblique, and a horizontal. In this study, the human PCA muscle was examined for evidence of neural compartments. Fifteen human PCA muscles were processed by Sihler's stain, which renders the muscle translucent while counterstaining the nerve supply. The results clearly show that in all specimens the nerve supply of the human PCA muscle is separated into at least two main branches: one supplies the horizontal compartment and a second further subdivides to innervate both the vertical and oblique compartments. In 10 of the specimens, these nerve branches arose as separate branches from the recurrent laryngeal nerve. In all specimens, the nerve branch to the horizontal compartment was either combined or connected with the nerve branch to the interarytenoid muscle. The results suggest that the different compartments of the PCA muscle have distinct functions. In addition, the strong connections with the interarytenoid nerve complicate reinnervation procedures to reanimate a paralyzed or transplanted larynx.

A systematic approach to functional reconstruction of the oral cavity following partial and total glossectomy

Mobility, sensation, volume, and to a lesser extent, the shape of the tongue following partial glossectomy are critical elements to the successful rehabilitation of the patient with oral cancer. Our approach to tongue reconstruction is based on the extent and functional status of the residual tongue and whether there is an associated mandibulectomy. Despite the devastating effects of ablative surgery and radiation, the application of available reconstructive techniques can help to improve the quality of life of these patients. Herein, we present a revised classification scheme for tongue defects along with a discussion of the optimal method for reconstruction based on available techniques.

The varied presentations of papillary thyroid carcinoma cervical nodal disease: CT and MR findings

PURPOSE

To review the varied presentations of metastatic cervical lymph node disease in patients with papillary thyroid carcinoma.

METHODS

Thirteen cases were retrospectively collected and their clinical, imaging, surgical, and pathologic material was reviewed. In the cases reviewed there was no clinical or imaging evidence of a primary thyroid mass.

RESULTS

On CT, metastatic nodes can have multiple discrete calcifications, appear as benign cysts or hyperplastic or hypervascular nodes, or have areas of high attenuation which reflect intranodal hemorrhage and/or high concentrations of thyroglobulin. On MR, the nodes can have low to intermediate T1- and high T2-weighted signal intensities or high T1- and T2-weighted signal intensities, the latter reflecting primarily a high thyroglobulin content.

CONCLUSION

If any of these varied appearances of cervical lymph nodes are identified on CT or MR, especially in a woman between 20 and 40 years of age, the radiologist should suspect the diagnosis of papillary thyroid carcinoma, even in the absence of a thyroid mass.

Microvascular free flaps in head and neck reconstruction. Report of 200 cases and review of complications

OBJECTIVE

Microvascular free-tissue transfer to the head and neck has become an accepted method of reconstruction owing to increased success rates and superior aesthetic and functional results. Although the large number of arteries and veins in the neck make free-flap revascularization easier than in other recipient sites of the body, there are also unique problems that pose significant risks to the success of the procedure. We report our experience with 200 microvascular free flaps performed between 1987 and 1992.

SETTING

This study was conducted at a tertiary referral center.

PATIENTS

The majority of patients in this series underwent surgery for squamous cell cancer. Approximately 75% of the reconstructions were performed for defects of the oral cavity. There were 120 vascularized bone-containing free flaps for mandibular and midface reconstruction. The remaining 80 soft-tissue flaps were used for a variety of defects ranging from the scalp to the pharyngoesophagus.

RESULTS

An overall success rate of 93.5% for free-tissue transfers is reported. Greater experience with this technique has resulted in a reduction and a change in the nature of the complications encountered compared with those seen in the early part of our series. Donor and recipient site complications, including flap failures and anastomotic revisions, are analyzed in detail with respect to age, radiation status, donor site, and whether the ablative procedure was done for a primary or recurrent neoplasm.

Evaluation and management of congenital cervical teratoma. Case report and review

Congenital cervical teratoma can be clinically dramatic, although essentially benign. Prognosis is good provided that the airway is quickly stabilized and resection is not delayed. We present a case of massive cervical teratoma diagnosed using antenatal magnetic resonance imaging. The child was maintained on maternal circulation after cesarean section until successfully intubated, with a second team ready for emergent bronchoscopy or tracheotomy. After delivery, the lesion grew rapidly with persistent bleeding; biopsy revealed a benign, immature teratoma. On computed tomography all anatomy ventral to the vertebrae was obliterated. At surgery, however, the tumor was easily resected. The literature is reviewed, with attention to malignancy in neonatal cervical teratoma. Surgery was delayed because of the aggressive imaging appearance and rapid growth. This case suggests that when evaluating neonatal tumors, the standard criteria for infiltration and resectability may require modification.

Arytenoid motion evoked by regional electrical stimulation of the canine posterior cricoarytenoid muscle

Anatomical studies have demonstrated that the posterior cricoarytenoid muscle in the dog is composed of three bellies. These bellies are termed vertical, oblique, and horizontal on the basis of their orientation. The purpose of this study was to show whether each of these bellies can move the vocal fold in different ways. Ten anesthetized dogs underwent laryngectomies while paralyzed with curare. The posterior cricoarytenoid muscles were then exposed by dissecting the overlying esophageal mucosa. Electrical stimulation was applied to each belly, and the motion of the arytenoid cartilage was measured. Because the oblique belly overlies the vertical belly, they were usually stimulated together. It was found that the vertical and oblique bellies rock the arytenoid backwards while sliding it laterally, thus causing a maximal dilation of the airway. The horizontal belly caused a swiveling motion of the arytenoid. It is proposed that the vertical and oblique bellies normally cause vocal fold abduction during respiration, while the horizontal belly primarily is used to adjust finely the position of the vocal process during phonation. Because the human posterior cricoarytenoid is also composed of separate bellies it, too, may have distinct functions.

Ambulatory pediatric tonsillectomy and the identification of high-risk subgroups

Financial and utilization concerns have focused on reducing hospitalization costs for many procedures, including tonsillectomy. However, the safety of ambulatory tonsillectomy for all patients remains questionable. At our institution, tonsillectomy has essentially been an inpatient procedure by policy. We have reviewed the charts of 153 consecutive patients under 19 years of age who underwent this procedure between 1989 and 1990, in an attempt to identify "high-risk" subgroups. Variables examined were: indication for surgery, hours to adequate oral intake and to discharge, age, sex, surgeon status, underlying medical condition, complications, and concomitant procedures. Statistically significant differences (p < 0.05) were found in the time to adequate oral intake and discharge for children under 4 years of age as compared to older patients. Furthermore, 7% of patients with a preoperative diagnosis of obstructive sleep apnea showed clinical evidence of significant airway compromise postoperatively. No patient in the study group experienced postoperative bleeding before discharge. Our results have identified high-risk subgroups of children undergoing tonsillectomy who are at greater risk for these complications, and therefore may benefit from an inpatient setting.

A new bilobed design for the sensate radial forearm flap to preserve tongue mobility following significant glossectomy

OBJECTIVE

A new bilobed design of the sensate radial forearm flap is presented for reconstruction of the oral cavity following significant glossectomy. One lobe of the flap is used to restore the shape and volume of the tongue, while the second lobe is used to resurface the floor of the mouth and the gingiva.

SETTING

Tertiary referral center.

PATIENTS

Ten patients who underwent significant glossectomy for squamous cell cancer were included in this study. Patients were deemed candidates for this form of reconstruction when at least one half of the mobile tongue was resected and the residual tongue had an intact motor nerve supply.

RESULTS

In addition to the thin, pliable, and sensate tissue of the radial forearm skin, the bilobed design helps to prevent tethering of the root of the tongue to the inner table of the mandible. This factor is felt to be important in maximizing the mobility of the residual tongue. There were no flap failures or partial necroses. Tongue mobility, oral alimentation, articulation, and return of sensation are described.

Vascularized bone flaps in oromandibular reconstruction. A comparative anatomic study of bone stock from various donor sites to assess suitability for enosseous dental implants

OBJECTIVE

To identify donor sites from which vascularized bone may be harvested capable of accepting osseointegrated implants of the minimum dimensions required to ensure long-term implant stability.

DESIGN

An anatomic study of the most commonly employed donor sites for vascularized bone in oromandibular reconstruction was conducted on 28 cadavers.

SETTING

Academic tertiary referral center.

PARTICIPANTS

Twenty-eight freshly embalmed, adult white cadavers (16 male, 12 female) were dissected.

INTERVENTION

The ipsilateral fibula, iliac crest, radius, and lateral border of the scapula were harvested and multiply sectioned at predetermined sites.

OUTCOME MEASURE

Implantability was determined for each section based on measurements of height, width, and cross-sectional area utilizing computer planimetry.

RESULTS

The iliac crest was the most consistently implantable donor site, followed by the scapula, fibula, and radius (83%, 78%, 67%, and 21% of sections from each donor site satisfying the criteria for implantability). Consistent regional differences in implantability were encountered at each donor site except the scapula.

CONCLUSIONS

Following ablation of oromandibular malignant neoplasms, restoration of stable retentive dentition is a prerequisite to a successful functional oral rehabilitation. This is best achieved with enosseous implants, capable of supporting a stable dental prosthesis, placed directly into vascularized bone flaps at the time of mandibular reconstruction. The implications of the results obtained in this study for gender, donor site selection, and orientation of the vascularized bone flap are discussed.

The intramuscular innervation of the human interarytenoid muscle

The nerve supply of the human interarytenoid (IA) muscle has been controversial for more than a century. In this study the contribution of the recurrent and superior laryngeal nerves to the IA was investigated in 10 adult human larynges. The larynges were obtained from autopsies and processed with the modified Sihler's technique which clears soft tissue while staining nerve. The IA muscles were dissected off the specimens and transilluminated to demonstrate their nerve supply. The results demonstrated that all 10 IA muscles were bilaterally innervated by both recurrent laryngeal nerves (RLNs) as well as branches of both superior laryngeal nerves (SLNs). These nerves combined within the IA muscles to form a dense anastomotic plexus which was highly variable between specimens. The exact nature of the internal SLN neurons, whether motor or sensory, their innervation targets, or their function, were not discernible. Additional anatomic findings were the presence of large neural communications directly between the SLN and RLN, and smaller neural connections from side to side. All of these results disagree with currently accepted descriptions of laryngeal neuroanatomy.

Free Tissue Transfer for Skull Base Reconstruction Analysis of Complications and a Classification Scheme for Defining Skull Base Defects

OBJECTIVE

The role of free flaps in skull base reconstruction is discussed in detail. Twenty-six microvascular free tissue transfers performed in 22 patients are reviewed in detail. A classification scheme for skull base defects is presented.

SETTING

Tertiary referral center.

PATIENTS

Twenty-two patients with neoplasms that involve the skull base underwent a combined craniotomy and facial approach for resection. The resultant defects were reconstructed with a variety of microvascular free flaps.

RESULTS

All 22 patients were ultimately successfully reconstructed with a free flap. One patient required a second free flap following ablative surgery for a recurrent tumor. The initial free flaps in three patients were unsuccessful and a second flap was required. The classification scheme was applied to all defects.

CONCLUSIONS

The creation of a functional separation of the intracranial and extracranial cavities can be extremely difficult to accomplish, especially when multiple cavities (nasal, oral, pharyngeal) are violated. Free flaps provide a solution to this problem in select cases. Skull base defects can and should be classified for the purpose of communication, treatment planning, prognosis of reconstruction, and judging therapeutic outcome.

The intramuscular nerve supply of the human lateral cricoarytenoid muscle

The lateral cricoarytenoid (LCA) muscle is one of the adductors of the vocal cords; however, some investigators believe that the lateral edge of the muscle may be involved in abduction. The possibility of functionally distinct compartments within the LCA was investigated by observing the pattern of the intramuscular nerve supply. This technique has previously clearly demonstrated neural compartments in the posterior cricoarytenoid, thyroarytenoid and cricothyroid muscles. Five adult human larynges were processed by the Sihler's stain which clears all soft tissue while counterstaining the nerves. The results of our study showed that the innervation pattern of the human LCA muscle is composed of a homogenous nerve plexus localized to the middle region of the muscle. This pattern correlates with the location of motor endplates described by prior investigators. The consistent neural pattern suggests that the LCA is composed of a single neuromuscular compartment.

The innervation of the human larynx

OBJECTIVE

To investigate the gross anatomy of the recurrent and superior laryngeal nerves (RLNs and SLNs) in 10 human larynges.

METHODS

Whole larynges were processed to clear all soft tissue while leaving nerves stained. Then the main laryngeal nerves and the muscles they innervate were dissected and analyzed.

RESULTS

It was found that in all larynges the RLNs and SLNs are connected by nerve branches other than Galen's anastomosis. The most consistent connection is in the interarytenoid muscle, where RLNs and internal SLNs combine in a neural plexus. A less consistent connection occurs in the piriform fossa, where a continuation of the external SLN passes from the cricothyroid muscle to the thyroarytenoid muscle.

CONCLUSION

Based on these findings it is proposed that there are significant neural connections between the RLN and SLN systems. In addition, limited cross-innervation is seen from side to side in the area of the interarytenoid muscle. Other findings concern the innervation patterns within the laryngeal muscles. The posterior cricoarytenoid, cricothyroid, and thyroarytenoid muscles all appear to be composed of separate bellies based on the configuration of their nerve supply. Most notable is the region of the thyroarytenoid muscle at the vocal cord margin that is innervated by a nerve plexus of extreme complexity. The details of the innervation patterns suggest functional differences within and between laryngeal muscles.

Hemodynamics of the rodent abdominal skin flap following primary ischemia

The effect of varying periods of ischemia and reperfusion times on subsequent blood flow was studied in the rodent abdominal skin flap. Using perfusion fluorometry, measurements of blood flow were quantified in 60 Sprague-Dawley rats undergoing clamp-induced ischemic periods ranging from 0 to 6 hours and reperfusion times ranging from 2 to 8 hours. Flaps subjected to ischemia times of 0, 2, 4, or 6 hours require 8 hours of reperfusion time before reaching baseline levels of blood flow. Blood flow in flaps subjected to 6 hours of ischemia was statistically less than the flow in flaps ischemic for 0, 2, and 4 hours and was directly related to length of reperfusion. These results demonstrate that flap perfusion does not fully take place immediately after clamp release. The factors thought to be responsible for these findings and the implications for the design and interpretation of flap ischemia experiments are discussed.

Extended osteoplastic maxillotomy. A versatile new procedure for wide access to the central skull base and infratemporal fossa

Extended osteoplastic maxillotomy provides wide, direct exposure of the lateral and/or central skull base. This procedure, developed in cadavers, has been used successfully in six patients. Briefly, the maxillofacial skeleton is partially exposed via a Weber-Fergusson incision. Osteotomies in the maxilla and zygoma completely disengage the maxilla from the facial skeleton. The maxilla is mobilized on the skin and soft tissues of the ipsilateral cheek, maintaining its vascularity. Medial positioning of the anterior osteotomy through the face of the maxilla determines the extent of exposure to the nasopharynx. The lateral osteotomy can be placed anteriorly at the malar eminence or posteriorly to include the glenoid fossa, thus determining the extent of exposure to the infratemporal fossa. Concurrent use of a pterional or temporal craniotomy provides corresponding access to the cranial cavity. Miniplate fixation of the maxilla and zygoma reestablishes skeletal contour. This new, versatile procedure can be used for benign and malignant lesions of the nasopharynx and infratemporal fossa, particularly in those patients requiring preoperative or postoperative adjuvant therapy.

A technique for displaying the entire nerve branching pattern of a whole muscle: results in 10 canine posterior cricoarytenoid muscles

There is anatomical and histological evidence for three functionally distinct muscle bellies in the canine posterior cricoarytenoid (PCA) muscle. This study attempted to define the exact nerve branching pattern to each muscle belly in 10 dogs using a modification of Sihler's neural staining technique. The results are presented here as photographs and schematic nerve maps which illustrate the following points. 1. the final terminal branches within the PCA do correspond to the three bellies of the PCA; 2. the initial nerve branch to the PCA is usually composed of multiple fascicles which rearrange before their final branching to the three bellies; 3. there is tremendous variability of the nerve branching patterns including bilateral asymmetry within the same animal; 4. the terminal branching within each belly can be surprisingly complex and contain multiple anastomoses; 5. the fast- and slow-twitch bellies of the PCA have different terminal branching patterns. These results support the functional subdivision of the canine PCA into three distinct neuromuscular compartments. This microanatomical technique appears useful for studying the basic neuromuscular organization of laryngeal muscles and their developmental and pathological changes.

The three bellies of the canine posterior cricoarytenoid muscle: implications for understanding laryngeal function

The posterior cricoarytenoid (PCA) muscle is known to be active during phonation and respiration. The presence of muscle compartments (bellies) that might subserve these functions was investigated in the canine PCA by anatomical dissection and muscle fiber histochemistry. Five PCA muscles were microdissected and the origins and insertions of all muscle bundles were recorded. An additional six PCA muscles were frozen, sectioned, and stained for adenosine triphosphatase (ATPase) activity. The total number of fast- and slow-twitch fibers were counted and their proportion was determined for each region of the muscle. The PCA muscle was found to contain three distinct neuromuscular compartments. The vertical compartment is oriented at 24 degrees from true vertical, inserts on the lateral aspect of the muscular process of the arytenoid, and is composed of 65% type 2 (fast) muscle fibers. The oblique is oriented at 44 degrees from vertical, inserts on the top of the muscular process of the arytenoid, and is composed of 77% type 2 muscle fibers. The horizontal is oriented at 63 degrees from vertical, inserts on the medial aspect of the muscular process of the arytenoid, and is composed of 59% type 2 muscle fibers. The cricoarytenoid joint is capable of three arcs of motion and the physical arrangement of each compartment appears to correspond to each of these motions. Moreover, the histochemical profiles show that the activity of the three bellies is quite different. These results suggest that the different compartments of the PCA perform distinctive motions during phonation and inspiration.

Prolongation of secondary critical ischemia time of experimental skin flaps using UW solution as a normothermic perfusate

A myriad of investigations have been published on the pharmacologic manipulation of flaps to enhance tolerance to ischemia. We recently reported a threefold increase in ischemic tolerance of the rat abdominal skin flap pedicle after 6 hours of primary ischemia and 12 hours of reperfusion. Flaps underwent normothermic perfusion washout with lactated Ringer's or U.W. solution, a newly developed organ preservation medium. Perfusion washouts were performed at one of three different points in the protocol: (1) onset of primary ischemia; (2) onset of secondary ischemia; or (3) 2 hours after onset of secondary ischemia. The last group was used to simulate the clinical situation in which flaps are discovered and salvage procedures instituted at a delayed time interval. This is the longest normothermic ischemic interval reported. We undertook the present study to determine the utility of the U.W solution in prolonging the tolerance of the flap to a second ischemic insult after a period of reperfusion. Seventy-five unilateral rat abdominal skin flaps were raised. Secondary ischemia was produced by placing a microvascular clamp across the inferior epigastric pedicle. Flap survival was assessed at 1 week postoperatively. While none of the nonperfused flaps survived 8 hours of secondary ischemia, at least 50% of the U.W. perfused flaps survived an average of 14 hours of secondary ischemia. Lactated Ringer's perfusion washout only modestly increased the ischemic tolerance. Perfusion washout in the secondary ischemic phase improved the ischemic tolerance to a significantly greater degree than in the primary ischemic interval.

Quantitative mapping of the effect of botulinum toxin injections in the thyroarytenoid muscle

Spasmodic dysphonia has been successfully treated by thyroarytenoid muscle injections of botulinum toxin (Botox) with dosages ranging from 0.625 to 25 U. In some patients, excessive paralysis with resulting breathiness and aspiration have been noted. In order to maximize the efficiency of Botox injections, the histologic effects of various Botox dosages were examined in the dog. Nine canine thyroarytenoid muscles were injected with 0.5 to 12.5 U of Botox. After 24 hours, the recurrent laryngeal nerve to the injected muscle was electrically stimulated in order to deplete the glycogen within the muscle fibers. Frozen sections of this muscle were then stained for glycogen. Those fibers that retained their glycogen were presumed paralyzed by the Botox injection. The extent of paralysis was found to be dose-related from 1.0 to 7.5 U. At 10 U and above the muscle was completely paralyzed. Spread of the toxin to the lateral cricoarytenoid muscle was seen at doses as low as 1.0 U. Clearly, doses less than 10 U appear sufficient for clinical paralysis.

Combined infrahyoid and inferior constrictor muscle release for tension-free anastomosis during primary tracheal repair

Although tracheal stenosis is not a common clinical entity, it still presents a significant management problem, despite recent endoscopic advances. Surgical correction by resection and primary anastomosis is the preferred treatment, provided the repair can be performed without excessive tension. Various release techniques have been described in order to achieve mobility and, thereby, a tension-free anastomosis. This article presents a combined infrahyoid muscle and inferior constrictor muscle release to assure maximum mobility of the laryngotracheal complex, thus allowing tension-free closure. A series of ten patients who underwent primary repair using the combined technique is presented, and the operative technique is described. The indications, age, length of stenosis, and minimum 1 year followup of these patients are presented, as well as perioperative management and complications. The success rate with this technique is 90%.