Necrotizing fasciitis of the ear: an unusual case

We describe a rare case of necrotizing fasciitis of the ear in an otherwise generally healthy 39-year-old man. The ear is rarely involved in this often-fatal disease. The diagnosis was suspected on the basis of clinical examination and confirmed by computed tomography and pathology of a biopsy specimen, which revealed subcutaneous gas formation and dermal infiltration of inflammatory cells, respectively. The patient was promptly treated with surgical debridement, intravenous antibiotics, and hyperbaric oxygen. He recovered well and subsequently underwent otoplastic reconstruction with very satisfactory results. By documenting this case, we aim to heighten awareness of necrotizing fasciitis of the head and neck in an effort to improve survival rates.

Oropharyngeal and Esophageal Swallowing Impairments: Their Association and the Predictive Value of the Modified Barium Swallow Impairment Profile and Combined Multichannel Intraluminal Impedance—Esophageal Manometry

Objectives:

Deglutition is a highly integrated process of neural signaling and coordinated muscular contraction that begins with bolus preparation in the oral cavity and ends with closure of the lower esophageal sphincter after bolus passage. The goal of this study was to examine the relationship between measures of oropharyngeal and esophageal swallow function.

Methods:

A retrospective review was performed of patients who underwent modified barium swallow study (MBSS) and multichannel intraluminal impedance–esophageal manometry (MII-EM) over 7 years at an academic institution. The MBSS was scored with the Modified Barium Swallow Impairment Profile (MBSImP). Associations between impairments as measured by the MBSImP and MII-EM were assessed with a 2-sided Fisher's exact test.

Results:

One hundred sixty-four patients met the inclusion criteria for the study. Comparison of MBSImPcomponent and oral and pharyngeal total regional scores to MII-EM scores revealed a significant association between abnormal esophageal clearance on MBSS (MBSImP component 17) and abnormal findings on MII-EM (p < 0.001). Delay in initiation of pharyngeal swallow (MBSImPcomponent 6) was significantly associated with abnormal esophageal clearance on MBSS (p = 0.023).

Conclusions:

Abnormal esophageal clearance on MBSS (MBSImP component 17) indicates a need for further esophageal testing. A functional interrelationship between abnormalities of oropharyngeal and esophageal swallowing does exist, illuminating the importance of thorough pharyngoesophageal examination for dysphagia symptoms.

Recurrent laryngeal nerve paresis postpneumonectomy contralateral to site of surgery

Recurrent laryngeal nerve (RLN) injury is a serious complication of thoracic surgery that increases morbidity and mortality. It is important to consider the long-term effects of mediastinal shift and the possibility of postpneumonectomy syndrome on RLN function. This report documents a unilateral vocal fold paresis contralateral to the side of pneumonectomy that presents for investigation 6 six years after surgery.

Trends and Outcomes in the Management of Upper Esophageal Disorders

Objective: 1) Compare the outcomes of 2 surgical modalities used to treat hypopharyngeal diverticulum and esophageal stenosis at the Medical University of South Carolina (MUSC) and analyze the economic efficiency of each. 2) Compare the MUSC experience with statewide treatment in South Carolina (SC) Medicare patients.

Method: Retrospective analysis was conducted of 50 patients treated at MUSC. The 2 approaches utilized were endoscopic laser diverticulotomy and transcervical open diverticulectomy with cricopharyngeal myotomy. SC Medicare data was collected for patients undergoing these procedures. Primary outcomes investigated were intraoperative complications, operative charge, hospital stay, and postoperative complications.

Results: Statistically significant differences between the 2 operative groups at MUSC were observed in length of stay (1.08 days endoscopic group and 4.75 days transcervical open group; P > .0001) and operative charge (US $ 2842 endoscopic and US$ 3425 transcervical; P > .0001). The perioperative complication and readmission rates were similar. The rate of reoperation was the same between the 2 groups; however, most of the patients who underwent transcervical open diverticulectomy were initially planned as endoscopic approaches. The Medicare data group differed significantly in length of hospital stay and patient charges compared to MUSC group.

Conclusion: The comparison of techniques reveals that long-term outcomes are similar, but the immediate postoperative sequelae of prolonged hospital stay and increased operative charge with transcervical open diverticulotomy is evident. Although further cost analysis is indicated, endoscopic laser diverticulotomy is a safe, cost effective alternative to transcervical open diverticulectomy.

Modified endoscopic medial maxillectomy for recalcitrant chronic maxillary sinusitis

BACKGROUND

Modified endoscopic medial maxillectomy (MEMM) is an accepted alternative treatment for benign sinonasal neoplasms. Its use as definitive treatment for inflammatory disease of the maxillary sinus has yet to be adequately explored. We evaluate the efficacy of MEMM for chronic maxillary sinusitis and attempt to identify factors that predispose patients for failure.

METHODS

A retrospective chart review of 46 patients who underwent a total of 61 medial maxillectomies for recurrent chronic maxillary sinusitis from 2003 to 2010 was performed. Data was collected regarding patient demographics, prior therapies, and exudative cultures.

RESULTS

Complete resolution of disease was achieved in 37 of 46 patients (80%). Four patients required additional topical medical management prior to resolution of their inflammatory disease. When the culture was negative, resolution of disease was seen in 90% of patient. However if P. aeruginosa was cultured, the rate of disease resolution dropped to 75%. Similarly if S. aureus was culture, only 56% of patient demonstrated complete disease resolution. Of patients who had previous Caldwell-Luc procedures, 73% were successfully salvaged. No revision surgeries were required. The mean follow-up time was 35 months.

CONCLUSION

MEMM is an effective and acceptable alternative treatment for chronic maxillary sinusitis refractory to standard medical treatment and endoscopic surgical treatment. Cultures positive for P. aeruginosa and S. aureus may be associated with worse outcomes.