The value of postoperative anticoagulants to improve flap survival in the free radial forearm flap: a systematic review and retrospective multicentre analysis

BACKGROUND

Free radial forearm flap (FRFF) reconstruction is a valuable technique in head and neck surgery, which allows closure of large defects while striving to maintain functionality. Anticoagulative drugs are often administered to improve flap survival, although evidence regarding effectiveness is lacking.

OBJECTIVE OF REVIEW

To investigate the effectiveness of postoperative anticoagulants to improve survival of the FRFF in head and neck reconstruction.

TYPE OF REVIEW

Systematic review and multicentre, individual patient data meta-analysis.

SEARCH STRATEGY

MEDLINE, EMBASE, Web of Science and CINAHL were searched for synonyms of 'anticoagulants' and 'free flap reconstruction'.

EVALUATION METHOD

Studies were critically appraised for directness of evidence and risk of bias. Authors of the highest quality publications were invited to submit their original data for meta-analysis.

RESULTS

Five studies were of adequate quality, and data from four studies (80%) were available for meta-analysis, describing 759 FRFF procedures. Anticoagulants used were as follows: aspirin (12%), low molecular weight dextran (18.3%), unfractioned heparin (28.1%), low molecular weight heparin (49%) and prostaglandin-E1 (2.1%). Thirty-one per cent did not receive anticoagulants. Flap failure occurred in 40 of 759 patients (5.3%) On univariate analysis, use of unfractioned heparin was associated with a higher rate of flap failure. However, these regimens were often administered to patients who had revision surgery of the anastomosis. In multivariate logistic regression analysis, anticoagulant use was not associated with improved flap survival or flap-related complications.

CONCLUSIONS

The studied anticoagulative drugs did not improve FRFF survival or lower the rate of flap-related complications. In addition, some anticoagulants may cause systemic complications.

Radial forearm osteocutaneous free flap in maxillofacial and oromandibular reconstructions

OBJECTIVES/HYPOTHESIS

The radial forearm osteocutaneous free flap is an excellent reconstructive modality for oromandibular and maxillofacial reconstruction in certain well-defined circumstances. The initial concern over donor site morbidity and the ability of the bone to reconstruct mandibular defects have led to only a few published series.

STUDY DESIGN

Retrospective study of the experience of two tertiary medical centers with radial forearm osteocutaneous free flap.

METHODS

Retrospectively, 52 patients were studied who underwent radial forearm osteocutaneous free flap reconstruction for cancer (49 cases) and trauma (3 cases). Bone length and skin paddle harvested, general morbidity (hematoma, wound infection, and dehiscence), recipient site morbidity (nonunion of neomandible, flap failure, and bone or plate exposure), and donor site morbidity (radius bone fracture, plate exposure, and skin graft failure) were reviewed.

RESULTS

The average skin paddle size was 55.1 cm (range, 15-112 cm). The average radius bone harvest length was 6.3 cm (range, 2.5-11 cm). Donor site complications included tendon exposure (3 cases), radius bone fracture (1 case), and exposure of the plate (0). Recipient site complications included nonunion of the mandible (4), exposed mandible (1), exposed mandibular plates (2), exposed maxillary plates or bone (0), venous compromise (1), and flap failure (1). Two patients had perioperative deaths.

CONCLUSION

Radial forearm osteocutaneous free flap is a valuable and viable option for oromandibular and maxillofacial reconstruction.

The mucosal invasion model: a novel in vitro model for evaluating the invasive behavior of mucocutaneous malignancies

BACKGROUND

Prevention of regional and metastatic spread of cutaneous malignancies requires understanding the physiologic mechanism of tumor cell invasion. In vitro models are convenient for studying the in vitro invasive phenotype of normal cells, tumor cell lines, or genetically altered cells in a 3-dimensional matrix, but they should attempt to recapitulate the complex in vivo submucosal environment. A new acellular extracellular matrix, porcine submucosal matrix (PSM), is thought to accurately recapitulate the submucosal matrix. A novel in vitro model using PSM to assess mucocutaneous tumor cell invasion was studied.

METHODS

The morphologic characteristics, growth, and invasive behavior of human head and neck squamous cell carcinoma (UM-SCC-1, UM-SCC-5, UM-SCC-17B, and OSC-19) cell lines were assessed on the PSM gel and compared with commonly used in vitro invasion models (type I collagen and Matrigel matrices). The invasive phenotype of canine kidney cells was also assessed on each matrix, because this cell line is known to demonstrate a characteristic in vitro invasive phenotype.

RESULTS

The PSM-supported head and neck squamous cell carcinoma tumor cell line growth and single cell invasion were seen under stimulated conditions, similar to type I collagen gels. The invasive phenotype of canine kidney cells behaved similarly on PSM and collagen. Matrigel did not support growth well, and invasion occurred only superficially in isolated areas.

CONCLUSION

The PSM is a good in vitro model for assessment of pharmacologic and genetic manipulations of head and neck squamous cell carcinoma tumor cell lines and has several advantages over other commonly used matrices.

MRI detection of cervical metastasis from differentiated thyroid carcinoma

BACKGROUND

With the advent of the use of serum thyroglobulin as a marker for the recurrence of well-differentiated thyroid cancer (WDTC) after total thyroidectomy, clinicians are increasingly faced with the diagnostic dilemma of detecting the site of recurrence in thyroglobulin-positive patients with normal clinical examinations. The high protein content of this thyroglobulin may make it specifically detectable by magnetic resonance (MR) imaging.

OBJECTIVE

To determine the ability of MR imaging to detect the presence of metastatic WDTC in cervical lymph nodes.

STUDY DESIGN

Retrospective cohort.

METHODS

Blinded review by two independent head and neck radiologists of 34 head and neck MR scans obtained from 26 patients with thyroid cancer (12 with primary disease and 14 with recurrent disease) all of whom subsequently underwent surgical removal of the lymph nodes considered at risk by imaging.

RESULTS

The average overall percent sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MR imaging were 95%, 51%, 84%, 78%, and 83%, respectively. The concordance between the two radiologists was 69%. There was no overall difference in the ability of the MR scan to detect the presence of disease in the upper jugular, lower jugular, or paratracheal nodal stations. However, it was more useful for papillary carcinoma (PPV 86%, accuracy 85%) than for follicular carcinoma or the follicular variant of papillary carcinoma (PPV 63%, accuracy 67%).

CONCLUSION

MR imaging is a sensitive and accurate technique for the detection of WDTC, particularly papillary carcinoma, metastatic to cervical lymph nodes. However, the lower specificity of this modality precludes its use as a screening tool.

Emerging perceptions of facial plastic surgery among medical students

OBJECTIVE

The purpose of this study was to examine the perceptions of medical students regarding facial aesthetic surgery and those specialists most likely to perform aesthetic or reconstructive facial surgery.

METHODS

A survey was designed based on a review of the literature to assess the desirable characteristics and the perceived role of the facial plastic and reconstructive surgeon (FPRS). The surveys were distributed to 2 populations: medical students from 4 medical schools and members of the general public.

RESULTS

A total of 339 surveys were collected, 217 from medical students and 122 from the general public. Medical students and the public had similar responses. The results demonstrated that respondents preferred a male plastic surgeon from the ages of 41 to 50 years old and would look to their family doctor for a recommendation. Facial aesthetic and reconstructive surgery was considered the domain of maxillofacial and general plastic surgeons, not the FPRS.

CONCLUSION

Integration of the FPRS into the medical school curriculum may help to improve the perceived role of the specialty within the medical community. It is important for the specialty to communicate to aspiring physicians the dedicated training of an otolaryngologist specializing in FPRS.

Postoperative antibiotic use of septoplasty: a survey of practice habits of the membership of the American Rhinologic Society

Prophylactic antibiotics are used routinely in otolaryngology. Little objective data exist concerning their use in sinonasal procedures. We wished to determine the practice patterns of otolaryngologists regarding prophylactic antibiotics for septoplasty patients. A survey of 743 (60.3% responded) members of the American Rhinologic Society was used to get information about their practice habits and rationale for using antibiotics after septoplasty. Sixty-six percent of respondents routinely used antibiotics. Postoperative infection and toxic shock syndrome (TSS) were the primary indications. Forty-four percent of respondents used some form of packing and 38% used a splint. There was no relationship between the annual number of procedures and the reasons for using antibiotics. Doctors who performed more than 50 cases a year were less likely to use packing or splints (p < 0.001). Older surgeons used less younger surgeons a packing/splints (p < 0.001). Respondents who used packing/ splints were more likely to use antibiotics (p = 0.008). Older respondents used packing whereas younger respondents used splints (p = 0.002). The rationale for antibiotics varied by age; re more concerned with TSS and older physicians were more concerned with infection (p = 0.005). This survey shows great variability in the usage and rationale for antibiotics after septoplasty.

Tracheoesophageal puncture in the office setting with local anesthesia

Tracheoesophageal puncture (TEP) with voice prosthesis placement is currently the method of choice for vocal rehabilitation of patients who have undergone total laryngectomy. Occasionally, secondary TEP needs to be performed. We have used a TEP technique that is performed in the clinic setting with local anesthesia and no sedation. The purpose of this study was to review our technique and experience and to evaluate results, complications, and patients' acceptance of the procedure. We performed a retrospective chart review of the records of 14 patients who had undergone total laryngectomy and secondary TEP placement in the clinic setting. The procedure was well tolerated. The voice results were fair to good in 11 of 12 patients. There was 1 complication, a false passage between the trachea and the esophagus. Voicing was immediate in 12 of the 14 cases. We conclude that TEP can be performed in the office setting with local anesthesia. The voice results are excellent, and the procedure is well tolerated by the patient. Proper patient selection and regular follow-up by a speech-language pathologist are important.

Use of the radial forearm free tissue flap to treat persistent stricture after esophagogastrectomy

BACKGROUND

Persistent stricturing or anastomotic leakage at the cervical esophagogastric anastomosis can be a troublesome complication of gastric pull-up procedures. When the stricture is the result of ischemia of the stomach, the strictures are long and often not responsive to dilatation and require large operations such as jejunal interposition or replacement with colonic pull-up. In this report we describe the use of a radial forearm flap to patch strictures.

METHODS

The radial forearm flap is a fascia cutaneous flap taken from the forearm and based on the radial artery and its venae comitantes. The advantages of this flap are that it is thin and pliable, conforms easily, has excellent reliability due to the size of the feeding vessels, and has a relatively long pedicle. The vascular anastomosis can be made to several arteries and veins within the neck. The epithelial component can be made in sizes up to 10 by 20 cm.

RESULTS

We have used the radial forearm flap to patch strictures in 6 patients with persistent complex strictures in the cervical region after esophagectomy. Results were excellent in 4 patients (able to eat liquids and solids without problems) and good in 1 patient (liquids okay, some problem with solids), and 1 patient died postoperatively. Follow-up is 4 months to 7 years.

CONCLUSIONS

The radial forearm flap is an excellent option for handling persistent stricture after esophagogastrectomy. In many instances, this flap can be used in lieu of a jejunal interposition flap and obviates a laparotomy to harvest jejunum. The flap fits easily into the neck and conforms to the space.

A Prospective Comparison of Scalpel Versus Bipolar Scissors in the Elevation of Radial Forearm Fasciocutaneous Free Flaps

OBJECTIVES/HYPOTHESIS

The radial forearm fasciocutaneous free flap has become the workhorse for reconstruction of head and neck ablative defects. A location distal to the head and neck allows this flap to be elevated concurrent with the ablation. Most commonly, the flap is elevated under tourniquet control. This involves a primary ischemic insult with a certain amount of hemorrhage after the tourniquet is released. Bipolar scissors are a new method of dissection. They may allow for a speedier dissection with a concomitant decrease in ischemic time. Their hemostatic properties may control hemorrhage after use of the tourniquet.

STUDY DESIGN

A prospective study of patients undergoing radial forearm free flaps over a 12-month period at a tertiary care referral center was undertaken.

RESULTS

Forty patients were entered into the study, flaps were elevated with scalpel (20) and with bipolar scissors (20). Mean time under tourniquet was 39 minutes (range, 30-56 min) with scalpel compared with 27 minutes (range, 21-31 min) with bipolar scissors (P <.001). Total mean time of elevation (including control of hemostasis and pedicle dissection) for scalpel elevation was 50 minutes (range, 35-61 min) compared with 32 minutes (range, 20-41 min) for bipolar scissors elevation (P <.001). Mean blood loss was 46 mL (range, 15-110 mL) in the scalpel elevation group compared with 14 mL (range, 0-50 mL) in the bipolar scissors elevation group (P <.001). Complications at the donor site were equal between groups.

CONCLUSIONS

Bipolar scissors are a safe, efficient method for elevating radial forearm free flaps.

Effect of Anemia on the Fasciocutaneous Flap Survival in a Rat Model

OBJECTIVE/HYPOTHESIS

Ablative surgery for head and neck cancer that creates large composite defects often results in a significant decrease in the hematocrit level. These defects are best reconstructed with a microvascular free tissue transfer. Effect of the decreased hematocrit on microvascular flap survival is controversial. The purpose of this study was to assess the effect of isovolemic anemia on flap survival in a rat model.

STUDY DESIGN

Prospective analysis.

METHODS

Ninety rats were used (30 control and 60 experimental animals). Experimental animals were rendered anemic by blood draw and volume resuscitated with either a colloid (30 animals) or crystalloid (30 animals) solution. In all animals a ventral fasciocutaneous flap was raised. A vascular clamp was applied to the arteriovenous pedicle, and different ischemic times were allowed to elapse before clamp removal. Flap survival was assessed at 5 days. Probit analysis was performed for the three animal groups.

RESULTS

A significantly increased probability of the flap survival was found in the anemic animals compared with the control group (P < or = .05). No difference was found between the colloid and crystalloid resuscitation groups.

CONCLUSIONS

A decreased hematocrit level increases fasciocutaneous flap tolerance to ischemia and significantly increases the primary ischemic time in the ventral flap clamp model in rats. Fluid replacement with either crystalloid or colloid produces identical results.

Dysphonia and dysphagia following the anterior approach to the cervical spine

BACKGROUND

Speech and swallowing dysfunctions are common following the anterior approach to the cervical spine. Despite functional morbidity and legal implications, the incidence and etiologic factors of these complications have not been adequately elucidated.

OBJECTIVE

To better define speech and swallowing dysfunction both in the quantitative and qualitative sense.

METHODS

A questionnaire was mailed to 497 patients who had undergone anterior cervical fusion or anterior cervical discectomy at a university hospital (study group). One hundred fifty questionnaires were sent to a control group.

RESULTS

The study group response rate was 46%; the control group response was 51%. The incidence of hoarseness in the study group was 51%; the incidence in the control group was 19%. The difference was statistically significant (P<.01). Dysphagia was present in 60% of study group patients vs 23% of control group patients (P<.01). Qualitative questions revealed that constant hoarseness, pain with talking, difficulty eating solid foods, and odynophagia were significantly more common following the anterior approach to the cervical spine.

CONCLUSIONS

Our findings show a much higher incidence than previously reported of both voice and swallowing impairment following the anterior approach to the cervical spine. Hoarseness and dysphagia may adversely affect recovery and the patient's sense of well-being. Preoperative counseling and postoperative evaluation are essential.

Accuracy of computed tomography in determining the presence or absence of metastatic retropharyngeal adenopathy

OBJECTIVE

To decide the accuracy of computed tomography in determining the presence or absence of metastatic retropharygeal adenopathy in patients with squamous cell carcinoma of the head and neck.

DESIGN

A comparison of the results of retrospective blinded review of preoperative computed tomographic scans with the histologic findings of retropharyngeal node dissection at the time of surgery.

SETTING

Academic tertiary care center.

PATIENTS

Twenty-six patients with advanced stage squamous cell carcinoma of the head and neck.

MAIN OUTCOME MEASURES

Computed tomographic findings and histologic results of retropharyngeal node dissection.

RESULTS

The retropharyngeal nodes were pathologically positive for metastasis in 6 (23%) of the 26 patients. The radiologist (J.M.T.) correctly read the scan in 3 of 6 patients with histologically proved metastasis, and in 14 of 20 patients with histologic features negative for metastasis. The sensitivity of the radiologist reading was 50%, and the specificity was 70%. The positive predictive value was 33%, and the negative predictive value was 82%.

CONCLUSION

The presence of retropharyngeal node metastasis cannot be determined by computed tomographic imaging alone. Arch Otolaryngol Head Neck Surg. 2000;126:1478-1481

The relative value of fine-needle aspiration and imaging in the preoperative evaluation of parotid masses

BACKGROUND

To establish the sensitivity, specificity, and accuracy of imaging and fine-needle aspiration (FNA), alone or in combination, in distinguishing benign from malignant histologic findings for parotid lesions.

METHODS

Retrospective blinded review of preoperative imaging and FNA studies of parotid masses and comparison with histologic findings after excision.

RESULTS

Forty-eight patients were identified (13 with CT, 35 with MRI); 23 (48%) of the lesions were malignant, 25 (52%) were benign. MRI, CT, and FNA misclassified 17%, 46%, and 21% of the lesions, respectively. The sensitivity/specificity/accuracy of these tests for detecting malignant lesions were as follows: MRI (88%,77%,83%), CT (100%,42%, 69%), and FNA (83%,86%,85%) and were not significantly different. Combinations of imaging and FNA were not significantly better in detecting malignancy.

CONCLUSIONS

Imaging and FNA are comparable in their ability to correctly identify malignant parotid lesions preoperatively. Combining these two modalities yields no advantage in terms of specificity, sensitivity, or accuracy of a malignant diagnosis.

Pursestring closure of radial forearm fasciocutaneous donor sites

BACKGROUND

The radial forearm fasciocutaneous free flap has become one of the most common methods of reconstructing defects after head and neck ablative surgery. The fasciocutaneous flap is an excellent replacement for the tissue that has been removed. Unfortunately, donor site morbidity remains a problem. Donor site morbidity is primarily related to poor skin graft take, cosmesis, and neural dysfunction. Decreasing the size of the donor site defect may allow for improved cosmesis with decreased morbidity.

MATERIAL AND METHODS

Prospective evaluation of a pursestring closure of radial forearm fasciocutaneous donor sites over a 16-month period.

RESULTS

Seventy-one radial forearm free flaps were used. Sixty-seven had a pursestring closure of the donor site. After flap elevation the mean size of the defect was 61 cm2 (range, 28-140 cm2). Pursestring closure decreased the mean of the defect to 34 cm2 (range, 10-104 cm2) (P <.0001). Defect size was decreased by a mean of 44.5% (range, 24.5%-66.7%) (P <.0001).

COMPLICATIONS

The rate of skin graft loss (>25%) (9% of patients) was less than that reported in the literature. No patient required a second surgical procedure. Neural morbidity was equal in both groups. Cosmesis was much improved.

CONCLUSIONS

Pursestring closure allowed for a significantly decreased donor defect, associated with better cosmesis and less skin graft loss.

Unilocular cervical lymphatic cyst in an adult

Unilocular cervical lymphatic lesions are rare clinical entities. These endothelial-lined, fluid-filled structures must be distinguished from true cysts (epithelial lining), and pseudocysts (no cellular lining). This article presents a case report of a unilocular cervical lymphatic cyst in an adult. The embryology and anatomy of the cervical lymphatic system is discussed.

External beam radiation followed by planned neck dissection and brachytherapy for base of tongue squamous cell carcinoma

BACKGROUND

Surgical resection of tongue base cancer can leave the patient with significant functional deficits. Other therapies, such as external beam radiation followed by neck dissection and radiation implants, have shown equal tumor control with good functional outcome.

METHODS

Between March 1991 and July 1999, 12 patients at Oregon Health Sciences University, the Portland Veterans Administration Medical Center and West Virginia University School of Medicine Hospital were treated with external beam radiation followed by neck dissection and Ir192 implants. Two patients had T1 disease, two had T2, five patients had T3 tumors, and three had T4 tumors. Six had N2a necks, three had N2b necks, and three had N2c. Follow-up ranged from 13 months to 8 years.

RESULTS

After external beam radiation, five patients had complete response and seven had partial response in the neck without complications. One patient underwent a unilateral radical neck dissection, eight had unilateral selective neck dissections involving levels I to IV, and three had dissections involving levels I to III. One of the five patients who had a complete clinical response in the neck had pathologically positive nodes. One patient had a pulmonary embolus that was treated and had no permanent sequelae. There were three complications from brachytherapy. Two patients had soft tissue necrosis at the primary site and one patient had radionecrosis of the mandible. All healed without further therapy. One patient had persistent disease and underwent a partial glossectomy but died of local disease. Distant metastasis developed in two patients. All others show no evidence of disease and are able to eat a normal diet by mouth.

CONCLUSION

This combination of therapies should be considered when treating tongue base cancer.

Chest radiographs after dilatational percutaneous tracheotomy: are they necessary?

BACKGROUND

The efficacy of routinely obtaining chest radiographs after standard open tracheotomy has been questioned. Recent literature would suggest that after a routine, uncomplicated tracheotomy, chest radiography is a low-yield procedure that incurs unnecessary expense. Percutaneous dilatational tracheotomy (PDT) is rapidly replacing open tracheotomy as the intensive care unit procedure of choice for airway management. Complication rates are equivalent between the two procedures.

OBJECTIVE

We examined the value and cost-effectiveness of routine postoperative chest radiographs in patients undergoing PDT.

STUDY DESIGN AND SETTING

The study was a prospective analysis of 54 consecutive PDTs performed at a tertiary care academic institution.

RESULTS

Eighteen (33%) patients had chest radiographs obtained within 1 hour of PDT (6 at the request of the otolaryngology service); 35 (66%) underwent radiography more than 2 hours later at the request of the intensive care unit for reasons other than PDT. There were no incidents of pneumothorax, pneumomediastinum, or tracheotomy tube malposition in any patient. Patients undergoing chest radiography within 1 hour of the PDT also had chest radiographs within 12 hours at the request of ICU staff for their underlying disease.

CONCLUSIONS

Routine chest radiography after PDT is of low yield. Because most of these patients require chest radiographs for their underlying disease within 12 hours, a cost savings of approximately $13,500 would be realized in this patient population.

SIGNIFICANCE

Routine chest radiography after PDT is unwarranted in most cases.

Endoscopically monitored percutaneous dilational tracheotomy in a residency program

OBJECTIVES/HYPOTHESIS

Endoscopically guided percutaneous dilational tracheotomy (PDT) has become a well-established alternative to the more traditional open tracheotomy, yet its use by otolaryngologists is limited. As airway management specialists, otolaryngologists should be familiar with a wide range of definitive procedures, including PDT. Few otolaryngology programs teach the technique. The objective of the present study was to determine the complication rate and outcome of PDT after its introduction in a residency teaching program. We also wished to evaluate whether the time savings reported by experienced surgeons could be repeated in our setting.

SETTING

Tertiary referral teaching hospital.

METHODS

We prospectively reviewed our first 54 consecutive PDTs and compared them to 29 consecutive standard open tracheotomies, which were reviewed retrospectively.

RESULTS

Complications (13% vs. 33%, P = .030), operative time (12 vs. 24 min, P < .0001) and total procedure time (37 vs. 80 min, P < .001) were significantly reduced in the PDT group as compared with standard tracheotomy. Initial outcome data were equal in both groups.

CONCLUSIONS

We found that PDT can be safely and effectively taught as part of an otolaryngology residency training program.

Bipolar scissors in facial plastic surgery

BACKGROUND

Many methods are available to the facial plastic surgeon for elevating and separating tissue, from cold steel to monopolar cautery to various laser-cutting technologies. Bipolar cautery has replaced monopolar cautery as the optimal hemostatic technique because of its decreased tissue damage and improved capabilities. Bipolar scissors concurrently offer a dissecting technique with hemostatic capability. Little exists in the otolaryngology literature on the use of bipolar scissors for soft tissue dissection.

OBJECTIVE

To describe our experience using bipolar scissors in a variety of facial plastic and reconstructive procedures.

SETTING

Tertiary care referral academic center.

DESIGN

We retrospectively reviewed 78 procedures performed using bipolar scissors between June 1997 and August 1999. In facial plastic cosmetic surgery, bipolar scissors were used 31 times for deep plane face-lifts and 16 times for endoscopic browlifts. In facial plastic reconstructive surgery, bipolar scissors were used in 15 radial forearm free flaps, 10 fibula osteocutaneous flaps, 3 rectus abdominis free flaps, and 3 latissimus dorsi myocutaneous free flaps.

RESULTS

In all procedures, bipolar scissors facilitated the dissection. By allowing for a drier field, less time was required to elevate the flap and obtain hemostasis. Complications were not increased compared with historical controls. In the harvesting of fibula osteocutaneous free flaps, use of bipolar scissors allowed harvesting without use of a tourniquet.

CONCLUSION

Bipolar scissors, a new technology in facial plastic surgery, allow the same control as sharp dissection and provide simultaneous hemostasis.

Effect of photodynamic therapy on revascularization of fasciocutaneous flaps

OBJECTIVE

Photodynamic therapy (PDT) may be used as an adjuvant intraoperative treatment to improve locoregional control. PDT has been shown both to delay wound healing and to have a deleterious effect on flap survival after a primary ischemic insult. This delay in wound healing may make the flap dependent on its pedicled blood supply for a prolonged period. Long-term flap loss may be experienced. The effect of PDT on flap revascularization, with subsequent dependence on its vascular pedicle, is evaluated.

STUDY DESIGN

Randomized controlled trial using a rodent model.

METHODS

A rat fasciocutaneous flap was used. Study groups were as follows: group I received no treatment; group II received treatment with 630-nm light; groups IH and IV were given Photofrin (in group III, loupes without a fiberoptic light source were used for flap elevation, and in group IV, light source was employed); and group V was given Photofrin and 630-nm light. Primary ischemic times of 2 or 4 hours were used. Vascular pedicles were ligated on postoperative day (POD) 5, 6, or 7, and percentage of flap survival was evaluated 7 days later.

RESULTS

With 2 hours of ischemia, revascularization was decreased in the PDT group on POD 6 (P < .05) and on day 7 (P < .005) when compared with the other groups. With 4 hours of ischemia, revascularization was decreased in the PDT group on PODs 5 (P < .001), 6 (P < .01), and 7 (P < .005).

CONCLUSION

Intraoperative PDT decreases revascularization of a rat fasciocutaneous flap.

A retrospective analysis of temporomandibular joint reconstruction with free fibula microvascular flap

OBJECTIVES

The temporomandibular joint is occasionally encountered in extirpative surgery of the head and neck. It presents a difficult management issue. Little has been reported on functional outcomes after resection and reconstruction of the temporomandibular joint.

DESIGN

A retrospective analysis consisting of chart reviews and phone interviews was performed on 17 patients who underwent fibular free flap reconstruction of the temporomandibular joint from 1993 to 1998.

RESULTS

Mean follow-up in surviving patients (10) was 41.3 months. Mean age of the group was 62; male-to-female ratio was 11:6. Average hospital stay was 11.6 days. Four patients had no radiation therapy, 2 had preoperative and 11 had postoperative treatment. Five patients had one osteotomy, seven had two, one had three, and one had four. Ten patients could chew, one could not, and none were recorded for the remaining. Diet consisted of regular food for two patients, soft food for seven, full liquids for four, and tube feeds for four. Cosmesis was judged as excellent by eight patients, acceptable by two, and unacceptable by two. Five patients did not describe cosmesis. Most patients stated that bony contour was excellent, but that the soft tissue defect was noticeable. Speech was judged as intelligible by seven and moderately understandable by one. Nine patients did not describe speech. Two patients had postoperative displacement of the fibular head out of the fossa.

CONCLUSION

Primary reconstruction of the temporomandibular joint with microvascular fibular flaps is a viable and effective means of restoring function. The majority of patients are able to resume oral feeds, obtain excellent or pleasing cosmetic results, and maintain intelligible speech.

Sensory changes associated with selective neck dissection

OBJECTIVE

To evaluate sensory changes in the head and neck region associated with selective neck dissection with or without preservation of cervical root branches.

DESIGN

Retrospective cohort study.

SETTING

University tertiary referral hospital and a Veterans Affairs hospital.

PATIENTS

Fifty-seven patients who had undergone 84 neck dissections with or without preservation of the sensory cervical root branches 3 or more months before evaluation.

INTERVENTIONS

Questionnaire combined with head and neck sensory examination.

MAIN OUTCOME MEASURES

Neck and facial sensory function.

RESULTS

Neck dissections with preservation of the cervical rootlets were most likely to be associated with a small area of anesthesia in the upper neck below the body of the mandible and anterior to the mid-body of the mandible (P=.03). Neck dissections without rootlet-preserving technique increased the area of anesthesia to include all other areas of the neck (P= .02).

CONCLUSIONS

Preservation of the cervical root branches resulted in a small, limited, and uniform area of the neck rendered permanently anesthetic. Conversely, sacrifice of the nerve branches led to a pattern of anesthesia involving the entire neck.

Management of tracheostomal stenosis

BACKGROUND

Tracheostomal stenosis following laryngectomy is a distressing complication with major effects on patient rehabilitation. Management ranges from stenting with a prosthetic device to surgical revision. The goal is a widely patent stoma that is amenable to tracheoesophageal puncture.

OBJECTIVE

Review the long-term results of different methods of tracheostomal revision.

METHODS

Review of 43 patients with symptomatic tracheostomal stenosis. End point was ability to function with no artificial stenting of their stoma.

RESULTS

Forty-three patients underwent 55 revisions. The male-to-female ratio was 1.3:1.0. The age range was from 38 to 81 years (mean age, 59.5 y). Median time to revision was 11 months following the initial surgical procedure (range, 1-150 mo). Thirty-three patients underwent one revision; eight patients, two revisions; and two patients, three revisions. In 40 of 43 patients (93%) revision was successful. Of the last 21 patients who underwent revision, 18 had tracheoesophageal punctures placed. Fifteen developed excellent tracheoesophageal speech. The initial rates of success for these procedures were as follows: advancement flaps, 8 of 9; Z-plasty, 13 of 15; V-Y inset, 8 of 8; other procedures, 2 of 4; and dilation, 2 of 7 (P < .05 for dilation vs. all others). The ultimate success rates for these procedures were as follows: advancement flaps, 8 of 11; Z-plasty, 15 of 18; V-Y inset, 12 of 13; other procedures, 3 of 6; and dilation, 2 of 7. Other procedures and dilation were inferior (P < .05) compared with advancement flap, Z-plasty, and V-Y insets.

CONCLUSION

Tracheostomal stenosis can be successfully managed in a multitude of ways.

Management paradigms for posterior epistaxis: A comparison of costs and complications

OBJECTIVES

Posterior epistaxis is a common otolaryngologic emergency. Management is controversial because of the many treatment options available. These options vary in efficacy, rates of complications, and cost. Posterior nasal packing is the medical management most frequently used to control posterior epistaxis. It is associated with major complications, including stroke, myocardial infarction, arrhythmias, and death. Because of these potential complications, many otolaryngologists monitor patients with posterior nasal packing in the intensive care unit (ICU). However, the level of care used to monitor these patients is variable, and standards have not been established.

METHODS

From 1991 to 1997, 46 patients had posterior nasal packing placed to control epistaxis. Management, complications, and hospital charges were analyzed.

RESULTS

Six patients (13%) were admitted to the ICU, 2 (4%) were admitted for telemetry monitoring, and 38 (83%) were sent to the ENT ward for continuous pulse oximetry. Four major complications occurred (1 episode of syncope [emergency department], 2 arrhythmias [ICU], and 1 death [hospice]). Twenty-six patients were treated with posterior packing in the ENT ward, at a mean cost of $2988. Fourteen patients underwent intervention (5 ligations, 6 endoscopic cauterizations, and 3 angiograms), with a mean cost of $5482. Six patients spent time in the ICU, with a mean cost of $8242. Patients treated in the ENT ward had significantly lower costs than those undergoing intervention (P = 0.017) or those admitted to the ICU (P = 0.020).

CONCLUSION

We propose that most patients with posterior epistaxis can be treated in specialized ENT wards. This can be done without increasing complications and with significantly decreased costs.

Effect of photodynamic therapy on the critical primary ischemic time of fasciocutaneous flaps

BACKGROUND

Photodynamic therapy (PDT) may be used as an adjuvant intraoperative therapy to improve locoregional control. PDT has been shown to delay wound healing. This raises concern about PDTs effect on survival of fasciocutaneous flaps.

OBJECTIVE

Evaluate the effect of 1) PDT on the critical ischemic time in a rat fasciocutaneous flap model and 2) photosensitizer activation by the surgical light source.

DESIGN

A fasciocutaneous flap, based on the left inferior epigastric vessels, was used. Ischemic times of 2, 4, 6, 8, 10, and 12 hours were induced by clamping the vascular pedicle. Animals were randomly divided into five groups: ischemia only, group I; light treatment to wound bed, group II; Photofrin before surgery with the flap elevated without a fiber optic head light, group III, or with a headlight, group IV; Photofrin prior to surgery with light treatment to the wound bed, group V. Flap survival was assessed on postoperative day 7.

RESULTS

The critical primary ischemic time of group V (PDT) was significantly less (P < .05) than groups I, II, III, and IV. There was no statistical difference in the critical primary ischemic time when a fiber optic headlight was used (group III vs. group IV).

CONCLUSION

Intraoperative PDT significantly reduces the critical primary ischemic time of the rat fasciocutaneous flap. White light illumination of the operative field does not result in photosensitizer activation and has no effect on the critical primary ischemic time.

Effect of clamp versus anastomotic-induced ischemia on critical ischemic time and survival of rat epigastric fasciocutaneous flap

BACKGROUND

There are many models used to explore ischemic-related phenomena. The rat epigastric fasciocutaneous flap model is the one most commonly used. Critical ischemic time is the maximum ischemic insult that tissue can undergo and still remain viable. Experimentally, ischemia is induced either by clamping the vascular pedicle or by dividing the pedicle then performing microvascular arterial and venous anastomosis. We sought to determine what effect the different methods of inducing ischemia have on the critical primary ischemic time and, thus, flap survival.

METHODS

A right 3 cm x 6 cm groin flap based on the inferior epigastric vessels was raised in each rat. Ischemic times of 4, 6, 8, or 10 hours were induced either by placing temporary occlusion clamps on each vessel of the vascular pedicle (island pedicle group) or by ligation and division of the pedicle with subsequent microvascular anastomosis (free flap group). Survival was assessed at 7 days.

RESULTS

The primary ischemic time at which one half of free flaps are predicted to die was calculated to be 7.60 hours, compared with 6.09 hours for the island pedicle flaps (p<.05).

CONCLUSIONS

Fasciocutaneous flaps undergoing ligation and anastomosis are more resistant to ischemia than are those undergoing clamping of the pedicle. Possible etiologic factors responsible for this experimental finding are discussed.

Atypical presentations of actinomycosis

BACKGROUND

Actinomycotic infections of the cervicofacial region are uncommon. Most major medical centers report approximately one case per year. Presenting clinical manifestations are confusing because they often mimic other disease processes. Diagnosis may be difficult due to a general lack of familiarity with the disease and the fastidious nature of the organism in culture. The cervicofacial manifestations of actinomycosis are varied, and a high index of suspicion is required to make an accurate and timely diagnosis.

METHODS

Retrospective chart review with the presentation of four unusual cases of actinomycosis were performed.

RESULTS

Two patients were initially seen with dysphagia from a tongue base mass. The third patient was initially seen with a 3-week history of worsening hoarseness and stridor. Examination revealed an ulcerative lesion of the left hemilarynx and pyriform sinus. All three patients were thought to have a neoplastic process. Diagnosis was made on histologic examination of a tissue biopsy. The fourth patient was initially seen with a buccal space mass that was draining externally. Culture of the purulent drainage revealed Actinomyces. In all four cases, symptoms resolved after appropriate antimicrobial therapy.

CONCLUSIONS

Actinomycosis of the head and neck, although rare, is an important entity to the otolaryngologist. A confusing clinical presentation combined with the fastidious nature of the organism make for a difficult diagnosis. A high index of suspicion is required to make an accurate diagnosis and institute the appropriate antibiotic therapy.

Effects of acute thyroxin depletion on hearing in humans

OBJECTIVE

To study the physiologic effect of acute thyroid hormone depletion on hearing and the function of outer hair cells.

DESIGN

Audiologic and otoacoustic emission testing of subjects undergoing total thyroidectomy before surgery and up to 6 weeks after surgery. Magnitude of thyroxin depletion monitored by serum thyroid-stimulating hormone levels.

SETTING

Hearing research laboratory at a state university.

SUBJECTS

Ten patients undergoing total thyroidectomy.

MAIN OUTCOME MEASURES

Detection of hearing loss on audiogram and decrease or disappearance of otoacoustic emissions as a result of acute thyroxin depletion.

RESULTS

No significant changes in the audiogram and otoacoustic emission configurations were detected, although thyroid-stimulating hormone levels became elevated after total thyroidectomy.

CONCLUSION

Although thyroid hormone is thought to play a role in the physiology of hearing in humans, no deleterious effects on hearing can be identified up to 6 weeks after thyroxin depletion.

Nonrecurrent laryngeal nerves: anatomic considerations during thyroid and parathyroid surgery

PURPOSE

In head and neck surgery, damage to the recurrent laryngeal nerve (RLN) during thyroid surgery is the most common iatrogenic cause of vocal cord paralysis. Identification of the RLNs and meticulous surgical technique can significantly decrease the incidence of this complication. Nonrecurrent RLNs (NRRLNs) are exceedingly rare. Surgeons need to be aware of their position to avoid damage to them.

MATERIALS AND METHODS

A retrospective review of 513 RLN exposures over a 7-year period was performed.

RESULTS

Two NRRLNs were encountered, for an incidence of 0.39%.

CONCLUSION

NRRLNs are rare. Awareness of their existence will prevent the surgeon from accidentally severing one if it is encountered during routine thyroid or parathyroid surgery.

Management of the N0 neck during salvage laryngectomy

BACKGROUND

Radiotherapy is effective treatment for laryngeal carcinoma. Early-stage laryngeal carcinoma has a low incidence of cervical metastasis. Patients initially clinically N0 usually remain N0 when they fail at the primary site. The incidence of subclinical metastasis in these patients is not well described. Watchful waiting or elective neck dissections are advocated.

OBJECTIVE

Examine the incidence of subclinical metastatic disease in patients undergoing elective neck dissections with salvage laryngectomy.

STUDY DESIGN

Prospective study (1991-1996) of patients who failed radiotherapy and underwent salvage laryngectomy with elective neck dissection.

METHODS

Thirty-four patients underwent salvage laryngectomy with neck dissection (30 bilateral, 4 unilateral). All were clinically N0 at initial presentation and remained N0 at recurrence. Pathologic study of the neck dissection specimens was undertaken. Patients were followed for a minimum of 2 years (mean, 4 y).

RESULTS

The male-to-female ratio was 4.5:1, with a mean age of 62 years (range, 38 to 75 y). Metastatic disease was present in 6 patients (17%); 4 of 14 (28%) supraglottic, and 2 of 20 (10%) glottic. Presence of disease in the neck according to stage at recurrence was as follows: T2, 2 of 12; T3, 3 of 14; and T4, 2 of 8. Neck disease was ipsilateral in 4 and contralateral in 2 patients (both supraglottic primaries).

CONCLUSIONS

Subclinical cervical metastasis may be present in N0 laryngeal carcinoma patients who have recurrence following radiotherapy. Morbidity of a lateral neck dissection is minimal, with excellent control of the neck being possible. Supraglottic and advanced glottic (T3-T4) patients may benefit the most.

Positron emission tomography in the evaluation of the negative neck in patients with oral cavity cancer

OBJECTIVE

Proper management of the clinically negative neck (N0) in patients with squamous cell carcinoma (SCC) of the oral cavity (OC) is controversial. Detecting cervical metastasis in these patients is important, because cervical lymph node metastasis is associated with an unfavourable prognosis. Conventional radiographic studies, such as computerized tomography (CT) and magnetic resonance imaging (MRI), may augment physical examination. However, there are still limitations of these modalities in detecting the presence of metastatic cervical disease. Positron emission tomography (PET) is a functional imaging modality that has recently been used in patients to detect head and neck neoplasms. We report using PET in the evaluation of the N0 neck in 11 consecutive patients with SCC of the OC who underwent neck dissection.

METHOD

The results of PET scans were correlated with the pathologic findings of 19 neck dissections.

RESULTS

Four patients (36%) undergoing 7 neck dissections (37%) had pathologic evidence of disease. Positron emission tomography scans were positive in all of these patients and in all pathologically confirmed cervical metastasis. Seven patients (64%) undergoing 12 neck dissections (63%) had no pathologic evidence of cervical metastasis. Positron emission tomography scans were negative for malignancy in all of these seven patients. In the patient with SCC of the OC with a clinically N0 neck, we found PET to have an overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 100%. Computerized tomography demonstrated 40%, 88%, 67%, 70%, 69%, respectively. In all statistical categories except specificity (p = .1), PET demonstrated statistical significance (p < .05) over CT.

CONCLUSION

Positron emission tomography appears to be a promising diagnostic aid that may be applied when evaluating the N0 neck for patients with SCC of the OC.

Tracheostomal stenosis revision with simultaneous tracheoesophageal puncture

OBJECTIVES/HYPOTHESIS

Vocal rehabilitation of patients who have undergone laryngectomy is best accomplished by a tracheoesophageal puncture. Optimal function of the prosthesis requires an adequate stoma. Patients with tracheostomal stenosis require revision of the stoma if vocal rehabilitation is to take place. Revision and tracheoesophageal placement are usually done as two separate procedures. Creating a tracheoesophageal fistula at the time of stomal revision has not been addressed in the literature.

STUDY DESIGN

Prospective analysis and follow-up of 10 patients undergoing simultaneous tracheoesophageal puncture and stomal revision for tracheostomal stenosis between 1991 and 1996.

METHODS

Ten patients were reviewed. An inferiorly based V-Y advancement flap was used so as not to interfere with the tracheoesophageal puncture. All patients had received radiation prior to revision and tracheoesophageal puncture. Patients were followed for a minimum of 2 years (range, 2-6 y; median, 3 y).

RESULTS

All patients maintained an adequate stoma without stenting. Eight of ten patients (80%) developed and maintained good tracheoesophageal speech. Two patients had their speech fistulas removed. There were no intraoperative or postoperative complications.

CONCLUSIONS

Creation of a tracheoesophageal fistula at the time of stomal revision allows for vocal rehabilitation with a single visit to the operating room.

Role of antral puncture in the treatment of sinusitis in the intensive care unit

OBJECTIVE

The objective of this study was to determine whether maxillary sinus puncture caused an alteration in antibiotic treatment and thus affected the outcome of sinusitis in the intensive care unit.

STUDY DESIGN

A retrospective review was done of cases of maxillary sinus puncture between 1991 and 1994.

RESULTS

Forty-two patients were identified. All patients had findings suggestive of sinusitis on plain sinus films or CT scans of the sinuses. Twenty-five punctures (60%) recovered pus, of which 80% grew organisms. Fourteen patients (33%) had a negative lavage, and 12% of these samples grew organisms (p = 0.001). Sixty-eight percent of the cultures identified a single organism compared with 32% with multiple organisms. Gram-negative organisms were found most commonly, followed by anaerobes. In 57% of the cases antibiotic therapy was changed. In 77% of the cases the change was directed by the culture result and in 35% the therapy was changed despite a negative culture result (p = 0.002). Resolution of symptoms occurred in 83% of patients who had antibiotics changed whereas with no change in antibiotics only 42% had resolution (p = 0.001).

CONCLUSION

A sinus puncture seems to be helpful in patients with fever and positive findings on sinus films. If pus is obtained by maxillary puncture, a positive culture may be found in 80% of the cases. Changes in antibiotic regimen on the basis of culture findings seem to give a better outcome.

Neck dissection with simultaneous carotid endarterectomy

BACKGROUND

Patients with metastatic neck disease from upper aerodigestive tract carcinomas have an extensive history of tobacco and alcohol abuse. These patients are predisposed to develop atherosclerotic vascular disease.

OBJECTIVE

An increased incidence and severity of carotid stenosis in patients receiving radiotherapy for head and neck cancers is known. Management of patients with severe carotid stenosis who require surgical treatment of their neck disease has not been described. The authors describe our experience with simultaneous carotid endarterectomy and neck dissection.

STUDY DESIGN

Prospective data collection.

METHODS

From 1991 to 1997 at West Virginia University Hospitals, Morgantown, West Virginia, and State University of New York (SUNY) at Buffalo, three patients with severe carotid stenosis required surgery for metastatic neck disease. Preoperative evaluation revealed a bilateral carotid stenosis greater than 90% in all patients. All patients underwent modified radical neck dissections and simultaneous carotid endarterectomies with saphenous vein grafting. Two patients, one undergoing partial pharyngectomy and laryngectomy and the other a laryngectomy and neck dissection, had coverage of the carotid artery with the myogenous component of a pectoral major graft. One patient had only a neck dissection.

RESULTS

Two patients healed with no local morbidity, no neck recurrence, and a patent carotid artery by Doppler. No strokes were encountered. One patient died of a myocardial infarction.

CONCLUSION

Severe carotid stenosis that requires revascularization may have endarterectomy performed simultaneously with treatment of head and neck primary with no increase in morbidity.

Significance of unilateral submandibular gland excision on salivary flow in noncancer patients

OBJECTIVES/HYPOTHESIS

Normal salivary flow is important for maintaining good oral hygiene. Lack of normal flow predisposes to an increased incidence of dental caries and symptomatic xerostomia. The submandibular glands are responsible for 70% of resting salivary flow. Removal of the submandibular gland is most commonly performed for sialolithiasis, chronic sialoadenitis, or as part of a neck dissection. The effect of unilateral gland resection for benign disease on resting salivary flow has not been well examined in the literature.

STUDY DESIGN

Case controlled study involving patients who had undergone a unilateral submandibular gland resection matched with normal control subjects.

METHOD

Stimulated and unstimulated salivary flow rates in surgical and control subjects were measured in a controlled setting.

RESULTS

Unstimulated salivary flow rates were 0.805 mL/min in the control group and 0.405 mL/min in the surgical group (P = .01). Stimulated salivary flow rates were not significantly different between the two groups (P > .05). Fifty-seven percent of patients in the surgical group and 14% in the control group had xerostomia (P < .05).

CONCLUSION

Unilateral submandibular gland excision results in a decreased rate of resting salivary flow and an increase in subjective xerostomia.

The difficult airway: cardiopulmonary bypass--the ultimate solution

BACKGROUND

Large, compressive thyroid masses are usually removed as an elective procedure. Rarely is a patient's condition allowed to progress to severe respiratory distress before surgical intervention is recommended. When allowed to progress, management of the airway can be problematic.

METHODS

A case report of a patient with a neglected thyroid lymphoma is presented.

RESULTS

The natural progression of the disease, leading to impending airway collapse, necessitated emergency management of the airway. Due to supraglottic edema and a large neck mass, traditional methods of securing the airway were not feasible. Initiation of femoral-femoral cardiopulmonary bypass, under local anesthesia, ensured adequate oxygenation and allowed a controlled tracheotomy to be performed.

CONCLUSIONS

The result obtained suggests that this approach provides a safe solution for airway control when intubation or a surgically created airway is either unsuccessful or too hazardous.

Transient-evoked otoacoustic emissions in children after cisplatin chemotherapy

Little is known about cisplatin ototoxicity in pediatric patients. Measurement of otoacoustic emissions is a rapid, reproducible, objective method of evaluating hearing. We examined whether transient-evoked otoacoustic emissions in pediatric patients exposed to cisplatin in the past correlated with audiographic findings. Twelve patients were entered into the study (mean age at treatment 7.8 years, mean cumulative dose 442.5 mg/mm2, mean 7.1 doses). Hearing at 3000 Hz was preserved in 82.6% of patients. In the higher frequencies significant sensorineural hearing loss was noted: 43.5% at 4 kHz; 81.0% at 6 kHz; and 90.5% at 8 kHz. Transient-evoked otoacoustic emissions were measurable in 11 of 12 patients. Middle ear disease accounted for abnormal otoacoustic emission seen in three patients (1 with effusion, 2 with significant negative middle ear pressure). When the middle ear was normal, a statistically significant correlation was seen between the transient-evoked otoacoustic emissions reproducibility and pure-tone threshold (correlation coefficient = -0.69, p = 0.008). Increased hearing loss was also associated with young age at first dose of cisplatin (p = 0.044), high number of chemotherapy cycles (p = 0.042), and high cumulative dose (p = 0.042).

Relationship between tympanic membrane perforations and retained ventilation tubes

OBJECTIVES

To determine the effects of prolonged ventilation tube retention on tympanic membrane healing and the efficacy of patching procedures used concomitantly at the time of tube removal.

DESIGN

Retrospective chart review.

SETTING

Tertiary referral academic institution.

PATIENTS

Seventy-six patients aged 12 years and younger, with a total of 99 ears identified from January 1989 to December 1994. All patients underwent ventilation tube removal for prolonged tube retention or infection unresponsive to medical management. A minimum of 6 months of follow-up was required for inclusion.

INTERVENTION

Ventilation tube removal under general anesthesia, with or without concomitant patching.

OUTCOME MEASURES

All medical charts were reviewed for age, sex, indications for tube removal, tube retention time, type of patch used (if any), type of tube, outcome after removal, other medical problems, and previous surgical history.

RESULTS

The perforation rate was significantly higher in children with tubes retained beyond 36 months (P=.02). History of previous adenoidectomy predicted poor outcome, with a rate of 47% vs 17% in patients with no such history (P=.002). Patching did not improve healing. No other patient factors significantly influenced the perforation rate.

CONCLUSIONS

Ventilation tube retention longer than 36 months resulted in an increased perforation rate after surgical removal. Paper patching at the time of tube removal does not improve healing. Prospective studies are needed to confirm these findings and to determine the efficacy of other patching techniques.

Positron emission tomography in the evaluation of the N0 neck

The presence of cervical lymph node metastasis in patients with head and neck cancer is associated with an unfavorable prognosis. Reports vary as to whether various conventional radiographic studies, such as computed tomography (CT) and magnetic resonance imaging, confer an advantage over physical examination in the patient without clinical findings of cervical metastasis (N0). Positron emission tomography (PET) is a functional imaging modality that has recently been used for head and neck neoplasms. The use of PET in the evaluation of the N0-staged neck in 14 consecutive patients with squamous cell carcinoma (SCC) of the upper aerodigestive tract is reported. Seven patients (50%) undergoing 13 neck dissections had pathologic evidence of disease. PET scans were positive in five patients with pathologically confirmed cervical metastasis. PET scans were negative in seven patients (11 neck dissections) with no pathologic evidence of disease. PET scans were positive for unilateral cervical metastasis in two of three patients with involvement of a single lymph node. PET scans were positive in two of three patients with more than two lymph nodes involved. PET had an accuracy of 100% in the eight patients with SCC of the oral cavity. In patients with oropharyngeal or hypopharyngeal carcinoma PET localized cervical metastasis in two of four patients with neck metastasis. In the patient with an N0-staged neck on clinical examination, PET was found to have an overall sensitivity of 78%, specificity of 100%, positive predictive value of 100%, negative predictive value of 88%, and accuracy of 92%. CT demonstrated sensitivity of 57%, specificity of 90%, positive predictive value of 80%, negative predictive value of 75%, and accuracy of 76%. PET showed a trend in increased accuracy (P = 0.11) over CT. PET appears to be a promising diagnostic aid that may be applied when evaluating the N0-staged neck, especially for SCC of the oral cavity.

Outcome and changing cause of unilateral vocal cord paralysis

Unilateral vocal cord paralysis (UVCP) is relatively common, and previously, thyroidectomy used to be the leading cause. We retrospectively reviewed 98 cases of UVCP. The left vocal cord was involved in 70% of the cases and the right vocal cord in 30%. The cause was neoplastic in 32%, surgical in 30%, idiopathic in 16%, traumatic in 11%, central in 8%, and infectious in 3% of the cases. Only 4 cases were the result of thyroid surgery. Evaluation consisted of a review of the history, a physical examination, and computerized scanning or magnetic resonance imaging, as needed. The functional recovery rate as related to the cause was as follows: surgery 31%, idiopathic 19%, traumatic 18%, and neoplastic 0%. Thirty-five percent of patients required medialization laryngoplasty or Teflon injection. Lung and skull base tumors and their surgical treatment are the most common causes of UVCP.

Value of Preoperative Prothrombin Time/Partial Thromboplastin Time as a Predictor of Postoperative Hemorrhage in Pediatric Patients Undergoing Tonsillectomy

OBJECTIVE: Hemorrhage after tonsillectomy is a potentially lethal complication. Preoperative assessment consisting of prothrombin time (PT) and activated partial thromboplastin time (PTT) has been used to identify patients at risk for hemorrhage after tonsillectomy and adenoidectomy. We sought to assess the value of PT/PTT screening as a predictor of posttonsillectomy hemorrhage.

DESIGN: A retrospective chart review was carried out with a minimum of 1 month follow-up.

SETTING: Tertiary academic referral center.

PATIENTS: Between January 1992 and June 1995, 382 patients undergoing tonsillectomy were examined; 339 patients with a minimum of 1 month follow-up were reviewed for this study.

MAIN OUTCOME MEASURE: Normal and prolonged PT/PTT values were examined. Bleeding in the intraoperative, immediate postoperative, and delayed phases of healing was examined.

RESULTS: Two-hundred and twenty-two patients had normal PT/PTT, 39 had prolonged PT/PTT, and 78 had no preoperative studies performed. Bleeding occurred in 2.7%, 2.6%, and 3.3%, respectively, of patients. Eight patients had positive family histories of bleeding tendencies. One patient (12.5%) with a normal PT/PTT experienced a delayed posttonsillectomy bleed. Of 39 patients with abnormal coagulation studies, 30 were borderline elevations with no repeat studies done; one patient experienced postoperative hemorrhage. Nine abnormal results were repeated; three returned to normal, three remained prolonged but underwent tonsillectomy with no intervention, and three received hematology consultations. One patient had lupus anticoagulant, one had Hageman Factor deficiency, and one was cleared for surgery with no diagnosis. All patients underwent tonsillectomy with no episodes of postoperative bleeding.

CONCLUSIONS: Preoperative PT/PTT provides no additional information than does a bleeding history for the general pediatric population undergoing tonsillectomy. This should only be done in selective cases where warranted by history.

Value of preoperative prothrombin time/partial thromboplastin time as a predictor of postoperative hemorrhage in pediatric patients undergoing tonsillectomy

OBJECTIVE

Hemorrhage after tonsillectomy is a potentially lethal complication. Preoperative assessment consisting of prothrombin time (PT) and activated partial thromboplastin time (PTT) has been used to identify patients at risk for hemorrhage after tonsillectomy and adenoidectomy. We sought to assess the value of PT/PTT screening as a predictor of posttonsillectomy hemorrhage.

DESIGN

A retrospective chart review was carried out with a minimum of 1 month follow-up.

SETTING

Tertiary academic referral center.

PATIENTS

Between January 1992 and June 1995, 382 patients undergoing tonsillectomy were examined; 339 patients with a minimum of 1 month follow-up were reviewed for this study.

MAIN OUTCOME MEASURE

Normal and prolonged PT/PTT values were examined. Bleeding in the intraoperative, immediate postoperative, and delayed phases of healing was examined.

RESULTS

Two-hundred and twenty-two patients had normal PT/PTT, 39 had prolonged PT/PTT, and 78 had no preoperative studies performed. Bleeding occurred in 2.7%, 2.6%, and 3.3%, respectively, of patients. Eight patients had positive family histories of bleeding tendencies. One patient (12.5%) with a normal PT/PTT experienced a delayed posttonsillectomy bleed. Of 39 patients with abnormal coagulation studies, 30 were borderline elevations with no repeat studies done; one patient experienced postoperative hemorrhage. Nine abnormal results were repeated; three returned to normal, three remained prolonged but underwent tonsillectomy with no intervention, and three received hematology consultations. One patient had lupus anticoagulant, one had Hageman Factor deficiency, and one was cleared for surgery with no diagnosis. All patients underwent tonsillectomy with no episodes of postoperative bleeding.

CONCLUSIONS

Preoperative PT/PTT provides no additional information than does a bleeding history for the general pediatric population undergoing tonsillectomy. This should only be done in selective cases where warranted by history.