Surgery

Balloon sinus dilation in the office setting

August 27, 2014     Joseph P. Mirante, MD, FACS; Michael A. Munier, MD, FACS; Dewey A. Christmas Jr., MD; Eiji Yanagisawa, MD, FACS
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The ability to complete operative procedures in the office setting avoids the time and cost of working in a hospital or outpatient surgical center operating room.

Using a sternocleidomastoid muscle flap to prevent postoperative pharyngocutaneous fistula after total laryngectomy: A study of 88 cases

August 27, 2014     Masoud Naghibzadeh, MD; Ramin Zojaji, MD; Nematollah Mokhtari Amir Majdi, MD; Morteza Mazloum Farsi Baf, MD
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Abstract

Complications of total laryngectomy can have serious implications for the final outcome of treatment, including pharyngocutaneous fistula. We conducted a retrospective study of surgical techniques to determine how to best prevent or decrease the incidence of pharyngocutaneous fistula following total laryngectomy. We reviewed the hospital records of all patients who had undergone total laryngectomy for laryngeal carcinoma at Ghaem Hospital in Mashhad, Iran, from March 1989 through February 2005. We identified 88 such patients-80 men and 8 women. We divided this cohort into two groups according to the type of pharyngeal defect closure they received. A total of 37 patients-31 men and 6 women (mean age: 61.4 ± 5.9 yr) underwent primary closure along with a sternocleidomastoid muscle (SCMM) flap (flap group). The other 51 patients-49 men and 2 women (mean age: 61.3 ± 4.4 yr)-underwent standard primary closure without creation of an SCMM flap (nonflap group). Overall, postoperative pharyngocutaneous fistula occurred in 9 of the 88 patients (10.2%)-1 case in the flap group (2.7%) and 8 cases in the nonflap group (15.7%). The difference between the two groups was statistically significant (p < 0.001; odds ratio = 0.612, 95% confidence interval = 0.451 to 0.832), independent of other factors. We found no correlation between fistula development and age (p = 0.073), sex (p = 0.065), or tumor location (p = 0.435). Likewise, we found no correlation between tumor location and either sex (p = 0.140) or age (p = 0.241). We conclude that including an SCMM flap in the surgical process would significantly decrease the development of fistula, regardless of age, sex, and tumor site.

Two cases of pyogenic granuloma in pregnancy

August 27, 2014     Alex Fernandez, MS; Jason Hamilton, MD, FACS; Raphael Nach, MD
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Management and treatment of rhinologic issues in pregnant patients can be complex because of the limited availability of safety data.

Transoral robotic surgery and oropharyngeal cancer: A literature review

August 27, 2014     Paraig O'Leary, MD; Thomas Kjaergaard, MD, PhD
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Abstract

The incidence of head and neck squamous cell carcinoma has risen steadily over the past decade due to the increase in cancers associated with the human papillomavirus (HPV). The prognosis for the treatment of this type of cancer with radiotherapy and chemoradiotherapy is good. However, because these treatments can have detrimental effects on organ function and quality of life, researchers are looking into transoral robotic surgery (TORS) as a possible alternate therapy. TORS might have a positive effect on postoperative function and quality of life for cancer survivors. The aim of this review is to report on the current situation regarding the treatment of oropharyngeal cancer with TORS, with a focus on the long-term oncologic and functional outcomes of this strategy. The articles cited in this review were selected from the PubMed and MEDLINE database. They contain study results pertaining to TORS implementation, complications, oncologic and functional outcomes, and the implications of HPV-associated cancer. We found that while TORS has some clear advantages and strengths and almost certainly a permanent place in future treatment, further research is necessary to correctly evaluate the role it will play in the complete management of oropharyngeal cancer.

Retropharyngeal pseudoabscess manifesting in nephrotic syndrome

May 7, 2014     Shirish Johari, DLO, MRCSEd, DOHNS(Edin); Pankaj Handa, MD, MRCP(Ire), FAMS; Jin Keat Siow, MD, MBBS, FRCSEd
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Abstract

We describe a case of nephrotic syndrome that manifested as a retropharyngeal pseudoabscess. The patient was a 32-year-old man who presented with a short history of throat discomfort and a choking sensation. Laryngoscopy identified bulging of the posterior pharyngeal wall that partially occluded the laryngeal inlet. A lateral neck x-ray revealed that the prevertebral space was widened, and computed tomography detected fluid in the retropharyngeal and parapharyngeal spaces. Neck exploration revealed that the edema had been caused by nonsuppurative fluid. Biochemical analyses revealed marked hypoalbuminemia and heavy proteinuria suggestive of nephrotic syndrome. Following surgery, the patient's symptoms resolved. Aseptic effusion into the retropharyngeal space is rare; reported etiologies include internal jugular vein thrombosis, neoplasia, radiation therapy, trauma, acute calcific tendinitis, hereditary angioedema, and myxedema of hypothyroidism. To the best of our knowledge, this is the first case of nephrotic syndrome initially manifesting as retropharyngeal pseudoabscess to be reported in the literature. Thrombotic occlusion of the pharyngeal venous plexus secondary to hypercoagulability is a plausible explanation for such isolated retropharyngeal effusion.

Modified radical mastoidectomy and its complications-12 years' experience

May 7, 2014     Sardar U. Khan, DLO, FCPS, FRCS(Ire); Rajesh K. Tewary, MS, FRCS(Ed); Timothy J. O'Sullivan, FRCS(Canada)
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Abstract

To find the incidence of complications of modified radical mastoidectomy and to evaluate different parameters that play a role in their causation, we conducted a retrospective study spanning a period of 12 years. Included were 210 patients who underwent primary modified radical mastoidectomies performed by one senior surgeon; of these patients, 163 fulfilled the inclusion criteria. The charts were evaluated for patients' age and sex, laterality, intraoperative pathology, and complications. The complications were grouped into nine categories for analysis of their etiology. The results in this study were compared with those from other published reports. Complications were documented in 46 of 163 (28.2%) operated ears; 21 (45.7%) of them were noted in children <15 years of age, and 25 (54.3%) were found in adults. Sex and laterality were of no significance. The most common complication recorded was residual/recurrent cholesteatoma (20 [12.3%]), followed by meatal stenosis (11 [6.7%]). A moist cavity with discharging ear was noted in only 4 (2.5%) patients. No facial nerve palsies or dead ears were observed. Eleven (6.7%) patients had more than one complication. The parameters evaluated were size of the meatus, tympanic membrane appearance, status of the mastoid cavity, height of the facial ridge, and extent of the disease process. Complications can be caused by a number of factors, such as congenital anomalies, disease process, and the surgeon's skill. Each complication must be thoroughly evaluated for immediate management and to learn how to avoid it in the future.

Nasal valve surgery: Assessment of quality of life with the Glasgow Benefit Inventory

May 7, 2014     Jaiganesh Manickavasagam, MRCS(Edin), DOHNS(Lond); Smeeta Wong, MRCS; Veronika Varabei, MBBS; Ullas Raghavan, FRCS(ORL)
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Abstract

We used the 18-question Glasgow Benefit Inventory (GBI) to conduct a retrospective assessment of quality of life following nasal valve surgery. We telephoned 53 patients who had undergone open rhinoplasty for the treatment of nasal valve collapse over a 2-year period. A total of 39 patients-24 men and 15 women, aged 20 to 50 years (mean: 38)-agreed to participate and answer the questions. Follow-up ranged from 3 to 12 months (mean: 8). The spectrum of possible GBI scores ranges from -100 (maximum negative outcome) to 0 (no change) to +100 (maximum benefit); in our group, the median total score was +56 (interquartile range: +32 to +90.5) and the overall total score was +58. The three subscale components of the GBI-general benefit, physical benefit, and social benefit-were analyzed individually; the respective median scores were +46 (+21 to +71), +67 (+25 to +91.5), and +50 (+17 to +100), and the respective overall scores were +60, +59, and +50. Based on these findings, we conclude that nasal valve surgery significantly improves quality of life.

Anatomic measurements of the anterior and posterior ethmoid arteries in cadaveric heads using endoscopic sinus instrumentation

May 7, 2014     Zeeshan S. Aziz, MD; Ninef E. Zaya, MD; Richard M. Bass, MD
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Abstract

The challenges of endoscopic sinus surgery lie in the complexity of the anatomy of the nasal vault and side walls and the proximity to critical structures. Additionally, operating in a three-dimensional space while relying on a two-dimensional image for surgical navigation can be a disorienting task. Successful sinus surgery relies on the surgeon having a clear understanding of the anatomy and relationships within the operative field. We performed a study of 8 adult cadaveric heads to better elucidate the location of the ethmoid arteries in relation to an accessible external landmark, the nasal sill. Sinus endoscopy was performed on the heads to identify and measure the distance from the nasal sill to the anterior and posterior ethmoid arteries. We found that the distance from the nasal sill to the anterior ethmoid artery was approximately 6.0 cm, and the distance to the posterior ethmoid artery was approximately 6.7 cm. The interarterial distance was approximately 1.2 cm. With a better understanding of these vessels, surgeons will be better able to avoid them during surgery and thereby minimize the risk of excessive intraoperative bleeding and perioperative orbital hematoma.

Endoscopic modified Lothrop approach for the excision of bilateral frontal sinus tumors

March 18, 2014     Jiun Fong Thong, MRCS; Deyali Chatterjee, MD; Siew Yoong Hwang, FRCS
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Abstract

We describe the use of an endoscopic modified Lothrop approach for clearance of an extensive sinonasal-type hemangiopericytoma of the nasal cavity and paranasal sinuses with bilateral frontal sinus involvement in a 44-year-old woman. The modified Lothrop approach is conventionally used to treat sinusitis, but with some slight modifications to the technique, it can also be used for tumor excision.

Schwannoma of the nasal septum: An unusual finding

March 18, 2014     Shruti Dhingra, MS, DNB; Jaimanti Bakshi, MS, DNB; Satyawati Mohindra, MS, DNB
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Abstract

Schwannomas of the nasal cavity are rare benign tumors, and those that arise from the nasal septum are even rarer. When they do occur, they usually become symptomatic early because of the close confines of the nasal cavity. We describe a case of nasal septal schwannoma that was noteworthy in that the patient-a 28-year-old woman-waited 8 months after the onset of symptoms to seek medical care. Her symptoms included complete right-sided nasal obstruction, occasional epistaxis, and hemifacial pain. The tumor was completely removed via an endoscopic approach. We discuss the clinical presentation, differential diagnosis, and treatment of this rarely encountered neoplasm.

Endoscopic view of sphenoid sinus illumination and transillumination

February 12, 2014     Ken Yanagisawa, MD, FACS; Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; and Eiji Yanagisawa, MD, FACS
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The sphenoid sinus has been considered a more challenging sinus to view with the lighted guide wire; unlike the other three paranasal sinuses, the sphenoid sinus is “hidden” from view because of its more posterior location.

Accessory parotid malignancy requiring ductal transection

February 12, 2014     Avery Kaplan; Alex Fernandez, MS; and Ryan Osborne, MD, FACS
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While malignancies of the accessory parotid gland are rare, when they do occur they jeopardize ductal integrity.

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