Surgery

Endoscopic view of a biodegradable middle meatal spacer

January 21, 2014     Joseph P. Mirante, MD, FACS; Dewey A. Christmas, MD; Eiji Yanagisawa, MD, FACS
article

Middle meatal spacers have included simple packing of the middle meatus for several days in the postoperative period, as well as insertion of various preformed splints.

Severe symptomatic hypocalcemia following total thyroidectomy in a patient with a history of Roux-en-Y gastric bypass surgery

January 21, 2014     Justin A. Gross, MD; Steven M. Olsen, MD; Cody A. Koch, MD, PhD; Eric J. Moore, MD
article

Abstract

Patients who undergo a Roux-en-Y gastric bypass (RYGB) procedure are at moderate risk for calcium and vitamin D deficiency. Those who subsequently undergo thyroid or parathyroid surgery are at high risk for developing severe symptomatic hypocalcemia if they are not monitored and adequately treated prophylactically. We describe the case of a morbidly obese 40-year-old man who had undergone RYGB surgery 6 months prior to the discovery of metastatic papillary thyroid carcinoma. He subsequently underwent total thyroidectomy with central and bilateral neck dissection. Following surgery, he developed severe symptomatic hypocalcemia, as his calcium level fell to a nadir of 6.0 mg/dl. He required aggressive oral and intravenous repletion therapy with calcium, vitamin D, and magnesium for 10 days before hospital discharge. Providers should institute careful preoperative screening, patient counseling, and prophylactic calcium and vitamin D therapy for all thyroid surgery patients who have previously undergone RYGB surgery to prevent the development of severe and life-threatening hypocalcemia. Only a few reports of patients have been published on the dangers of thyroid and parathyroid surgery in patients who have undergone bariatric surgery. We report a new case to add to the body of literature on this patient population. We also review calcium homeostasis and supplementation as they relate to this situation.

Angioleiomyoma on the dorsum of the nose excised via an open rhinoplasty approach

December 20, 2013     Philip W. Stather, MBChB; Zuhair O. Kirresh, FRCS; Paul N. Jervis, FRCS
article

Abstract

We describe what we believe is the first reported case of an angioleiomyoma on the dorsum of the nose. The patient was a 65-year-old woman who presented with a year-long history of an intermittently recurrent lump on the right side of the dorsum. The lesion was removed via an open rhinoplasty approach. Histologic examination identified it as an angioleiomyoma.

Endoscopic view of the sphenoid sinus seen through the posterior ethmoid sinus

October 23, 2013     Joseph P. Mirante, MD, FACS; Dewey A. Christmas, MD; Eiji Yanagisawa, MD, FACS
article

Care must be taken when entering the sphenoid sinus, to dissect inferiorly and medially to avoid injury to the vital structures of the lateral wall of the sphenoid sinus.

Endoscopic appearance of a healed skull base resection reconstructed with a pedicled nasoseptal flap

October 23, 2013     Hadia M. Leon, MD; Mark H. Tabor, MD
article

Expanded endonasal approaches to the skull base are becoming more common, and closure of CSF leaks with reliable separation of the sinonasal tract from the cranial cavity is critical to a successful outcome.

Thiersch skin grafting in otologic surgery

August 21, 2013     Helen Xu, MD; Natasha Pollak, MD, MS; and Michael M. Paparella, MD
article

Abstract

Thiersch skin grafting is an old but highly effective surgical technique in otology. We frequently place a Thiersch graft after otologic procedures that either create a mastoid cavity or result in reduced skin coverage of a portion of the external auditory canal. The purpose of this article is to introduce this surgical technique to a new generation of otologists. We discuss its indications, the surgical technique, tips for a successful outcome, and postoperative care. A key to successful skin grafting is to perform the procedure about 10 days after the primary procedure to allow sufficient time for the formation of an adequate vascular bed at the recipient site. The goal in all cases is to achieve a safe, dry ear that is covered with keratinizing squamous epithelium. Thiersch grafting accomplishes this very well.

Comparison of complication rates associated with stapling and traditional suture closure after total laryngectomy for advanced cancer

August 21, 2013     Brett A. Miles, DDS, MD; Deborah Larrison, MD; and Larry L. Myers, MD
article

Abstract

We conducted a retrospective, matched-cohort, case-control study to compare complication rates associated with two wound closure procedures-stapling vs. traditional hand suturing-following total laryngectomy. Our study population was made up of 42 consecutively presenting patients-38 men and 4 women, aged 34 to 92 years (mean: 60.3) whose pharyngotomies were amenable to primary closure. Of this group, 37 patients had active endolaryngeal squamous cell carcinoma (SCC), 2 patients had inactive endolaryngeal SCC, 2 patients had thyroid cancer, and 1 patient had been treated for chronic aspiration. A total of 26 patients (61.9%) had undergone traditional suture closure of the neopharynx (suture group) and 16 patients (38.1%) had undergone closure with a linear stapling device (staple group). Other than the fact that the patients in the staple group were significantly older than those in the suture group (median: 71.0 vs. 56.5 yr, p = 0.002), there were no significant differences between the two groups in terms of comorbidities or cricopharyngeal myotomy, tracheoesophageal puncture, or neck dissection. There was a total of 8 postoperative infections-5 in the staple group (31.3%) and 3 in the suture group (11.5%)-not a statistically significant difference. Fistulas occurred in 4 staple patients (25.0%) and 6 suture patients (23.1%)-again, not statistically significant. We conclude that in appropriately selected patients, primary closure of the neopharynx can be safely and effectively achieved with a linear stapling device.

Mummified leiomyoma of the midline anterior neck: Case report and literature review

August 21, 2013     Jacob Minor, MD; Mona Rizeq, MD; and Todd Wine, MD
article

Abstract

Leiomyomas are benign smooth-muscle tumors that have only rarely been reported in the head and neck. Extensive calcification (mummification) is occasionally seen in deep somatic soft-tissue leiomyomas, which represent a rare subtype. We describe a case of mummified leiomyoma of the soft tissues of the midline anterior neck in a 31-year-old man. His tumor was successfully managed with surgical excision. To the best of our knowledge, this case represents the only description of a mummified leiomyoma at this particular site and the first reported case of any leiomyoma at this site in more than 50 years. We also review the literature concerning leiomyomas of the head and neck, their subtypes, diagnostic and management considerations, and outcomes.

Multilevel treatment of moderate and severe obstructive sleep apnea with bone-anchored pharyngeal suspension sutures

August 21, 2013     Eric E. Berg, MD; Frederick Bunge, MD; and John M. DelGaudio, MD
article

Abstract

Success rates for the surgical treatment of obstructive sleep apnea (OSA) vary, with phase I surgical success ranging from 40 to 75%. Pharyngeal suspension suture procedures are minimally invasive techniques with a reported efficacy of 20 to 78%. We conducted a study to evaluate the effectiveness of pharyngeal suspension suture procedures in conjunction with uvulopalatopharyngoplasty (UPPP) as a multilevel treatment for OSA. We retrospectively reviewed the charts of 30 adults-22 men and 8 women, with a mean age of 49 years and a mean BMI of 30.6-who were treated at a tertiary care academic medical center and a private otolaryngology practice. All patients had moderate or severe OSA, and all had failed continuous positive airway pressure therapy. Of this group, 20 patients underwent tongue base and hyoid suspension (TBHS) and 10 underwent tongue base suspension (TBS) alone; 23 patients had undergone concurrent or previous UPPP, 13 in the TBHS group and all 10 in the TBS group. Polysomnography was performed an average of 3.9 months postoperatively. Surgical success was defined as a reduction in respiratory distress index (RDI) of more than 50% and a postoperative RDI of 20 or less. The overall surgical success rate was 63% (19/30). In the surgical success group, the mean RDI fell from 44.6 to 9.4 (p < 0.0001); in the surgical failure group, the mean RDI rose from 41.3 to 48.9 (p = 0.58). There were 6 complications: 3 seromas, 2 suture breaks, and 1 dislodged screw. We conclude that pharyngeal suspension suture procedures as part of the multilevel treatment of moderate and severe OSA yields better outcomes than conventional surgical treatments with the added benefit of being minimally invasive.

Post-thyroidectomy early serum ionic calcium level: Predictor of prolonged hypocalcemia

August 21, 2013     Sanjana V. Nemade, MS, FCPS(ENT) and Atul P. Chirmade, MS
article

Abstract

One of the more common complications of thyroid surgery is postoperative hypocalcemia, which is potentially serious. Its clinical manifestations range from minimal twitching to life-threatening tetany. Affected patients might require a prolonged hospital stay and supplementation with calcium and vitamin D. In cases of post-thyroidectomy hypocalcemia, it is not always easy to predict which patients will require close monitoring of serum calcium levels. We conducted a study to determine whether early (<24 hr) measurement of serum ionic calcium (SiCa) levels can predict the development of post-thyroidectomy hypocalcemia. We retrospectively analyzed the charts of 150 adults (144 women and 6 men) who had undergone total or partial thyroidectomy, and we identified 42 patients (all women) who had either transient (<1 mo; n = 27) or prolonged (1 to 6 mo; n = 15) temporary hypocalcemia. We found that the patients who turned out to have prolonged hypocalcemia had significantly lower early levels of SiCa than did the patients who later developed only transient hypocalcemia (p = 0.000002). Also, patients with prolonged hypocalcemia had a significantly higher incidence of serious sequelae, including carpopedal spasms and signs of tetany. We conclude that early measurement of SiCa is a reliable predictor of prolonged temporary hypocalcemia following total or partial thyroidectomy.

Iatrogenic epiglottic inversion during intubation

August 21, 2013     Adam Rourke, DO and Adam Rubin, MD
article

The otolaryngologist must recognize when the epiglottis is inverted or risk inserting the laryngoscope too far and traumatizing the vocal folds.

Subcutaneous emphysema and pneumolabyrinth plus pneumocephalus as complications of middle ear implant and cochlear implant surgery

July 21, 2013     Brian J. McKinnon, MD, MBA; Tamara Watts, MD, PhD
article

Abstract

We conducted a retrospective case review at a tertiary academic medical center for the complications of pneumolabyrinth with pneumocephalus and subcutaneous emphysema after surgery for middle ear and cochlear implants. Charts of 76 cochlear implant and 2 middle ear implant patients from January 2001 through June 2009 were reviewed. We identified 1 cochlear implant recipient with pneumolabyrinth and pneumocephalus, and 1 middle ear implant recipient with subcutaneous emphysema. Surgical exploration was performed for the pneumolabyrinth with pneumocephalus; the subcutaneous emphysema was managed conservatively. The patient with the cochlear implant, who had had a ventriculoperitoneal shunt placed, experienced pneumolabyrinth with pneumocephalus 6 years after uneventful surgery. Middle ear exploration revealed no residual fibrous tissue seal at the cochleostomy. The middle ear and cochleostomy were obliterated with muscle, fat, and fibrin glue. The ventriculoperitoneal shunt was deactivated, with clinical and radiographic resolution. On postoperative day 5, the patient who had undergone the middle ear implant reported crepitance over the mastoid and implant device site after repeated Valsalva maneuvers. Computed tomography showed air surrounding the internal processor. A mastoid pressure dressing was applied and the subcutaneous emphysema resolved. These 2 cases support the importance of recognizing the clinical presentation of pneumolabyrinth with associated pneumocephalus, as well as subcutaneous emphysema. Securing the internal processor, adequately sealing the cochleostomy, and providing preoperative counseling regarding Valsalva maneuvers and the potential risk of cochlear implantation in the presence of a ventriculoperitoneal shunt may prevent adverse sequelae.

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