Surgery

Thiersch skin grafting in otologic surgery

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

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
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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.

Using a capsule flap for the reconstruction of a partial auricular defect

July 21, 2013     Barsil Keklik, MD; Memet Yazar, MD; Karaca Basaran, MD; Erdem Guven, MD; Samet Vasfi Kuvat, MD
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Abstract

In this article we describe the capsular flap for covering the posterior surface of cartilaginous framework in ear reconstruction. This technique has not been previously described in the published literature.

Double deep inferior epigastric arteries encountered during vertical rectus abdominis flap harvest: A case report and literature review

June 11, 2013     Thomas K. Chung, MA; Keith Wilson, MD; and Yash J. Patil, MD
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Abstract

The rectus abdominis flap offers a number of advantages over other flaps used in head and neck reconstruction. The flap can be harvested by a separate team and can be tailored to include skin, muscle, and fat. In addition, the available vascular pedicle is long and its large caliber provides an appropriate size match with recipient neck vessels. Central to reconstructive success is defining an arterial and venous pedicle that provides balanced perfusion to all components of the flap. Anomalous vascular anatomy presents principal challenges in reestablishing free flap perfusion. We present a case of double, right deep inferior epigastric arteries encountered during vertical rectus abdominis myocutaneous flap reconstruction of the tongue and floor of the mouth and discuss the clinical outcomes of this reconstruction.

Outcomes following ossicular chain reconstruction with composite prostheses: Hydroxyapatite-polyethylene vs. hydroxyapatite-titanium

June 11, 2013     Yoav Hahn, MD; and Dennis I. Bojrab, MD
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Abstract

We conducted a retrospective study to compare the results of ossicular chain reconstruction (OCR) with two types of composite prosthesis: a hydroxyapatite-polyethylene (HAPEX) implant and a hydroxyapatite-titanium (HATi) prosthesis. We reviewed the records of 222 patients-104 males and 118 females, aged 8 to 79 years (mean: 39.7)-who had undergone OCR for ossicular chain dysfunction and who met our eligibility criteria. In addition to demographic data and the type of prosthesis, we compiled information on pre- and postoperative audiometric findings, the underlying diagnosis, the timing of surgery (primary, planned, or revision), the type of surgery (tympanoplasty alone, tympanoplasty with antrotomy, intact-canal-wall tympanomastoidectomy, or canal-wall-down tympanomastoidectomy), the extent of reconstruction (partial or total), the use of the malleus, the use of a tragal cartilage graft, and evidence of extrusion. Of the 222 patients, 46 had undergone insertion of either a partial (n = 36) or total (n = 10) ossicular replacement prosthesis (PORP and TORP, respectively) made with HAPEX, and 176 had received a PORP (n = 101) or TORP (n = 75) made with HATi. Postoperatively, the mean air-bone gap (ABG) was 14.0 dB in the HAPEX group and 14.7 dB in the HATi group, which was not a significant difference (p = 0.61). Postoperative success (ABG ≤20 dB) with PORP was obtained in 30 of the 36 patients in the HAPEX group (83.3%) and in 87 of the 101 patients in the HATi group (86.1%), while success with TORP was achieved in 7 of 10 HAPEX patients (70.0%) and 56 of 75 HATi patients (74.7%); there was no significant difference in either PORP or TORP success rates between the HAPEX and HATi groups (p = 0.32). A significantly better hearing result was obtained when the malleus was used in reconstruction (p = 0.035), but the use of tragal cartilage led to a significantly worse outcome (p = 0.026). Revision surgery was associated with a significantly worse postoperative result (p = 0.034). Prosthesis extrusion was observed in 9.0% of all cases. The two types of composite assessed in this study yielded similar results in terms of functional hearing and stability, but the HATi prosthesis had some significant advantages. For example, it was associated with more cases in which the ABG closed to less than 10 dB. In addition, because of its thinner stem and lower profile, it can be used in situations that are not possible with the HAPEX implant.

Facial nerve preservation in total parotidectomy for parotid tumors: A review of 27 cases

June 11, 2013     Soliman El-Shakhs, MD; Yaser Khalil, MD; and Asmaa Gaber Abdou, MD
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Abstract

We conducted a study to evaluate the success of facial nerve preservation in 27 adults with a parotid tumor who underwent total parotidectomy. Of this group, 11 patients had a malignant tumor, 10 had a recurrent benign tumor, and 6 had a primary benign tumor. Preoperatively, 7 patients had facial nerve paresis. Postoperatively, facial nerve preservation was achieved in all but 1 case; in the exception, the nerve was sacrificed and grafting was necessary. In conclusion, facial nerve preservation can be achieved in almost all cases of total parotidectomy.

Relief from cluster headaches following extraction of an ipsilateral infected tooth

June 11, 2013     Matthew R. Hoffman, PhD; and Timothy M. McCulloch, MD
article

Abstract

A 60-year-old man with a 7-year history of cluster headaches was seen by an oral surgeon for evaluation of pain in the left upper second molar ipsilateral to the side affected by the headaches. During extraction of the tooth, infection, decay, and inflammation were discovered. Since the extraction in November 2008, the patient has experienced one episode of cluster headaches as of April 2013.

Endoscopic view of the posterior septal branch of the sphenopalatine artery

April 17, 2013     Jae Hoon Lee, MD
article

Moderate posterior epistaxis can be avoided if the posterior septal branch of the sphenopalatine artery is accounted for when extending the natural ostium inferiorly to a distance greater than approximately 5 mm.

A prospective study of parents' compliance with their child's prescribed analgesia following tonsillectomy

March 24, 2013     Paul Lennon, MB BCh BAO, MRCS; Mohamed Amin, FRCSI; Michael P. Colreavy, FRCS(ORL)
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Abstract

We conducted a prospective study to assess how well parents ensured that their children received their prescribed analgesia following tonsillectomy. Our study was based on 69 cases of tonsillectomy that were carried out at our tertiary pediatric care center. Postoperatively, all patients were prescribed paracetamol (acetaminophen) on the basis of their weight; the standard pediatric dosage of this agent at the time of our study was 60 mg/kg/day. The parents were telephoned 2 weeks postoperatively to assess their compliance with this regimen. Of the original 69 patients who had been recruited, 66 completed the study-35 girls and 31 boys, aged 2 to 15 years (mean: 7.0; median 5.5). According to the parents, only 15 children (22.7%) received our recommended 60-mg/kg/day dosage and were thus determined to be fully compliant. Overall, parents reported a wide variation in the amount of drug administered, ranging from 12.5 to 111.0 mg/kg/day (mean: 44.8), indicating that parents often underdose their children. We recommend that more emphasis be placed on weight-directed, parent-provided analgesia during the post-tonsillectomy period.

Bilateral Gore-Tex implant extrusion following type I thyroplasty

March 24, 2013     Farhad R. Chowdhury, DO; Adam L. Baker, MD; Robert T. Sataloff, MD, DMA, FACS
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Gore-Tex thyroplasty permits easy revision, and minor adjustments can be made, often without removing and replacing the entire prosthesis.

Cerebrospinal fluid leak of the fallopian canal

March 24, 2013     Karen B. Teufert, MD; William H. Slattery, MD
article

Abstract

Spontaneous cerebrospinal fluid (CSF) leaks from the fallopian canal are extremely rare, as only a few cases have been reported in the world literature. We describe a case of spontaneous CSF otorrhea through an enlarged geniculate fallopian canal. The patient was a 45-year-old woman who presented with a history of CSF rhinorrhea and otorrhea from the right ear. Myringotomy and tube insertion revealed CSF otorrhea. Contrast-enhanced computed tomography revealed that the geniculate fossa was smoothly enlarged (demonstrating remodeling of bone). A middle fossa craniotomy with temporal bone exploration was performed. Intraoperative inspection detected the presence of a fistula secondary to a lateral extension of the subarachnoid space through the labyrinthine segments of the fallopian canal. We discuss the management of this unusual finding, which involves sealing the fistula while preserving facial nerve function.

Does tonsillectomy affect the outcome of drug treatment for the eradication of gastric H pylori infection? A pilot study

March 24, 2013     Ozan Seymen Sezen, MD; Utku Kubilay, MD; Yusuf Erzin, MD; Murat Tuncer, MD; Seref Unver, MD
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Abstract

Eradication of Helicobacter pylori, which is associated with diverse gastroduodenal pathologies of varying severity, is sometimes challenging. We conducted a prospective study to determine the effect of tonsillectomy on the eradication of H pylori from the gastrointestinal tract. Our study population was made up of 46 patients-32 females and 14 males, aged 14 to 58 years (mean: 28.84 ± 9.65)-who had chronic tonsillitis and concomitant dyspepsia. An initial gastrointestinal endoscopy was performed to obtain specimens for histology and a rapid urease test. These gastroscopies revealed that 32 patients were H pylori-positive (69.6%) and 14 were H pylori-negative (30.4%); these groups were designated A and B, respectively. The 32 H pylori-positive patients were divided into three subgroups based on the sequence in which they underwent drug therapy and tonsillectomy. All 3 subgroups received the same 14-day combination-drug regimen for eradication of gastric H pylori. The patients in group A1 (n = 12) underwent tonsillectomy prior to receiving drug treatment; 2 months after the cessation of drug therapy, they underwent a second gastroscopy. The patients in group A2 (n = 10) received drug treatment first followed by tonsillectomy; 2 months later, they underwent their second gastroscopy. The patients in group A3 (n = 10) received drug treatment first, then they underwent a second gastroscopy, and then they were taken for tonsillectomy. The success or failure of H pylori eradication was determined by the second gastroscopy. Also, analyses were performed after tonsillectomy to look for H pylori infection in tonsillar specimens. Eradication of gastric H pylori was achieved in 9 of the 12 group A1 patients (75.0%), 8 of the 10 group A2 patients (80.0%), and 7 of the 10 group A3 patients (70.0%); there were no statistically significant differences among the three groups. Likewise, there were no significant differences between any subgroups or combination of subgroups in terms of tonsillar positivity. As far as we know, this is the first study to investigate the effect of tonsillectomy on the outcome of H pylori eradication treatment. In light of our findings, we may speculate that tonsillar tissue does not seem to be a reservoir for H pylori infection. Although tonsillectomy had no significant effect on gastric H pylori eradication in our study, our results might have been skewed by the relatively small size of our sample.

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