Surgery

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.

Cerebrospinal fluid leak of the fallopian canal

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

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.

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.

Transoral surgery alone for human-papillomavirus-associated oropharyngeal squamous cell carcinoma

February 25, 2013     Steven M. Olsen, MD; Eric J. Moore, MD; Rebecca R. Laborde, PhD; Joaquin J. Garcia, MD; Jeffrey R. Janus, MD; Daniel L. Price, MD; Kerry D. Olsen, MD
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Abstract

The aim of this retrospective study was to describe the oncologic and functional results of treating oropharyngeal squamous cell carcinoma with transoral robotic surgery and neck dissection as monotherapy. A review was performed, including all patients who underwent transoral robotic surgery and neck dissection as the only means of therapy for oropharyngeal carcinoma from March 2007 to July 2009 at a single tertiary care academic medical center. We reviewed all cases with ≥24-month follow-up. Functional outcomes included tracheostomy dependence and oral feeding ability. Oncologic outcomes were stratified by human papillomavirus (HPV) status and tobacco use and included local, regional, and distant disease control, as well as disease-specific and recurrence-free survival. Eighteen patients met study criteria. Ten patients (55.6%) were able to eat orally in the immediate postoperative period, and 8 (44.4%) required a temporary nasogastric tube for a mean duration of 13.6 days (range 3 to 24 days) before returning to an oral diet. No patient required placement of a gastrostomy tube, and all patients are tracheostomy-tube-free. Among the HPV-positive nonsmokers (12/18, 66.7%), Kaplan-Meier estimated 3-year local, regional, and distant control rates were 90.9%, 100%, and 100%, respectively. Kaplan-Meier estimated disease-specific survival and recurrence-free survival were 100% and 90.9%, respectively. No complications occurred.

This study suggests that carefully selected patients with HPV-positive oropharyngeal carcinoma can be effectively treated with surgery alone with excellent functional and oncologic outcomes.

Idiopathic incus necrosis: Analysis of 4 cases

February 25, 2013     Leyla Kansu, MD; Ismail Yilmaz, MD; Volkan Akdogan, MD; Suat Avci, MD; Levent Ozluoglu, MD
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Abstract

We evaluated ossicular chain reconstruction in patients with idiopathic incus necrosis who have conductive hearing loss and an intact ear drum. The study included four patients (3 women and 1 man; the ages of the patients were 22, 31, 35, and 56 years, respectively) with unilateral conductive hearing loss, no history of chronic serous otitis media, an intact ear drum, normal middle ear mucosa, and necrosis of the long processes of the incus. On preoperative pure tone audiometry, air-bone gaps were 24, 25, 38, and 33 dB. Bilateral tympanometry and temporal bone computed tomography results were normal. All 4 patients underwent an exploratory tympanotomy. During the operation, the mucosa of the middle ear was normal, with a mobile stapes foot plate and malleus. No evidence of any granulation tissue was found; however, necrosis of the incus long processes was seen. For ossicular reconstruction, we used tragal cartilage between the incus and the stapes in 1 patient; in the other 3 patients, glass ionomer bone cement was used (an interposition cartilage graft also was used in the patients who received the glass ionomer bone cement). In all patients, air-bone gaps under 20 dB were established in the first year after surgery. In the ossicular disorders within the middle ear, the incus is the most commonly affected ossicle. While, the most common cause of these disorders is chronic otitis media, it may be idiopathic rarely. Several ossicular reconstruction techniques have been used to repair incudostapedial discontinuity.

Acute dystonic reaction to general anesthesia with propofol and ondansetron: A graded response

January 24, 2013     Matthew H.J. Size, MBChB, FRCA; John S. Rubin, MD, FACS, FRCS; Anil Patel, MBBS, FRCA
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Abstract

Propofol and ondansetron, alone and in combination, have been associated with acute dystonic reactions during recovery from anesthesia. We report the case of a 44-year-old woman who had undergone microlaryngoscopic fat injection to the vocal folds three times over a period of 10 months. Each procedure was performed by the same surgeon. On each occasion, the patient received an identical anesthetic that was administered by the same anesthetist. The anesthetic regimen included propofol and ondansetron. Following the first procedure, the patient experienced no reaction to these agents. However, she experienced a mild reaction after the second procedure and a severe acute dystonic reaction after the third. We believe this is the first report of a graded reaction to either propofol or ondansetron.

Intraparotid arterial aneurysm treated with embolization followed by surgical resection

December 31, 2012     Daniel T. Ganc, MD; Charles Prestigiacomo, MD; Soly Baredes, MD
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Abstract

We describe the case of a 41-year-old woman who presented to a local facial plastic surgeon for evaluation of a cosmetic defect of the cheek of 1 month's duration. When imaging revealed the presence of a vascular mass, the patient was referred to us. Further imaging identified the mass as an intraparotid external carotid artery aneurysm. The decision was then made to treat the patient with embolization of the lesion followed by surgical resection the next day. During the resection, the lateral-most aspect of the aneurysm was found to be adherent to and splaying the facial nerve. The embolized mass and the surrounding fascial layer were removed, and the branches of the facial nerve were retracted superiorly and inferiorly. Dissection proceeded around the aneurysm in this plane. Blood loss during the procedure was minimal. On postoperative day 1, the patient exhibited minimal lower facial asymmetry. In this case, performing embolization prior to surgical resection appeared to be a prudent and efficacious strategy. The preoperative embolization greatly reduced the risk of damage to the facial nerve.

Endoscopic view of iatrogenic nasal septal perforations

December 31, 2012     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS
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While many surgically created nasal septal perforations are asymptomatic, others can create long-term problems.

Rapidly developing iatrogenic hyponatremia in a child following tonsillectomy

October 31, 2012     Umit Taskin, MD; Omer Binay, MD; Cigdem Binay, MD; Ozgur Yigit, MD
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Abstract

Hyponatremia develops as a result of the inappropriate secretion of antidiuretic hormone. In rare cases, it develops as an iatrogenic complication. For example, acute iatrogenic post-tonsillectomy hyponatremia has been described in children following the infusion of hypo- or isotonic fluid. We report a case of rapidly developing post-tonsillectomy iatrogenic hyponatremia in a 5-year-old girl following an excessive infusion of hypotonic fluid. Her signs and symptoms began with nausea and vomiting and progressed to seizures and coma. We corrected the electrolyte disturbance by infusing a 3% sodium chloride solution until her neurologic manifestations disappeared, at which time her serum sodium concentration had risen back to 135 mEq/L. Otolaryngologists are not generally exposed to much information about hyponatremia, so we must be aware of its associated neurologic signs and symptoms.

Double fenestration of the internal jugular vein: A rare anatomic variant

October 8, 2012     Jagdeep S. Thakur, MBBS, MS; Dev R. Sharma, MBBS, MS; Narinder K. Mohindroo, MBBS, MS, DORL
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Even the most experienced head and neck surgeons can encounter problems during neck dissections in patients with rare anatomic variations in their major vessels, such as the internal jugular vein.

Endoscopic view of bilateral maxillary sinus cysts removed with a powered instrument

September 7, 2012     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS
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Powered instrumentation is a good choice for the removal of maxillary sinus lesions. It is efficient and safe and preserves normal sinus mucosa.

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