Surgery

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.

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.

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.

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.

Clindamycin-induced neutropenia following major head and neck surgery

September 7, 2012     Robert S. Schmidt, MD; Evan R. Reiter, MD
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Abstract

A 64-year-old man undergoing major head and neck surgery received clindamycin for perioperative antimicrobial prophylaxis. On the third postoperative day, he became acutely neutropenic. The neutropenia resolved 3 days later, after the administration of filgrastim. After ruling out other causes of acute neutropenia, we determined that the neutropenia was secondary to clindamycin toxicity. While clindamycin-induced neutropenia has been reported elsewhere, to our knowledge this is the first report of its occurrence following head and neck surgery. Otolaryngologists should be aware of this potentially serious reaction.

Mandibular condyle reconstruction with fibula free-tissue transfer

September 7, 2012     Eric J. Moore, MD; Steven S. Hamilton, MD
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Abstract

We conducted a study to evaluate functional and cosmetic outcomes following reconstruction of the mandibular condyle with direct placement of a vascularized free fibula. We retrospectively reviewed the cases of all patients who had undergone hemimandibulectomy and condyle resection with immediate reconstruction at the Mayo Clinic in Rochester, Minn., between Nov. 1, 2005, and Jan. 31, 2007. We found 7 such cases, all of which occurred in men aged 32 to 61 years (mean: 50.7). Six of these patients had a malignancy and 1 had osteomyelitis. Postoperatively, 6 patients had no difficulty with occlusion, which was rated as “good” or “excellent” at their 6-month follow-up visit; the other patient had an open-bite deformity, but he was able to masticate solid food and maintain an oral diet. Cosmesis was generally satisfactory, and all patients maintained intelligible speech. We conclude that free fibula transfer with direct seating of the fibula into the condylar fossa followed by aggressive physiotherapy provides acceptable functional reconstruction of the mandibulectomy-condylectomy defect.

A comparison of unilevel and multilevel surgery in obstructive sleep apnea syndrome

August 10, 2012     Ümit Tunçel, MD; Hasan Mete İnançlı, MD; Şefik Sinan Kürkçüoğlu, MD; Murat Enoz, MD
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Abstract

We conducted a retrospective study of 35 adults who had undergone tongue base suspension in addition to other surgery for the treatment of obstructive sleep apnea syndrome (OSAS). Our goal was to determine the most effective surgical approach by comparing these patients’ preoperative apnea-hypopnea index (AHI) with their postoperative scores at 6 months. The 35 patients were divided into three groups based on a preoperative assessment of their level of airway obstruction; the assessment included a determination of AHI and endoscopic findings during the Müller maneuver. Patients in group 1 (n = 9) exhibited unilevel obstruction, and they were treated with lateral pharyngoplasty; patients in group 2 (n = 13) also had unilevel obstruction, and they underwent Z-palatoplasty; patients in group 3 (n = 13) had multilevel obstruction, and they underwent combined surgery. Postoperatively, all three groups exhibited statistically significant improvements in AHI, but we determined that of the three approaches, multilevel surgery was significantly more effective (p < 0.001).

An adjustable implant for nasal valve dysfunction: A 3-year experience

August 10, 2012     Charles G. Hurbis, MD, FACS
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Abstract

A 3-year, single-center, prospective study was undertaken to measure the effect and long-term results of using the Monarch Nasal Implant to surgically correct nasal valve dysfunction. Thirty-nine patients were implanted, with follow-up lasting 36 months for 9 of the patients. Implant effectiveness and maintenance of effectiveness were determined through acoustic rhinomanometry and a subjective patient questionnaire. Rhinomanometry studies and patient questionnaires revealed a significant initial improvement in internal nasal valve areas and patient symptoms; the improvements were maintained or had even increased at 36 months. The cosmetic changes were acceptable to the patients. The Monarch Nasal Implant provides a consistent and lasting correction of nasal valve dysfunction with minimal drawbacks when properly used.

Topical mitomycin C application before myringotomy and ventilation tube insertion: Does it affect the final outcome?

August 10, 2012     Ahmed Hesham, MD; Ayman Hussien, MD; Ahmed Hussein, MD
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Abstract

Previous animal studies have shown that the topical application of mitomycin C is safe and effective in prolonging the patency of myringotomy openings in ears that have not received a ventilation tube. We conducted a randomized, controlled study in humans to determine if this treatment would make a difference in outcomes when a ventilation tube is inserted. To that end, we prospectively studied a group of patients with resistant otitis media with effusion who underwent bilateral myringotomy and ventilation tube insertion. Our original study population was made up of 55 children aged 2 to 12 years; 15 of these patients were lost to follow-up, leaving us with 40 patients and 80 ears. Each patient served as his or her own control, as mitomycin C was applied to the tympanic membrane on one side just prior to myringotomy creation and normal saline was applied to the other side. Our main outcomes measures were the duration of tube placement (i.e., the length of time before extrusion of the tube) and the incidence of other early and late postoperative complications. We found no statistically significant difference between the mitomycin C-treated ears and the control ears in any of these parameters. We conclude that the use of mitomycin C prior to myringotomy and ventilation tube insertion is not worthwhile.

Management of head and neck paragangliomas: A series of 9 cases and review of the literature

August 10, 2012     Domenico Destito, MD; Sebastiano Bucolo, MD; Alessandra Florio, MD; Carmelo Quattrocchi, MD
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Abstract

We conducted a retrospective study of the long-term functional results of surgery for head and neck paragangliomas. Our study population was made up of 9 patients—4 men and 5 women, aged 22 to 59 years (mean: 46.6; median: 51)—who had undergone surgical excision of a head and neck paraganglioma from January 2002 through December 2006 in the ENT Department at Pugliese-Ciaccio Hospital in Catanzaro, Italy. Of the 9 paragangliomas, 4 were carotid body tumors, 2 were glomus tympanicum tumors, and 3 were glomus vagale tumors. None of the cases was bilateral or hereditary. Complete tumor resection was achieved in 8 patients; in the remaining patient, a small amount of intradural residual vagus nerve paraganglioma had to be left in situ. The internal carotid artery was preserved in all 4 resections of carotid body tumors. There was only 1 case of postoperative lower cranial nerve deficits, which occurred in a patient with a carotid body tumor. Follow-up ranged from 12 to 53 months (mean: 37.2; median: 36), and no recurrences were documented. Our small sample showed that surgical treatment of head and neck paragangliomas provided excellent tumor control with low postoperative morbidity, even in patients with large tumors. A wait-and-scan policy may be more appropriate for patients at an advanced age or who are otherwise at high surgical risk, as well as for those whose tumors have recurred following radiotherapy.

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