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

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

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


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


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


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


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


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


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.

Hyoid suspension surgery with UPPP for the treatment of hypopharyngeal airway obstruction in obstructive sleep apnea

August 10, 2012     Selmin Karataylı-Özgürsoy, MD; Alp Demireller, MD


We report our experience with hyoid suspension surgery in patients with obstructive sleep apnea (OSA) diagnosed on the basis of polysomnographic criteria. We conducted a prospective, observational study of 20 patients—18 males and 2 females, aged 15 to 52 years (mean: 42.1)—who were treated at our tertiary care center. All patients underwent hyoid suspension surgery and uvulopalatopharyngoplasty (UPPP) in a single session. Postoperative success was defined as either (1) a reduction in the apnea-hypopnea index (AHI) from 20 or higher to less than 20 or (2) a reduction in AHI of at least 50%. Postoperative follow-up polysomnography indicated that surgery was successful in 18 of 20 patients (90%). No important complications were observed. We conclude that hyoid suspension surgery is an effective procedure with low morbidity for the treatment of OSA in selected patients with hypopharyngeal obstruction. We believe it is a good option for those patients who will not or cannot tolerate therapy with continuous positive airway pressure.

Utility of preoperative hematologic screening for pediatric adenotonsillectomy

August 10, 2012     Yekaterina A. Koshkareva, MD; Michael Cohen, MD; John P. Gaughan, PhD; Vincent Callanan, MD; Wasyl Szeremeta, MD


We conducted a 3-year retrospective study to examine the results of preoperative 
hematologic screening, the incidence of postoperative bleeding, and the possible 
relationship between the two factors in patients who had undergone tonsillectomy 
with or without adenoidectomy. Our study population was made up of 875 patients—441 
boys and 434 girls, aged 2 to 18 years (mean: 7.52 ± 4.25)—who had been treated at 
our institution from January 2004 through December 2006. In addition to demographic 
data, we compiled information on each patient’s medical and surgical history, personal 
and family history of abnormal bleeding, indication for tonsillectomy, and preoperative 
hematologic screening results. The latter included determinations of the prothrombin 
time, activated partial thromboplastin time, international normalized ratio (INR), and 
platelet count. A total of 748 patients (85.5%) had normal findings on preoperative 
hematologic screening, and 127 (14.5%) had at least one abnormality. Postoperatively, 
hemorrhagic complications occurred in 31 children (3.5%)—in 22 of the 748 patients 
with normal screening results (2.9%) and in 9 of the 127 with a screening abnormality 
(7.1%); the difference between the two groups was statistically significant (p = 0.041). 
The abnormalities in the latter group consisted of an elevated INR but no otherwise 
identifiable coagulopathy. Another 14 patients with an abnormal screening result 
(11.0%) were found to have at least one coagulopathy that was newly diagnosed during 
our preoperative evaluation; they were treated perioperatively, and none bled 
postoperatively. Of 21 patients who had a personal or family history of abnormal 
bleeding, 5 (23.8%) were found to have a coagulopathy, but none bled following surgery. 
In conclusion, we found that preoperative hematologic screening identified patients 
with undiagnosed coagulopathies, and with appropriate treatment our surgeons were able 
to prevent some bleeding events in these patients. Our finding that patients with a 
mildly elevated INR had a higher incidence of postoperative hemorrhage warrants 
further study.

Bipolar microdebrider may reduce intraoperative blood loss and operating time during nasal polyp surgery

August 10, 2012     Nishant Kumar, MD; Raj Sindwani, MD, FACS


Bleeding during endoscopic sinus surgery (ESS) can interrupt the flow of the procedure and increase the risk of complications. Advances in microdebrider design now allow for bleeding to be controlled by bipolar energy during the suctioning and shaving of polyps. We conducted a retrospective study to examine the effects of this technology on blood loss and operating times during ESS for chronic rhinosinusitis with nasal polyps (CRS+P). Our patient population was made up of 80 patients who had undergone ESS for CRS+P by the same surgeon from January 2007 through May 2008. All surgeries were performed with either the PK diego bipolar microdebrider (Gyrus ACMI, ENT Division; Bartlett, Tenn.) or a standard microdebrider. There were 40 patients in each group. The PK group was made up of 23 males and 17 females, aged 14 to 66 years (mean: 43.1), and the control group included 21 males and 19 females, aged 17 to 71 years (mean: 43.1); there were no statistically significant differences between the two groups in terms of sex and age. In addition to demographic data, the charts were reviewed for comorbidities and operative variables; the latter included blood loss, operating room (OR) time, and complications. The preoperative treatment and anesthesia protocols were similar for all patients, and all patients demonstrated a similar disease burden on imaging (mean Harvard CT stage: 3.12 for the PK group and 3.15 for the controls; p > 0.05). We found that during ESS, the PK group experienced significantly less intraoperative blood loss than did the controls (means: 86.0 and 123.0 ml, respectively; p = 0.015). In addition, the PK device was associated with significantly shorter OR times (means: 88.9 and 101.4 min, respectively; p = 0.026). There were no complications in either group. We conclude that using a microdebrider with bipolar capabilities during ESS may offer the advantages of less blood loss and shorter operating times in patients with nasal polyps.

Expression and clinical significance of PLUNC protein in nasal polyp and chronic sinusitis tissue

July 5, 2012     Min-man Wu, MD; Hong Sun, MD, PhD; Qiong Nan, MD


We conducted a study to validate the expression of PLUNC (palate, lung, and nasal epithelial clone) protein in nasal polyp and chronic sinusitis tissue by immunohistochemistry. We also explored the relationship between the intensity of positive immunohistochemical staining for PLUNC protein and postoperative therapeutic efficacy. Our study population consisted of 34 patients with nasal polyps and 30 with chronic sinusitis who had undergone surgical treatment, along with 18 healthy controls who did not undergo surgery. All samples were stained according to the streptavidin-peroxidase immunohistochemical method to examine PLUNC protein expression. The surgical patients were evaluated for clinical therapeutic efficacy 6 months postoperatively. The association between efficacy and the intensity of PLUNC protein positivity was examined by the Spearman rank correlation analysis. Intensity was rated as either +++(>50% positive cells), ++ (26 to 50% positive cells),+ (≤25% positive cells), or(no positive cells). We found that the most common levels of PLUNC positivity were + in the patients with nasal polyps, +++ in the patients with chronic sinusitis, and ++ in the controls (p< 0.01). Analysis of the Spearman rank correlation indicated that the intensity of PLUNC protein expression was significantly correlated with postoperative therapeutic efficacy (p< 0.001). We conclude that PLUNC protein is an essential factor in the innate defense mechanism of the nasal mucosa. The immunohistochemical staining of PLUNC protein could have clinical benefit in terms of predicting therapeutic efficacy and outcomes in patients with nasal polyps or chronic sinusitis.

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