Endoscopic management of spontaneous CSF rhinorrhea with septal graft and middle turbinate rotational flap technique: A review of 31 cases

June 8, 2014     Shawky M. Elmorsy, MD; Yasser W. Khafagy, MD
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Abstract

Spontaneous cerebrospinal fluid (CSF) rhinorrhea poses a major challenge to rhinologists. Much controversy attends its cause, pathophysiology, management, and prognosis. It has been suggested that endoscopic placement of a septal graft with a middle turbinate rotational flap may represent the ideal approach to closing skull base defects. We conducted a retrospective chart review to compile the results of this approach in 31 patients with spontaneous CSF rhinorrhea-22 women and 9 men, aged 18 to 67 years (mean 38.5 ± 8.96) at diagnosis. After one surgery, success had been achieved in 27 of these patients (87.1%). The remaining 4 patients underwent a second surgery, and 2 of them experienced a successful closure. In the remaining 2 patients, a third surgery was still unsuccessful, and they were referred to the neurosurgical team for a shunt procedure. Thus, the overall success rate with the septal graft and a middle turbinate rotational flap was 93.5% (29/31). Septal grafts and middle turbinate flaps are easy to harvest and easy to place. Accurate localization of the defect, meticulous surgical technique, and cerebral dehydrating measures may improve outcomes. Further study of spontaneous CSF rhinorrhea to better evaluate its pathophysiology and prognostic factors is warranted.

Introduction A finding of cerebrospinal fluid (CSF) rhinorrhea implies the presence of a fistula between the subarachnoid space and the sinonasal tract. Patients with a CSF leak exhibit symptoms such as clear nasal discharge and headache. Immediate identification plus repair of a CSF fistula can prevent the development of life-threatening...

Bacteriology and antimicrobial susceptibility of ENT infections in a tropical hospital

June 8, 2014     Yok Kuan Chew, MBBS; Jack Pein Cheong, MBBS; Nambiar Ramesh, MBBS; Mohamad Din Noorafidah, MPath; Sushil Brito-Mutunayagam, MS; Abdullah Khir, MS; Narayanan Prepageran, FRCS
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Abstract

We conducted a retrospective observational study to determine the spectrum and antibiotic sensitivity pattern of organisms isolated in otorhinolaryngologic (ORL) infections. We reviewed the laboratory culture and sensitivity records of 4,909 patients-2,773 males (56.5%) and 2,136 females (43.5%), aged 2 to 90 years (mean: 45.3 ± 12.6)-who had been seen at two government hospitals in Malaysia. Of this group, 4,332 patients had a respiratory tract infection (88.2%), 206 had an ear infection (4.2%), 188 had a deep neck infection (3.8%), and 183 had an oropharyngeal infection (3.7%). The most common isolated organisms were Klebsiella spp, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, methicillin-susceptible S aureus, coagulase-negative S aureus, and Acinetobacter baumannii. We also identified the antimicrobial susceptibility of these organisms. We conclude that since the spectrum of causative pathogens in some infections differs between tropical and nontropical areas of the world, tropical hospitals should not completely adopt the antibiotic guidelines for ORL infections that have been recommended for hospitals in nontropical regions. We hope that our review and analysis of local data will help practitioners in Malaysia develop an appropriate prescribing policy with respect to ORL pathogens and antimicrobial susceptibility. The goal is to reduce the morbidity and mortality associated with these infections.

Pediatric sensorineural hearing loss

June 8, 2014     Dennis J. Kitsko, DO, FACS, FAOCO
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Children with hearing loss should avoid noise exposure, and families should be counseled to protect their child's hearing environment and to educate their children about the long-term need to avoid excessive noise exposure.

[Editor's note: This Guest Editorial has been adapted with permission from an article entitled “Update on Pediatric Sensorineural Hearing Loss” that appeared in the Fall 2012 issue of Soundings, the Pennsylvania Academy of Otolaryngology-Head and Neck Surgery's newsletter.]

Helical tomotherapy of the complete scalp and the ipsilateral lymph nodes in a case of scalp angiosarcoma

June 8, 2014     Sonja Katayama, MD; Markus Hantschke, MD; Steffen Lissner, PhD; Katja Lindel, MD; Dieter Oetzel, PhD; Klaus Herfarth, MD; Juergen Debus, MD, PhD; Florian Sterzing, MD
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Abstract

Scalp angiosarcoma represents a therapeutic challenge to all disciplines. This case report demonstrates the potential usefulness of helical tomotherapy (HT) as a new radiotherapeutic treatment option. A 71-year-old woman presented with a superficial angiosarcoma of the scalp, forehead, and left pre- and postauricular areas, with several nodular ulcerating and bleeding lesions. Irradiation of the gross tumor was performed with a total dose of 70 Gy in 2-Gy fractions and of the left cervical lymph nodes with 56 Gy in 1.6-Gy fractions. Good target coverage was achieved without compromising organs at risk, notably the brain. Treatment was very fast (661 seconds per fraction) and was administered with minimal acute toxicity (National Cancer Institute Common Toxicity Criteria: grade 2 erythema and grade 2 dysphagia). During treatment, tumor nodules dissolved into hyperkeratosis. We conclude that with HT, irradiation of the scalp and cervical lymph nodes can be conducted with minimal acute toxicity and without junction problems.

Automastoidectomy

June 8, 2014     Danielle M. Blake, BA; Alejandro Vazquez, MD; Senja Tomovic, MD; Robert W. Jyung, MD
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Treatment of automastoidectomy depends on the nature of the patient's symptoms, the presence or absence of pathologic tissue, the presence of complications, and the shape and degree of epithelialization of the resulting mastoid cavity.

A 77-year-old woman with a history of recurrent otitis media in the left ear as a child presented for follow-up after diagnosis of a left-sided cholesteatoma 2 years earlier. She had declined surgery at the time of diagnosis. She reported left-sided hearing loss that had remained unchanged since her cholesteatoma diagnosis. She denied tinnitus,...

Postauricular fascia in augmentation rhinoplasty

June 8, 2014     Aldo Benjamin Guerra, MD, FACS
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Abstract

Ten rhinoplasty operations performed using postauricular fascia for the purpose of augmenting the radix and dorsum of the nose were analyzed retrospectively. All the operations were performed over a 1-year period, between 2005 and 2006. The fascia of the postauricular area has been used as a source of pliable soft-tissue grafts in primary and revision rhinoplasty. It may be easily accessed using a single sulcus incision that also enables harvesting of ear cartilage grafts. Deficiency in the radix is an overlooked abnormality seen in many patients undergoing primary as well as revision rhinoplasty after aggressive hump removal. Recent trends in rhinoplasty have been to avoid the overly reduced nasal skeleton and to create a more balanced nasal surgery result. This article presents the use of the postauricular fascia as a radix graft that has been found to be simple to carry out, reliable, and long lasting. In addition, the fascia graft is useful in the camouflage of various nasal deformities in the dorsum and sidewalls. The average patient follow-up for the study was 24 months.

Harmonic Scalpel versus electrocautery and surgical clips in head and neck free-flap harvesting

June 8, 2014     Nichole R. Dean, DO; Eben L. Rosenthal, MD; Bruce A. Morgan, MD; J. Scott Magnuson, MD; William R. Carroll, MD
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Abstract

We sought to determine the safety and utility of Harmonic Scalpel-assisted free-flap harvesting as an alternative to a combined electrocautery and surgical clip technique. The medical records of 103 patients undergoing radial forearm free-flap reconstruction (105 free flaps) for head and neck surgical defects between 2006 and 2008 were reviewed. The use of bipolar electrocautery and surgical clips for division of small perforating vessels (n = 53) was compared to ultrasonic energy (Harmonic Scalpel; Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) (n = 52) free tissue harvesting techniques. Flap-harvesting time was reduced with the use of the Harmonic Scalpel when compared with electrocautery and surgical clip harvest (31.4 vs. 36.9 minutes, respectively; p = 0.06). Two patients who underwent flap harvest with electrocautery and surgical clips developed postoperative donor site hematomas, whereas no donor site complications were noted in the Harmonic Scalpel group. Recipient site complication rates for infection, fistula, and hematoma were similar for both harvesting techniques (p = 0.77). Two flap failures occurred in the clip-assisted radial forearm free-flap harvest group, and none in the Harmonic Scalpel group. Median length of hospitalization was significantly reduced for patients who underwent free-flap harvest with the Harmonic Scalpel when compared with the other technique (7 vs. 8 days; p = 0.01). The Harmonic Scalpel is safe, and its use is feasible for radial forearm free-flap harvest.

Introduction Free tissue transfer has become the standard for reconstruction of most large head and neck cancer defects, with the radial forearm fasciocutaneous free flap being utilized in the majority of cases.1 The flap is typically harvested under tourniquet control, and hemostasis is maintained through the use of bipolar electrocautery and...

Condyloma acuminatum of the buccal mucosa

June 8, 2014     Rashmi Jaiswal, PhD; Manoj Pandey, MS; Mridula Shukla, DipNB; Mohan Kumar, MD
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Abstract

Condyloma acuminatum is a human papillomavirus (HPV)-induced disease. It is usually transmitted sexually, and it frequently occurs in the anogenital area. A finding of condyloma acuminatum in the oral cavity is rare. Besides HPV, other risk factors for oral condyloma include chewing betel quid and smoking. We report the case of a 52-year-old man who presented with a 2 x 2-cm verrucous white patch on his buccal mucosa. He was habituated to both betel quid and cigarette smoking. A biopsy of the lesion identified it as a verrucous hyperplasia of the squamous epithelium with HPV-related koilocytic changes. The lesion was excised, and further histopathology identified it as condyloma acuminatum. The patient was disease-free 9 months postoperatively. The possibility of condyloma acuminatum should be considered in the differential diagnosis of an oral white lesion. The most common treatments are surgical excision, cryosurgery, electrocautery, and laser excision. There is no known role for antiviral therapy.

An abnormal sigmoid sinus with a dire clinical implication

June 8, 2014     Perianan Puraviappan, MS(ORL); Naryanan Prepageran, FRCS Ed; Cheng Ai Ong, MS(ORL); Raffique Abd Karim, MS(ORL); Omkara Rubini Lingham, MS(ORL); Rajagopalan Raman, MS(ORL)
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In reviewing CT scans before surgery, the location of the sigmoid sinus should always be noted.

A "nail-biting" case of an airway foreign body

May 7, 2014     Parker A. Velargo, MD; Jennifer D. McLevy, MD
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While cases of large, completely obstructing foreign bodies in the subglottis would lead to sudden respiratory distress, the initial presentation of smaller foreign bodies in the subglottis can be quite similar to croup, presenting with biphasic stridor, cough, and/or the steeple sign.

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