Otolaryngologic Emergencies in the Primary Care Setting.

Most otolaryngology-related complaints are straightforward and easily recognized and treated. However, given the proximity of the ears, nose, and throat to numerous vital structures in the head and neck, the potential for serious consequences exists if disease processes go unrecognized and untreated. This article serves to familiarize the primary care provider with the clinical presentation of various complications associated with common otolaryngologic complaints. Clinicians who care for patients presenting with otolaryngologic complaints should keep these entities in mind and attempt to rule out any serious complication.

Reconstruction Outcomes Following Lateral Skull Base Resection.

OBJECTIVE: Compare reconstruction outcomes for various lateral skull base closure techniques. STUDY DESIGN: Retrospective medical records review. SETTING: University-based tertiary referral center. PATIENTS: Patients who underwent resections of tumors involving the lateral skull base requiring reconstruction beyond primary closure. INTERVENTION(S): Reconstructive techniques, from rotational flaps to free tissue transfer. MAIN OUTCOME MEASURE(S): Outcome data including wound complications, cerebrospinal fluid (CSF) leakage, and need for surgical revision were tabulated. RESULTS: Eighty-six patients underwent lateral skull base tumor resection and reconstruction. Procedures were primarily lateral temporal bone resections but also included subtotal temporal bone, total temporal bone, and infratemporal fossa resections. Cutaneous malignancy was the most common resection indication (83%) and the temporalis rotational flap was the most commonly employed reconstructive option (30%). When free tissue transfer techniques were used, the radial forearm, anterolateral thigh, and latissimus dorsi were the most frequent donor sites. Patients with T2 disease were more likely to undergo temporalis flaps, whereas patients with T4 disease were more likely to undergo free flap reconstruction. Major complications were uncommon (∼8%), the most frequent being stroke (∼3%). The postoperative wound complication rate was approximately 45%. The majority involved minor dehiscences and were managed conservatively. Patients with T4 disease were more likely to have wound complications (p < 0.05). Radial forearm free flaps were less likely to have wound complications when compared with other reconstruction techniques (p < 0.05). CONCLUSIONS: Many factors go into planning lateral skull base reconstruction. Free flaps were more often used for T4 disease. Radial forearm free flaps tended to have lower wound complication rates when compared with other techniques.

Ketorolac after free tissue transfer: a comparative effectiveness study.

OBJECTIVE: We sought to compare postoperative pain and complications in patients undergoing free tissue transfer for reconstruction of head and neck defects with and without ketorolac. METHODS: In this retrospective cohort study, we identified patients who underwent head and neck free tissue transfer procedures at the University of Iowa between July 2010 and December 2012. A subset of patients received ketorolac as an anti-platelet agent. Main outcome measures include postoperative analgesic use, pain scores, and bleeding complications. RESULTS: We identified 138 free tissue transfers, with 42 procedures in the ketorolac cohort. In the first 7 postoperative days, patients in the ketorolac and non-ketorolac cohorts received equivalent narcotic doses (morphine equivalents, 48.9 mg/day vs 46.6 mg/day, P = .72). The ketorolac group reported higher mean pain scores (3.1 vs 2.4, P = .004). Ketorolac use was not associated with need for transfusion (P = .86) or number of days with neck drains (P = .79). CONCLUSION: Ketorolac did not demonstrate a significant analgesic effect in this group of patients in terms of pain scores and opioid requirements. However, there also was no evidence to suggest a higher likelihood of bleeding complications. Ketorolac may be safely used as an anti-platelet agent, with narcotic requirements unchanged.

Airway algorithm for the management of patients with a King LT.

OBJECTIVES/HYPOTHESIS: To discuss an algorithm for managing the airway in patients presenting with a King LT in place. STUDY DESIGN: Case series at a single institution with planned chart review. METHODS: This study reviewed the management of three patients who presented to a tertiary academic medical facility emergency department following placement of a King LT at an outside hospital or in the field. Clinical history at admission as well as each patient's hospital course was evaluated. We discuss the management of the airway in each of these cases and use these to help design an algorithm for improving outcomes in patients with a King LT in place. RESULTS: In each of the three cases presented, the Otolaryngology Department was consulted for definitive airway management. In two of these patients, the airway was successfully secured using endotracheal intubation. Only one patient required tracheostomy. We discuss an algorithm for managing these patients to obtain a safe airway, which includes assessing the airway with flexible endoscopy and then proceeding with intubation by the Seldinger technique or intubation using a video laryngoscope. In some cases, tracheostomy will be required to definitively secure the airway. CONCLUSIONS: The King LT is a valuable tool available in the field to help to temporarily secure the airway. Otolaryngologists should have an appropriate airway algorithm for managing patients with a King LT in place to minimize the need for a tracheostomy.

Validation of a task-specific scoring system for a microvascular surgery simulation model.

OBJECTIVE/HYPOTHESIS: Simulation models can help develop procedural skills outside the clinical setting while also providing a means for evaluation of trainees. Objective Structured Assessment of Technical Skills (OSATS) have been developed for several procedures. The purpose of this study was to demonstrate the construct validity of an OSATS for microvascular anastomosis performed on a simulation model using chicken thigh vessels. STUDY DESIGN: Validation study. METHODS: An expert panel constructed a task-specific checklist for an OSATS for microvascular anastomosis. Twenty surgical staff and trainees performed a microvascular anastomosis of a chicken ischiatic artery. Training level and microsurgical experience were assessed by questionnaire. The performances were recorded and scored by two experts using the task-specific and global scales of the OSATS. RESULTS: Analysis of variance revealed a significant effect of training and microvascular experience for both the task-specific score and global rating scale score (P < .005). Interrater reliability was 0.7. Experience level demonstrated a logarithmic relationship with task time. CONCLUSIONS: The microvascular OSATS applied to the chicken thigh simulator model differentiated between levels of microvascular experience. It demonstrated construct validity and reliability for the assessment of procedural competence using a cost-effective and easily accessible model.

Primary intraosseous cavernous hemangioma of the zygoma: a case report and literature review.

Intraosseous hemangiomas are rare. We report the case of a 47-year-old man who presented with a gradually enlarging left zygomatic mass that had caused pain, deformity, and superficial soft-tissue swelling. Computed tomography revealed a well-circumscribed 2.0 × 2.5-cm mass with a ground-glass matrix in the left zygoma. Following surgical excision, the patient's symptoms resolved. Findings on pathologic examination of the excised tissue were consistent with an intraosseous cavernous hemangioma. We describe the features of this rare case, we discuss the pertinent radiologic features and pathophysiology of intraosseous hemangiomas, and we review the available literature.

Endoscopic resection of calcifying pseudoneoplasm of the neuraxis (CAPNON) of the anterior skull base with sinonasal extension.

We present a calcifying pseudoneoplasm of the neuraxis (CAPNON) of the anterior skull base that was resected endoscopically. The clinical details are reported with a review of the relevant literature. CAPNON, although rare, should be considered in the differential diagnosis of tumors presenting along the anterior skull base with radiographic characteristics consistent with a fibro-osseous lesion. Endoscopic resection of these lesions is feasible in select patients with sinonasal extension.

Use of the King LT for emergency airway management.

OBJECTIVE: To discuss the role of the King LT reusable supraglottic airway in emergency airway management. DESIGN: Retrospective case series review. SETTING: Tertiary academic medical facility. PATIENTS: We studied patients who presented to the emergency trauma center having undergone intubation at an outside facility or at the scene of the incident. The otolaryngology service was consulted for definitive management of the airway. MAIN OUTCOME MEASURE: Airway evaluation and management once the King LT has been placed. RESULTS: Six patients with known prehospitalization use of the King LT presented to the emergency trauma center and subsequently required emergency tracheostomy for establishment of a secure airway. Fiberoptic and/or direct laryngoscopic evaluation performed with the tube in place failed to reveal whether safe oral endotracheal intubation could be performed because of visualization problems. Examination after tracheostomy and removal of the King LT revealed that in 2 patients, orotracheal intubation would have been difficult or impossible, whereas another 4 patients could have been intubated. One patient had prehospitalization placement of a King LT, which resulted in subcutaneous emphysema because of placement within the mediastinum. The patient was able to be successfully intubated and did not require tracheostomy. CONCLUSIONS: The King LT offers benefits in emergency situations, but evaluation of the airway is challenging and often necessitates tracheostomy for establishment of a safe and secure airway. Even if tracheostomy is not required, serious complications may occur.

Adverse events associated with concurrent chemoradiation therapy in patients with head and neck cancer.

OBJECTIVE: To assess toxicities, functional outcomes, and health-related quality of life associated with concurrent chemoradiation therapy (CRT) in patients with head and neck cancer. DESIGN: Prospective and retrospective outcomes study. SETTING: Tertiary care institution. PATIENTS: Participants in the longitudinal Outcomes Assessment Project whose head and neck cancer was treated with CRT between February 1, 2000, and March 1, 2007 (n = 104). INTERVENTIONS: Patients prospectively provided functional and health-related quality of life information, including data from the 1-year and most current follow-up visits. Medical records were reviewed to determine toxicity and survival rates. MAIN OUTCOME MEASURES: Well-defined acute and late toxicities; functional outcomes (diet, dentition, tracheostomies); head and neck cancer-specific, general health, and depression outcomes; and survival rates. RESULTS: Most patients had oropharyngeal or laryngeal tumors (87.5%) and advanced-stage disease (75.0%). Approximately one-half had hematologic toxicities and toxicity-related treatment delays. Approximately one-quarter had neurotoxicities and/or ototoxicites, moist desquamation, pneumonia, nausea and vomiting requiring hospitalization or intravenous fluids, dehydration or malnutrition requiring hospitalization, and mild or moderate fever. Although patients receiving the current intensity-modulated radiation therapy (IMRT) protocol using the Pinnacle(3) planning system had more toxicity-related treatment delays, they had fewer toxicities and better functional and health-related quality of life outcomes compared with those receiving conventional lateral opposing-field radiation or the initial IMRT protocol using the Best nomos PEACOCK planning system. CONCLUSIONS: Patients receiving CRT experience a substantial number of treatment-related adverse events, primarily affecting oropharyngeal and laryngeal function, with improvement noted for the current IMRT protocol. Improving dental prosthetic rehabilitation and including evaluations with speech and swallowing pathologists before and during treatment may enhance patient outcomes.

Management of the radial forearm free flap donor site with the vacuum-assisted closure (VAC) system.

INTRODUCTION: The radial forearm free flap is a popular reconstructive flap in modern head and neck surgery. Poor wound healing at the forearm donor site is common and frequently results in tendon exposure. The Vacuum-Assisted Closure (VAC) system (Kinetic Concepts Inc., San Antonio, TX) is a topical negative pressure dressing that has been shown to improve skin graft viability when used as a bolster dressing. In this study, we investigated the use of the VAC system in the management of the radial forearm free flap donor site. METHODS: A retrospective chart review was performed on all subjects who underwent a radial forearm free flap reconstruction in which the VAC system was used as a bolster dressing at the donor site from January 1, 2003, through March 31, 2005. RESULTS: Thirty-four consecutive subjects were included in the study. Exposed tendon did not occur in 14 (0%) subjects in which the VAC bolster was used for a minimum of 6 days. Eleven of the 20 subjects (55%) who used the VAC bolster for 5 days demonstrated small amounts of tendon exposure (<2 cm) on follow-up clinic examination. The minimum follow up for all subjects was 4 months. CONCLUSION: This study demonstrates that the VAC system is a feasible alternative to conventional bolster dressing in the management of the radial forearm free flap skin-grafted donor site. Based on this study, when used for a minimum of 6 days, the VAC bolster dressing eliminated tendon exposure at the forearm donor site.