Adult Maxillofacial Trauma Patterns in American Football.

INTRODUCTION: The authors aimed to identify and categorize adult maxillofacial trauma patterns in the setting of American football. METHODS: The National Electronic Injury Surveillance System was accessed to identify adult patients presenting with football-related head and facial injuries from 2009 to 2018. Data surrounding each event were collected including age, injury type, injury location, and disposition of the patient. Chi-squared testing was performed to compare categorical variables, with a Bonferroni correction applied. RESULTS: During the study period, 1784 total patients (national estimate = 65,052) were identified. The average age for this cohort was 27.26 (SD ±â€Š8.49), with young adults (86.1%) and males (87.9%) sustaining the majority of injuries. Lacerations were the most common injury type (43.1%). Maxillofacial fractures comprised 15.8% of the sample, with nasal bone (52.8%) being the most common subtype. Female patients were significantly more likely to present with head injuries than men (46.8% versus 29.0%, P < 0.001). Young and middle-aged adults combined were more likely to be discharged from the emergency department, whereas the elderly were significantly less likely (P = 0.002). Patients with fractures were significantly more likely to be admitted to the hospital compared to all other types of injuries (P < 0.001). CONCLUSIONS: An understanding of maxillofacial injuries while participating in American football is important in developing safety initiatives. To address these, it is crucial that providers understand the patterns of craniofacial injuries as they relate to American football trauma.

Golf-Related Craniofacial Injuries in Adults: A NEISS Database Study.

INTRODUCTION: Despite its popularity, there have been no reports outlining adult craniofacial trauma in the setting of golf injuries. Our main objective was to identify and describe trends in head and neck injuries incurred while participating in golf including injury type, anatomic location, and patient disposition. METHODS: A retrospective cohort analysis of the National Electronic Injury Surveillance System (NEISS) was conducted from 2009-2018. Population characteristics of golf-related injuries were recorded, including, age, sex, and race distributions. Distribution of injury anatomic location, injury type, distribution of fracture location, patient disposition was further analyzed. A one way ANOVA was utilized to obtain the mean ages for all injuries and compare them for any statistical difference. To identify statistical significance, a Fisher exact test with a Monte Carlo simulation was performed. RESULTS: A total of 509 golf-related injuries (national estimate 24,425 cases) were recorded over the study period. Lacerations were the most common injury overall (54.2%), while contusions and abrasions were the next most common injuries (27.3%). The most common fracture subtype observed was midface (40.43%), followed by nasal bone (27.66%), mandible (12.77%), skull (12.77%), and cervical spine (6.38%). The highest proportion of patients admitted for further treatment were individuals >70 years of age. Fractures had the highest rate of admission (29.8%). CONCLUSIONS: A better understanding of golf injuries can allow for rapid detection and appropriate treatment when encountered. This knowledge can also help to develop safety precautions by potentially reforming rules and regulations as well as protective equipment.

Nuances in the management of rhinophyma.

Rhinophyma is a cosmetically disfiguring disease of the external nose that most frequently affects elderly Caucasian males. Frequently, there is associated derangement of nasal airway patency. Although the true incidence of rhinophyma and its exact etiology remain unknown, it is widely believed to represent the final stage in a continuum of acne rosacea. Medical therapy has not been effective in reversing the disease process, and surgery remains the most accepted method of treating rhinophyma. A wide variety of surgical techniques have been developed and modified over the years in an effort to treat this disorder safely and without significant sequelae. Despite many advances in fundamental understanding, surgical techniques, and related technologies, no single method has been universally embraced and employed as the "gold standard." This review describes the most commonly employed modern surgical techniques and methods used throughout the world to treat rhinophyma. There is special emphasis on the authors' preferred method of excision and postoperative management (tumescent anesthesia, Weck blade excision, and argon beam coagulation), which has been demonstrated to be effective and expeditious.

Slippery Slopes: Skiing-Related Facial Trauma in Adults.

Study Design: Retrospective, observational, cross-sectional study. Objective: To determine the incidence of skiing-related facial trauma and to identify their patterns in terms of potential risk factors, mechanism of injury, anatomical location, and degree of severity. Methods: Data was collected using the National Electronic Injury Surveillance System and included snow skiing-related incidents during the years 2009 to 2018. Specifically, injuries limited to the facial region including the head, face, eye(s), mouth, neck or ear(s) were reported. Patients with fractures were further classified by the study variables. Descriptive statistics were used to classify continuous variables while chi-square analysis was used to compare categorical variables. Results: A total of 514 (n = 514) patients met the inclusion criteria within the study period. The majority of injuries were due to concussions (59%), followed by lacerations (18%), fractures (11%), contusions (11%) and dental injuries (1%). Of the fractures seen, the majority were nasal (30%) and cervical spine (30%), followed by midface (27%), mandible (9%) and skull (4%). In our population, head injuries were more common in females (80%) than in males (60%), whereas, mouth injuries were more common in males (8%) than females (1%) [χ2 = 30.2, p < 0.001]. Conclusions: Skiing-related craniofacial trauma remains a significant mechanism of injury. Our data illustrates a need to correlate these injuries to the use of personal protective equipment. Furthermore, this data calls for the strict implementation of such equipment and the development of safety protocols to further prevent deleterious injury.

Topical mitomycin C in the prevention of keloid scar recurrence.

OBJECTIVE: To assess the ability of mitomycin C to prevent the recurrence of surgically excised keloid scars. Mitomycin C has been successfully used to prevent scar tissue formation at the site of subglottic stenosis in the field of pediatric otolaryngology. It appears that mitomycin C interferes with the ability of fibroblasts to produce a scar without causing changes in epithelialization. DESIGN: We excised keloid scars from various sites in the head and neck and then applied mitomycin C to the resected bed prior to closure of the wound at a concentration of 0.4 mg/mL for 5 minutes. All patients had multiple keloids and acted as their own control. At 1 month after the procedure both wounds were started on a regimen of triamcinolone acetonide, 40 mg/mL injections, repeated every month for 6 months. At the end of the study, photos and measurements were again taken. RESULTS: Fifteen patients (13 female and 2 male) ranging in age from 10 to 55 years enrolled in the study. No infections or nonhealing wounds were seen. There was no difference in postoperative pain. Eight patients completed the triamcinolone injections, 5 had fewer than 6 injections, and 2 patients had no steroid injections. Twelve patients completed follow-up and were evaluated for surgical complications and recurrence of the keloids at either site. Two patients had partial postoperative follow-up in person and then completed follow-up via telephone. One patient could not be found for follow-up. Four patients had recurrence of both excised lesions. Ten patients had no recurrence of their keloids at either site. CONCLUSION: Mitomycin C made no difference in the prevention of keloid recurrence after excision when topically applied.

African American rhinoplasty.

This article describes the topographic and surgical anatomy of the African American nose and the surgical techniques used in the authors' practice.

Cavernous sinus involvement by extramedullary plasmacytoma of the sphenoid sinus. An argument for the use of adjuvant chemotherapy.

A 63-year-old man with cavernous sinus involvement from extramedullary plasmacytoma (EMP) of the sphenoid sinus is described. Transient resolution of retro-orbital headache and continued progression of the locally extensive tumor were noted after chemotherapy was given following a poor response to 5400 cGy of local irradiation. To determine whether adjunctive chemotherapy will improve the outcome of these particular patients, we propose that a randomized trial comparing radiotherapy to chemoradiation be conducted.

A method to repair auricular defects after perichondrial cutaneous grafting.

OBJECTIVE: To describe and illustrate the technique for closing the auricular bowl defect after perichondrial cutaneous grafting. The postauricular flip-flop flap is used for this purpose. STUDY DESIGN: A retrospective clinical study of 354 patients using the perichondrial cutaneous graft for various reconstructions of the face and then performing the postauricular flip-flop flap procedure. METHODS: The perichondrial cutaneous graft is a reliable, versatile graft that possesses unique properties for reconstructive surgery of the face. The postauricular flip-flop flap is our particular technique for closure of the donor site wound after using the perichondrial cutaneous graft. It is a relatively simple procedure that has predictable results. We used this technique in patients ranging in age from 7 days to 92 years and noted excellent cosmetic results and rare complications. RESULTS: Two patients had failure of the perichondrial cutaneous graft. Two patients had partial necrosis of the postauricular flip-flop flap. Two patients had dehiscence of the postauricular closure. CONCLUSION: The postauricular flip-flop flap is a reliable method to repair the donor site after perichondrial cutaneous grafting.

Otoplasty: an analysis of technique over a 33-year period.

OBJECTIVE: To compare the merits of otoplasty technique with a diverse patient population as experienced spanning a period greater 30 years. STUDY DESIGN: A review of a series of otoplasty cases that occurred in two distinctly different clinical settings during a 33-year period. METHODS: A retrospective analysis of 211 patients undergoing otoplasty from 1969 to 1982 in a military hospital setting was compared with 118 patients receiving otoplasty from 1982 to 2002 in a university/private practice setting. The patient population consisted of 180 adults and 149 children. RESULTS: Otoplasty patients in the military setting were primarily adults, whereas those in the university/private practice setting were primarily children. In the adult population, 98.9% of patients required use of lateral conchal cartilage resection combined with a mattress suture technique. In the pediatric population, all patients required use of a mattress suture technique and in 83.2% of selected cases limited lateral conchal cartilage resection was required. CONCLUSION: Otoplasty technique involving lateral conchal cartilage resection, mattress suture fixation, or a combination of both is applicable to diverse patient populations.

Molecular analysis of surgical margins in head and neck squamous cell carcinoma patients.

OBJECTIVES/HYPOTHESIS: Molecular analysis of surgical margins is playing an increasingly important role in establishing surgical margins. Most markers lack the sensitivity and ease of applicability for effective clinical use. To date, the proto-oncogene eIF4E (4E) is elevated in 100% of head and neck squamous cell carcinoma tumors and is of prognostic value in predicting recurrence. In a retrospective study, 4E overexpression in the margins appeared to be a more sensitive predictor of recurrence when compared with p53. The goal was to confirm this finding in a prospective study and also to compare the expression of matrix metalloproteinase-9 (MMP-9) to 4E expression in tumors and margins. Other objectives were to determine which of these markers have prognostic significance in predicting recurrence and elucidate whether there is any additional benefit to analysis of surgical margins with a combination of the three molecular markers. STUDY DESIGN: A prospective study was performed on all patients who consecutively underwent primary surgical resection between 1998 and 1999 for head and neck squamous cell carcinoma. Patient and tumor characteristics were reviewed, and time to recurrence was noted. METHODS: Paraffin-embedded sections of tumors and all histologically tumor-free margins were analyzed for the presence or absence of 4E, p53, and MMP-9 with immunohistochemical analysis. Patients were followed according to the institution's head and neck cancer protocol, and time to recurrence was noted. RESULTS: Ninety-eight percent of tumors overexpressed 4E, 65% overexpressed p53, and 92% overexpressed MMP-9. Of the 52 patients with tumor-free margins, 52%, 46%, and 54% had positive margins for 4E, p53, and MMP-9, respectively. Although no significant correlation between 4E and p53 expression was seen in the margins (P =.16), a significant correlation between 4E and MMP-9 expression was noted (P =.0002). However, when expression of 4E and p53 in the margins of only the patients who overexpressed p53 in the tumors was compared (n = 34), there was a significant correlation (P =.04). There was also a significant difference in the disease-free interval between patients with 4E-positive and 4E-negative margins (P =.003). This difference in time to recurrence was not significant for the p53-positive versus the p53-negative group (P =.18) but approached significance when MMP-9 was used as a marker (P =.07). Although the univariate analysis showed that stage, nodal disease, grade, and 4E expression in the margins were significantly associated with disease-free interval, in the Cox multiple regression analysis, only 4E expression in the margin was significantly associated with disease-free interval (P =.01). CONCLUSIONS: The era for molecular analysis of surgical margins is here. Although a significant correlation was seen between 4E and MMP-9, overexpression of 4E appears to be a significant predictor of recurrence when compared with the well-studied tumor suppressor gene p53 and a relatively novel marker, MMP-9.

Management of the keel nose and associated valve collapse.

OBJECTIVES: To analyze the anatomical abnormality of the keel nose and correlate the findings with etiologic maneuvers of a routine rhinoplasty procedure; to identify the contributing factors and offer suggestions to avoid or decrease the severity of these surgical complications; and to present an effective revisional procedure to correct the functional and cosmetic consequences of this deformity. PATIENTS AND METHODS: A total of 47 patients (31 women and 16 men; age range, 18-71 years) with a keel-appearing nose presented for revision rhinoplasty. All had undergone at least 1 rhinoplasty procedure, and 39 had undergone 2 or more previous nasal procedures. All patients had bilateral lateral nasal wall collapse and an associated severely compromised internal nasal valve. All patients underwent reconstruction with a conchal cartilage overlay graft. RESULTS: All patients had a moderate to excellent cosmetic improvement; the subjective improvement in nasal airway was more dramatic. Since patients with a keel nose have an associated internal valve collapse, both abnormalities are addressed simultaneously with the conchal cartilage overlay repair, which results in minimal morbidity with no major complications. CONCLUSIONS: Conchal cartilage overlay repair uses a cartilage graft from the auricle with a recommended external rhinoplasty for placement. Appropriate sizing and fashioning precede the precise placement and suture fixation. This technique addresses both functional and cosmetic abnormalities.

Salvage treatment of recurrent skin cancer of the midface.

Nine patients with recurrent cutaneous cancers of the midface were treated by definitive surgery (with adjuvant radiotherapy in five individuals). The clinical courses were marked by local and regional relapses in six cases. Although the prognosis may be generally poor, aggressive therapy, as feasible, seems warranted in these patients because death was not typically rapid after reappearance of disease in several patients.

Expression of the proto-oncogene eIF4E in inflammation of the oral cavity.

OBJECTIVE: eIF4E (4E) is elevated in 100% of head and neck squamous cell carcinoma (HNSCC) and in premalignant lesions of the larynx. However, it is not elevated in normal mucosa. In this study, we hypothesize that 4E is not significantly elevated in inflammation unlike its expression in premalignant lesions of the oral cavity. STUDY DESIGN: Biopsies from the oral cavity were divided into 5 groups: (1) normal mucosa, (2) chronic inflammation, (3) mild dysplasia from leukoplakic lesions, (4) mild dysplasia in surgical margins of patients with HNSCC, and (5) HNSCC. Immunohistochemical qualitative analysis was then performed. RESULTS: None of the 15 specimens in group 1 and 100% of the 15 specimens in group 5 expressed 4E. Of the 29 specimens in group 2 only 4/29 (13%) overexpressed 4E compared with 10/31 (32%) in group 3 and 9/21 (42%) in group 4. There was a significant difference between groups 2 and 3 and groups 2 and 4 (P < 0.0001 and P < 0.003 respectively) but no significant difference between groups 1 and 2 (P = 0.13) and between groups 3 and 4 (P = 0.30). CONCLUSION: 4E is not significantly elevated in inflammation of the oral cavity thus fulfilling one of the criteria that biomarkers require to be useful in a clinical setting.

Induction chemotherapy followed by concomitant chemoradiation-induced regression of advanced cervical lymphadenopathy in head and neck cancer as a predictor of outcome.

OBJECTIVE: We sought to determine whether induction chemotherapy followed by concomitant chemoradiation (ICCR)-induced advanced neck disease regression could predict outcome, especially the need for complete neck dissection in patients with N2-3 stage IV head and neck cancer (HNC). METHODS: A retrospective study of 339 patients evaluated for treatment of stage IV HNC during the years 1988 to 1997 revealed 36 individuals with N2-3 cervical lymphadenopathy who were treated with ICCR. Responses to treatment, patterns of failure, and survival rates were analyzed. RESULTS: Primary and regional tumor regressions were complete in 21 patients (58%), partial in 9 (25%), and absent in 6 (17%); the corresponding local failure rates were 5%, 44%, and 33% (P < 0.02). The regional failure rates were 24%, 89%, and 83%, respectively (P < 0.001); distant failure rates were 10%, 0%, and 0% (P > 0.99). The estimated 2-year survival rates for complete and partial/nonresponders were 57% and 20%, respectively (P < 0.02). CONCLUSION: Patients with advanced regional metastases of HNC who respond completely to ICCR have an excellent chance for survival. However, such ICCR-induced complete regression of regional tumor cannot reliably predict ultimate neck disease control.

Subdermal carbon dioxide laser cutaneous contraction.

BACKGROUND: Conventional carbon dioxide (CO(2)) skin laser resurfacing reverses the effects of photoaging. A recent clinical series reported the efficacy of performing subdermal CO(2)resurfacing to obtain the same skin contracture as epidermal skin resurfacing. OBJECTIVE: To assess surface area contraction that occurs with subdermal CO(2) laser resurfacing in the rat model. DESIGN: A nonrandomized control study was performed using 32 rats. The 3 test groups were divided by CO(2) laser strength (5 vs 7 W) and the pattern of resurfacing (cross-hatched vs parallel lines). MATERIALS AND METHODS: The rats underwent subdermal continuous 2-mm defocused CO(2)beam treatment of the right-sided experimental flap. The left subdermal flap acted as a control. In the first group (n = 12), a subdermal cross-hatching of the subdermal flap was performed with 7 W. The second group (n = 10) was resurfaced in a parallel fashion with 7 W. The third group (n = 10) was resurfaced in a parallel fashion with 5 W. Measurements of skin area were taken immediately after laser resurfacing and 3 weeks after the treatment. RESULTS: None of the treatment arms showed a change in skin surface area immediately or 3 weeks after treatment. In the first treatment group, all of the treated flaps showed an entire full-thickness slough. Of the controls, 75% showed minimal sloughing. The second and third experimental groups showed a 100% slough of the flaps. Of the 20 control flaps in the second and third groups, only 1 had a partial slough. CONCLUSIONS: In this animal model, subdermal CO(2) laser resurfacing showed a 100% rate of skin sloughing. No change in skin surface area was evident immediately or 3 weeks after treatment.

Aggressive fibromatosis of the parapharyngeal space: two cases and treatment recommendations.

Aggressive fibromatosis is an uncommon tumor that is locally aggressive but not malignant. Therefore, its classification falls between the benign and malignant neoplasms of soft-tissue origin. In the past, these lesions were misdiagnosed as low-grade fibrosarcomas. Otolaryngologists should be familiar with these lesions because as many as 15% of them occur in the head and neck. The treatment of choice is wide surgical excision, which is often difficult. Postexcision recurrence rates are high. Nonsurgical treatment includes radiation and chemotherapy, both of which are usually reserved for recurrences. We describe two cases of aggressive fibromatosis of the parapharyngeal space, and we review the available treatment options.

African American rhinoplasty.

Rhinoplasty in patients of African descent requires a patient-specific approach, because the goals and ideal proportions differ from the white nose. This article discusses approaches to surgical correction of common anatomic variations. In addition, common pitfalls are outlined.

Rhinoplasty from the Goldman/Cottle schools to the present: a survey of 7447 personal cases.

BACKGROUND: To review the personal experience of a single surgeon over a 31 year period. METHOD: A retrospective analysis of 7447 rhinoplasties performed by a single surgeon from 1969 to 2000. Ninety-five surgeries performed at educational courses were excluded from this series. RESULTS: During the many years of performing rhinoplasties, cartilage splitting, delivery, and external approach are among the most common techniques. In the first decade, 62% were cartilage splitting, 33% delivery, and 3% externaL In the second decade, 13% were cartilage splitting, 58% delivery, and 26% external. In the third decade, 11% were cartilage splitting, 52% delivery, and 36% external. CONCLUSION: Over a three-decade period, the techniques of the author have been influenced by national trends, training, and patient outcomes.