Reinnervation of skeletal muscle with a neuromuscular pedicle.

In the past decade the otolaryngologist has become interested in the problem of muscle reinnervation as it relates to laryngeal and facial paralysis. Although reinnervation by neuromuscular pedicle transfer has shown promising results in the laboratory and clinic, some investigators have had difficulty in achieving reliable results with this procedure. To further assess the technique's validity, we investigated the neuromuscular pedicle. This study utilized a strap muscle neuromuscular pedicle transfer to a contralateral strap muscle in the rabbit. The results were analyzed by the use of a number of independent measures, including electrical stimulation of the nerve, muscle contractibility, electromyography, enzyme histochemistry, reduced-silver staining for normal fibers, and the retrograde transport of the enzyme marker horseradish peroxidase. The physiologic and anatomic results demonstrated that morphologic and functional reinnervation of the experimentally isolated muscle by the transferred neuromuscular pedicle occurred. The most convincing data were produced by gross electrical stimulation, twitch and tetanic contraction, and horseradish peroxidase labeling. Electromyographic activity and other histologic findings supported the above conclusions.

Prognostication of myocutaneous flap viability using laser Doppler velocimetry and fluorescein microfluorometry.

Formerly, flap perfusion was assessed clinically by gross evaluation of the amount of fluorescein in the developed flap prior to transfer. Recently the laser Doppler velocimeter and the perfusion microfluorometer have been developed as aids in perfusion assessment. We have used each instrument in a series of reconstructive procedures employing pectoralis or trapezius myocutaneous flaps and a series of pig groin myocutaneous flaps to assess the contribution of each to the prognostication of flap viability. While the laser Doppler does provide useful information, we have found that the microfluorometer is more selective in representing the hemodynamics of the developed flap.

The cheek-neck rotation flap for closure of temporozygomatic-cheek wounds.

The head and neck surgeon is often consulted for evaluation and treatment of traumatic or neoplastic lesions of the lateral aspect of the face. Large malignant cutaneous lesions may require excision with wide margins, often parotidectomy, and possibly neck dissection. Traumatic lesions may involve notable soft-tissue loss, and parotid, facial nerve, or mandibular injury. Management of such planned or unplanned wounds challenges the surgeon due to the magnitude of the soft-tissue defect, cosmetic and functional considerations, and the need for soft-tissue protection and nourishment of repaired structures. Primary reconstruction with a large cheek-neck rotation flap provides the advantages of reliability, simplicity, excellent exposure, vital-structure protection, superior aesthetic results, and eliminates the need for a second operative site to harvest skin grafts or distant flaps. Four illustrative cases are reported, with a discussion to address parotid metastases from carcinoma of the lateral aspect of the face and initial treatment of shotgun injuries to the face.

Treatment of the clinically negative neck in floor of the mouth carcinoma.

A retrospective study of 61 consecutive patients with floor of mouth carcinoma and a clinically negative neck was done to determine the value of elective treatment to the neck. Subsequent histologically proven nodal disease was analyzed according to initial treatment modality (23 surgical, 38 irradiation), stage (29--T1,27--T2,5--T3), hemi-neck at risk (midline lesions placed both hemi-necks at risk), and primary control for a minimum of 2 years (50 patients, 78 hemi-necks at risk). Neck failures were classified by T stage, extent of neck treatment (upper neck or complete) and by primary control at the time of manifest neck metastasis. Of the hemi-necks at risk with the primary controlled, 10% (17% of patients) developed nodal disease without complete neck treatment; 86% (6/7) of these patients were salvaged. The occult positive node incidence, conservatively calculated by elimination of all patients treated with elective partial or total neck irradiation, was 10% for patients with T1 and T2 lesions (7% for hemi-necks at risk). Based on the clinical course of patients with primary control, only 1 patient (2%) might have benefited from initial complete elective neck treatment. These results suggest that elective neck treatment in early (T1 and T2, N0) floor of mouth carcinoma is of doubtful value. Supraomohyoid , rather than suprahyoid dissection, is recommended if surgical treatment of the neck is undertaken.

Facial squamous carcinoma with parotid metastasis--closure with cheek-neck rotation.

Because squamous carcinoma of the face is usually recognized and treated early, regional metastasis occurs infrequently. However, due to neglect or initial treatment failure, aggressive lesions of the temporal-zygomatic area may metastasize to parotid nodes. These tumors are most effectively treated with en bloc primary excision and regional node dissection, which includes superficial parotidectomy with or without neck dissection. Closure of such large defects presents a technical challenge and often skin grafts are utilized. This report deals with our experience with a large lateral facial squamous carcinoma with parotid metastasis. Surgical options and a method of primary closure with cheek-neck rotation flap are discussed. Controversy exists regarding elective neck dissection and/or postoperative irradiation. Postoperative irradiation is advised for pathological evidence of perineural invasion, multiple positive nodes, extranodal spread, or questionable margins.

Mycotic aneurysm of the internal carotid artery. A surgical emergency.

A 17-year-old man presented with signs of rupture of a high cervical internal carotid aneurysm. Following angiographic demonstration of the aneurysm, he was immediately treated by balloon catheter occlusion. Eight days later the ligation of the supraclinoid portion of the internal carotid on the left was prompted by the formation of blood clots and emboli from this segment. The patient tolerated both procedures well.

Facial keratoacanthoma.

The keratoacanthoma is a common tumor of hair follicle origin that appears predominantly on sun-exposed skin of elderly persons. Approximately 80% of the tumors arise on the face. It is characterized by the rapid growth of a painless, dome-shaped, 10 to 25 mm solitary lesion with a central keratinous plug that undergoes spontaneous involution over 6 to 12 months, leaving behind a puckered scar. Alarming growth and early histologic appearance (pseudocarcinomatous infiltration, cell atypicality, mitoses) are suggestive of squamous cell carcinoma, but biologic behavior and tumor architecture confirm its benign nature. However, evidence that all keratoacanthomas regress is lacking, malignant transformation has been reported, and less than excisional biopsy may render a difficult histologic diagnosis either inconclusive or erroneous, even in expert hands. Excisional biopsy is recommended as expedient and definitive management that offers optimal prognosis. Local flap or full-thickness graft closure affords cosmetic results that are superior to those provided by other treatment methods.

Ludwig's angina: an update.

Despite a reduction in preantibiotic mortality rates that exceeded 50%, Ludwig's angina remains a potentially lethal entity primarily because of rapidly progressive airway obstruction. Since the reports of several large series in the 1940's, there have been put sporadic case reports because of widespread use of antibiotics in orodental infection, improved dental care, as well as adherence to strict diagnostic criteria. Since this entity is now uncommon, unnecessary delay in diagnosis and management may occur and may result in serious complications. This presentation will consist of an historical review, discussion of pathogenesis followed by clinical presentation, bacteriology and treatment, as well as a detailed analysis of our most recent 20 cases. There were no complications and no deaths. The infection resolved with medical therapy in 11 patients, while 9 patients required surgical procedures. Penicillin, clindamycin or chloramphenicol were started initially in all cases. Four of these 9 patients developed a localized abscess, while on antibiotics, which required drainage. Tracheotomy or intubation was necessary in 7 patients. Early and aggressive use of appropriate antibiotics and protection of the airway are the mainstays of a successful treatment regimen. Judicious surgical intervention is indicated in those patients who develop localized abscesses while on antibiotics or are unresponsive to medical management.

Intraoral insertion of grafts to project the nasal tip.

Certain tip-projecting techniques require insertion of grafts and/or implants into the premaxillary region. These grafts may extend anteriorly into the columella or may have to reach all the way to the tip to exert the projecting forces exactly where the surgeon wishes to have them applied. The most direct technique for insertion of these long grafts is one of the columella-splitting maneuvers, but some patients will not accept the external scarline necessitated. An intraoral approach can be used in these patients or in any others in whom the surgeon wishes to have no external scar. It allows good exposure, easy insertion of the grafts and/or implants, and secure closure for stabilization and fixation of the grafts.

Hamartoma of the hypopharynx.

Hamartomas of the hypopharynx are rare. Detailed microscopic study is necessary to differentiate these tumors from the adult-type rhabdomyoma, pleomorphic rhabdomyosarcoma, and granular cell tumor. To our knowledge, our case of a hypopharyngeal rhabdomyomatous hamartoma removed by a lateral pharyngotomy is the only verified hypopharyngeal case in the literature, although a lesion reported by H. W. Smith in 1959 as a laryngeal rhabdomyoma most probably represents a rhabdomyomatous hamartoma, similar to that of the present case.

Cholecystostomy--an old dog with new tricks.

A large minority of patients having cholecystostomy show cystic duct or common duct stones on postoperative tube cholangiograms. The use of mechanical (Dormia stone basket) and chemical (heparin and sodium cholate) means to remove gallstones via the cholecystostomy fistula reduces the need for additional surgery (ie, cholecystectomy), which is particularly important in poor-risk elderly patients.