The pectoralis myocutaneous flap for salvage of necrotic wounds.

The authors have utilized six pectoralis major myocutaneous flaps in attempts to salvage extensive necrotic wounds of the pharynx and neck. The flap was employed in the following situations: massive necrosis of the entire neck skin with both carotid artery systems exposed, radiation necrosis of the neck skin with exposure of carotid artery, dehiscence of gastric pull-up from pharynx with resultant carotid exposure, failed trapezius flap in a radionecrotic oral cavity, and two cases of pharyngocutaneous fistula with extensive soft tissue necrosis. These flaps achieved healing in all cases. One death occurred 3 weeks following complete cutaneous healing secondary to a ruptured carotid pseudoaneurysm. One flap underwent total skin loss but the entirety of the muscle survived and the fistula was successfully closed with the back of the muscle being subsequently skin grafted. One case of dehiscence of the flap from oral mucosa resulted in a minor exposure of mandible with limited osteoradionecrosis controlled by topical means. This flap has performed extremely well in these precarious and difficult situations that previously may not have been salvageable. It has also been effective in abbreviating the required hospitalization and wound care. We conclude that the pectoralis myocutaneous flap should be the primary choice for the management of extensive postsurgical wound necrosis.

Pseudomonas aeruginosa in chronic maxillary sinusitis.

Pseudomonas aeruginosa (Ps. Au.) infection of the maxillary sinus has been reported as an incidental finding on routine antrostomy; however, it has also been noted in several studies as the significant organism in the etiology of chronic sinusitis. Four case reports of culture verified Ps. Au. maxillary sinusitis are presented. The therapeutic modality used in two of the cases was a Caldwell-Luc operation and in two, an intranasal antrostomy. In all cases, multiple irrigations through the surgically created nasoantral windows were done postoperatively, as was the instillation of gentamicin ophthalmic drops intranasally. In all four cases the infection cleared with this combined surgical and medical therapy.

Early complications of airway management in head-injured patients.

Head-injured patients are frequently young, healthy individuals whose excellent medical condition is suddenly altered by trauma. The purpose of this study is to evaluate the early complications of airway management which occur in head-injured patients and to determine if these are different from what has been reported in patients with chronic illnesses (i.e., diabetes, atherosclerosis, or immunosuppression). Chart review of 52 head-injured patients reveals an early complication rate of 61% for endotracheal intubation and 20% for tracheotomy. Discriminant analysis shows that increasing duration of intubation is the most significant factor in predicting airway management complications (P less than 0.008). The incidence of complications seen in head-injured patients is similar to that of the chronically ill. Complications of endotracheal intubation are judged to be more severe than those of tracheotomy. Data from this study supports the early tracheotomy of severely head-injured patients who are likely to require prolonged airway management.

Starplasty: a new technique of pediatric tracheotomy.

OBJECTIVE: To report a new technique of pediatric tracheotomy that reduces the problems of pneumothorax and recannulation after accidental decannulation in a recently performed tracheotomy. DESIGN: Retrospective chart review for 1990-1997. PATIENTS: Sixty-eight children aged between 2 days and 14 years. METHOD: The starplasty procedure is based on the geometry of a 3-dimensional Z-plasty. The technique of the procedure is described and illustrated in detail. RESULTS: There were 27 short-term complications, including 4 accidental decannulations. There were no instances of pneumothorax or tracheotomy-related deaths. There were 25 long-term minor complications. There were no instances of tracheotomy-related death, suprastomal collapse, or tracheal stenosis. Thirty-eight children remain tracheotomy tube dependent, 17 underwent decannulation, 7 died of primary disease, and 6 were lost to follow-up. All 17 children who underwent decannulation have a persistent tracheocutaneous fistula. CONCLUSIONS: I conclude that starplasty reduces the incidence of major complications and death. Its only drawback seems to be persistent tracheocutaneous fistula.

Treatment of experimental frostbite with pentoxifylline and aloe vera cream.

OBJECTIVE: To compare the therapeutic effects of systemic pentoxifylline and topical aloe vera cream in the treatment of frostbite. DESIGN: The frostbitten ears of 10 New Zealand white rabbits were assigned to one of four treatment groups: untreated controls, those treated with aloe vera cream, those treated with pentoxifylline, and those treated with aloe vera cream and pentoxifylline. MAIN OUTCOME MEASURES: Tissue survival was calculated as the percent of total frostbite area that remained after 2 weeks. RESULTS: The control group had a 6% tissue survival. Tissue survival was notably improved with pentoxifylline (20%), better with aloe vera cream (24%), and the best with the combination therapy (30%). CONCLUSION: Pentoxifylline is as effective as aloe vera cream in improving tissue survival after frostbite injury.

The external rhinoplasty approach for rhinologic surgery in children.

The external rhinoplasty is a versatile approach for exposing nasal anatomy in children and has been utilized for a variety of rhinologic problems (N = 35). These have included septal deviation (11), cleft lip nasal deformity (10), unilateral choanal atresia (five), nasal dermoids (four), and problems of the sphenoidal sinus (five). For children with septal deformities, the external approach allows complete intranasal visualization, providing access for careful and conservative reconstruction. In children with cleft lip nasal deformity, decortication allows for direct sculpting of the alar cartilages. For unilateral choanal atresia, the external technique provides exposure of the posterior vomer as in the transpalatal approach, but without the risk to palatal growth. For nasal dermoids, the open rhinoplasty offers wider exposure with more control over the medial osteotomies, a better view of the cribriform plate, and enhanced cosmesis. For problems of the sphenoid, the external route utilizes the guiding midline intranasal structures for rapid and direct entry into the sinus. In our study, the age range of the children was between 7 months and 18 years. The range of follow-up was between 6 months and 5 years. The techniques for the individual procedures are described, along with a rationale for their employment. There were no postoperative complications, and no long-term problems associated with the use of the external technique. In conclusion, the enhanced exposure provided by the external rhinoplasty approach in children facilitates rhinologic procedures on the soft tissues of the nose and the nasal architecture, as well as in the central core of the face.

Endoscopic repair of supraglottic laryngeal clefts.

We describe the technique of endoscopic diagnosis and endoscopic surgical repair used in the management of supraglottic interarytenoid laryngeal clefts in 11 children seen between 1981 and 1988 at the Hospital for Sick Children, London, England. Six of the children had primary type I clefts that required endoscopic repair. The symptoms included inspiratory stridor, choking during eating, and aspiration. Five of the children had previous transcervical repair of type II clefts that had partial breakdown in the interarytenoid area causing symptoms of aspiration, which required secondary repair endoscopically. All the patients had successful microlaryngoscopic closure; in two children, however, the breakdown of the repair necessitated repeated endoscopic correction. The only complication occurred in a case of postoperative supraglottitis, which was successfully managed with intubation and antibiotics. We conclude that endoscopic repair is a useful and reliable technique and an elegant alternative to the open transcervical approach for the closure of supraglottic laryngeal clefts.

Comparison of power-assisted adenoidectomy vs adenoid curette adenoidectomy.

OBJECTIVE: To compare the safety and efficacy of power-assisted adenoidectomy (PAA) vs adenoid curette adenoidectomy (ACA). DESIGN: A prospective randomized study. SETTING: Children's hospital of a tertiary care medical center. PATIENTS: Ninety patients (aged 1-13 years) underwent PAA, and 87 patients (aged 1-12 years) underwent ACA. MAIN OUTCOME MEASURES: The parameters evaluated were operative time, blood loss, completeness and depth of resection, injuries to surrounding structures, short- and long-term complications, surgeon satisfaction with the procedure, and parents' assessment of the patient's postoperative recovery period. RESULTS: The PAA was 20% faster (P<.001) and had 27% less blood loss (P<.001) than the ACA. It provided a more complete resection(P<.001) and better control of the depth of resection (P<.05). Surgeon satisfaction was greater with PAA (P<.001). There was no difference in the recovery period or parent satisfaction. One patient in the PAA group returned to the operating room for control of postoperative bleeding, and 1 child in the ACA group returned to the hospital for postoperative dehydration. CONCLUSION: The PAA provides a faster, dryer, more complete, and more surgically satisfying resection than the ACA.

Bacterial antigens and neutrophil granule proteins in middle ear effusions.

Otitis media with effusion is a significant cause of hearing loss in young children. We hypothesized that persistent bacterial antigens in middle ear effusions (MEEs) might act as chronic inflammatory stimuli causing release of neutrophil proteins. Concentrations of neutrophil lactoferrin and a 37-kd cationic bactericidal protein (CAP 37) were measured in 47 MEEs collected from 27 children at the time of tympanostomy tube placement. Antigens of Streptococcus pneumoniae were detected by latex particle agglutination and those of Haemophilus influenzae by dot-blot assay. Bacterial antigens were detectable in 24 (51%) of MEEs: S pneumoniae in 10 (21%), H influenzae in 12 (26%), and both antigens in 2 (4%). Concentrations of lactoferrin and CAP 37 in H influenzae antigen-positive MEEs were significantly higher than in either S pneumoniae antigen-positive or antigen-negative MEEs. We conclude that H influenzae antigen causes a greater middle-ear inflammatory response, as judged by neutrophil products, than does S pneumoniae antigen.

Power-assisted adenoidectomy.

OBJECTIVE: To quantify that the use of powered instrumentation for adenoidectomy is an improvement over traditional techniques. DESIGN: Retrospective case series of 40 consecutive children undergoing power-assisted adenoidectomy compared with 40 consecutive children undergoing conventional transoral adenoidectomy with a curet. SETTINGS: Tertiary care center. MAIN OUTCOME MEASURES: Operative time, blood loss, length of hospitalization, and complications. RESULTS: With power-assisted adenoidectomy, the mean operative time was significantly faster (11 minutes vs 19 minutes for the conventional method), mean blood loss was not significantly different (22 mL vs 32 mL for the conventional method), mean length of hospitalization after the procedure was not significantly different (2.95 hours vs 2.8 hours for the conventional method), and there were no surgical complications with either technique. CONCLUSION: In comparison with conventional techniques, power-assisted adenoidectomy provides significant advantages that are subjectively apparent but can also be objectively measured.

Orbital fractures in children.

OBJECTIVE: To determine if the pattern of orbital fractures may be influenced by the changing craniofacial ratio of the growing child, as the orbit is the boundary between the face and the cranium. DESIGN: Retrospective case series of 40 patients between the ages of 1 year and 16 years with orbital fractures. SETTING: The Albany (NY) Medical Center Hospital, a tertiary level 1 trauma center. OUTCOME MEASURES: The sex, age, site, and mechanism of injury, associated injury, and treatment methods for children admitted to the Albany Medical Center Hospital with orbital fractures between July 1986 and June 1992. RESULTS: Fourteen children had fractures of the orbital roof, 10 children had fractures of the orbital floor, 14 children had mixed fractures, and two children had fractures of the medial wall. The mean age (4.8 +/- 3.3 years) of the 14 patients with roof fractures was significantly less than the mean age (12.0 +/- 4.2 years) of the 26 children with other orbital fractures. Logistic regression demonstrated that the age at which the probability of lower orbital fractures exceeds the probability of orbital roof fractures is 7.1 +/- 1.0 years. Orbital roof fractures had a significantly greater likelihood of associated neurocranial injuries. The need for surgical repair was significantly lower among children with roof fractures as well as among children 7 years of age and younger. CONCLUSIONS: Orbital roof fractures are a type of skull fracture that occur primarily in younger children as a consequence of the proportionally larger cranium and the lack of frontal sinus pneumatization. Lower orbital fractures are a type of facial fracture that occur primarily in older children as a consequence of the increased vulnerability of the face due to growth and the pneumatization of the paranasal sinuses.

Evaluation of orbital stress dissipation in pediatric and adult skulls using electronic speckle pattern interferometry.

OBJECTIVES: To measure and quantitatively compare the degree of force dissipation in pediatric and adult skulls subjected to similar dynamic forces. DESIGN: An anatomical study using electronic speckle pattern interferometry, which allows generation of displacement vectors after application of a force. SUBJECTS: Five human skulls (3 pediatric and 2 adult). INTERVENTION: Each skull was subjected to a reproducible and quantifiable force created by a steel ball pendulum striking a precise periorbital focus: (1) infraorbital foramen, (2) supraorbital notch, (3) malar eminence, and (4) nasofrontal suture. Electronic speckle pattern interferometry was used to construct interferogram fringe patterns to determine skull regions with the greatest degree of displacement. RESULTS: Interferogram analysis revealed that the adult skull has a tendency to dissipate force with minimal resultant displacement. In contrast, the pediatric skulls demonstrated greater displacements (ie, increased fringe density) at the same periorbital foci. CONCLUSIONS: The pediatric skull dissipates periorbital stress differently than the adult skull, as illustrated by quantitative interferogram analysis. This finding parallels clinical data that demonstrate a varying pattern of fractures in pediatric and adult skulls related to craniofacial development.

Comparison of computed tomography and magnetic resonance imaging in chronic otitis media with cholesteatoma.

We prospectively studied 10 patients with chronic otitis media suspected of having cholesteatoma with computed tomography and magnetic resonance imaging to assess which imaging modality would be most specific in predicting the presence of cholesteatoma. The interpretation of images was then correlated with the operative findings. In 9 of the 10 cases, computed tomography accurately predicted the extent and destructiveness of the disease but did not consistently differentiate between cholesteatoma and associated granulation tissue. In 2 of the 10 cases, the T1-weighted magnetic resonance imaging demonstrated high signal, suggestive of cholesteatoma. In one case, magnetic resonance imaging predicted cholesteatoma on the basis of bony destruction. However, in 7 of 10 cases the scan was nonspecific for cholesteatoma. We conclude that high-resolution computed tomography remains the primary imaging modality for chronic otitis media.

p53 protein expression in benign lesions of the upper respiratory tract.

OBJECTIVE: p53 is a tumor suppressor gene that is lost or mutated in most forms of human malignancy. There are, however, very few studies evaluating p53 expression in normal epithelium or benign lesions. DESIGN: We screened for p53 protein expression in a variety of benign epithelial lesions of upper respiratory tract using monoclonal antibody DO-1 on paraffin-embedded material. SUBJECTS: We studied a total of 109 cases: 16 cases of juvenile and 36 cases of adult laryngeal papillomatosis, 10 cases each of laryngeal nodules and laryngeal polyps, 17 cases of inverted papilloma, and 20 cases of nasal polyps. RESULTS: Nuclear immunoreactivity for p53 protein was demonstrated in 14 (88%) of 16 cases of juvenile laryngeal papillomatosis, 33 (92%) of 36 cases of adult laryngeal papillomatosis, 4 (40%) of 10 cases of laryngeal nodules, 8 (80%) of 10 cases of laryngeal polyps, 7 (41%) of 17 cases of inverted papilloma, and 2 (10%) of 20 cases of nasal polyps. These results pertained only to the basal epithelial layer in all cases of laryngeal nodules, laryngeal polyps, and nasal polyps. Intermediate layer cells were also positive for p53 in the majority of the cases of both juvenile (69%) and adult (75%) laryngeal papillomatosis and in a minority of the cases of inverted papilloma (18%). CONCLUSIONS: Overexpression of p53 protein is commonly demonstrable in benign epithelial lesions of the upper respiratory tract. This observation suggests that p53 protein accumulation may occur in the absence of mutation of the p53 gene and may correlate with epithelial proliferative activity.

First branchial cleft anomalies: a study of 39 cases and a review of the literature.

OBJECTIVES: To identify the clinical and anatomical presentations and to discuss the guidelines for surgical management of anomalies of the first branchial cleft. DESIGN: Retrospective study. SETTING: Three tertiary care centers. PATIENTS: Thirty-nine patients with first branchial cleft anomalies operated on between 1980 and 1996. INTERVENTION: All patients were treated surgically. Complete removal of the lesion required superficial parotidectomy with facial nerve dissection in 36 cases. The relationship of the facial nerve and anomalies is discussed. RESULTS: Anatomically, 3 types of first branchial cleft anomalies are identified: fistulas (n=11), sinuses (n=20), and cysts (n=8). Clinically, 3 types of presentation are noted: chronic purulent drainage from the ear (n=12), periauricular swelling in the parotid area (n=18), and abscess or persistent fistula in the neck located above a horizontal plane passing through the hyoid bone (n=21). A membranous attachment between the floor of the external auditory canal and the tympanic membrane was observed in 10% of cases. The facial nerve was located lateral to the anomaly in 39% of cases. CONCLUSIONS: Before definitive surgery, many patients (n=17) underwent incision and drainage for infection owing to the difficulties in diagnosing this anomaly. Wide exposure is necessary in most cases, and a standard parotidectomy incision allows adequate exposure of the anomaly and preservation of the facial nerve. Complete removal without complications depends on a good understanding of regional embryogenesis, a knowledge of the circumstances surrounding discovery, an awareness of the different anatomical presentations, and a readiness to identify and protect the facial nerve during resection.

The impact of airbags and seat belts on the incidence and severity of maxillofacial injuries in automobile accidents in New York State.

OBJECTIVE: To evaluate the effect driver-side and passenger-side airbags have had on the incidence and severity of maxillofacial trauma in victims of automobile accidents. DESIGN: Retrospective analysis of all automobile (passenger cars and light trucks) accidents reported in 1994. SETTING: New York State. PATIENTS: Of the 595910 individuals involved in motor vehicle accidents in New York in 1994, 377054 individuals were initially selected from accidents involving cars and light trucks. Of this subset, 164238 drivers and 62755 right front passengers were selected for analysis. MAIN OUTCOME MEASURES: Each case is described in a single record with approximately 100 variables describing the accident, eg, vehicle, safety equipment installed and utilized or deployed, occupant position, patient demographics, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses, and procedural treatments rendered. A maxillofacial trauma severity scale was devised, based on the ICD-9-CM diagnoses. RESULTS: Individuals using airbags and seat belts sustained facial injuries at a rate of 1 in 449, compared with a rate of 1 in 40 for individuals who did not use seat belts or airbags (P<.001). Those using airbags alone sustained facial injuries at the intermediate rate of 1 in 148, and victims using seat belts without airbags demonstrated an injury rate of 1 in 217 (P<.001). CONCLUSION: Use of driver-side airbags, when combined with use of seat belts, has resulted in a decrease in the incidence and severity of maxillofacial trauma.

Noninvasive imaging of the normal temporal bone. Comparison of sagittal surface coil magnetic imaging and high-resolution computed tomography.

High-resolution computed tomography (HRCT) is a noninvasive technique for evaluating the middle ear for primary and recurrent cholesteatoma. However, a limitation of HRCT is that it cannot differentiate between cholesteatoma and granulation tissue. Magnetic resonance imaging (MRI) is a noninvasive, nonradiologic technique that has been effective in demonstrating histochemical differences between various soft tissues. We present images from a normal living subject's temporal bone in the sagittal plane obtained with both HRCT and MRI. Anatomic correlates in the same cut planes are presented. The HRCT provided excellent detail of the bony landmarks within the temporal bone and was used as the reference for the MRI. The soft-tissue structures such as cranial nerves, cochlea, vestibule, and semicircular canals were identified.

Management of facial trauma in children.

In today's fast-paced society, many children sustain severe maxillofacial injuries that require surgical reconstruction. The factor that differentiates the treatment of pediatric facial fractures from those of adults is facial growth. Anticipation of mandibular growth facilitates repair because most injuries can be treated with intermaxillary fixation. Midfacial injuries, on the other hand, may be more sensitive to alterations of facial growth, and complex cases require more sophisticated correction. The techniques of three-dimensional reconstruction of complex facial fractures has been facilitated greatly by the use of a rigid plating system, wide craniofacial exposure, and bone grafting. These techniques have sound theoretic and practical applications in severe pediatric facial trauma.

Familial occurrence of acinic cell carcinoma of the parotid gland.

We report the familial occurrence of acinic cell carcinoma involving the parotid gland, the first such report of which we are aware. The familial occurrence of any salivary gland neoplasm is rare. Several reports are present in the literature, including pleomorphic adenoma, Warthin tumor, carcinoma of the submandibular gland, and malignant lymphoepithelial lesion. We report the case of a 35-year-old man who underwent excision of a left parotid gland acinic cell carcinoma. Eight years later, his daughter presented at the age of 16 years with a nontender parotid gland mass that was excised and found also to be acinic cell carcinoma. The histologic features of both neoplasms were typical of acinic cell carcinoma. While this may represent a coincidental event, the possibility that this familial occurrence is a manifestation of common genetic or environmental risk cannot be excluded.

Effects of air pollution on the upper respiratory tract of children.

The impact of the environment on the upper respiratory tract of children has become an issue of recent interest. Sulfur dioxide causes nasal congestion in children as well as an increase in both mast cells and lymphocytes in nasal lavage fluids. Chlorpheniramine blocks the effect of sulfur dioxide on the nasal mucosa. Ozone exposure results in nasal congestion, increased levels of histamine, neutrophils, eosinophils, and mononuclear cells in nasal lavage fluid. No data are available on the effects of nitrogen dioxide or wood-burning stoves on the upper respiratory tracts of children. Formaldehyde in sufficient concentrations causes upper airway irritation; however, no data are available on its long-term effects. Detriments in air quality cause adverse changes in the lower respiratory tracts of susceptible individuals. The effects on the upper respiratory tract are more difficult to document. There may be a causal relationship, but definitive proof of whether air pollution results in significant increases in pediatric otitis media, sinusitis, rhinitis, and pharyngitis has yet to be demonstrated.