Complications of rhytidectomy in an otolaryngology training program.

OBJECTIVES/HYPOTHESIS: Complications of rhytidectomy have been widely reported in the literature. This study examines the incidence of complications after rhytidectomy in the hands of chief residents under appropriate attending supervision in an otolaryngology-head and neck surgery training program. MATERIALS AND METHODS: The charts of 96 consecutive SMAS rhytidectomy patients were retrospectively reviewed. Patients were selected for surgery from a clinic designed exclusively for cosmetic facial surgery patients. This clinic was run by the otolaryngology chief resident and was supervised by an attending staff surgeon. Most patients elected local anesthesia and sedation administered by the surgical team. Submental liposuction was performed followed by SMAS plication rhytidectomy. RESULTS: Follow-up ranged from 1 to 60 months. Complications included expanding hematoma (1%), temporary facial nerve weakness (3%), pretragal/mastoid skin slough (4.2%), permanent ear numbness (1%), hypertrophic scar (3.1%), wound infection (1%), and dissatisfaction with result (4%). There were no cases of permanent facial nerve injury. CONCLUSION: These complication rates compare favorably with reported rates of larger studies over the past 30 years. These data support the conclusion that rhytidectomy can be performed safely by otolaryngology residents with little morbidity and good patient satisfaction.

A new adhesive bonding material for the cementation of implantable devices in otologic surgery.

BACKGROUND: Presently, there are no U.S. Food and Drug Administration (FDA)-approved adhesive bone cements for the surgical fixation of prosthetic materials in the middle ear. A promising new cement, 4-META/MMA-TBB opaque resin, has shown remarkable adhesive properties as a bone cement in vivo. The cement is composed of 4-methacryloyloxyethyl trimellitate anhydride (4-META) and methyl methacrylate (MMA) as monomers and tri-n-butyl borane (TBB) as an initiator. METHODS: An electromagnetic semiimplantable hearing device presently under development was implanted into the middle ear of six cats using 4-META/MMA-TBB resin to cement a titanium-encased magnet to the incus. The animals were subsequently killed (at a mean of 9.6 months) to assess the (temporal bones and specifically the magnet-incus complex in each animal. RESULTS: The titanium-encapsulated magnet was firmly adherent to all incuses without any failure of the cement-bone interface. Histopathologic examination of the implanted temporal bones demonstrated lack of middle ear inflammation. Transmission electron microscopy of the incuses demonstrated a unique "hybrid layer" in the bone-side subsurface of the bone-cement interface that elucidates the mechanism of interfacial adhesion. CONCLUSIONS: Our investigation highlights the special biomechanical properties as well as the biocompatibility of 4-META/ MMA-TBB resin that make it an attractive bone-bonding agent for use in otologic surgery, including its potential usefulness during ossicular reconstruction.

Midfacial degloving for the management of nasal, sinus, and skull-base neoplasms.

The midfacial degloving approach to the midfacial orbital and anterior skull base structures is very versatile. It provides excellent access to a wide range of resections, such as medial maxillectomy, radical maxillectomy with and without orbital exenteration, anterior skull base cranifacial resection, and partial rhinectomy. This technique is useful for removal of benign and malignant lesions. The postoperative complications are rare. Because of absence of external skin incisions the cosmetic results are excellent.

Endolymphatic sac tumors: histopathologic confirmation, clinical characterization, and implication in von Hippel-Lindau disease.

The term "endolymphatic sac tumor" (ELST) was coined to identify the likely origin of aggressive papillary tumors of the temporal bone. To evaluate the validity of this designation, the temporal bone collection at the Massachusetts Eye and Ear Infirmary was accessed in an effort to determine the pathologic relationship between these tumors and the endolymphatic sac. The search resulted in the identification of a de-novo papillary epithelial lesion arising within the confines of the endolymphatic sac in a patient with von Hippel-Lindau (VHL) disease who harbored a large, destructive ELST in the opposite temporal bone. This finding provides the most substantial evidence to date regarding the origin of the ELST and the accuracy of its nomenclature. Seven additional clinical cases of ELST were identified and analyzed in order to define the natural history of these tumors. All patients had a history of sensorineural hearing loss diagnosed an average of 10.6 years prior to tumor discovery. The presence of a polypoid external auditory canal mass, facial paralysis, and evidence of a destructive mass arising on the posterior fossa surface of the temporal bone were common physical and radiographic findings. The management of these patients, as well as those who are probably prone to such tumors (i.e., VHL patients), is discussed.

Biomechanical assessment of a new adhesive bone cement for otologic surgery.

The adhesion of metallic prostheses to bone is a major problem in otologic surgery. Conventional bone cements lack significant adhesive strength, which predisposes the cemented prosthesis to loosening. The advent of surgically implantable hearing devices is one example where an adhesive cement to secure metal to bone would be useful. The biomechanical properties of a new cement, 4-META/MMA-TBB opaque resin, were evaluated in an animal model. The cement is composed of 4-methacryloyloxyethyl trimellitate anhydride (4-META) and methyl methacrylate (MMA) as monomers and tri-n-butyl borane (TBB) as an initiator. Titanium disks were cemented to the tibias of rabbits, which were sacrificed at 0 and 90 days. Tensile and shear bond strengths between bone and metal were tested at both times. The mean baseline tensile and shear bond strengths were 8.92 MPa and 11.96 MPa, respectively. Adhesive failure occurred at the bone-cement interface. The decrease in bond strength at 90 days was minimal. Thus, 4-META/MMA-TBB cement is a promising new metal-to-bone adhesive that may be useful for the surgical fixation of metallic prostheses in otologic surgery.

Parotidectomy: a ten year experience with fine needle aspiration and frozen section biopsy correlation.

During the years 1980 through 1990, 247 patients underwent parotidectomy at our institution for the removal of primary parotid lesions. Charts were reviewed in an effort to document the distribution of pathology in patients undergoing parotidectomy and the histopathology from each case was organized and tallied by virtue of the final specific diagnoses. An additional goal of this study was to evaluate the efficacy of pre-operative fine-needle aspiration biopsy (FNAB) and frozen section pathology in accurately predicting final histopathology. In our series, 86.7% of lesions were found to be benign and 13.3% were malignant in nature. When compared to final pathologic findings, FNAB yielded a diagnostic accuracy rate of 89.3% with a 2.1% false negative rate with regards to pre-operative detection of malignancy. Frozen section biopsy was found to have a diagnostic accuracy of 94.1% and also demonstrated a 2.1% false-negative rate. We believe these studies are indeed complementary to each other, as reflected in the 96.2% diagnostic accuracy achieved with a combination of FNAB and frozen section biopsy information. This report will review the patterns of misdiagnosis for each modality of diagnostic testing and present the parotid histopathology found over a 10-year period.

Chondrosarcoma of the larynx: challenges in diagnosis and management.

Chondrosarcoma is a rare neoplasm of the larynx with approximately 200 cases reported in the literature. The infrequent occurrence of this neoplasm, and its indolent pattern of growth, can result in a delayed or missed diagnosis, thereby jeopardizing the preservation of laryngeal function. Four cases of chondrosarcoma of the larynx are presented demonstrating the challenges in the diagnosis and management of this neoplasm. Conservation surgery remains the mainstay of therapy aiming towards preservation of the framework and function of the larynx. Two innovative reconstructive techniques are presented which made conservation laryngeal surgery possible in two of the four patients. Indeed, surgical resection with sound oncologic principles must be applied and total laryngectomy may be necessary. On rare occasion radiotherapy may be used, although its value remains controversial.

Pulmonary sequelae of intraparenchymal bismuth subgallate.

Bismuth subgallate (BSG) is a heavy metal compound which is effective in lowering the incidence of hemorrhage after adenotonsillectomy and has been demonstrated to activate Factor XII. In a minority of children, the paste has been suctioned from the cuffless oral endotracheal tube after adenotonsillectomy. No pulmonary sequelae have been noted in these patients. To assess the effect of BSG aspiration, 75 rats were divided into groups receiving either intratracheal BSG or saline. Early and late parenchymal effects were documented at 5 and 30 days following administration. Although there were no differences in the general well-being, activity level, or weight in these rats, acute pneumonia followed by a histiocytic, foreign-body response was noted in a significant number of rats in the BSG group. Although no clinical pulmonary sequelae of BSG use have been noted in our patients, this information should alert clinicians to the risks of BSG use in the pulmonary-compromised patient, and encourage them to either employ all methods of preventing aspiration in such patients when using BSG, or to use another hemostatic modality for the utmost safety.

Inferior mastoidectomy-hypotympanic approach for surgical removal of glomus jugulare tumors: an anatomical and radiologic study emphasizing distances between critical structures.

The technique of inferior mastoidectomy-hypotympanic dissection, with preservation of the middle and inner ear structures, has been established for radical surgical removal of glomus tumors involving the skull base. In order to study the gross anatomic differences and correlate with the computed tomography (CT) scan, 20 human temporal bones were dissected and accurate measurements between vital structures were made. This study revealed a wide variation in distances between the neurovascular structures, whereas the distances between inner ear structures were not statistically different. This original study of critical distances of gross topographic anatomical structures and CT correlation is very helpful indeed in the understanding of variations found in the surgical removal of lesions involving this important and challenging area of the skull base. The inferior mastoidectomy-hypotympanic dissection has been performed in the removal of six suitable tumors involving the jugular bulb area. This technique, combined with upper cervical dissection, is very useful for the radical removal of such neoplasms with preservation of external and middle ear structures as well as the function of the facial, eighth, and other lower cranial nerves.

Different options for treatment of inverting papilloma of the nose and paranasal sinuses: a report of 41 cases.

Forty-two cases of inverting papilloma of the nose and paranasal sinuses were reviewed from 1972 to 1989. Forty-one patients underwent surgical excision. Of those patients followed up for at least 6 months, lateral rhinotomy was performed in 14 patients and midfacial degloving in 9 patients. The recurrence rates were 29% and 22%, respectively. The other 10 patients underwent excision through an external ethmoidectomy, Caldwell-Luc operation, or intranasal approach. There were five patients (12%) diagnosed with squamous cell carcinoma associated with inverting papilloma. The correlation of malignancy with proptosis, visual changes, infraorbital hypesthesia, and skull base involvement on presenting symptomatology is noted. Inverting papilloma is a benign neoplastic lesion that shows variable aggressiveness. A computed tomography (CT) scan evaluation is very important for the work-up. An aggressive wide surgical excision is best performed through an open approach. The approach for surgical removal should be based on the location and extension of the lesion. A graduating approach from a lesser to a more major excision is advocated even though a risk exists of having to reoperate in about one fifth of the patients who experience a recurrence. A secondary surgical excision, even with craniofacial resection, is essential to eradicate disease in cases of recurrence. Close follow-up is necessary. Further surgery may be indicated. Post-operative radiation therapy is recommended if malignancy is indeed present.

Conservative medical management of traumatic pharyngoesophageal perforations.

Traditionally, surgical treatment has been the acceptable management for perforation of the pharyngoesophageal tract secondary to blunt and penetrating trauma. From July 1983 to June 1990, we managed 10 patients with this type of lesion by a conservative medical management approach. Mirror or fiberoptic flexible laryngoscopy was performed in the majority of cases to ascertain the nature of the injury. An esophagogram is very helpful to locate and evaluate the extent of the injury. All patients were treated with broad-spectrum intravenous antibiotic therapy and no oral feeding. There were no complications or need for surgical treatment in any of the cases. The head and neck surgeon, in selected cases, should consider the possibility of using conservative management of pharyngoesophageal perforations. This approach has proven in our hands to be relatively safe and cost-effective, resulting in no disability or prolonged hospitalization of our patients. This study involves two institutions (two affiliated hospitals of Case Western Reserve University School of Medicine) with different surgeons selecting appropriate antibiotic therapy. It is a retrospective review. No controls were made by random selection of cases treated surgically. These cases, if not properly managed, may lead to fatal outcomes.

Fatal and other major complications of endoscopic sinus surgery.

Endoscopic sinus surgery has become an acceptable technique for the treatment of chronic sinus disease. This report analyzes five complications which came to my attention. Two cases were orbital:1 bilateral blindness due to damage of the optic nerves, and 1 damage of medial rectus muscle. The other 3 cases were intracranial:two cribriform plate damage with frontal lobe injury and hematoma, and 1 damage of the anterior cerebral artery, resulting in death. This rather novel technique, especially when used by less-experienced surgeons, has major complications similar to what has been reported with the traditional intranasal sphenoethmoidectomy. Knowledge of anatomy, good training, and meticulous surgical technique are very important. Endoscopic sinus surgery in patients with extensive pathology should be used with caution, especially if general anesthesia is selected or if excessive bleeding occurs. It would be beneficial to otolaryngologists to have previous experience in the traditional technique before adopting endoscopic sinus surgery to their armamentarium. Even then, major complications may occur in the hands of very experienced surgeons. Early recognition and proper management of these complications are of utmost importance in order to minimize disability or prevent death.

Maxillary ameloblastoma: case report.

Ameloblastoma of the maxilla is an unusual epithelial tumor of odontogenic origin. Although it is considered benign, it can behave in a slowly growing infiltrative fashion, with multiple recurrences and eventual intracranial, or even distant, spread. Information on this tumor consists, to a large extent, of case reports presented in the oral surgery literature. This study is a retrospective review of our combined institutional experience with nasomaxillary tumors from 1980 to 1988. Among these cases were four patients with maxillary ameloblastoma, two males and two females, ranging in age from 16 to 66 years at presentation. Disease extent varied from ameloblastoma localized to a cyst in the maxillary sinus to extensive maxillary and ethmoid involvement. Follow-up ranged from 2 to 13 years, and disease course varied from apparent disease control to persistent intracranial tumor, despite attempts at extirpation. An analysis of this experience and the related literature is presented, along with recommendations for radical therapy, when appropriate, to best ensure control.

Metronidazole in head and neck surgery--the effect of lengthened prophylaxis.

Previous studies of antibiotic prophylaxis have shown that treatment for 24 hours has been beneficial for head and neck surgery and that longer periods of antibiotic therapy have not improved results. Metronidazole (Flagyl), unlike other antibiotics tested, has been shown to be effective in an experimental abscess, even if treatment is begun up to 120 hours after administration of inoculum. This article presents a prospective, randomized, multifactorial study comparing a brief vs. a prolonged duration of metronidazole and cefazolin prophylaxis in 50 consecutive patients with a head and neck cancer undergoing operation. Patients receiving 2 days vs. 7 or more days of antibiotic prophylaxis were compared. Statistical analysis of data demonstrated a striking reduction in severity of wound complications and a reduced incidence of wound infections in the group treated with 7 or more days of antibiotic prophylaxis.

Intraoral-extramaxillary sinus approach for ligation of the maxillary artery: an anatomic study with clinical correlates.

Surgical control of severe epistaxis is usually reserved for cases refractory to more conservative techniques. We present our experience with intraoral ligation of the maxillary artery as it courses through the buccal fat pad before it enters the pterygopalatine fossa and branches posterior to the maxilla. This technique has been found useful in the control of nasal hemorrhage as well as an adjunct to other surgical procedures, such as removal of benign and malignant neoplasms involving the maxilla and paranasal sinuses. This technique was used for ligation of the maxillary artery in 20 patients. The artery was readily identified in some cases, but required more extensive dissection in others; therefore, an anatomic study in 18 preserved and fresh cadaver specimens was undertaken to investigate the variability of the maxillary artery in the region of the buccal fat pad. There appeared to be significant variation in the distance from the buccal mucosal incision site, as well as variation in the relationship to the pterygoid muscles. This relationship to the pterygoids explains the occasional difficulty in locating the artery for ligation. This technique represents a reasonable alternative to the more traditional transantral approach to ligation of the maxillary artery, as long as the surgeon understands the anatomy of the region, its variations, and where the artery may be located if not immediately apparent. No major complications have been experienced.

Intracranial abscesses secondary to nasal, sinus, and orbital infections in adults and children.

Nineteen cases of intracranial abscesses secondary to infection of the midface are reported. The most common underlying cause was bacterial sinusitis. Other etiologic factors included mucormycosis following steroid therapy, Wegener's granulomatosis, nasal dermoid cyst and sinus tract, tooth abscesses, aspergillosis following chemotherapy for leukemia, squamous cell carcinoma of the frontal sinus, infected methylmethacrylate plate for a prior skull fracture, and a case of gauze packing left in the sinus following surgery. Anaerobic organisms were the predominant cause of the abscesses. The most dangerous intracranial complication was subdural abscess, which occurred in seven patients in this series. Three of them died. Four cases of frontal and parietal lobe abscesses were treated with systemic antibiotics only. This approach has not been well emphasized in our literature. Steroid therapy should not be used for the treatment of sinus and orbital infections. It can result in dreadful complications. The overall mortality rate in this series was 21% (4 of 19), despite aggressive treatment and close cooperation between the neurosurgeon, otolaryngologist, and other specialists. Early diagnosis and adequate treatment are paramount.