Absorbable Steroid-Impregnated Spacer After Endoscopic Sinus Surgery to Reduce Synechiae Formation.

OBJECTIVE: Middle meatal synechiae formation after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) leads to higher rates of revision surgery. We aimed to determine if there are different rates of postoperative synechiae following ESS for CRS between patients who received a nonabsorbable spacer (NAS) placed in the ethmoid cavity versus patients who had a steroid-impregnated absorbable spacer (AS) placed at the middle meatal entry. METHODS: We conducted a retrospective cohort study of patients who underwent ESS for CRS at a single tertiary referral center from October 2009 to October 2013. We collected data on synechiae formation between the middle turbinate and lateral nasal wall within 1 month of surgery and postoperative epistaxis. RESULTS: One hundred forty-six patients with 252 nasal cavities (52.0%) received steroid-impregnated AS, and 128 patients with 233 nasal cavities (48.0%) received NAS. Synechiae formation occurred in 2.0% of cavities with AS and 5.6% of cavities with NAS, but this difference was not statistically significant (OR = 0.34, P = .052). One patient in each cohort had significant postoperative epistaxis requiring additional nasal packing (P > .99). CONCLUSION: Steroid-impregnated absorbable spacers had statistically insignificant reduction in postoperative synechiae formation when compared to nonabsorbable spacers. Low rates of postoperative epistaxis were observed regardless of the type of spacer used.

Left ventricular contractile function is preserved during prolonged exercise in middle-aged men.

We examined left ventricular (LV) performance before, during, and following prolonged exercise (EX) in 12 healthy middle-aged men [means +/- SE: age = 43.5 +/- 1.9 yr; maximal O(2) uptake (Vo(2max)) = 51.7 +/- 1.5 ml.kg(-1).min(-1)]. Subjects cycled for 120 min at 65% Vo(2max) (75% of maximal heart rate). Two-dimensional echocardiography (ECHO) to determine tissue-Doppler longitudinal myocardial strain and strain rate, LV ejection fraction (EF), end-diastolic (EDV), end-systolic (ESV), and stroke volume (SV) at baseline and after 5, 30, and 120 min of EX and following 30 min of recovery. In addition, hematocrit and plasma norepinephrine (NE) were measured. From baseline to 5 min of EX, there were significant increases in LV longitudinal strain (-23.20 +/- 0.87 to -27.63 +/- 1.07%; P < 0.01), strain rate (-1.50 +/- 0.15 to -2.08 +/- 0.14 s(-1); P < 0.01), and EF (56.3 +/- 2.2 to 77.1 +/- 1.0%; P < 0.05) with continued increases by both at 30 min of exercise vs. SV, EDV, and ESV, which remained constant. After 120 min of EX, HR and NE increased further with reductions in SV, cardiac output, and systolic blood pressure without changes in strain or strain rate. EDV decreased after 120 min of EX (-9.2- vs. 30-min value; P = 0.05) along with a hemoconcentration (baseline = 41.3 +/- 1.0 vs. EX = 45.1 +/- 1.2%; P < 0001) and significant reduction in body mass despite a mean fluid consumption of 1.8 +/- 0.2 liters throughout EX. After 30 min of recovery, LV longitudinal strain was depressed relative to baseline (-23.20 +/- 0.87 to -19.57 +/- 1.21%; P < 0.01). The reduction in LV SV during prolonged EX occurred without changes in the LV contractile state and is likely secondary to reduced LV preload. A reduction in LV contractility despite a reduced afterload following exercise may be due to factors unique to the recovery period and do not appear to contribute to a reduction in SV during prolonged exercise.

Motor and sensory morbidity associated with the anterolateral thigh perforator free flap.

OBJECTIVE: To quantify changes in motor function, sensation, and lower extremity quality of life following anterior lateral thigh free flap (ALT) resection. METHODS: This mixed methods study contained both a prospective cohort arm (n = 20) and retrospective cross-sectional arm (n = 20). In both arms, patients underwent formal motor and sensation testing of the ipsilateral and contralateral thigh by sphygmomanometry and monofilament testing. In the prospective arm, data was collected preoperatively and at the 6-month and 1-year follow-up visits. In the retrospective arm, consecutive patients with a minimum of 6-month postoperative follow-up were enrolled. RESULTS: Postoperatively, 82% of participants endorsed some degree of numbness and tingling at the donor site. On monofilament testing, patients from the prospective arm showed decreased sensibility of the midthigh at both the 6- and 12-month assessment (P < 0.01). Two-point discrimination scores were moderately correlated with the cross-sectional surface area of the flap. Donor thighs demonstrated a similar peak isometric quadriceps contraction (retrospective [retro]: 47 ± 24 mmHg, prospective [pro]: 90 ± 36 mmHg) to the unoperated thighs (retro: 43 mmHg ± 22, pro: 69 ± 35.3 mmHg, P = 0.49). When stratified by perforator anatomy, no significant differences were noted. Subjective donor site morbidity measured with the lower extremity function scale demonstrated no statistically significant difference between the preoperative and 12-month postoperative assessment. CONCLUSION: The ALT flap offers minimal donor site morbidity. Reduced sensibility of the ALT flap is a common complaint among patients. Quadriceps strength is not significantly affected by an ALT free flap harvest. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1057-1061, 2018.

Vascularized composite autograft for adult laryngotracheal stenosis and reconstruction.

BACKGROUND: Adult laryngotracheal reconstruction for airway stenosis and after oncologic ablation can be extremely challenging. METHODS: Patients with the above conditions not amenable to or refractory to conventional treatments were offered specialized reconstruction by wrapping a contoured costal cartilage graft with a vascularized microvascular carrier. All constructs were lined with buccal mucosa grafts. Decannulation rates, quality of life questionnaires, and pulmonary function tests were performed and analyzed. RESULTS: Eleven patients underwent this procedure, 6 for stenosis and 5 for laryngotracheal oncologic defects. Ten patients were successfully decannulated after the procedure (91%). Median time to decannulation was 4 months. At mean follow-up of 76 months, all evaluated patients had a serviceable voice, tolerated a normal diet, and had minimal subjective shortness of breath. CONCLUSION: Vascularized composite autograft can be successfully used to treat severe subglottic stenosis or reconstruct large laryngotracheal defects not amenable to or refractory to conventional treatments.

Endoscopic ligation of the patulous eustachian tube as treatment for autophony.

OBJECTIVES/HYPOTHESIS: Patulous eustachian tube remains a challenging management problem in otolaryngology. The autophony experienced by this patient population can be severe, and as yet no reliable surgical method exists to reduce or eliminate this annoying symptom. Our objective was to develop a novel endoscopic technique to assist these patients. STUDY DESIGN: Longitudinal case series. METHODS: A prospective longitudinal study was conducted of a series of consecutive patients undergoing surgery for patulous eustachian tube. Under transnasal endoscopic guidance, using a combination of fat plugging, endoluminal cauterization, and suture ligation, 14 ears underwent surgical treatment during a 4-year period. The main outcome measure assessed was the level of autophony present after surgery as compared to baseline. Audiometric outcomes, surgical time, and complications were also recorded. RESULTS: There was sustained satisfactory subjective improvement in the autophony in 12 of the 14 ears (85.7%) at primary surgery, with nine of these 12 ears (75%) demonstrating full autophony cessation. Wilcoxon signed rank test showed a significant improvement in autophony in the study population compared to baseline (z = 3.16, P < .001). The mean operating length of time per ear over the full duration of our series was approximately 45 minutes. Postoperative audiometry showed that surgery had no impact on hearing. CONCLUSIONS: Multilayer endoscopic ligation of the patulous eustachian tube resulted in a high autophony improvement rate. The procedure is technically straightforward, and results were sustained at 6-month follow-up.

Left atrial reduction plasty: a novel technique.

We describe a novel technique of left atrial volume reduction in a patient presenting with severe dyspnea from severe mitral insufficiency, giant left atrium, and compressive symptoms of dysphagia and dysphonia. Resection involved circumferential excision of the left atrium anterior to the pulmonary venous vestibule and posterior to the mitral valve and fossa ovalis, including the left atrial appendage. A chordal-sparing bioprosthetic mitral valve replacement, tricuspid valve annuloplasty, and coronary bypass were also performed. Significant reduction of left atrial volume by 50% was achieved and clinical resolution of compressive symptoms was seen at 6-month follow-up.

Cardiac function following prolonged exercise: influence of age.

This study sought to determine the influence of age on the left ventricular (LV) response to prolonged exercise (PE; 150 min). LV systolic and diastolic performance was assessed using echocardiography (ECHO) before (pre) and 60 min following (post) exercise performed at 80% maximal aerobic power in young (28 ± 4.5 years; n = 18; mean ± SD) and middle-aged (52 ± 3.9 years; n = 18) participants. LV performance was assessed using two-dimensional ECHO, including speckle-tracking imaging, to determine LV strain (LV S) and LV S rate (LV SR), in addition to Doppler measures of diastolic function. We observed a postexercise elevation in LV S (young: -19.5 ± 2.1% vs. -21.6 ± 2.1%; middle-aged: -19.9 ± 2.3% vs. -20.8 ± 2.1%; P < 0.05) and LV SR (young: -1.19 ± 0.1 vs. -1.37 ± 0.2; middle-aged: -1.20 ± 0.2 vs. -1.38 ± 0.2; P < 0.05) during recovery in both groups. Diastolic function was reduced during recovery, including the LV SR ratio of early-to-late atrial diastolic filling (SR(e/a)), in young (2.35 ± 0.7 vs. 1.89 ± 0.5; P < 0.01) and middle-aged (1.51 ± 0.5 vs. 1.05 ± 0.2; P < 0.01) participants, as were conventional indices including the E/A ratio. Dobutamine stress ECHO revealed a postexercise depression in LV S in response to increasing dobutamine dose, which was similar in both young (pre-exercise dobutamine 0 vs. 20 µg·kg(-1)·min(-1): -19.5 ± 2.1 vs. -27.2 ± 2.2%; postexercise dobutamine 0 vs. 20 µg·kg(-1)·min(-1): -21.6 ± 2.1 vs. -23.7 ± 2.2%; P < 0.05) and middle-aged participants (pre: -19.9 ± 2.3 vs. -25.3 ± 2.7%; post: -20.8 ± 2.1 vs. -23.5 ± 2.7; P < 0.05). This was despite higher noradrenaline concentrations immediately postexercise in the middle-aged participants compared with young (4.26 ± 2.7 nmol/L vs. 3.00 ± 1.4 nmol/L; P = 0.12). These data indicate that LV dysfunction is observed following PE and that advancing age does not increase the magnitude of this response.

The buccinator flap: a review of current clinical applications.

PURPOSE OF REVIEW: This article reviews the buccinator flap, its relevant surgical anatomy, surgical technique, and applications in head and neck reconstruction. RECENT FINDINGS: Reconstruction of defects after extirpation of head and neck neoplasms can be challenging and complex. Various reconstructive techniques, including skin grafts, regional flaps, and free tissue transfer, can be employed in restoration of form and function after ablative surgery. Although a wide array of reconstructive options is available, the technique employed will largely depend on the surgeon preference and experience. Commonly used pedicled flaps and free tissue transfer techniques can share several disadvantages, including prolonged operative time, poor cosmesis, donor site morbidity, functional limitations, and excessive tissue bulk for intraoral reconstruction. The ideal reconstructive method would adhere to the plastic surgery principle of replacement of 'like with like'. The ease of dissection and useful application makes the buccinator flap an excellent additional reconstructive option for the head and neck surgeon. SUMMARY: The buccinator myomucosal flap is a versatile and dependable flap for head and neck reconstruction. Its minimal donor site morbidity, pliability, ease of elevation, and flexible usage while offering optimal functional and cosmetic results make it a viable option for select defects.