Treatment of Chronic Hypertrophic Burn Scars With a Fractional CO 2 Laser Is Well Tolerated in an Outpatient Clinic Setting.

INTRODUCTION: The necessity of treating hypertrophic burn scars has expanded significantly with increased burn survivorship. Ablative lasers, such as carbon dioxide (CO 2 ) lasers, have been the most common nonoperative option for improving functional outcomes in severe recalcitrant hypertrophic burn scars. However, the overwhelming majority of ablative lasers used for this indication require a combination of systemic analgesia, sedation, and/or general anesthesia due to the painful nature of the procedure. More recently, the technology of ablative lasers has advanced and is more tolerable than their first-generation counterparts. Herein, we hypothesized that refractory hypertrophic burn scars can be treated by a CO 2 laser in an outpatient clinic. METHODS: We enrolled 17 consecutive patients with chronic hypertrophic burn scars that were treated with a CO 2 laser. All patients were treated in the outpatient clinic with a combination of a topical solution (23% lidocaine and 7% tetracaine) applied to the scar 30 minutes before the procedure, Cryo 6 air chiller by Zimmer, and some patients received a mixture of N 2 O/O 2 . Laser treatments were repeated every 4 to 8 weeks until the patient's goals were met. Each patient completed a standardized questionnaire to assess tolerability and patient satisfaction of functional results. RESULTS: All patients tolerated the laser well in the outpatient clinic setting, with 0% indicating "not tolerable," 70.6% "tolerable," and 29.4% "very tolerable." Each patient received more than 1 laser treatment for the following complaints: decreased range of motion (n = 16, 94.1%), pain (n = 11, 64.7%), or pruritis (n = 12, 70.6%). Patients were also satisfied with the results of the laser treatments ("no improvement or worsened" = 0%, "improved" = 47.1%, and "significant improvement" = 52.9%). The age of patient, type of burn, location of burn, presence of skin graft, or age of scar did not significantly affect the tolerability of treatment or satisfaction of outcome. CONCLUSIONS: The treatment of chronic hypertrophic burn scars with a CO 2 laser is well tolerated in an outpatient clinic setting in select patients. Patients reported a high level of satisfaction with notable improvement in functional and cosmetic outcomes.

Papillary thyroid carcinoma and familial adenomatous polyposis of the colon.

OBJECTIVE: Case report and limited review of the literature on the topic of papillary thyroid carcinoma and familial adenomatous polyposis and its genetic associations. METHODS: A patient with multiple prior surgeries for colonic polyps, abdominal perineal resection for colorectal cancer, and wedge resection for metastatic adenocarcinoma (consistent with rectal primary) presented with a thyroid mass. Fine-needle aspiration demonstrated papillary thyroid carcinoma. RESULTS: The patient underwent total thyroidectomy. Pathologic examination revealed the cribriform-morular variant of papillary carcinoma that has been reported in patients with familial adenomatous polyposis. CONCLUSIONS: Cribriform-morular variant of papillary thyroid carcinoma is an uncommon diagnosis known to be associated with familial adenomatous polyposis. Although the incidence is rare, this diagnosis should raise the clinician's suspicions to recommend both colorectal screening and genetic counseling for family members.

Metastatic insular thyroid carcinoma in the pediatric patient.

OBJECTIVES: The clinical history of a pediatric patient with metastatic insular thyroid carcinoma will be reviewed. Previously reported cases will be examined to allow for comparison of prognosis. METHODS: A 4-year-old female with the complaint of chronic cough, progressive shortness of breath, and weight loss for 2 months underwent cervical lymph node biopsy. The biopsy revealed metastatic thyroid carcinoma. Preoperative imaging was suspicious for miliary metastatic spread to the lungs. RESULTS: Surgical intervention included total thyroidectomy with bilateral paratracheal and modified radical neck dissections. The right internal jugular vein and recurrent laryngeal nerve were removed at the time of surgery because of gross tumor invasion. Final pathologic finding revealed papillary thyroid carcinoma with insular variant features and bilateral regional metastasis. Postoperatively, the patient underwent radioactive iodine I 131 treatment. CONCLUSION: Pediatric metastatic insular thyroid carcinoma is an uncommon form of thyroid malignancy requiring aggressive surgical treatment and adjuvant radioactive iodine.

Helmet use is associated with a decrease in intracranial hemorrhage following all-terrain vehicle crashes.

BACKGROUND: With the recent increase in size and horsepower of all-terrain vehicles (ATVs), it is imperative that preventable injuries be identified to protect the large population using ATVs. Currently, many states have no laws regulating ATV or helmet use. By identifying preventable injuries, the legislature can design appropriate laws to protect both children and adults. METHODS: A retrospective review of all patients with ATV injuries presenting between the years 2005 and 2010 was conducted. The data were grouped in several ways for analysis. This included age less than 9 years, weight less than 30 kg, crash at night, substance abuse, and presence of a helmet. RESULTS: There were 481 patients included in the study. Only 28 (8%) were using a helmet at the time of the crash. Helmet use was associated with less intracranial hemorrhage (3% vs. 22%, p = 0.01) and a decreased incidence of loss of consciousness (14% vs. 35%, p = 0.01). Patients testing positive for alcohol intoxication with or without drugs were significantly more likely to have intracranial hemorrhage, to crash at night, to have facial fracture, to have rib fracture, to arrive intubated, and to have a higher Injury Severity Score (ISS) (p < 0.01 for all). CONCLUSION: With the recent increase in size and horsepower of ATVs, it is imperative that preventable injuries be identified to help protect a growing population of ATV operators. This study reveals a high rate of intracranial hemorrhage following an ATV crash in operators who do not use a helmet. Legislative efforts to implement strict helmet laws for ATV operators may be warranted. LEVEL OF EVIDENCE: Prognostic study, level III.

Career development resource for otolaryngology-head and neck surgery.

Otolaryngology-head and neck surgery, more commonly known as ear, nose, and throat surgery, is more than ear tubes and children's tonsils. It is an exciting and diverse surgical subspecialty that focuses on every kind of disorder of the head and neck. Otolaryngologists treat patients from infancy to geriatrics, delivering both medical and surgical care. There are also multiple opportunities to subspecialize after residency training. The information in this career development resource provides an understanding of otolaryngology and its subspecialty areas and training requirements.

Management of traumatic vascular injuries to the neck: a 7-year experience at a Level I trauma center.

Injury to the carotid artery results in significant mortality and morbidity. The general consensus is to repair all injuries to the common and internal carotid arteries. Ligation is usually reserved for neurologic or hemodynamic instability. We report our experience at a Level I trauma center with vascular injuries to the neck. Retrospective chart review of all patients with vascular injuries in the neck resulting from either blunt or penetrating trauma treated at a Level I trauma center between January 2000 and February 2007. Demographics and outcomes were collected from a chart review. Twenty-five patients with vascular injuries to the neck were identified. There were 13 carotid artery injuries (CAI), five internal jugular vein (IJV) injuries, and 13 external jugular vein (EJV) injuries. Of the carotid artery injuries, six (50%) underwent operative repair (4 primary repairs and 2 bypasses), five (38%) were managed nonoperatively, and one was treated using endovascular techniques. No patient had a postoperative decrease in Glasgow Coma Scale score. There were five isolated IJV injuries (3 primary repair and 2 ligations). Four of the venous injuries (all internal jugular veins) were repaired and the remaining 13 were ligated. Vascular injuries to the neck have significant mortality and morbidity. Treatment of these injuries must be individualized. All CAI in noncomatose patients should be repaired if hemodynamically stable. All IJV injuries should be repaired but may be ligated if hemodynamically unstable. All EJV injuries can be ligated without reservation regardless of neurological status.

Massive retropharyngeal neurofibroma in a pediatric patient.

Retropharyngeal tumors in Neurofibromatosis Type I patients have rarely been presented in the literature and none in a child. We present the case of an 11-year-old patient with a huge retropharyngeal plexiform neurofibroma which was successfully removed without sequelae. Radical resection is a viable option for treatment of these patients.

Massive retropharyngeal neurofibroma in a pediatric patient.

Retropharyngeal tumors in Neurofibromatosis Type I patients have rarely been presented in the literature and none in a child. We present the case of an 11-year-old patient with a huge retropharyngeal plexiform neurofibroma which was successfully removed without sequelae. Radical resection is a viable option for treatment of these patients.

Ductopapillary apocrine carcinoma of the eyelid metastatic to the parotid gland: report of a case diagnosed by fine-needle aspiration biopsy.

Ductopapillary apocrine carcinoma (DPAC) of the eyelid is a rare malignant neoplasm in the periocular region. The relative rarity of this tumor is a diagnostic challenge to the cytopathologist, especially when present as a metastatic lesion to an intraparotid lymph node, where the differential diagnosis includes primary parotid neoplasms, as well as various other metastatic malignancies. There are only a few reported cases of recurrent and metastatic DPAC of the eyelid, and to our knowledge, metastatic DPAC diagnosed by fine-needle aspiration biopsy (FNAB) has not been described. We report a case of a 65-year-old African-American male with a history of ductopapillary apocrine adenocarcinoma of the eyelid, diagnosed 6 weeks ago now presenting with a recurrence in the same area. Magnetic resonance imaging of the head and neck revealed an intraparotid mass also. FNAB of the parotid mass showed a well-differentiated papillary adenocarcinoma with a cystic component, similar to a previously excised ductopapillary apocrine adenocarcinoma of the eyelid.

Intraoperative laryngeal nerve monitoring during thyroidectomy.

OBJECTIVE: To determine whether nerve integrity monitor testing during thyroidectomy predicts recurrent laryngeal nerve (RLN) function after surgery. DESIGN: Prospective cohort outcomes study PATIENTS: The study included 210 consecutive patients with thyroid abnormalities who underwent thyroidectomy. METHODS: All patients were intraoperatively monitored with a nerve integrity monitoring system (Xomed NIM II; Medtronic Inc, Fridley, Minnesota), and their vocal cord function was assessed with fiberoptic laryngoscopy before and after surgery. Normal and impaired vocal cord function were compared using an independent t test with respect to postoperative vocal cord mobility, length of the RLN dissection, and the minimum stimulus needed to generate a response at the completion of surgery. RESULTS: There was a statistically significant difference between the stimulus in milliamperes required to stimulate normal vs abnormal functioning nerves at the completion of the procedure at the cricoarytenoid joint (P = .02) and at the distal end of the RLN dissection (P < .01). A greater length of dissected nerve was associated with normal vocal cord function; however, it was not statistically significant (P = .07). CONCLUSION: These data suggest that an RLN that responds at lower-intensity stimulation (