Dilation of the subarachnoid spaces surrounding the cranial nerves with petrous apex cephaloceles in Usher syndrome.

Limited studies of brain MR imaging findings in Usher syndrome have reported atrophy with enlarged subarachnoid spaces. However, the specific appearance of the subarachnoid spaces surrounding the cranial nerves has not yet been described. Herein we describe the skull base MR imaging findings in an adult with Usher syndrome. Multiple cranial nerve exits were enlarged to the point of causing cephaloceles with bony remodeling. A combination of uncommon findings in this rare disorder raises the question of an etiologic association.

Does primary tracheoesophageal puncture reduce complications after laryngectomy and improve patient communication?

The charts of 96 patients who had a laryngectomy at the University of Minnesota and affiliated hospitals were reviewed to assess the benefit of primary tracheoesophageal puncture (TEP). Patients were stratified into those with primary TEP and those without. There was no statistical difference in rates of esophageal stenosis, stomal stenosis, or wound breakdown without fistula. No fistulas developed in 33 patients who received primary TEP. 52% Of those with primary TEP, used their prosthesis for speech long-term. Only 5 of 63 patients whose surgery did not include primary TEP, received a secondary TEP, and only 2 retained the prosthesis for speech. There was no increased morbidity or incidence of complications after laryngectomy when performing a primary TEP. Patients will maintain the initial form of speech rehabilitation, even if it is less comprehensible. The early postoperative period is convenienced by using the puncture site as the entrance for nutrition during wound healing.

Condylar prostheses in head and neck cancer reconstruction.

OBJECTIVE: To discuss the use of condylar prostheses after mandibular resection for tumor. DESIGN: Case series and literature review. SETTING: Tertiary referral center. PATIENTS: Four patients underwent condylar reconstruction with metallic condylar prostheses after hemimandibulectomy for either squamous cell cancer or Ewing sarcoma. MAIN OUTCOME MEASURE: Complications related to the condylar prostheses. RESULTS: Clinical and radiological follow-up in these patients revealed several complications, including exposure or extrusion of the prosthesis and migration of the prosthesis into the epitympanum, resulting in profound sensorineural hearing loss owing to bony destruction of the cochlea. Two of our patients required removal of the mandibular hardware because of the seriousness of the complications, and 1 of the 2 underwent reconstruction of the condyle with a fibular free flap. CONCLUSIONS: Metallic condylar prostheses in the setting of tumor resection and reconstruction involve significant risks. Autogenous materials, such as vascularized bone grafts, should be used whenever possible.

The effects of conjugated deferoxamine in porcine skin flaps.

BACKGROUND: The free radical scavenger, deferoxamine (DFO) has been shown to reduce skin flap necrosis; however, its shortcomings are its toxicity and short plasma half-life. METHODS: This study investigates the effects of the less toxic, longer acting conjugated form, DFO-Hespan (DFO-H), to ischemic porcine skin flaps. During the study, DFO-H plasma concentrations and flap viability were evaluated over 10 days. RESULTS: Steady DFO serum levels were maintained with no evidence of systemic side effects. However, DFO-H was not effective in increasing porcine skin flap viability. Mean treated flap viability (n = 18) was 36.2% +/- 1.7% (mean +/- SE ) vs control (n = 16) 35.8% +/- 2.6%, p =.9. CONCLUSION: DFO-H conjugation increases its half-life and its systemic tolerance for DFO. However, this conjugation may also reduce DFO's effectiveness to preserve flap survival probably by decreasing its ability to reach the intracellular oxygen free radicals. In addition, further studies are needed to investigate whether longer DFO administration given postoperatively can be more effective in reducing ischemic injury.

Choosing the optimal wound dressing for irradiated soft tissue wounds.

This article reviews the healing state of the previously irradiated wound, the tenets for optimal wound care, and the choices of wound dressings now available for its management. The goal in assisting a previously irradiated surgical wound to heal is to transform its chronic wound state into an acute wound state. This transformation encourages wound healing to proceed. Six major moisture-retentive dressing categories exist to optimize its healing. They are classified into the alginates, foams, gauzes, hydrogels, hydrocolloids, and transparent films. Optimal wound care management for previously irradiated wounds involves (1) adequately debriding and cleansing the local wound, (2) accurately assessing the wound, (3) choosing the appropriate dressing based on the wound assessment, and (4) encouraging granulation tissue formation and reepithelialization.

Terazosin blockade of nicotine-induced skin flap necrosis in the rat.

OBJECTIVE: To examine the ability of terazosin hydrochloride to block the decrease in skin flap survival induced by nicotine. DESIGN: A randomized controlled animal trial. SUBJECTS: Ninety-two male Sprague-Dawley rats were randomized to 1 of 5 groups: double-placebo control (n = 15), nicotine opposed by oral placebo (n = 26), nicotine opposed by subcutaneous placebo (n = 16), nicotine opposed by oral terazosin (n = 21), and nicotine opposed by subcutaneous terazosin (n = 14). INTERVENTION: All rats received 1 mg of nicotine twice daily via subcutaneous injection except for those in the double-placebo control group, which received saline injections twice daily, for the 6-week study. The terazosin treatment groups received 1.5 mg of terazosin hydrochloride twice daily either orally or subcutaneously while the rest received a saline solution placebo either orally or subcutaneously for the last 4 weeks of the study. At the end of the fifth week, a 4 x 10-cm, caudally based, dorsal random-pattern flap was elevated and repositioned. The outcome was measured in percentage area of flap survival. RESULTS: The mean (+/-SEM) area of flap survival for the double-placebo control group was 79% +/- 2%. Nicotine opposed by oral placebo or subcutaneous placebo produced a significant decrease in survival areas (mean [+/-SEM] area, 73% +/- 2% and 74% +/- 2%, respectively). Nicotine opposed by oral terazosin produced a mean (+/-SEM) survival area of 81% +/- 2%, which was significantly better than the nicotine opposed by placebo group and similar to the control group (P = .02). CONCLUSION: Use of oral terazosin elevated flap survival rates to control levels in nicotine-treated rats.

Pediatric fiberoptic laser rigid bronchoscopy.

Use of the fiberoptic laser for treatment of tracheobronchial lesions in the adult is well established. However, there is a paucity of experience with the fiberoptic laser in the pediatric airway. Tracheal obstruction caused by granulation tissue or stenosis, as is often seen in children, may be effectively treated with this approach. This article documents the successful use as well as the technologic advantage of the flexible fiberoptic laser systems, primarily the potassium titanyl phosphate (KTP) laser, combined with standard pediatric rigid bronchoscopic equipment in 73 procedures involving 52 children (43 children younger than five years. with an average age of 21 months). Visualization was excellent, assisted or spontaneous ventilation was well maintained, and complications were few.

Cervical necrotizing fasciitis.

Nine cases of cervical necrotizing faciitis are presented. Five were odontogenic, three were pharyngeal in origin, and one developed from a soft-tissue spider bite. The bacteriology represented a polyculture of gram-positive, gram-negative, as well as anaerobic bacteria, and initial medical treatment by third-generation cephalosporin and metronidazole or clindamycin was successful and is recommended. Airway control is necessary early, as is a wide exploration of the fascial spaces of the neck, with frequent reexploration in either the operating room or at the bedside to evaluate the effects of treatment and to prevent further progression of the disease. Intensive medical support is crucial, and hyperbaric oxygen is advised for patients who are deteriorating under standard therapy.

The effects of the inhalational anesthetic agent combination, isoflurane-nitrous oxide, on survival in a pig random skin flap model.

Using a dorsally based, random skin flap model in 14 swine, the influence on skin flap survival of isoflurane used with nitrous oxide as maintenance anesthetic agents was examined. The mean area of skin flap survival was 54.9% for the experimental group compared with 28.6% in the control group. Arterial blood gas content (PO2, PCO2, and HCO3-), respiratory rate, acid-base balance, blood pressure level, pulse rate, and temperature were monitored. Improved survival of the isoflurane-nitrous oxide group was independent of these parameters. These data support the findings of a previous study that isoflurane positively affects random skin flap survival in a swine model. Furthermore, the addition of nitrous oxide partially reduces isoflurane's beneficial effects.

Computed tomographic analysis of pes cavus.

Patterns of muscle degeneration in patients with peripheral neuropathies exhibiting pes cavus deformity were studied by computed tomography (CT). Twenty-six patients attending the muscle disease clinic at Newington Children's Hospital with hereditary sensory motor neuropathies (HSMN) I, II, or III had clinical and radiographic assessment in addition to CT scans of the feet and legs at designated levels. The pattern of muscle degeneration was analyzed with other variables, including age, sex, tibial torsion, cavus, heel varus, and claw toes. Multiple regression/correlation analysis clearly demonstrated earlier and more severe involvement of the intrinsic muscles of the foot as compared with the extrinsic muscles. The most consistent early degeneration occurred in the pedal lumbricals and interossei, which have the most distal innervation. The order of muscle degeneration is a centripetal pattern, with two types of degeneration occurring in the leg muscles: type P patients had earlier degeneration of the leg muscles innervated by the peroneal nerve, and type T patients showed earlier degeneration of those extrinsics innervated by the posterior tibial nerve.

Postoperative radiation-associated changes in free jejunal autografts.

Free jejunal autografts are a preferred method of pharyngoesophageal reconstruction. Ten adult mongrel dogs underwent free jejunal transplantations to the neck, five being controls and five receiving a 55-Gy equivalent dose of radiation after 3 weeks. Histologic changes 10 months after radiotherapy included simplified and blunted villi with normal architecture loss; fibrous replacement of the lymphatics and microvasculature in the intravillous space; goblet cell increase; significant increase in lamina propria thickness and muscularis mucosa fibrous plates; focal destruction and replacement of muscle layers with fibrosis; gross hypertrophy of the myenteric plexus with increased fibrous tissue about the hypertrophied neural tissue; and significant perivascular fibrosis. Controls demonstrated only minimal changes. These adverse delayed effects of irradiation on revascularized jejunal autografts should be considered in planning the method of pharyngoesophageal reconstruction as well as timing of adjuvant radiotherapy.

Gross morphologic and functional effects of postoperative radiation on free jejunal autografts.

Twenty adult mongrel dogs underwent free jejunal transplants to the neck; 10 either died of or had to be sacrificed as a result of postoperative complications, 5 received a 55-Gy-equivalent dose of radiation after 3 weeks, and 5 were followed as controls. Serial manometric and endoscopic evaluations were performed over a 9-month period. Progressive deterioration of the quality and amplitude of peristalsis of the jejunal autografts was observed only in the radiated group. In addition, all dogs in the radiated group developed severe jejunal circumferential constriction and stricture formation. These delayed effects of irradiation on revascularized jejunal autografts should be considered in planning the method of pharyngoesophageal reconstruction as well as the timing of adjuvant radiotherapy.

Uvulopalatopharyngoplasty for obstructive sleep apnea: a community's experience.

Uvulopalatopharyngoplasty (UPPP) has become an accepted method for treating obstructive sleep apnea (OSA), with a reported success rate as high as 77%, depending upon inclusionary and outcome criteria. The authors reviewed the records of 90 patients with moderately severe OSA (apnea plus hypopnea index [AHI] greater than 20) who underwent UPPP at either a private community or an academic hospital. Forty percent of patients experienced more than a 50% reduction in their AHI with UPPP. Only 22 (24%) of the patients had a postoperative AHI less than 50% of the preoperative AHI and less than 20, i.e., met the authors' criteria for surgical success. The success rate for community otolaryngologists was no different than that achieved in the academic institution. When data from previously published reports were analyzed using these criteria for success, similar results were observed. This study suggests that the effectiveness of UPPP performed by the general otolaryngologic community is equivalent to that reported in the literature. However, more rigorous criteria must be applied to UPPP when evaluating its results and in counseling potential candidates for this procedure.

Angiogenic growth factors: their effects and potential in soft tissue wound healing.

Since their discovery 30 years ago, angiogenic growth factors have been demonstrated to stimulate neovascularization in vitro and in animal studies. Over the last decade, knowledge gained in the field of angiogenic growth factors has grown immensely. These angiogenic growth factors exist in four major families: fibroblast growth factor (FGF), transforming growth factor beta (TGF-beta), platelet-derived growth factor (PDGF), and epidermal growth factor (EGF). Each has the ability to induce soft tissue vascularization in microgram quantities. In animal models, FGF, TGF-beta, PDGF, and EGF have been shown to enhance soft tissue wound healing. In human clinical trials, EGF, and a mixture of PDGFs have been demonstrated to accelerate epidermal regeneration in cutaneous wounds. These factors have considerable therapeutic potential in the areas of soft tissue wound healing and otolaryngology. This article reviews important aspects of angiogenic growth factors and discusses their future potential in soft tissue wound healing.

In situ hybridization and laryngeal papillomas.

The technique of in situ hybridization with biotin-labeled probes was applied to 20 patients with laryngeal papillomatosis (9 with adult-onset disease and 11 with juvenile-onset). Ten patients were noted for epithelial transformation of their laryngeal disease. All patients, regardless of their clinical outcome, tested positive for human papillomavirus group 6/11. The biotin method of in situ hybridization proved to be a sensitive method in this study, identifying the infecting viral group in 23 of 24 samples. This study also tested for group 16/18 and is the first to test for the presence of group 31/33/35 in the larynx. These viruses or members of related groups have been reported in malignancies of the head and neck as well as the uterine cervix. They have yet, however, to be identified in benign laryngeal papillomas or laryngeal papillomas that have undergone epithelial transformation.

The effects of inhalation anesthetic agents on survival in a pig random skin flap model.

In recent years a myriad of studies have been performed investigating the effects on flap survival of various pharmacologic agents. One class of agents, however, that has received relatively little attention is the inhalational anesthetics. Yet, they are widely used during reconstructive efforts using skin flaps and they possess several pharmacologic properties shown to affect flap survival. Using a dorsally based random skin flap model in 28 swine, the influence of nitrous oxide and isoflurane on skin flap survival was examined. The mean area of skin flap survival in the isoflurane, nitrous oxide, euoxemic control, and hyperoxygenated control groups was 79.4%, 29.7%, 42.0%, and 28.6%, respectively. A significant improvement in flap viability was seen only in the group using isoflurane as the anesthetic agent. Arterial blood gas content (PO2, PCO2, and HCO3), respiratory rate, acid-base balance, blood pressure, pulse, and temperature were monitored. Improved survival of the isoflurane group was independent of these parameters. These data suggest that the choice of anesthetic agent may effect random skin flap survival with isoflurane providing the greatest benefit of the agents tested in this model.

Invasive Chrysosporium infection of the nose and paranasal sinuses in an immunocompromised host.

Aggressive fungal rhinosinusitis with Chrysosporium sp. occurred in a patient with acute lymphocytic leukemia. The infecting organism is an exceedingly rare human pathogen. Usually, human chrysosporial infections are mild and unmarked by symptoms. Most case reports appear in the pathology literature and describe the incidental finding of adiaspores in the pulmonary parenchyma at autopsy. Clinical disease from active growth of chrysosporial mycelia in human tissues has been noted on a porcine aortic valve prosthesis and in a tibial abscess. Hyphal elements were not recovered from any other body parts of these patients. Histopathologic and microbiologic studies permitted the identification of this rarely encountered organism. Our patient experienced systemic spread of Chrysosporium organisms. Treatment of this pathogen is the same as for other opportunistic fungal infections.