Retained crossbow bolt after penetrating facial trauma.

We present an unusual case of a retained crossbow bolt in the maxillofacial area of a 31-year-old man. While crossbow injuries are rare, this case is of interest because otolaryngologists are often faced with treating retained foreign objects after penetrating facial trauma. These cases are difficult to manage because of the complexity and variety of injuries that can occur during both the initial trauma and the removal. We focus on the management of the bolt's removal and provide a brief discussion of the relevant literature on crossbow injuries to the head and neck.

Midline approach to pediatric nasofrontal dermoid cysts.

IMPORTANCE: To highlight the advantages of the vertical midline incision in providing satisfactory cosmesis with complete excision of pediatric nasofrontal dermoid cysts. OBSERVATIONS: Retrospective case series of nasofrontal dermoid cysts in 4 patients treated at a single tertiary medical center from June 1, 2010, through July 31, 2012. The mean age at surgery was 2.5 years. The anatomical location of the nasofrontal dermoid cysts differed: (1) supratip extending through the upper lateral cartilages to the cartilaginous septum, (2) upper dorsum and subcutaneous tissue, (3) tip and supratip extending deep to the nasal bones with involvement of the anterior cranial fossae and dura, and (4) nasal tip extending deep to the level of the rhinion and involving the upper lateral cartilages and below the left medial canthus. Preoperative imaging was performed on all patients. There was one case of intracranial extension. All patients underwent surgical excision with the vertical midline incision. Nasal reconstruction was performed with local soft-tissue flaps (1 patient), regenerative tissue matrix (2 patients), and bone dust pate (1 patient). The patient with intracranial involvement also underwent a frontal craniotomy. All lesions were histologically confirmed as dermoid cysts. Mean follow-up was 1.5 years. There were no complications or recurrences. All patients had cosmetically acceptable scars. CONCLUSIONS AND RELEVANCE: A vertical midline incision with modifications to excise involved skin provides a satisfactory and cosmetically sound approach to congenital lesions of the nasofrontal region. It affords adequate exposure for complete excision and reconstruction. A multidisciplinary team consisting of a neurosurgeon, facial plastic surgeon, and pediatric otolaryngologist is needed to optimize outcomes.

Immature teratoma of the maxillary sinus: a rare pediatric tumor.

IMPORTANCE: Noncongenital immature teratomas in the head and neck are extremely rare, and to our knowledge have not previously been reported in the maxillary sinus of a pediatric patient. OBSERVATIONS: Teratomas are neoplasms that contain tissue from more than 1 embryonic cell layer that is foreign to the location where they arise and are most commonly found in the sacrococcygeal and gonadal regions in children. We present an unusual case of an immature teratoma in the maxillary sinus of a 10-year-old boy and discuss the diagnostic workup, management, and clinical course. CONCLUSIONS AND RELEVANCE: Immature teratomas represent a subset of benign teratomas with immature elements that may carry a worse prognosis.

Evaluation of superficial musculoaponeurotic system flap and fat graft outcomes for benign and malignant parotid disease.

OBJECTIVE: (1) To evaluate the effectiveness of the superficial musculoaponeurotic system (SMAS) flap and free fat graft in reconstructing the parotidectomy defect. (2) To evaluate the long-term viability of the free fat graft following parotidectomy for benign and malignant disease, including in the postradiation setting. STUDY DESIGN: Prospective study of consecutive patients. SETTING: Academic tertiary care medical center. Subjects and Methods Thirty-one consecutive patients underwent parotidectomy with SMAS flap and free fat graft reconstruction from 2006 to 2012. Data were compiled through a manual chart review. RESULTS: Twenty-three of the 31 total patients had benign disease, including pleomorphic adenoma, oncocytoma, and Warthin tumor. The 8 remaining patients (9 parotidectomies) underwent surgery for malignant disease, followed by postoperative radiation. The average age was 56 years (range, 16-84 years). The mean follow-up was 22.5 months. Satisfactory volumetric symmetry was achieved in all procedures for benign and malignant disease. Magnetic resonance imaging confirmed long-term fat graft viability in the postradiation setting. There was 1 case of Frey syndrome and no cases of unexpected, permanent facial nerve weakness among the patients. CONCLUSION: The combined technique of SMAS flap and free fat graft is effective for immediate reconstruction of the parotidectomy defect with minimal morbidity and low complication rates. This study demonstrates long-term viability of the free fat graft even in the setting of postoperative radiation.

Pediatric nasal injuries and management.

Although serious trauma injuries are uncommon in the pediatric population, nasal injuries are a more common problem. In this population, many physicians are uncomfortable managing these injuries. The evaluation and treatment of nasal trauma differ considerably in children compared with adult nasal fractures. Poor patient cooperation during the physical exam coupled with significant anatomic differences can present the nasal surgeon with a difficult diagnostic dilemma. The surgical management of pediatric nasoseptal injuries is not without controversy, as disturbing the nasal growth centers can have significant effect on future nasal and midfacial development. This article reviews the diagnostic and therapeutic challenges presented by these injuries for children and provides recommendations to successfully manage nasal injuries in this population.

Management of bite wounds in the head and neck.

An estimated 50% of people in the United States will incur an animal or human bite wound at least once in their lifetimes. Although the majority of these individuals do not seek medical attention, bite wounds to the head and neck are a common reason for emergency department visits. Facial bites are complex injuries due to the functional and cosmetic nature of the area, as well as the unique polymicrobial infection potential that exists. We present a review of the epidemiology and microbiology of bite injuries to the head and neck and provide evidence-based recommendations regarding surgical wound closure and antibiotic therapy.

Depression in the cosmetic surgery patient.

Studies show that patients seeking cosmetic surgery are more likely to suffer from depression than is the general population. Thus it behooves the cosmetic surgeon to be familiar with the diagnosis of depression and the unique challenges that it poses to a cosmetic practice. Does depression affect surgical outcomes? Could a surgical procedure improve or exacerbate depressive symptoms? When is referral to a mental health professional warranted? This article attempts to deal with these questions, and in doing so we suggest possible means for managing depression in the cosmetic surgery patient.

Psychological considerations in revision rhinoplasty.

Revision rhinoplasty is a unique challenge. In addition to the technical considerations that are inherently more difficult than those of primary cases, the surgeon must also be mindful of the psychological considerations that revision rhinoplasty presents. These patients are by definition unhappy with their prior rhinoplasty experience, and this perception of a suboptimal result is both legitimate and real, even if the surgeon is not in agreement. Tantamount to any intraoperative technique, the preoperative ability of the surgeon to sift through the myriad psychological and psychosocial issues is critical to achieving satisfactory outcomes for both patient and surgeon. Reasons for dissatisfaction with a primary surgery, reasons for seeking revision surgery, and the psychological profiles of revision rhinoplasty patients can differ from those related to other facial cosmetic procedures. This article attempts to provide the reader with a better understanding of the complex interplay of these issues and with this understanding help the reader to distinguish one who is a favorable surgical candidate from one who is best left unrevised.

Rabbit ear cartilage regeneration with a small intestinal submucosa graft.

OBJECTIVES/HYPOTHESIS: The objective was to demonstrate that interpositional grafting with porcine small intestinal submucosa promotes cartilage regeneration following excision of rabbit auricular cartilage. STUDY DESIGN: Blinded, controlled study. METHODS: Eight New Zealand white rabbits underwent excision of auricular cartilage on two sites with and two sites without preservation of perichondrium. Porcine small intestinal submucosa was implanted into one site with and one site without intact perichondrium. Remaining sites served as control sites. Histological assessment was performed at 3 (n = 4) and 6 (n = 3) months and at 1 year (n = 1) after grafting. RESULTS: Histological evaluation showed cartilage regeneration accompanied by chronic inflammation in areas in which porcine small intestinal submucosa was implanted between layers of intact perichondrium. Other sites failed to show significant cartilage regeneration. CONCLUSION: The results of the study using porcine small intestinal submucosa as a bioscaffold for cartilage regeneration are promising and justify further animal and human studies.

Nasal septal perforation repair with porcine small intestinal submucosa.

Repair of nasal septal perforations presents a difficult challenge to the otolaryngologist. Successful closure rates of greater than 90% have been published by several authors using bipedicled mucoperichondrial advancement flaps and interpositional grafts. A number of different materials, both autografts and allografts, have been used as interpositional grafts. We report a 100% closure rate (10 of 10) using an open rhinoplasty technique with bipedicled advancement flaps and porcine small intestinal submucosa (SurgiSIS; Cook Biotech Inc, West Lafayette, Ind) as an interpositional graft. We submit that SurgiSIS is an ideal material for use in the repair of nasal septal perforations because it is easy to work with, demonstrates the ability to support the regeneration of adjacent tissue, and avoids the increased operative time and morbidity associated with harvesting autografts.

Prescribing guidelines for ENT medications during pregnancy.

Profound physiologic changes occur during pregnancy, and they can alter the pharmacodynamics of an administered drug. Almost 85% of women take at least one prescription medication during a pregnancy. Nearly every drug administered to a mother crosses the placenta, and fetal drug levels can reach 50 to 100% of maternal serum concentrations. Because many otolaryngologic conditions are associated with pregnancy, it is essential that otolaryngologists who care for gravid patients know which drugs are safe and avoid unnecessary prescriptions so that the best care can be delivered to the pregnant patient without harming her unborn child. In this article, we discuss the relative safety and efficacy of various types of drugs frequently prescribed for pregnant women by otolaryngologists.

Evidence that taste buds are not present on the human adult uvula.

We conducted a study to investigate whether taste buds are present on the human adult uvula. Our impetus was to determine whether surgical procedures that involve removal of the uvula can affect taste perception. Five human uvulae were removed via a modified carbon dioxide laser-assisted uvulopalatoplasty in an outpatient office setting. The uvulae were serially sectioned and stained with a solution specific for membrane-bound calcium-modulated adenosine triphosphatase, a high concentration of which is found in taste receptors. Examination of the stained sections under light microscopy failed to show that any taste receptors were present in any of the uvulae. This finding suggests that the taste disturbances noted after surgical procedures involving removal of the uvula are not attributable to a loss of taste receptors.