Unusual complication of nasal CPAP: subcutaneous emphysema following facial trauma.

Subcutaneous emphysema is an unusual complication of nasal continuous positive airway pressure (CPAP). We report a case of a 58-year-old man who fell and sustained mild facial trauma to the left side of his head. After using CPAP the following night, he developed diffuse subcutaneous emphysema of his face and left neck. He discontinued CPAP, and his symptoms improved. The potential mechanisms of this patient's subcutaneous emphysema and the prior reports of this complication following facial trauma or dental procedure without use of CPAP are reviewed. Although there are case reports of bacterial meningitis and pneumocephalus following use of nasal CPAP, we are not aware of any prior reports of subcutaneous emphysema following use of CPAP. In light of our experience and the above related case reports, we would suggest nasal CPAP be withheld temporarily in the setting of acute facial trauma.

Iatrogenic hyponatremia: a cause of death following pediatric tonsillectomy.

Death following pediatric tonsillectomy is very rare. If deaths occur, they are most commonly due to bleeding or aspiration. In this presentation, we would like to illustrate another potentially lethal complication following the pediatric tonsillectomy, iatrogenic hyponatremia. We have encountered 3 patients who have developed post-operative hyponatremia. This has resulted in 2 deaths. The third patient was successfully treated and developed no permanent sequela. We will discuss the etiology and pathophysiology of post-operative hyponatremia including guidelines for administering fluid and electrolytes intra-operatively and post-operatively. We expect that fatal post-operative hyponatremia can be avoided in the pediatric tonsillectomy patients.

Selection of the approach to the distal internal carotid artery from the second cervical vertebra to the base of the skull.

Although several approaches for exposure of distal internal carotid artery lesions have been reported, the precise anatomic levels for which each of these maneuvers are most appropriate have not been well described. Since these techniques may require preoperative preparation, it is useful to determine in advance how much exposure will be needed and to select the most suitable and effective technique. We used anatomic dissection in 12 human cadaver specimens (24 carotid bifurcations) to define the limits of distal internal carotid artery exposure by several commonly advocated methods. The standard anterior approach along the sternocleidomastoid muscle allowed exposure of the internal carotid artery to the level of the upper one third of the second cervical vertebra. The upper limit of this exposure was extended to the middle of the first cervical vertebra by division of the posterior belly of the digastric muscle. Anterior subluxation of the mandible increased the distal exposure of the internal carotid artery to the superior border of the first cervical vertebra. Styloidectomy in combination with the preceding maneuvers extended the exposure an additional 0.5 cm cephalad. Lateral mandibulotomy did not significantly extend exposure beyond that obtained with mandibular subluxation and styloidectomy. Exposure of the internal carotid artery in the 1 cm immediately below the base of the skull required a posterior approach with mastoidectomy.

The importance of treating ENT allergy patients in an otolaryngologic practice.

Allergic disorders are common problems encountered by the otolaryngologist. If carefully organized, allergy management can become an important facet of the otolaryngologic office practice.

First branchial cleft anomalies and the facial nerve.

First branchial cleft anomaly is an uncommon clinical problem that can be difficult to diagnose and treacherous to treat. It is generally believed that branchial anomalies arise from incomplete resolution of branchial cleft remnants. They may be a fistulous tract or cystic lesions, and they may be found in all age groups. This article presents three cases of first branchial cleft anomaly and offers an overview of the regional embryology and guidelines for surgical management and facial nerve preservation.

Control of malignant melanoma of the nasal mucous membrane.

Malignant melanoma of the nasal mucous membrane continues to be a rare disorder which is difficult to treat. Five year survival rate appears to be less than 30% and most patients who die of the disease have distant metastasis. At this time, the otolaryngologist and head and neck surgeons must strive to control local and regional disease with surgical means. Unfortunately, these means are usually inadequate because survival is critically dependent on the biology of the melanoma and its interaction with the patient's immune system.

A modified intraoral electrolarynx.

Most electrolarynx devices currently available are designed to be hand-held. The postlaryngectomy patient who cannot develop esophageal speech and requires the use of both hands is clearly handicapped by this design. We report a modification of the intraoral (Cooper-Rand) electrolarynx that is not hand-held.