Lemierre syndrome complicating otitis externa: case report and literature review.

BACKGROUND: Septic thrombophlebitis of the internal jugular vein, known as Lemierre syndrome, is a rare disorder usually caused by Fusobacterium necrophorum, a Gram-negative anaerobic organism that normally inhabits the oropharynx. Lemierre syndrome usually follows primary oropharyngeal infections and affects previously healthy adolescents and young adults in a characteristic manner, often with fatal results if left untreated. There have been a significantly increasing number of reported cases of Lemierre syndrome, possibly reflecting the trend to withhold antibiotics for initially uncomplicated oropharyngeal infections. OBJECTIVES: We hope to alert the reader to a potentially fatal disease process that has recently been increasingly identified, by reporting a unique manifestation of Lemierre syndrome, and by reviewing the current literature. CASE REPORT: A 19-year-old woman presented to our Emergency Department with a chief complaint of fever, ear pain, and generalized weakness. She was noted to be in septic shock, with left neck erythema and swelling. A computed tomography scan showed thrombosis of the left internal jugular vein (IJV), which was later excised. She recovered after a course of intravenous and oral antibiotics. CONCLUSION: Septic thrombophlebitis of the IJV is associated with multiple sources and organisms. This case is unique in both the organism (Peptococcus anaerobius) and the source (otitis externa). This disease process must be identified early and aggressively treated to avoid significant morbidity and mortality.

Massive facial trauma following improvised explosive device blasts in Operation Iraqi Freedom.

OBJECTIVE: To investigate the association of massive facial trauma with brain and eye injuries, injury severity scores, and blood transfusion utilization. STUDY DESIGN: Retrospective study. SETTING: Air Force Theater Hospital, Balad, Iraq. SUBJECTS AND METHODS: Retrospective review of US service members injured by improvised explosive devices and treated at the Air Force Theater Hospital in Iraq from October 2004 to September 2007. Massive facial trauma was defined as any injury to the face involving 3 or more facial aesthetic units. The anatomic injury patterns, injury severity scores, and blood transfusion rates of simple and massive facial trauma were compared. RESULTS: One hundred four patients who sustained facial trauma from improvised explosive device blasts were reviewed, including 29 patients with massive facial trauma. The average injury severity score was 13.9 in the simple facial trauma group and 21.7 in the massive facial trauma group (P = .006). Sixteen (55%) of the patients in the massive facial trauma group received transfusions compared with only 21 (28%) in the simple facial trauma group (P = .009). The rate of associated eye injury was 55% in the massive facial trauma group and 27% in the simple facial trauma group (P = .006). Brain injuries occurred in 48% of the patients with massive facial trauma and 28% of the patients with simple facial trauma (P = .05). CONCLUSION: There is an association between massive facial trauma higher injury severity scores, higher transfusion rates, and an increased risk for eye and brain injuries.

Penetrating neck trauma in Operation Iraqi Freedom.

OBJECTIVES: To examine the surgical outcomes of penetrating neck trauma patients in Operation Iraqi Freedom (OIF) and compare treatment and perioperative survival to historical data with low-velocity penetrating neck trauma seen in a noncombat clinical setting. STUDY DESIGN: Case series with chart review. SETTING: Air Force Theater Hospital at Balad Air Base, Iraq. SUBJECTS AND METHODS: The surgical management of penetrating neck trauma by 6 otolaryngologists deployed over a 30-month period at the United States Air Force Theater Hospital in Balad, Iraq, was retrospectively reviewed. The presenting signs and symptoms, operative findings, and outcomes of patients who underwent neck exploration for high-velocity penetrating neck trauma were determined. A treatment algorithm defining the management of both high-velocity and low-velocity penetrating neck trauma is recommended. RESULTS: One hundred and twelve neck explorations for penetrating neck trauma were performed in OIF over 30 months. Ninety-eight percent of these neck injuries were due to high-velocity projectiles. In patients, zone 1 injuries occurred in 10%, zone 2 injuries in 77%, zone 3 injuries in 5%, combined zone 1/2 injuries in 5%, and combined zone 2/3 injuries in 3%. The positive exploration rate (patients with intraoperative findings necessitating surgical repair) was 69% (77/112). The mortality of patients undergoing neck exploration for high-velocity penetrating neck trauma was 3.7%. CONCLUSIONS: The perioperative mortality and the positive exploration rate for high-velocity penetrating neck trauma by deployed surgeons in OIF are very comparable to those rates seen in civilian centers managing low-velocity penetrating neck trauma.

Traumatic airway management in Operation Iraqi Freedom.

OBJECTIVES: To examine the role of head and neck surgeons in traumatic airway management in Operation Iraqi Freedom and to understand the lessons learned in traumatic airway management to include a simple airway triage classification that will guide surgical management. STUDY DESIGN: Case series with chart review. SETTING: Air Force Theater Hospital at Balad Air Base, Iraq. SUBJECTS AND METHODS: The traumatic airway experience of 6 otolaryngologists/head and neck surgeons deployed over a 30-month period in Iraq was retrospectively reviewed. RESULTS: One hundred and ninety-six patients presented with airway compromise necessitating either intubation or placement of a surgical airway over the 30-month timeframe. Penetrating face trauma (46%) and penetrating neck trauma (31%) were the most common mechanisms of injury necessitating airway control. The traumatic airways performed include 183 tracheotomies, 3 cricothyroidotomies, 9 complicated intubations, and 1 stoma placement. Red or emergent airways were performed in 10% of patients, yellow or delayed airways in 58% of patients, and green or elective airways in 32% of patients. Lastly, surgical repair of the laryngotracheal complex was performed in 25 patients with 16 thyroid cartilage repairs, 4 cricoid repairs, and 8 tracheal repairs. CONCLUSIONS: The role of the deployed otolaryngologist in traumatic airway management was crucial. Potentially lifesaving airways (red/yellow airways) were placed in 68% of the patients. The authors' recommended treatment classification should optimize future traumatic airway management by stratifying traumatic airways into red (airway less than 5 minutes), yellow (airway less than 12 hours), or green categories (airway greater than 12 hours).

Voice quality of prepubescent children with quiescent recurrent respiratory papillomatosis.

OBJECTIVE: The purpose of this study was to assess the long-term impact of recurrent respiratory papillomatosis (RRP) and its treatment on voice quality in prepubescent children. STUDY DESIGN: Case-control study. METHODS: Prepubescent children with RRP in remission for at least 12 [according to MM section] months were asked to participate. Remission was documented by absence of papillomas on fiberoptic flexible laryngoscopy. An age- and sex-matched control was selected for each patient enrolled. Voice was evaluated using the voice-related quality of life (V-RQOL) questionnaire, perceptual evaluations of voice quality by speech-language pathologists using the GRBAS (grade of hoarseness, roughness, breathiness, asthenia, strain) scale, and acoustic analysis (fundamental frequency, maximal phonation time, and relative average perturbation) using the Visi-Pitch II 3300. RESULTS: Medical records of 84 patients were reviewed and 15 met study criteria. Five agreed to participate but one was excluded due to the presence of papillomas. The four study patients and four matched controls were between 9- and 11-years old. On the V-RQOL questionnaire, each control rated V-RQOL as normal (10/50) and the average patient group score was within the normal range (11.5/50). On perceptual evaluations, the patient's voices were more hoarse, breathy, and rough compared to controls'. Acoustic analysis showed that patients' voices had a lower average fundamental frequency (F(0)) (200 Hz compared to 243 Hz for controls) and a higher relative average perturbation (RAP) (1.10 compared to 0.77), although only one patient's voice actually had elevated RAP (2.89), which had a large impact on raising the average score for the patient group. The average maximal phonation times were similar for the two groups (7.8s for patients and 7.4s for controls) but lower than average normal scores reported in the literature. CONCLUSIONS: Although children with RRP do not perceive their voice quality to have a negative impact on V-RQOL, speech-language pathologist evaluations and acoustic measurements show objective differences between the voices of children with quiescent RRP and those of normal, healthy controls.

Minimally invasive approaches to the sphenoid sinus.

OBJECTIVE: We sought to develop an algorithm for surgical approaches to the sphenoid sinus. STUDY DESIGN AND SETTING: Retrospective review was conducted of all patients who underwent a sphenoid sinusotomy by the senior author between July 1994 and August 2001. RESULTS: The study population consisted of 141 patients, in whom 5 different surgical approaches were used: transseptal (47 [33.3%]), transnasal (19 [13.5%]), transethmoid (72 [51.1%]), transmaxillary (2 [1.42%]), and external (1 [0.7%]). Of the 47 transseptal approaches, 43 (91.5%) were for extirpation of a neoplasm. In contrast, 60 of 72 (83.3%) transethmoid procedures were for infectious/inflammatory disorders. An endoscopic approach was used for 7 of 8 (87.5%) skull base repairs. Four transsphenoid optic nerve decompressions were performed. The minor and major complication rates were 2.1% and 0.71%, respectively. CONCLUSIONS: The anatomic location of the pathologic process can guide the surgeon in selecting the most appropriate technique. SIGNIFICANCE: Surgical treatment of sphenoid pathology can be safely and successfully performed through a variety of approaches.