Improvising a Posterior Nasal Pack with Equipment in a Basic First Aid Kit.

Posterior epistaxis is a serious condition that can be difficult to treat in a wilderness setting. The initial standard of care involves packing the affected nostril with a 7 to 9 cm nasal pack to tamponade the bleed. These packs are often unavailable outside of the emergency or operating room. This study set out to determine whether a posterior nasal pack could be constructed from the supplies present in a basic first aid kit in order to control massive nasal hemorrhage in a wilderness setting. A basic first aid kit was utilized to construct a posterior nasal pack that was inserted into an anatomical model and visibly compared with the Rapid Rhino (Posterior, 7.5 cm; Smith & Nephew, Austin, TX) nasal packing. The shape, size, and anatomical areas of compression (ie, into nasopharynx and posterior aspect of inferior turbinate) of this pack was similar to the commercially available posterior nasal pack. Placement in an anatomical model appears to provide similar compression as the commercially available posterior pack. This technique may provide short-term hemorrhage control in cases of serious posterior nasal hemorrhage where standard treatment options are not available.

The use of a prefabricated radial forearm free flap for closure of a large tracheocutaneous fistula: a case report and review of the literature.

INTRODUCTION: The closure of complex tracheocutaneous fistulae is a surgical challenge. We describe a staged approach for management of a patient with a large tracheocutaneous fistula in the setting of prior surgery and local radiation therapy. CASE PRESENTATION: A 66-year-old Caucasian man who had undergone prior surgery and radiation therapy to the lower neck presented to our hospital for treatment of a large tracheocutaneous fistula that had developed with an adjacent area of tracheal stenosis. A prefabricated composite graft made up of an inner mucosal lining (buccal mucosa), a central cartilage structure (conchal cartilage), and external skin lining was constructed on the patient's distal volar forearm and subsequently harvested in a staged fashion. This graft was transferred as a free flap and successfully used to close the patient's defect following revascularization. Sixty months after surgery, the patient had no airway compromise or new dysphonia. CONCLUSIONS: The use of a prefabricated mucosally lined composite graft can allow for successful closure of large tracheocutaneous fistulae, even in the setting of prior radiation therapy.

Otolaryngology Consult Carts: Maximizing Patient Care, Surgeon Efficiency, and Cost Containment.

OBJECTIVE: The objective of this study was to develop an otolaryngology consult cart system to ensure prompt delivery to the bedside of all the unique equipment and medications required for emergent and urgent otolaryngology consults. METHOD: An otolaryngology practice responsible for emergency room and hospital consult coverage sought to create a cart containing all equipment, medications, and supplies for otolaryngology consults. Meetings with hospital administration and emergency room, nursing, pharmacy, central processing, and operating room staff were held to develop a system for the emergent delivery of the cart to the needed location, sterilization and restocking of equipment between uses, and appropriate billing of supplies. RESULTS: Two months were required from conception to implementation. All equipment was purchased new, including flexible scopes and headlights. The cart is sterilized, restocked, and maintained by central processing after each use. The equipment is available to handle all airway emergencies as well as all common otolaryngology consults and is delivered bedside in less than 5 minutes. CONCLUSION: The development of a self-contained otolaryngology consult cart requires coordination with a wide variety of hospital departments. This system, while requiring initial monetary and time investment, has resulted in improved patient care, cost containment, and surgeon convenience.

Brief report: sound output of infant humidifiers.

The sound pressure levels (SPLs) of common infant humidifiers were determined to identify the likely sound exposure to infants and young children. This primary investigative research study was completed at a tertiary-level academic medical center otolaryngology and audiology laboratory. Five commercially available humidifiers were obtained from brick-and-mortar infant supply stores. Sound levels were measured at 20-, 100-, and 150-cm distances at all available humidifier settings. Two of 5 (40%) humidifiers tested had SPL readings greater than the recommended hospital infant nursery levels (50 dB) at distances up to 100 cm. In this preliminary study, it was demonstrated that humidifiers marketed for infant nurseries may produce appreciably high decibel levels. Further characterization of the effect of humidifier design on SPLs and further elucidation of ambient sound levels associated with hearing risk are necessary before definitive conclusions and recommendations can be made.

Rapid mandible margins for intraoperative assessment.

OBJECTIVES: To determine the feasibility of a rapid method of processing mandible bone margins for intraoperative histopathologic examination and to assess the relative value of fine, coarse, and core specimens in assessing bone margins. STUDY DESIGN: Prospective histologic controlled study. SETTING: A tertiary level academic medical center histopathology laboratory. SUBJECTS AND METHODS: Multiple bone samples were collected from fresh (<12 hours post-mortem) human cadaveric mandible using a 1) standard 4mm otolaryngologic cutting drill bit 2) diamond drill bit and 3) cutting core biopsy trocar. The specimens were placed in one of three decalcifying solutions (Decal A, Calex, EDTA Decal) from 15 to 75 minutes or control (fixation in 10% formalin). After each designated decalcification time period, specimens were cryosectioned or paraffin embedded and subsequently reviewed by a head and neck surgical pathologist. The specimens were assessed for overall quality, adequacy of decalcification, soft tissue quality, marrow quality, and presence of artifact. RESULTS: Bone margin specimens collected with a 4mm burr and processed with EDTA Decal for 30 minutes yielded the highest quality histopathologic slides compared to the other methods in a similar time frame. The adequacy of decalcification directly impacted the quality of histopathologic assessment. CONCLUSIONS: Mandible bone margins can be rapidly and safely prepared and adequately evaluated with only 30 minutes of decalcification. This method may provide acceptable intraoperative assessment of bone margins in patients with tumors which involve or approximate bone. We plan to examine this model in a prospective clinical study of patients with cancer invading mandibular bone.

Ultrasound gel causes fine needle aspiration artifact? A clear choice.

OBJECTIVES: Ultrasound-guided fine needle aspiration (FNA) is a commonly employed tool in cytopathologic practice. Artifacts resulting in misinterpretation of specimens have been noted with various ultrasound gel media. Our purpose was to perform a prospective human cadaveric study of this phenomenon to identify a low-cost solution that eliminates the artifact. STUDY DESIGN: Three separate ultrasound-guided FNAs were performed on the thyroid and parotid glands in situ of a fresh human cadaver using three different types of ultrasound gel media. Slides were prepared in standard fashion (Quik-Diff and Papanicolaou stains). Two cytopathologists subsequently analyzed the slides for the presence of any artifact interfering with their ability to visualize and interpret the cellular aspirate material. RESULTS: Two of the three gel media revealed significant artifacts mimicking apoptosis, necrosis or colloid, making it difficult to visualize the cellular components and differentiate the artifact from the thyroid colloid. One gel medium did not show any significant artifact, and there was no discernable difference in its quality with regard to the ultrasound image during FNA procedures. CONCLUSIONS: Ultrasound gels can be associated with a significant artifact in FNA specimens. To eliminate this artifact, which may alter the adequacy, diagnosis or cytologic appearance, we confirm a specific gel type that is useful for ultrasound-guided FNAs.

Genetic alterations in papillary thyroid carcinoma and hashimoto thyroiditis: An analysis of hOGG1 loss of heterozygosity.

OBJECTIVES: To determine the relationship between hOGG1 loss of heterozygosity (LOH), Hashimoto thyroiditis (HT), and papillary thyroid cancer (PTC). Hashimoto thyroiditis is an autoimmune mediated chronic inflammatory disease previously shown to coexist with papillary PTC. To further define the relationship between HT and PTC, we report an analysis of hOGG1, a major repair gene for free radical-induced oxidative DNA damages, in thyroidectomy specimens. DESIGN: Tissue samples from 20 cases of PTC, 20 cases of HT, and 15 cases of benign goiter were included in this study. Samples of DNA collected from laser-capture microdissection of thyroidectomy specimens were analyzed for hOGG1 LOH by polymerase chain reaction (PCR) amplification using 5 fluorescent-labeled microsatellite markers followed by fragment analysis. SETTING: A university tertiary care center and regional veterans' hospital. PATIENTS: Fifty-five patients undergoing partial or total thyroidectomies for various indications (PTC, HT, or goiter). INTERVENTIONS: Pathology specimens were analyzed by laser capture microdissection and PCR for hOGG1. MAIN OUTCOME MEASURE: The presence of hOGG1 in all thyroid specimens. RESULTS: Amplification by PCR was successful for all 5 markers in 18 cases of PTC, 15 cases of HT, and 12 cases of benign thyroid. Among these samples, hOGG1 LOH was found in 17 of 18 PTC specimens (94%), 11 of 15 HT specimens (73%), and 1 of 12 benign goiter specimens (8%). CONCLUSIONS: hOGG1 LOH is strongly associated with PTC and HT but not with benign thyroid. We hypothesize that thyroid follicular epithelia accumulate aberrant genetic changes in long-standing HT, which may represent a precursor lesion of PTC.

Sculpting resection of rhinophyma using the Shaw scalpel.

BACKGROUND: Rhinophyma is a disfiguring disorder of the nasal skin characterized by hypervascularity, sebaceous gland hyperplasia, occluded sebaceous ducts, and dermal fibrosis. It has no known effective medical treatment; however, a myriad of surgical treatments have been reported. We report an effective, efficient, and safe approach to treat this disorder using the Shaw scalpel to surgically sculpt the nose. OBJECTIVE: To evaluate the efficacy and safety of using the Shaw scalpel to treat rhinophyma. METHODS: We performed a retrospective review of 7 male patients (age range, 58-81 years) who underwent primary surgical treatment of rhinophyma with the Shaw scalpel. RESULTS: A good to excellent outcome was noted in all 7 patients. No perioperative complications occurred. Essentially no blood loss was noted during or after the procedures. CONCLUSION: Use of the Shaw scalpel as the sole surgical instrument and method is a safe, efficient, and effective means to treat rhinophyma.

Cholesterol granulomas.

PURPOSE OF REVIEW: This paper reviews the literature relating to the pathogenesis, diagnosis and management of petrous apex cholesterol granulomas. RECENT DEVELOPMENTS: Diagnosis of cholesterol granulomas can be challenging due to the rarity of this surgical condition and similarities to other petrous apex pathology. Recent literature reports novel locations of cholesterol granulomas, provides support for a new theory of pathogenesis, describes additional cases of endoscopic approaches to excision, and evaluates the efficacy of stenting to prevent recurrence of the lesion. SUMMARY: Cholesterol granulomas of the petrous apex are significant due to their similarity to other petrous apex lesions, their adverse effect on cranial nerves and their challenging surgical location. These lesions are now believed to be an inflammatory reaction to the by-products of eroded marrow cavities in the temporal bone. The ideal surgical approach takes into account the hearing status of the patient and lesion location and may include the endoscopic transsphenoid, transmastoid, infralabyrinthine, middle fossa, and transotic approaches. Lesions should be excised, drained, and stented with the largest diameter silicone stent possible.