Aberrant position of nonrecurrent inferior laryngeal nerve: Report of 3 cases and a review of the literature.

The presence of a nonrecurrent inferior laryngeal nerve (NRILN) is a significant risk factor for nerve injury during thyroid, parathyroid, and vascular surgeries involving the paratracheal area of the head and neck. The objective of this report is to review the association between an aberrant right subclavian artery (SCA) identified on preoperative imaging and an NRILN identified intraoperatively during thyroid and parathyroid surgery. We reviewed 3 selected cases in which we preoperatively identified an aberrant right SCA and determined the intraoperative position of the inferior laryngeal nerve on the right. It is important to note that 1 of these cases demonstrated that the inferior laryngeal nerve may be found in its normal anatomic position, coursing inferiorly through the tracheoesophageal groove. This anatomic finding is unexpected in a patient with a preoperatively identified aberrant right SCA. We also performed a literature review of more than 250 cases to investigate the association between an intraoperative finding of NRILN and vascular anomalies on imaging. We found 5 reported cases that involved an aberrant right SCA, predictive of NRILN, with the nerve identified in the tracheoesophageal groove.

The joint facial and invasive neck trauma (J-FAINT) project, Iraq and Afghanistan 2003-2011.

OBJECTIVE: Define the number and type of facial and penetrating neck trauma injuries sustained in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). STUDY DESIGN: Retrospective database study. SETTING: Tertiary care level I trauma center. SUBJECTS AND METHODS: The Joint Theater Trauma Registry (JTTR) was queried for data from OIF and OEF from January 2003 to May 2011. Information on demographics; type and severity of facial, neck, and associated trauma injures; and impact on overall mortality was recorded. RESULTS: There were 37,523 discrete facial and penetrating neck injuries that occurred in 7177 service members. There were 25,834 soft tissue injuries and 11,689 facial fractures. The most common soft injury sites were the face/cheek (48%), neck/larynx/trachea (17%), and mouth/lip (12%). The maxilla (25%), mandible (21%), and orbit (19%) were the most common facial fracture sites. The most common mechanism of injury was penetrating (49.1%), followed by blunt (25.7%), blast (24.2%), and other/unknown/burn (1%). Injuries were associated with an overall mortality rate of 3.5%. The highest risks for mortality were treatment at a level IIa facility, female sex, prehospital intubation, and blast injury. Most injuries were mild to moderate. CONCLUSION: Facial and penetrating neck trauma are common in modern warfare. Most injuries are minor to moderate and survivable. Training and potential body armor updates can be made. Medical personnel deploying to support OIF and OEF could benefit from specific training in the management of facial and penetrating neck injuries. A surgeon skilled in managing these injuries would likely be beneficial in a deployed setting.

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.

Coblation lesion formation in a porcine tongue model.

OBJECTIVE: To investigate, in a porcine tongue model, the lesions created by coblation to define the optimal application of this method in treating the enlarged tongue base in patients with obstructive sleep apnea syndrome. STUDY DESIGN: A prospective, experimental animal study. SETTING: Military medical center. SUBJECTS AND METHODS: Fifteen fresh porcine tongue specimens were injected with normal saline, and a single coblation probe was applied to the tongue specimens to create multiple submucosal lesions at specific energy settings. Control lesions were created without the use of saline injections. After creating the lesions, the porcine tongue specimens were sectioned and examined grossly. Size and character of lesions were recorded for each of the specimens and were compared across energy settings. RESULTS: The energy applied at each setting was calculated on the basis of watts multiplied by treatment time. Coblation with saline injection created visible lesions with an average lesion area of 1.20 to 2.87 cm(2). The average lesion area increased as setting increased. Without saline injection, the average lesion area was 0.15 to 0.8 cm(2). CONCLUSION: The porcine tongue model describes the relationship between lesion size and cold ablation device settings. Setting, but not time, significantly affects lesion size. The coblation setting and treatment time directly impact the amount of energy delivered. Additionally, submucosal normal saline injection significantly increases lesion size at all settings and application times. Given the average lesion diameter described in this study, placing lesions 1 cm apart will optimize the area affected by coblation while minimizing lesion overlap.

Mass casualty response of a modern deployed head and neck surgical team.

BACKGROUND: The battlefields of the Global War on Terror have created unique demands on deployed surgical teams. Modern high-energy fragmentation devices often inflict complex head and neck injuries. This series analyzes the role of the head and neck surgical team during 3 separate single explosive events that led to civilian multiple casualty incidents (MCIs) treated at a military theater hospital in Iraq from February to April 2007. METHODS: All MCIs occurring between February and April 2008 with triage and treatment at the 332nd Air Force Theater Hospital in Balad, Iraq, were identified and reviewed. Injury Severity Score, admission injury pattern, length of hospital stay, head and neck procedures, non-head and neck procedures, and clinical duties performed by the otolaryngology surgeon were recorded and analyzed. RESULTS: Three MCIs occurring during the period of February to April 2008 were reviewed and described as incidents A, B, and C. A total of 50 patients were involved. Eighteen patients (36%) were treated for head and neck trauma. The average ISS for the non-head and neck trauma group was 15.8 (range, 1-43), whereas the head and neck trauma group average ISS was 23.6 (range, 2-75) (P < 0.06). The most commonly performed head and neck procedures included repair of facial lacerations, maxillomandibular fixation, and operative reduction internal fixation of facial fractures. The head and neck surgeon also performed airway triage and assisted with procedures performed by other specialties. CONCLUSIONS: : By reviewing 3 MCIs and the operative log of the involved otolaryngologist, this review illustrates how the otolaryngologist's clinical knowledge base and surgical domain allow this specialist to uniquely contribute in response to a mass casualty incident.

Facial trauma in Operation Iraqi Freedom casualties: an outcomes study of patients treated from April 2006 through October 2006.

This study investigates the postoperative complication rate in American military members treated for fractures of the facial skeleton with either immediate fixation in the Operation Iraqi Freedom combat theater or delayed fixation after transport out of the combat theater. Based on an army head and neck surgeon's case log, retrospective chart review was performed on 21 American active-duty patients evaluated for facial fractures in Balad, Iraq, between April 16, 2006, and October 30, 2006. Follow-up standardized patient interviews and review of electronic medical records were conducted to assess the postoperative clinical course and identify postoperative complications. Facial fractures involved the mandible (62%), the orbit (62%), nasal bones (48%), the midface (38%), the frontal bone (29%), the zygoma (24%), and the temporal bone (5%). Fourteen patients (67%) with facial fractures were treated definitively with open reduction and internal fixation surgery in Balad. Seven patients (33%) had delayed treatment. Overall, the major complication rate was 7% in the immediate fixation group, compared with 57% in the delayed treatment group (P < 0.04). Infectious complications occurred in 1 patient (7%) from the immediate fixation group requiring removal of exposed hardware, whereas 3 patients (43%) from the delayed treatment group experienced infectious complications requiring reoperation (P < 0.09). Although major complications were associated with both immediate and delayed definitive treatment, major complications were more likely to be associated with delayed treatment. The deployed surgeon should use clinical judgment in repairing facial fractures in theater. If treatment is delayed, every effort should be made to affect a timely repair of the fractures.

Anatomical dissection and modified Sihler stain of the lower branches of the facial nerve.

BACKGROUND: The cervical branch of the facial nerve and the muscles it supplies play a role in perioral function and neck aesthetics. Paralysis of the cervical branch in some patients may result in lip depressor deficiency and an asymmetric smile. It is unclear whether this is the result of platysmal weakness alone, or attributable to coinnervation of the lip depressor muscles by the cervical and marginal mandibular branches of the facial nerve. The purpose of this study was to provide a detailed description of the anatomy and function of the cervical branch to assist surgeons operating in the face and neck. METHODS: Anatomical dissection of the marginal mandibular and cervical branches was performed in 20 hemifacial human cadaver specimens. The modified Sihler stain was used to stain the extramuscular and intramuscular nerve branches in eight specimens. The course, branching patterns, and neuromuscular relationships of the cervical and marginal mandibular branches were examined. RESULTS: Multiple cervical branches were identified in 85 percent of specimens, and an anastomosis with the transverse cervical cutaneous nerve was documented consistently. A communication between the marginal mandibular and cervical branches was identified in seven specimens, and coinnervation of the depressor anguli oris by intramuscular cervical branch ramifications was seen in one. CONCLUSIONS: A detailed description of the anatomy of the cervical branch is provided. Coinnervation of the lower lip depressors by the cervical branch remains a plausible explanation for the lower lip deformity attributed to cervical branch paralysis in some patients.

A surprising twist to an old problem: sigmoid volvulus in a 19-year-old man.

Sigmoid volvulus classically presents in the seventh or eighth decade, therefore, diagnosis of sigmoid volvulus in an adolescent may be delayed or missed. This life-threatening diagnosis should be considered in young patients presenting with abdominal pain, nausea, vomiting, and constipation. Intraoperative findings in a 19-year-old man with a sigmoid volvulus highlight the importance of considering further studies, such as an abdominal CT scan, which goes beyond the typical obstruction evaluation in the adolescent patient. When nonoperative management fails to decompress the volvulus, complicating factors should be considered, and laparotomy is indicated to provide definitive treatment for this condition.