A useful technique for adjusting nasal tip projection in Asian rhinoplasty: Trapezoidal caudal extension cartilage grafting.

The purpose of this article is to present our experience with Asian patients in (1) using a trapezoidal caudal extension cartilage graft to adjust the tip projection in tip refinement for augmentation rhinoplasty, especially for the correction of short nose, and (2) avoiding complications of augmentation rhinoplasty with alloplastic implants. We conducted a retrospective chart review of 358 rhinoplasties that were performed by the corresponding author from January 2004 through July 2009. Patients were included in this study if they had undergone open rhinoplasty with a trapezoidal caudal extension cartilage graft as the only tip-modifying procedure. Patients in whom any additional grafting was performed that might have altered the nasal tip position were excluded. The surgical results were analyzed in terms of the degree of satisfaction judged separately by investigators and by patients. A total of 84 patients-46 males and 38 females, all Asians, aged 13 to 61 years (mean: 29.3)-met our eligibility criteria. Postoperative follow-up for 24 months was achieved in 62 patients. At the 24-month follow-up, the surgeons judged the results to be good or very good in 57 of the 62 patients (91.9%); at the same time, 56 patients (90.3%) said they were satisfied or very satisfied with their aesthetic outcome. Good nasal tip projection, a natural columellar appearance, and improvement in the nasolabial angle were achieved for most patients. Two patients required revision rhinoplasty to correct an insufficient augmentation and migration of the onlay graft. No severe complications were observed during the 2-year follow-up. We have found that trapezoidal caudal extension cartilage grafting in nasal tip refinement is an easy technique to learn and execute, its results are predictable, and it has been associated with no major complications. We recommend trapezoidal caudal extension cartilage grafting for Asian patients as a good and reliable alternative for managing tip projection and support.

Steroids and antihistamines synergize to inhibit rat's airway smooth muscle contractility.

Both glucocorticoids and H1-antihistamines were widely used on patients with allergic rhinitis (AR) and obstructive airway diseases. However, their direct effects on airway smooth muscle were not fully explored. In this study, we tested the effectiveness of prednisolone (Kidsolone) and levocetirizine (Xyzal) on isolated rat trachea submersed in Kreb's solution in a muscle bath. Changes in tracheal contractility in response to the application of parasympathetic mimetic agents were measured. The following assessments of the drug were performed: (1) effect on tracheal smooth muscle resting tension; (2) effect on contraction caused by 10(-6) M methacholine; (3) effect of the drug on electrical field stimulation (EFS) induced tracheal smooth muscle contractions. The result revealed sole use of Kidsolone or Xyzal elicited no significant effect or only a little relaxation response on tracheal tension after methacholine treatment. The tension was 90.5 ± 7.5 and 99.5 ± 0.8 % at 10(-4) M for Xyzal and 10(-5) M for Kidsolone, respectively. However, a dramatically spasmolytic effect was observed after co-administration of Kidsolone and Xyzal and the tension dropped to 67.5 ± 13.6 %, with statistical significance (p < 0.05). As for EFS-induced contractions, Kidsolone had no direct effect but Xyzal could inhibit it, with increasing basal tension. In conclusion, using glucocorticoids alone had no spasmolytic effect but they can be synergized with antihistamines to dramatically relax the trachea smooth muscle within minutes. Therefore, for AR patients with acute asthma attack, combined use of those two drugs is recommended.

Lymphangiomatous macroglossia associated with extensive cervicomediastinal cystic hygromas.

Children with lymphangiomatous macroglossia often have difficulty eating and talking, and their airways may be compromised because of bleeding and infection, especially when extensive cervicomediastinal cystic hygromas are present. We report a case of lymphangiomatous macroglossia associated with extensive cystic hygromas in the cervicomediastinal region. The 3-year-old girl was treated with anterior wedge reduction of the tongue, needle aspiration of the cervicomediastinal cystic hygromas, and systemic steroids and antibiotics. The extensive cystic cervicomediastinal hygromas spontaneously regressed, and further surgery was not needed until 4 years later. Surprisingly, subtotal or partial lymphatic malformation removal improved the complicated lymphatic malformation.

Multiple-parameter evaluation demonstrates low donor-site morbidity after submental flap harvesting.

PURPOSE: The objective of this study was to implement a scoring system to analyze the authors' experience of donor-site morbidity after harvesting a submental flap for the reconstruction of surgical defects at the head and neck region after oncologic resection. MATERIALS AND METHODS: A retrospective case series study was conducted of patients who underwent reconstruction with a submental flap at the Tri-Service General Hospital (Taipei, Taiwan) from 2008 through 2012. Five parameters representing donor-site morbidity (whistling, smiling, neck extension, beard change, and esthetic outcome) were evaluated with a scoring system developed by a blinded panel of 2 clinicians and the patients. Scores were analyzed and compared between patient subgroups. RESULTS: Twenty-two patients (20 men and 2 women; mean age, 56 yr) underwent reconstruction with a submental flap after head and neck tumor ablation. Primary lesion sites included the oral cavity (13 patients), pharynx (6 patients), larynx (1 patient), neck (1 patient), and sinus (1 patient). The means of all 5 parameters evaluated were higher than 8 on a scale of 0 to 9 (whistling, 8.7; smiling, 8.7; beard change, 8.9; neck extension, 8.2; esthetic outcome, 8.2), showing that submental flap harvesting led to low donor-site morbidity. CONCLUSIONS: Donor-site morbidity after submental flap harvesting was evaluated with a scoring system measuring 5 parameters, namely whistling, smiling, beard change, neck extension, and esthetic outcome. In general, donor-site morbidity was very low. This implemented system and these findings will be helpful in future reconstructive surgical planning and management.

Reconstruction of hypopharyngeal defects with submental flap after laryngopharyngectomy.

The submental flap has rekindled interest in using cervical flaps for reconstruction of head and neck defects. In this article, the authors present their experience of using this flap for hypopharyngeal defects after laryngopharyngectomy. This is a retrospective study of six patients who underwent hypopharyngeal defect reconstruction with submental flap from 2008 to 2011, operated upon by a single surgeon (JC Lee). The flap was used primarily to reconstruct defects after tumor extirpation. The maximum flap size was 12 × 7 cm and the minimum size was 9 × 4 cm (average, 10.5 × 5.3 cm). No flap failures were observed. All the donor site defects were closed primarily. Two patients developed a small pharyngocutaneous fistula that resolved spontaneously. No other complications were observed. After speech reeducation, all achieved a good-quality, understandable artificial voice. All patients were able to eat by mouth without the need for tube feeding. The submental flap is an excellent alternative in the reconstruction of hypopharyngeal defects because of its reliability, versatility, pliability, and relative ease of application. Our initial reports confirm that this kind of reconstruction is feasible and time-saving, and restored a good quality of life.

Comparison of the intraoral and transcervical approach in submandibular gland excision.

The purpose of this study is to evaluate the benefits of the intraoral approach for removal of the submandibular gland (SMG) by comparing it with the usual method of the transcervical approach. Sixteen patients who required SMG resection for benign disorders were divided into two surgical groups who underwent surgery via the intraoral (n = 8) or transcervical (n = 8) approach. The intraoral approach (IOA) consisted of an incision on the floor of mouth from the caruncle of Wharton's duct to the retromolar trigone while the transcervical approach (TCA) consisted of an incision along the natural skin crease overlying the gland. The operation time, hospital stay, complications, and cosmetic appearance were compared between groups. The mean operation time of the IOA group was significantly longer than that of the TCA group, but decreased gradually with surgical experience. The mean hospital stay of the IOA group was significantly shorter than that of the TCA group. Most patients (88 %) of the IOA group experienced sensory defects of the lingual nerve, but these symptoms were temporary. No lasting complications were noted in the IOA group; however, one patient of the TCA group had permanent paralysis of the marginal mandibular branch of the facial nerve. The incision scars were invisible owing to the location on the mouth floor in the IOA group, whereas they were apparent even on the natural skin crease of the neck in the TCA group. In conclusion, the SMG can be removed safely and effectively by IOA with the avoidance of an external scar and of injury to the marginal mandibular nerve. We suggest that the IOA be substituted for the TCA as the primary procedure for removal of the SMG in suitably selected patients.

Head and neck cancers manifested as deep neck infection.

The incidence of head and neck cancers in patients with an initial presentation of deep neck infection is unclear and may be underestimated. Thus, the aim of this study was to assess the incidence of head and neck cancers initially manifested as deep neck infection. Also, the possible risk factors and pathophysiology are discussed. This study was a retrospective medical chart review in a tertiary referral center. A total of 81 consecutive patients admitted with a diagnosis of deep neck infection over a 46-month period were analyzed. The demographic data, physical examinations, laboratory findings, radiographic studies, and pathology report were analyzed. Among the 81 deep neck infection patients, head and neck cancers were histologically demonstrated in four patients (4.9%) with the initial symptom of a painful neck mass. The incidence of head and neck cancer initially manifested as deep neck infection was found to increase in patients aged over 40 years (6.7%; 3/45 vs. 2.8%; 1/36). A detailed history of all patients with deep neck infection should be taken. Furthermore, endoscopic examination, thyroid examination and routine pathological examination should be performed, especially in those aged over 40. Also, careful explanation to the patient and his/her family about the possibility of underlying head and neck cancer (incidence 1-5%) may be needed. If the neck swelling diminishes, but does not disappear completely after full course of antibiotics, repeated fine needle aspiration, endoscopy, or image study should be considered.

Anti-cholinergic effect of singulair on isolated rat's tracheal smooth muscle.

Singulair (Montelukast) is a potent and selective leukotriene D(4) receptor antagonist, often used in treating inflammatory conditions of the respiratory system such as allergic rhinitis and asthma. However, the effects of singulair given intratracheally have rarely been well explored. To verify the effect of singulair, which acts on the tracheal smooth muscle directly in vitro. We used our preparation to test the effects of singulair on isolated rat's tracheal smooth muscle. The following assessments of singulair were performed: (1) effect on the tracheal smooth muscle resting tension, (2) effect on contraction caused by 10(-6) M methacholine as a parasympathetic mimetic, and (3) effect of the drugs on electrically induced tracheal smooth muscle contractions. The results indicated that the addition of methacholine to the incubation medium caused the trachea to contract in a dose-dependent manner. Addition of singulair at doses of 10(-5) M or above elicited a significant relaxation response to 10(-6) M methacholine-induced contraction. Singulair could not inhibit electrical field stimulation-induced spike contraction. It also had a minimal effect on the basal tension of trachea as the concentration increased. This study showed that the high concentrations of singulair also had an anti-cholinergic effect for relieving symptoms of asthma.

Twisted nose: a new simple classification and surgical algorithm in Asians.

The purpose of this study was to present our experiences with correction of twisted nose in Asian patients using a new and simple classification and a surgical algorithm. A classification and standard surgical algorithm was followed to determine treatment strategies for 384 patients with twisted nose between June 2001 and July 2009. A retrospective chart review from the Tri-Service General Hospital archives was performed to collect patients' data and surgical details. A follow-up self-evaluation survey regarding satisfaction with nasal function and esthetics was distributed to all participants. Preoperative and postoperative standardized photography of the face were evaluated to judge objectively the esthetic outcomes of the surgery. There were 147, 131, and 106 patients in Type I, Type II, and Type III patients, respectively. The percentages of functionally satisfied and very satisfied patients were 95.2, 93.9, and 93.4% in Type I, Type II, and Type III groups, respectively. The percentages of esthetically satisfied or very satisfied patients were 89.1, 88.5, and 87.7% in Type I, Type II, and Type III groups, respectively. There were only 2 patients with type III deviation with residual deviation of dorsum objectively who were satisfied with the results after undergoing a revision rhinoplasty. Aside from residual deviation, the postoperative periods were uneventful and without major complications. We propose a new and simple classification and surgical algorithm to optimally correct twisted nose deformities for Asian patients. The classification and surgical algorithm, which is simple and reproducible especially for beginner, guides surgical decisions that yield consistently satisfactory functional and esthetic results.

Varicella zoster virus infection of the pharynx and larynx with multiple cranial neuropathies.

Varicella zoster virus (VZV) infection of the head and neck region may present with various clinical symptoms, involving different entities and different routes of viral spreading. We present a case of VZV infection of the pharynx and larynx with multiple cranial nerve (CN) neuropathies (CN VII, VIII, IX, and X) of a 52-year-old woman who complained of the sudden onset of hoarseness, odynophagia, dysphagia, and hearing loss in the left ear, followed by left-side facial weakness lasting for 1 week. Endoscopic examination revealed multiple mucosal erosions over the oropharynx, with extension upward to the nasopharynx and downward to the mucosa overlying the epiglottis, arytenoid, and vocal cord. All of these lesions tended to lateralize to the left side, suggesting a VZV infection diagnosis; this was confirmed by polymerase chain reaction on eruptional exudates, as well as serologic examination.

Endoscopic transsphenoidal vidian neurectomy.

The purpose of this report is to describe a novel technique for endoscopic vidian neurectomy (EVN) based on preoperative computed tomography (CT) classification of the vidian canal (VC), and to present anatomical and surgical findings from an initial series. Retrospective study, consisting of medical chart review and patient interviews, of all preoperative CT-guided EVN procedures was performed from 2006 to 2010 at a tertiary-care medical center. A total of 89 patients with intractable rhinorrhea (77 males and 12 females, mean age 29 years, age range 16-57 years) underwent bilateral EVN. Configuration of the VC was classified into three types based on preoperative CT findings. The technique for surgical access of each of these configurations is presented. The most common configuration of the VC was type 2 (47%). A wide, direct, and safe exposure of the vidian nerve was achieved in all cases. 84 of 89 patients completed the questionnaires regarding the postoperative improvement in quality of life. Follow-up ranged from 2 to 42 months, with an average of 19.6 months. 77 of 84 (91.7%) patients were satisfied with their surgical result. Two patients underwent revision ETSVN due to relapsed symptoms. With the help of a preoperative CT scan of the paranasal sinuses, the vidian nerve can be identified precisely via an endoscopic intrasphenoidal or transsphenoidal approach, which provides an easy and reliable way to perform vidian neurectomy.

Effects of lidocaine on rat's isolated tracheal smooth muscle.

Lidocaine has been used as an injection or spray solution to protect spasm reaction during tracheal intubation and bronchoscopy. The effect of lidocaine for local anesthesia is well known. However, the effect of the drug to tracheal smooth muscle is not well explored. We used our preparation to test the effectiveness of lidocaine on rat's isolated tracheal smooth muscle. The following assessments of lidocaine were performed: (1) effect on tracheal smooth muscle resting tension; (2) effect on contraction caused by 5 x 10(-6) M methacholine as a parasympathetic mimetic; (3) effect of lidocaine on electrically induced tracheal smooth muscle contractions. The addition of lidocaine induced a relaxation response to methacholine-induced contraction. Low doses of the drug resulted in a slight decrease in contraction and higher doses relaxed the trachea much more quickly. At 10(-3) M of lidocaine, almost 51% of 5 x 10(-6) M methacholine-induced contraction was decreased. Using the same concentration, the drug also could totally inhibit the electrical field stimulation-induced spike contraction. Lidocaine elicited a negligible response to the resting tension of trachea as the concentration increased. The study indicated that lidocaine could cause bronchodilation not only from blocking parasympathetic tone, but also from directly antagonizing the effect of cholinergic receptors.

Effects of cetirizine on isolated rat's tracheal smooth muscle.

Cetirizine (Zytec) is often used as a histamine receptor-1 (H(1)) antagonist in rhinitis patients who are suffering from sneezing and rhinorrhea. This H(1) antagonist is used as an oral tablet or nasal spray solution. The effect of H(1) antagonist on nasal mucosa in vivo is well known; however, the effect of the drug on tracheal smooth muscle has been rarely explored. Therefore, during administration of the H(1) antagonist for nasal symptoms, it might also affect the trachea via oral intake or inhalation. We used our preparation to test the effectiveness of Zytec on isolated rat's tracheal smooth muscle. The following assessments of Zytec were performed: (1) effect on tracheal smooth muscle resting tension; (2) effect on contraction caused by 5 x 10(-6) M methacholine as a parasympathetic mimetic; (3) effect of the drug on electrically induced tracheal smooth muscle contractions. Results indicated that addition of a parasympathetic mimetic to the incubation medium caused the trachea to contract in a dose-dependent manner. Addition of Zytec at doses of 10(-5) M or above elicited a relaxation response to 5 x 10(-6) M methacholine-induced contraction. Zytec could inhibit electrical field stimulation induced spike contraction, and basal tension was increased at the same time. However, it alone had a minimal effect on the basal tension of trachea as the concentration increased. This study indicated that high concentrations of Zytec might actually inhibit parasympathetic function of the trachea.

Low temperature decreased basal tension in isolated rat tongue.

The tongue is a complex organ that plays a vital role in the functions of mastication, deglutition, articulation, airway protection, and oral hygiene maintenance. The tongue also has the function of regulating body temperature. The aim of this study was to evaluate the effect of temperature on the tension changes of isolated rat tongue, with or without electric field stimulation (EFS). Tissue bath for isolated tongue was used. An in vitro isometric contraction of tongue from healthy Sprague-Dawley rat (body weight > or =200 g) was continuously recorded. Tension in strips of rat tongues that were untreated and treated with EFS, was recorded continuously in stepwise manner in temperatures that varied from 37 to 7 degrees C or 7 to 37 degrees C. Descent and reascent of temperature produced temperature-dependent tension changes. Basal tension of the tongue decreased as temperature was reduced, while EFS-induced spike contraction increased as temperature was reduced. Low temperature induced rapid and reproducible relaxation in isolated rat tongue strip. Increasing temperature enhanced basal tension and reduced EFS-induced spike contraction of the tongue.

A surgical algorithm using open rhinoplasty for correction of traumatic twisted nose.

In this series, the authors present their experience with correction of the traumatic twisted nose in Asians using open rhinoplasty. A standard surgical algorithm was followed to determine treatment strategies for 92 patients with traumatic twisted nose at the Tri-Service General Hospital in Taiwan between 1 August 2001 and 1 June 2004. A retrospective chart review was performed to collect patient data and surgical details. A follow-up self-evaluation survey regarding satisfaction with nasal function and aesthetics was distributed to all the participants. All the patients underwent open rhinoplasties under general anesthesia. The 87 males and 5 females were 15 to 53 years of age (mean, 28 years). Their postoperative periods were uneventful and without complications. Patient self-evaluations were largely positive, reporting improvement in nasal function. The authors propose a simple surgical algorithm using open rhinoplasty for optimal correction of traumatic twisted nose deformities. The algorithm, which is adaptable to a variety of anatomic deformities, guides surgical decision making that yields consistently satisfactory functional and aesthetic results.

Subglottic stenosis after thoracotomy--a case report.

Traumatic intubation, reintubation, intubation with endotracheal tube of inappropriate size, and failure to firmly secure the tube may contribute to the development of subglottic stenosis. Systemic factors such as sepsis, hypotension, autoimmune and granulomatous disorders have all been implicated as contributing causes. In addition, a risky circumstance that might be considered important in the development of airway damage is the occurrence of gastreoesophageal reflux (GER), particularly in thoracotomy operations, where the patients are placed in the lateral position. The purpose of this report is to describe a patient who developed subglottic stenosis following a thoracotomy. The possible causes are macrotrauma due to multiple intubations and microtrauma due to inappropriate tube size in the course of anesthesia. Furthermore, GER may worsen mucosal injuries, which may be precipitated by the lateral position.

A new in vitro method of decongestant assay of nasal mucosa: a preliminary report.

BACKGROUND: The calculation of cell planar surface area, successfully used for glomerular mesangial cell-altered contractility, also is a reasonable methodology to assess nasal mucosal contractility. A simple technique that works particularly well with vasoconstriction-inducing agents has been introduced to test the effects of several drugs on patient turbinate nasal mucosa in vitro. This report will introduce this technique and present some of the initial findings. METHODS: We tested epinephrine, norepinephrine, pseudoephedrine HCl, and methoxamine, respectively, for effectiveness as a vasoconstricting drug. We also tested the effectiveness of verapamil as a vasodilating drug. A piece of nasal mucosa approximately 3 x 4 mm in size was mounted with a 27-gauge needle and submersed in a 4-mL muscle bath in a Petri dish at room temperature. The bath consisted of 4 mL of Kreb's solution. We recorded the decrease of nasal mucosa planar surface area in response to the application of vasoconstricting agents, as measured using a digital microscope connected to a Pentium III with morphometric software, as the estimated degree of contraction. A photograph of the same mucosa was taken every 3 minutes for a total period of 18 minutes. RESULTS: Nasal mucosa that was mounted in a muscle bath in a Petri dish and treated with a small dose of a nasal decongestant was l observed to contract. Drug dosage determined the degree of nasal mucosa contraction. Nasal mucosa similarly prepared but treated with a vasodilating agent, such as verapamil, exhibited a relaxation response only when pretreated with a vasoconstricting agent, such as methoxamine. Both vasoconstricting and vasodilating drugs induce dose-related responses in planar surface calculation. CONCLUSION: In this study, drug dosage determined the degree of nasal mucosa contraction. We also found that the rate of contraction and percent of contraction were dose dependent. We believe this new method will prove useful in studying the effects of drugs on nasal blood vessels.

Low temperature decreased tension in isolated hypertrophic human nasal mucosa.

BACKGROUND: The purpose of this study was to evaluate the effect of low temperature on basal tension in isolated hypertrophic human nasal mucosa with or without alpha1-agonist stimulation. METHODS: A tissue bath for isolated nasal mucosa was used. Tension in strips of human turbinate mucosa that were untreated and treated with an alpha1-adrenoreceptor agonist, methoxamine (10 microM), was recorded continuously in a stepwise manner in temperatures that varied from 37 to 10 degrees C. RESULTS: The changes of tension in the human nasal mucosa were found to be temperature-dependent in both untreated and treated tissues, with tension decreasing to 48.6% at 10 degrees C in comparison with 100% at 37 degrees C in the untreated group, the presence of methoxamine (10 microM) had minimal effect. CONCLUSION: Low temperature induced a rapid and reproducible relaxation in isolated hypertrophic human nasal mucosa that was not affected by the presence of the alpha1-agonist methoxamine (10 microM).

Precaruncular medial canthopexy.

OBJECTIVES: To describe a new 3-dimensional technique for medial canthal repositioning, precaruncular medial canthopexy (PMC), and to present an outcome study demonstrating its efficacy. METHODS: Data (age, sex, cause, and initial symptoms) were collected prospectively on patients with malposition of the lower eyelid. All patients were photographed before and after surgery in a set protocol. The type and severity of eyelid malposition were documented using the Ectropion Grading Scale (EGS) before and after each procedure. Surgical outcome was evaluated by objective improvement of ectropion grading and subjective resolution of symptoms. RESULTS: Precaruncular medial canthopexy was performed on 30 eyelids of 27 consecutive patients (10 were revisions) for correction of medial eyelid laxity or malposition. Twenty-six patients had ectropion, and 1 had bilateral entropion. The most common cause of eyelid malposition was facial paralysis (n = 21). Ancillary procedures, most commonly lateral transorbital canthopexy (for correction of lateral ectropion), were performed on 60% of the eyelids at the time of PMC. Twenty-eight procedures resulted in complete restoration of the medial canthus to a normal position (EGS grade I). Two patients had minimal residual medial scleral show after surgery (EGS grade II) but experienced symptom relief. There were no wound infections or perioperative complications. CONCLUSIONS: Precaruncular medial canthopexy rapidly and safely restores support in all 3 dimensions without blocking the visual field or damaging the lacrimal system, with minimal morbidity and excellent wound healing. In addition to being a primary technique for correcting medial eyelid malposition, PMC should be routinely considered as an adjunct procedure when correcting lateral eyelid malposition.