Mandibular reconstruction using a titanium plate: the impact of radiation therapy on plate preservation.

PURPOSE: To evaluate the soft tissue and bone tolerance of radiation therapy (RT) in patients undergoing radical composite resection and mandibular reconstruction using a bridging titanium plate with myocutaneous flap closure. METHODS AND MATERIALS: From 1990 to 1994, 47 patients with primary or recurrent oral cavity or oropharyngeal carcinomas were treated with radical composite resection and mandibular reconstruction using a bridging titanium plate with myocutaneous flap closure. Eleven patients received no RT (no RT), 10 patients received RT greater than 10 months from the time of surgery (remote RT), and 26 patients received RT within 12 weeks of surgery (perioperative RT). The radiation dose to the reconstructed mandible ranged from 45 to 75 Gy (median 63 Gy). The effect of the titanium plate on the radiation dose was measured using film dosimetry and soft tissue and bone-equivalent materials. The median follow-up was 17 months (range: 3-50 months). RESULTS: Late complications included four patients with osteomyelitis or necrosis, two plate exposures requiring flap revision, one chronic infection, two cases of chronic pain, two fistulae, and one case of trismus and malocclusion. The crude incidence of late complications by treatment was: (a) no RT: 3 of 11 patients (27%); (b) remote RT: 2 of 10 patients (20%); and (c) perioperative RT: 9 of 26 patients (35%). One patient in the no-RT group lost the plate due to chronic pain. Five patients in the perioperative RT group also had plate loss, four due to osteomyelitis and/or necrosis, and one due to pain related to a recurrent tumor. No patients in the remote RT group had plate loss. The actuarial prosthesis preservation rate at 2 years was 88% for the no RT, 100% for the remote RT, and 57% for the perioperative RT groups (p = 0.05). Phantom dose measurements showed that for parallel opposed 6 MV photon beams, there was no significant increase in the dose proximal or distal to the plate in either a soft tissue- or bone-equivalent phantom. CONCLUSIONS: The impact of radiation therapy on plate preservation after mandibular reconstructive surgery using a titanium plate may be dependent on the timing of RT relative to surgery. Significantly more mandibular reconstruction plates were lost when the involved mandible received RT in the perioperative period than when RT was delivered beyond 10 months from surgery or when no RT was given. The use of alloplastic implants such as titanium plates in conjunction with myocutaneous flap coverage for mandibular reconstruction is attractive because it allows immediate reconstruction of the defect and promotes a good functional and cosmetic result; however, administration of perioperative RT may result in a higher plate failure rate.

Recent advances in paranasal sinus surgery.

Recent advances in paranasal sinus surgery have occurred in the treatment of trauma and neoplasia, rather than in the more traditional management of inflammatory disease. Cranialization of the frontal sinus in severe penetrating trauma was first described in 1978. By removal of the sinus posterior wall, excision of the mucosa, and preservation of the anterior wall fragments, the forehead contour can be preserved and the cavity ablated by the forward expansion of the frontal lobes. Craniofacial surgery for malignancies of the paranasal sinuses has vastly improved the survival rate for these patients. Simultaneous en bloc resection, done transcranially to establish the margins of resection of the superior-most extent and transfacially to ablate the site of origin of the neoplasm, has produced five-year survival rates of 50%. Involvement of even the cavernous sinus can be handled, providing initial control of the internal carotid artery is achieved and an adequate cerebral circulation is ensured. Decompression of the optic nerve following facial trauma that results in fractures of the orbital apex remains controversial. Documented cases of progressively failing vision in such patients provides the clearest indication. Surgical decompression through the transethmoidal sphenoidal route provides excellent access to remove the maximum amount of bone from the optic canal.

Voice change surgery in the transsexual.

Sexual reassignment surgery for individuals with gender identity confusion has been highly successful, especially in the male-to-female transformation. A troublesome problem for some of these individuals is the retention of their male voice. Although castration and estrogen therapy may produce minor elevations of pitch and the assumption of a falsetto voice produces a more typical but contrived female tone, the basic male anatomic structure of the larynx must be altered to effect a physiological transformation. In three transsexuals, an attempt was made to effect a more female tonal quality by shortening the vibrating length of the vocal folds. Through a laryngofissure, the anterior one third of each cord was denuded and the raw edges approximated. This produced an anterior web that successfully resulted in pitch elevation in all three cases.

Alveolar soft part sarcoma of the tongue.

Alveolar soft part sarcoma (ASPS) is a rare malignancy; only 39 cases have been reported in the head and neck region. A 19-year-old woman is presented here who had ASPS of the tongue. Surgical resection was followed by irradiation therapy. She is tumor-free 2 years after treatment.

Carcinoma in a Zenker's diverticulum.

Zenker's diverticulum is a common developmental anomaly seen usually in the elderly. Carcinoma in this pharyngoesophageal outpouching has been reported in only 23 instances. A 55-year-old woman is presented whose only symptoms were dysphagia and periodic regurgitation of bloodstained material. Barium swallow and esophagoscopy confirmed the presence of a neoplasm, and biopsy revealed an epidermoid carcinoma. Wide field resection was followed by a full course of irradiation and secondary pharyngoesophageal reconstruction. The patient was free of disease at three-year follow-up.

Frontal bone defect with frontal sinus mucopyocele.

For this patient's treatment, all three consultants advise against the Lynch-type frontoethmoidectomy procedure, with or without mucoperiosteal flap reconstruction of the nasofrontal duct. Treatment plan: Culture and sensitivity of pus; 2-3 weeks of intravenous antibiotics followed by osteoplastic flap fat obliteration of frontal sinus; delayed defect repair with methyl methacrylate (Montgomery). Trephination followed by treatment with local and systemic antibiotics (Donald); removal of infected bone and soft tissue (sinus collapse) and delayed defect repair in 6-12 months (Donald, Calcaterra) with metylmethacrylate (Donald) or in situ cured silicone elastomer (Calcaterra).

Radiologic evaluation of irradiated cartilage grafts on the facial skeleton of sheep.

Augmentation mentoplasty is a commonly performed procedure for correction of retrognathia and microgenia. Implantable Silastic prostheses have become the mainstay of therapy, but have some disadvantages. One of the most important complications is erosion of the underlying mandible. An attempt was made to produce an experimental animal model to test the efficacy of irradiated costochondral cartilage in this regard. In order to prevent a biological material from eroding the underlying bone, the irradiated sheep cartilage grafts were placed subperiosteally, deep to a pair of large muscles of facial expression in five Suffolk sheep. Irradiated cartilage was used as the test material and merthiolate-treated cartilage as the control. Only 1 of the 20 grafts showed any absorption after 1 year, and this was only 1 mm in depth. Because of the meager amount of absorption of irradiated cartilage grafts, the ease with which they can be carved, and their ready availability, they would appear to be ideal implants for chin augmentation.

Prediction of major vascular injury in patients with gunshot wounds to the neck.

PURPOSE: To determine whether plain film and CT findings help predict the presence and severity of vascular trauma. METHODS: The records of 65 patients with gunshot wounds of the neck were reviewed. There were 58 men and 7 women ranging in age from 2 to 72 years. All had angiography of the cervical vessels; in addition, 64 had plain radiography, 22 had CT, and 14 had a barium swallow. The results of plain films, barium swallow, and CT scans were correlated. RESULTS: Eighteen patients (28%) had major vascular injury, which included 10 pseudoaneurysms, six vascular occlusions, four intimal injuries, and one arteriovenous fistula. Ten patients had prevertebral soft-tissue swelling (sensitivity, 59%; specificity, 77%), 14 had a bullet fragment close to a vessel (sensitivity, 78%; specificity, 36%), and 13 had missile fragmentation (sensitivity, 72%; specificity, 45%). CONCLUSION: Prevertebral soft-tissue swelling, missile fragmentation, and missiles adjacent to major vessels are useful but nonspecific radiographic signs and are present in many patients with normal angiographic findings. A knowledge of the physical findings, including the entry and exit wounds, plus the results of plain radiography and CT can help define bullet trajectories and guide angiographic evaluation.

Cartilage grafting in facial reconstruction with special consideration of irradiated grafts.

The search for the perfect facial implant for reconstruction of the face continues. Cartilage, once thought to be an undesirable graft material because of its propensity for absorption, has regained popularity in the past decade. Various preparation techniques have been employed to ensure graft sterility and diminished absorption. An improved understanding of cartilage structure and physiology has shed considerable light on the host-graft relationship. Gamma irradiation is a time-honored method of preservation. An experiment was undertaken to investigate the physiology of irradiated cartilage grafts following prolonged implantation on the facial skeleton of sheep and dog. Merthiolate preserved grafts were used as controls. Direct observation, histochemical techniques, autoradiography, and transmission electron micrography were used to determine chondrocyte viability and matrix composition. It was surprising to note that following implantation of 16 to 72 months, complete resorption was seen in 87.7% of the irradiated grafts and in 43.8% of the Merthiolate stored controls. Many of the grafts acquired chondrocytes from the host and produced new proteoglycan matrix as well as undergoing some degree of ossification. A comparison to the clinical situation in humans is made.

Surgical rehabilitation following anterior resection for oral cavity carcinoma.

Resection of large tumors located in the anterior aspect of the oral cavity is commonly complicated by problems of functional disturbance and esthetic aberration. Oral incompetence with defects in swallowing and inadvertent drooling are often major hurdles to overcome. The cosmetic deformity produced by the loss of support of the anterior floor of mouth and tongue due to the resected mandibular arch provides one of the most challenging reconstructive exercises facing the head and neck surgeon. Surgical rehabilitation is most adequately achieved by a consideration of each physiological defect produced by the surgical alteration of each anatomical entity in the lower third of the face. Reestablishment of mandibular arch continuity is the keystone of the reconstructive effort; however, procedures that improve lip support, lingual mobility, and alveolar ridge enhancement are vital features in the rehabilitation of a functioning esthetically acceptable oral and perioral region.

Complications in skull base surgery for malignancy.

OBJECTIVES: To review a consecutive series of skull base surgeries, establish the rate of complications, and outline their prevention and management. STUDY DESIGN: A retrospective review of 107 consecutive intracranial/extracranial operations performed for malignancy that transgresses the skull base. METHODS: The hospital charts of 107 operations performed on 98 patients at the University of California at Davis Medical Center. The type of operation, cause of death, and complications were noted. RESULTS: The complication rate was 50.5%. Forty-eight patients had no complications. There were six perioperative deaths. The most common surgical complications were cerebrospinal fluid leak (11.2%), meningitis (4.8%), and wound breakdown (15%). The most common medical complications were pneumonia (6.5%), cardiac disturbance (4.7%), and electrolyte imbalance (3.7%). The only prior treatment that was accompanied by a significant increase in complications was previous surgery. CONCLUSIONS: patients who had cranial base surgery for the intracranial spread of head and neck cancer. The perioperative death rate is less than 4%. The major complications were at an acceptable rate.

Sphenoid marsupialization for chronic sphenoidal sinusitis.

OBJECTIVES: To review experience with sphenoid marsupialization and describe the technique using new instrumentation. STUDY DESIGN: Retrospective review of five cases of chronic sphenoid sinusitis that were resistant to standard medical and surgical methods, which were treated by sphenoid marsupialization. METHODS: Charts were reviewed and patients were interviewed regarding postoperative resolution of symptoms. RESULTS: Five cases of recalcitrant sphenoid sinusitis were reviewed. All patients had headache before surgery, and two had visual disturbance. In follow-up ranging from 1 to 87 months, all were free of symptoms related to the sphenoid sinus. CONCLUSIONS: Marsupialization is an effective method of exteriorizing a chronically infected sphenoid sinus. The use of functional endoscopic sinus surgery instruments and the TAC attachment of the Midas Rex drill make this surgery possible.

Hearing results following atticotomy.

Transmeatal atticotomy, a common otosurgical procedure near the turn of the century, has since enjoyed only sporadic periods of popularity. An earlier report illustrated the efficacy of the atticotomy operation in ablating cholesteatoma in 83% of cases. However, the ossicular chain usually suffers discontinuity either through erosion by cholesteatoma or surgical disarticulation. In ears with an intact chain, the incudostapedial joint is usually separated to avoid injury that may be transmitted to the inner ear if the rotating burr contacts the ossicles. The purpose of this paper is to portray the types of hearing restoration attempted and the results achieved in 55 patients who had an atticotomy procedure and had been followed for six months to eight years. The number of patients who attained serviceable hearing are compared to those that did not, with regard to such factors as the hearing level and state of the ossicles preoperatively as well as the extent of the surgery required for removal of the disease. The hearing results in these patients who underwent atticotomy compare favorably to those cited in the literature for tympanoplasties done with the modified radical mastoidectomy or the intact canal wall tympanomastoidectomy.

Compound frontal sinus injuries with intracranial penetration.

Extensive trauma to the forehead, resulting in large penetrating wounds of the frontal sinus that extend into the frontal lobes of the brain, has traditionally been treated by frontal sinus ablation. Although this operation eliminates dead space, it leaves the patient with a depressed area in the forehead with little protection for the brain. The success of Nadell and Kline in replacing skull fragments following compound depressed skull fractures yet avoiding infection has spurred us to attempt this technique in penetrating injuries of the frontal sinus. By preserving the anterior frontal sinus wall, we have not only afforded protection for the frontal lobes of the brain, but, at the same time, avoided the cosmetic defect that would be left by an ablation procedure. This procedure has been performed on two patients at our institution. After a two-year follow-up, excellent forehead profile preservation has been achieved and there has been no evidence of bone absorption or infection at any time since surgery.

The safety of frontal sinus fat obliteration when sinus walls are missing.

The dilemma of the management of a severely fractured frontal sinus when portions of the walls are missing presents a number of therapeutic options. The safety of placing a fat graft in such a sinus for obliteration when the graft will be required to obtain its nourishment from the scant vessels contained within the subcutaneous tissue or dura, or worse still, from a dural or bone graft is questioned. Clinical experience has suggested that such a procedure may not be safe. An experiment was performed in nine cats in which all of either the anterior or posterior frontal sinus wall was removed in eight sinuses, and 50% of either wall in the remaining ten. A standard osteoplastic flap and fat obliteration technique was then done. On microscopic examination 3 months later, 50% of the sinuses showed either reepithelialization, mucocele formation, infection, or some combination. This gives some support to the contention that patients undergoing fat obliteration after fracture in which frontal sinus walls are missing are in jeopardy of subsequent mucocele formation and infection.

Frontal sinus fractures: a review of 72 cases.

A retrospective review is presented of 72 patients who sustained frontal sinus fractures (FSF) and were subsequently treated by the department of otolaryngology/head and neck surgery between the years of 1974 and 1986. Eighty-four percent of FSF occurred in males and 71% were a result of motor vehicle accidents. Only 24% remained conscious at the time of trauma, and in only one third of the cases was there no other fracture. Seventy-six percent of FSF involved both the anterior and posterior walls--a figure that possibly reflects the referral patterns to a hospital that is a major regional trauma center. Patients were treated with a variety of procedures including cranialization (42%), osteoplastic flap and fat obliteration (30%), open reduction and internal fixation of the anterior wall (20%), osteoplastic flap and sinus ablation (6%), and intersinus septectomy (1%). Some difficulty was encountered in documenting sustained follow-up, which ranged from 2 months to 9 years, and averaged 22 months. Nine percent of patients died in the post-trauma period. Minor complications were relatively common, but major complications occurred in only 10% of patients. Four patients (6%) suffered meningitis (although the portal of infection was not necessarily through the frontal sinus); one patient (1%) suffered severe pain over the sinus and forehead for at least 12 months after surgery; and a mucocele developed in four patients (6%).

Superior based trapezius flap.

The most revolutionary innovation in reconstructive surgery of the past decade is the development of the musculocutaneous flaps. These flaps permit the reconstruction of large head and neck defects in one stage. They carry an excellent reliable blood supply and the inclusion of the underlying muscle adds sorely needed bulk to the resected area. The trapezius musculocutaneous flap is one of the most versatile. Its color and texture match for facial reconstruction is excellent. Moreover, the pliability of the cutaneous component lends itself well to lining the oral cavity and the oropharynx. The trapezius musculocutaneous flap is an outstanding advance in head and neck reconstructive surgery. The discovery that it can be successfully pedicled superiorly greatly enhances its versatility.

Use of the levator scapulae muscle flap in head and neck reconstruction.

There are numerous techniques available for reconstruction of defects following composite resection of oral cavity and oropharyngeal tumors. No single technique is applicable in all situations. The levator scapulae muscle flap is well known for its application in carotid protection. Little attention is paid to its usefulness in other aspects of head and neck reconstruction. We have been using the levator scapulae muscle flap for a variety of reconstructive problems. The flap is useful for buttressing intraoral suture lines, closing intraoral defects, and providing soft tissue to fill in dead spaces and bulk out lateral and anterior oral defects. The levator flap was found to be easy to elevate, safe, and reliable with a minimum of wound complications. A review of 18 patients, representative case studies, and a discussion of surgical technique and relevant anatomy and blood supply is presented.

Internal carotid artery resection for invasion of malignant tumors.

BACKGROUND: To study the preoperative investigation and outcome of patients who underwent resection of the internal carotid artery for malignant disease. A retrospective analysis using a chart review of these patients was performed, and the results were analyzed. All patients were treated by one of us (U.K.N.) at the University of California-Davis Medical Center, Sacramento. A population of 18 patients who underwent a transcervical, transpetrosal, or petrocavernous resection of the internal carotid artery from 1976 to 1993 was studied. Preoperative study consisted of four-vessel arteriography, balloon test occlusion, electroencephalographic intraoperative monitoring, and, after 1990, single-photon emission computed tomographic scanning. Disease-free interval and neurologic complications were assessed. RESULTS: Two patients were alive and well without disease at 6 and 9 months postoperatively. One patient was alive and well at 12 months, and three have survived more than 2 years without recurrent tumor. Eleven patients died within 1 year of surgery (three postoperatively, six of recurrent disease, and two of unknown causes). One patient died of disease at 14 months. CONCLUSIONS: Internal carotid artery invasion by malignancy portends a poor prognosis. Carotid artery resection can provide reasonable palliation. Early results of skull-base surgery on patients with intrapetrous and petrocavernous carotid artery involvement are encouraging. Balloon test occlusion and single-photon emission computed tomographic scanning provide a valuable assessment of contralateral cerebral blood flow.

The pressure exerted by mucoceles in the frontal sinus. An experimental study in the cat.

The pathophysiologic process that results in bone erosion from frontal sinus mucoceles has long been a mystery. Traditionally, bone erosion has been attributed to pressure. However, no scientific evidence has yet been presented to support this hypothesis. To answer this question, seven cats had a mucocele created in one frontal sinus, with the other sinus left as a control. A manometer was inserted into each frontal sinus. Pressure readings were taken over a 7-month period. Pressures on the mucocele side were higher than on the control side and were sufficient to erode bone. Bone was thicker on the mucocele side than on the control side. This study established that mucoceles exert sufficient pressure to erode bone, and that such erosion may be part of a two-stage process.