A new technique for hypoglossal-facial nerve repair.

Hypoglossal reinnervation of the facial nerve may be required after a proximal facial nerve injury. The classic hypoglossal-facial graft procedure involves transection of the donor hypoglossal nerve, resulting in hemiglottic paralysis that, in association with paralysis of other cranial nerves, may cause speech and swallowing difficulties. Multiple lower cranial nerve palsies in conjunction with facial paralysis, as may occur after procedures such as skull base surgery, contraindicate the use of such techniques. The successful use of XII-VII "interposition jump grafts" without hemiglossal weakness has been described However, a prolonged recovery period and weaker facial reanimation have been seen. In order to attain maximum facial reinnervation while preserving hypoglossal function, we have developed a new technique of XII-VII repair. This method involves mobilization of the intratemporal portion of the facial nerve remnant, achieving a single anastomosis with the hypoglossal nerve, which has been partially incised. This technique has been used in three patients to date, with 6 to 11 months follow-up. In all cases facial tone and symmetry have been restored and voluntary facial expression accomplished. The authors conclude that by employing the techniques described highly satisfactory cosmetic and functional results may be expected, without compromising hypoglossal nerve function.

A management strategy for vocal process granulomas.

OBJECTIVES/HYPOTHESIS: Review the roles of aggressive gastroesophageal reflux management and speech therapy in the treatment of patients with vocal process granulomas. Describe and assess our investigation and management protocol. STUDY DESIGN: Retrospective review of 55 patients with 61 vocal granulomas treated according to a standard protocol at the Sydney Voice Clinic. Comparison with previous published series and review of the relevant literature pertaining to granulomas and to reflux. Description of laryngopharyngeal reflux grading, investigative modalities, and treatment regimen. METHODS: Case notes were reviewed and tabulated for age, sex, diagnosis, predisposing factors for granuloma formation, grade of laryngopharyngeal reflux, investigations, treatment, resolution, and recurrence. All patients were followed up for at least 12 months after resolution. RESULTS: Fourteen of the 61 granulomas occurred after intubation. Ten patients were professional voice users. Our assessment of the 55 granuloma patients revealed an incidence of 76% of gastroesophageal reflux disease in patients with and without known vocal fold trauma. There was a 50% recurrence rate following surgical excision. However, aggressive antireflux therapy, lifestyle modifications, and adjuvant speech therapy were successful in achieving resolution of most of the granulomas and preventing recurrence. In four patients, antireflux surgery was required and total resolution of the granulomas followed. CONCLUSIONS: Vocal process granulomas have perplexed laryngologists with their indeterminate pathogenesis and tendency to recur. Multiple surgical excisions and a variety of combined medical regimens have been used to treat granulomas with variable success. Recurrence after excision commonly occurs as the underlying causative factors have not been appropriately managed and may re-establish the chronic inflammatory process. We found acid reflux to be a common factor in the majority of our patients with granulomas. Therefore treatment should focus on managing both reflux and any functional voice disease or disorder. The only indications for laryngeal surgery are to resolve diagnostic doubt or to treat acute airway compromise. Based on results, we suggest an algorithm for the investigation and management of vocal process granulomas founded on appropriate antireflux and speech therapy.

Comparison of functional endonasal sinus surgery with and without partial middle turbinate resection.

The aim of endonasal sinus surgery is to ameliorate sinonasal symptoms and to achieve a functional nose. Although the importance of opening the ostiomeatal complex is accepted, the role of middle turbinate surgery remains controversial. Although some surgeons emphasize the importance of maintaining the middle turbinate as a physiological humidifier and anatomic landmark, others resect it without adverse sequelae. To date, there have only been limited reviews published to support either approach. This paper examines 1,106 matched patients who underwent similar functional endonasal sinus surgery with (509 patients) or without (597 patients) middle turbinate surgery. We demonstrate a paucity of complications and the potential outcome benefits of judicious partial middle turbinate resection in some patients with more severe rhinosinusitis.