Superomedial submucosal partial arytenoidectomy for improved posterior glottic closure: surgical technique and case presentation.

OBJECTIVE: Endoscopic medial partial arytenoidectomy has been described previously for expansion of the posterior glottic airway in bilateral vocal fold paralysis. Superomedial submucosal partial arytenoidectomy (SSPA), a modification of this technique, can improve glottic closure in the setting of an obstructing anteromedially prolapsed arytenoid. We present our surgical technique and a case example. METHODS AND RESULTS: A 45-year-old man presented with dysphonia attributable to unilateral true vocal fold paralysis. Laryngoscopy revealed right true vocal fold atrophy and an anteriorly prolapsed right arytenoid cartilage preventing posterior glottic closure during adduction. Right SSPA and ipsilateral vocal fold injection augmentation were performed without complication. One-month and 11-month postoperative evaluations showed marked improvement in voice, with complete glottic closure. Quality-of-life assessment and patient report showed a durable result at 50 months. CONCLUSION: SSPA may be a valuable technique in the management of breathy dysphonia associated with posterior glottic gap and other sequelae of the malpositioned arytenoid.

Cosmetics and function: quality-of-life changes after rhinoplasty surgery.

OBJECTIVES/HYPOTHESIS: To measure patient quality of life after rhinoplasty in regard to nose appearance and function with use of the modern structural and functional surgical approach. STUDY DESIGN: Retrospective chart review at a tertiary referral center. METHODS: We performed a retrospective chart review with prospective follow-up. All patients with rhinoplasty in the past 5 years by the senior author were identified. Patients who simultaneously underwent additional nasal surgery were excluded. McNemar test was used to compare preoperative and postoperative clinical evaluations. Paired t tests were used to evaluate questionnaire scores preoperatively and postoperatively from the nasal obstruction symptom evaluation and rhinoplasty outcome evaluation. Two-group t tests were used for comparative analysis after dividing patients into two groups on the basis of dorsal reduction, osteotomies, open versus closed approach, and revisions. RESULTS: Among 370 patients invited, 126 participated and 113 provided completed questionnaires. Analysis of preoperative and postoperative nasal-obstruction symptom evaluation scores showed a median difference of -40 (quartiles, -25 and -60), indicating improvement (P < .01). Preoperative and postoperative rhinoplasty outcome evaluation scores showed a median difference of 29.2 (quartiles, 12 and 50), also indicating improvement (P < .01). Difference in improvement in scores was not significant when groups were divided on the basis of dorsal reduction, osteotomies, and open versus closed approach or whether rhinoplasty was primary versus revision. CONCLUSIONS: Modern rhinoplasty techniques that depend on a strong structural framework of grafts compared with the traditional reduction rhinoplasty techniques significantly improve patient quality of life in regard to nose function and appearance.

Mesenchymal hamartomas of the pediatric head and neck.

We describe the fifth published report of a mesenchymal hamartoma presenting as a cheek mass. A 5-month-old infant was brought to our institution for evaluation of an enlarging left-sided congenital cheek mass. Over time, the lesion had begun to cause significant facial asymmetry and oral incompetence. Radiologic imaging revealed an approximate 2.5 × 3.5-cm, noncystic lesion located in the left buccal space, separate from the mandible and surrounding the salivary glands. Magnetic resonance imaging (MRI) sequences demonstrated an isointense, T1-weighted lesion with avid gadolinium uptake, and increased intensity of T2-weighted sequences. The patient subsequently underwent biopsy and subtotal resection through a left gingivobuccal incision with the goal of improving lip contour and facial symmetry. Histologic examination revealed an admixed arrangement of mature smooth muscle, vascular, adipose, and neural tissue elements within a slightly myxoid stroma, consistent with a mixed mesenchymal hamartoma. An 8-month postoperative MRI demonstrated near-total removal without evidence of regrowth. While rare, hamartomas should be included in the differential diagnosis of a slow-growing pediatric head and neck mass. Gross total resection may provide cure; however, given this lesion's benign nature, less-than-complete resection should be considered when lesions infiltrate opposing critical structures. Thorough clinical and histologic evaluation is critical to avoid overly aggressive treatment and unnecessary morbidity.

Prophylactic perioperative antibiotic use in endoscopic sinus surgery: a systematic review and meta-analysis.

CONTEXT: Perioperative antibiotics are widely used to improve the outcomes of endoscopic sinus surgery. OBJECTIVE: The aim of this study was to summarize the evidence on the effect of perioperative antibiotic prophylaxis on outcomes of endoscopic sinus surgery. DATA SOURCES AND REVIEW METHODS: We searched electronic databases from inception through May 2011 for any relevant clinical trials or observational studies. Two reviewers working independently extracted study characteristics, quality, and the outcomes of interest. Random-effects meta-analysis was used to pool the relative risks (RRs) and the standardized mean differences (SMDs) across trials. RESULTS: We found 4 eligible trials with varying quality, of which 3 were included in the quantitative analysis. Antibiotic prophylaxis was associated with a nonsignificant reduction in the incidence of infections (relative risk, 0.76; 95% confidence interval [CI], 0.64 to 1.09), symptoms scores (SMD, -0.04; 95% CI, -0.46 to 0.38), and endoscopic scores (SMD, -0.09; 95% CI, 0.30 to 0.13). The heterogeneity associated with the analysis was significant only for the outcome of change in symptoms score (I-squared values, 0%, 70%, and 0% for the 3 outcomes, respectively). CONCLUSIONS: Trial data available to date are unable to demonstrate a statistically significant reduction in infection, symptom scores, or endoscopic scores to support the routine use of postoperative prophylactic antibiotics following endoscopic sinus surgery. Our analysis was limited by the number of published trials related to this topic.

Spontaneous epiglottic hematoma secondary to supratherapeutic anticoagulation.

Hemorrhage into the soft tissues of the airway represents a potentially life-threatening complication of long-term anticoagulation. We report the case of a chronically anticoagulated 37-year-old male who developed a spontaneous hematoma of the epiglottis secondary to a supra-therapeutic INR. Epiglottic hematoma should be considered in the differential of any anticoagulated patient presenting with upper airway compromise. The airway should be secured in a controlled fashion, and the coagulopathy should be rapidly corrected.