Adi Yoskovitch

Mycobacterial Infections of the Head and Neck

Despite the decline of pulmonary tuberculosis in the Western world, the incidence of cervical mycobacterial infections has remained relatively unaffected. A retrospective review was conducted of 20 patients treated for head and neck tuberculosis from 1984 to 1991. They were mostly an immigrant group coming from underdeveloped countries close to the equator. All cases were treated with antituberculous chemotherapy; 18 patients also underwent surgical excision of their lymphadenopathy. Sixteen patients showed complete response to combined treatment and one relapse was successfully retreated with antituberculous medication. Three patients died from unrelated causes–two from human immunodeficiency virus infection and one from nasopharyngeal carcinoma. The most reliable indicator of mycobacterial infection was the pathologic specimen, making the need for surgical intervention an important diagnostic consideration. As with other reports, most patients in our series had negative chest x-ray films, variable responses to skin testing, and negative cultures. The epidemiology, pathogenesis, and management of this disease are discussed. (OTOLARYNGOL HEAD NECK SURG 1993;109:427-33.)

Skin Metastases in Squamous Cell Carcinoma of the Head and Neck

Distant metastases in squamous cell carcinoma of the head and neck (SCCHN) are most often to the lung, liver, and bone. SCCHN rarely metastasizes to skin sites. OBJECTIVE: To ascertain the significance of skin metastases (SM) on the prognosis of patients with SCCHN. METHODS: A retrospective review of all patients between 1987 and 1999 with SCCHN was conducted. Patients in whom SM developed were identified. Data pertaining to demographics, primary tumor staging, SM development, and outcome were investigated. RESULTS: In 798 consecutive patients diagnosed with SCCHN between 1987 and 2000, 19 developed SM. The average time of onset of the SM was 17.65 months. The average survival time was 7.2 months after the development of SM. The overall survival time of patients who developed SM from the initial presentation of the primary tumor was 24.85 months. The 1-year survival rate from the time of development of SM was 0%. CONCLUSIONS: Metastasis to skin sites is an uncommon feature of SCCHN. SM may represent the first clinical evidence of impending loco-regional recurrence or distant metastasis. The development of SM is an ominous sign associated with an extremely poor prognosis, similar to the development of distant metastasis at more typical sites. Both the development of SM and survival of patients developing SM are independent of primary tumor stage. Current treatment options of SM are limited in their efficacy.

Acute airway obstruction in Hunter syndrome

Hunter syndrome is one of the mucopolysaccharidoses, characterized by a deficiency of the lysosomal enzyme iduronate sulfatase. Among its physical manifestations, there are numerous head and neck signs, including characteristic facial features, macroglossia and short neck. The accumulation of glycosaminoglycans in the soft tissues of the head and neck can be associated with acute airway obstruction. We report a 7 year old boy with Hunter syndrome who developed acute airway compromise requiring an emergency tracheotomy. A review of the literature of airway management in patients with this disease is also presented.

Endoscopic repair of a nasal septal perforation.

The repair of septal perforations represents a challenging problem, with numerous techniques existing to address the defect. The use of sinonasal endoscopy represents a novel approach to solving this problem. By using the endoscope, excellent visualization and exposure can be achieved without excessive dissection. In addition, the use of the camera and monitor allows for excellent teaching capabilities.

Cervical osteophytes presenting as unilateral vocal fold paralysis and dysphagia

Any process involving either the vagus nerve, its recurrent laryngeal branch or the external branch of the superior laryngeal nerve may cause paralysis of the vocal fold. The most common cause is neoplasm. Clinically, the patients often present with a hoarse, breathy voice as well as symptoms of aspiration. The following represents a unique case of unilateral vocal fold paralysis and dysphagia caused by a degenerative disease of the cervical spine, resluting in extrinsic compression of the recurrent laryngeal nerve.

Premaxillary augmentation : Adjunct to rhinoplasty

Recession of the premaxillary area is a relatively common deformity. Typically, it presents as a mild weakness of the central maxilla, but in certain instances, such as in the Black and Asian communities, it may be moderate to severe. This condition can be compounded by a narrow nasolabial angle, recessed alar bases, and sunken cheeks. To resolve this deficiency, a new design for premaxillary augmentation is suggested. A bat-shaped premaxillary implant is used for correction. The implant is introduced by means of an intranasal or intraoral approach, while the patient is under either local or general anesthesia. Thirty-three patients have been managed for premaxillary recession and have been corrected by premaxillary augmentation. Satisfactory cosmetic results have been achieved, with only a few minor complications.

Analysis of human papillomavirus in schneiderian papillomas as compared to chronic sinusitis and normal nasal mucosa.

Schneiderian papillomas (SPs) are tumours arising from the surface epithelium (schneiderian epithelium) of the nasal cavity and paranasal sinuses. Evidence points toward a viral etiology, specifically human papillomavirus (HPV). Although substantial data indicate HPV as a likely etiology, little is known about the role of HPV in benign nasal pathologies or in normal nasal mucosa. The objective of this study was to characterize the relationship between HPV and SP, chronic sinusitis (CS), and normal nasal mucosa. A case-control study was undertaken, matching patients with SP to patients with CS. Patients with normal nasal mucosa served as a control group. All patients had their tissues analyzed for the presence of various HPV subtypes using line blot assay. A total of 168 patients were identified (74 SP, 74 CS, 20 control). Of these, 70 (41.7%) had detectable deoxyribonucleic acid and 9 of 70 (12.9%) had detectable HPV of subtypes 6, 11, and 16. None had detectable HPV type 18. Significant differences were detected in the presence of HPV in the CS, SP, and control groups, as well as in the presence of low- versus high-risk subtypes among investigation and control groups. Significant differences exist in HPV infectivity among SP, benign nasal pathologies such as CS, and normal nasal mucosa. Human papillomavirus plays an important role, at least in part, in the development of SP, with types 6, 11, and 16 being more pivotal than other types. Line blot assay is a useful technique in identifying HPV in SP.

Correction of thin lips: a 17-year follow-up of the original technique.

The demand for lip augmentation in the older population and, occasionally, the younger one remains high. During the natural course of the aging process, the progressive loss of soft-tissue bulk and the flattening of the lip contour create an appearance of thin lips and their associated stigmata of old age. In general, methods for lip augmentation fall into two categories: (1) local oral mucosal flaps and (2) autologous grafts, alloplastic implants, or injections.1 Numerous techniques have been described to address the senile lip,2–9 including V-Y plasty, lip-lifting buffalo horn excision, frenulum plasty, fat or dermal-fat grafting, use of polyacrylamide hydrogel, use of polytetrafluoroethylene tube, and silicone microgel injection, among others. In 1984, the lip lift technique10 was published as a procedure for correcting thin lips. Since its original publication, several modifications have been introduced. Outlined below are the revised evaluation of the lip complex and the modifications to the original lip lift technique, as experienced by the authors over a 17-year period.

Guillain-Barré syndrome presenting as bilateral vocal cord paralysis.

Guillain-Barré syndrome (GBS), also known as acute idiopathic polyneuritis, is the most common acquired demyelinating neuropathy, characterized by muscular weakness and mild distal sensory loss. GBS presenting as bilateral vocal cord paralysis (BVCP) is extremely rare, with only 1 other case reported in the literature. 1 The following is a case of BVCP as the presenting symptom of GBS in an elderly man.

New classification scheme for laser resurfacing and chemical peels: Modifications for the different ethnic groups

Historically, classifications for laser rejuvenation and chemical peels of the skin are based on pigmentary color, with skin quality playing a less prominent role. Although useful in predicting aesthetic outcomes, these classifications do not, for the most part, take into consideration the patient’s origin and its associated relevance in predicting final results. Herein, a new classification system is proposed that not only takes into account skin color but also genetic predisposition as a key determinant of a patient’s response to skin injury, namely, laser resurfacing and chemical peels. This de novo classification takes into account both skin pigmentation and physical attributes in hopes of improving the predictability of patients’ response to skin treatments by physicians. Six categories are described: Nordic, European, Mediterranean, Indo-Pakistani, African, and Asian. The reactions of each category to peels, laser resurfacing, or dermabrasion are analyzed, and the potential risks associated with each group are noted. Most popular classifications [1–6] for patients undergoing chemical peels, laser resurfacing, or dermabrasion are based primarily on the color of their facial skin. The general tendency is to relate the result of a peel, dermabrasion, or skin resurfacing to skin color. It is generally accepted that the lighter the skin color and pigmentation, such as Fitzpatrick types I and II, the better the final result. The converse of this is also considered true: the darker the skin, such as Fitzpatrick types III to VI, the poorer the result. Skin color is often subdivided into categories: white, olive, tan, brown, yellow, and black. Classifications such as those of Fitzpatrick, Obagi, and Glogau, in addition to accounting for skin color, also account for certain characteristics (dryness, oiliness, thickness, and so forth) and the skin response to sun exposure. Those additional criteria are all valid and, to date, the ‘‘gold standard’’ has been the Fitzpatrick classification scheme. The physician, however, faced with a prospective patient, must evaluate multiple and, occasionally, contradictory factors. Traditional classifications, useful as they are, may sometimes be inadequate or confusing. They ignore a crucial factor: the patient’s racial origin, which is often associated with a characteristic skin color and almost always with characteristic features.