Aijaz Alvi

Post-tonsillectomy hemorrhage: an assessment of risk factors

Hemorrhage is the most frequent complication of tonsillectomy and is responsible for the majority of post-tonsillectomy fatalities. The incidence of this hemorrhage has been reported to be as high as 20% [6]. Despite continued efforts to reduce this problem, it remains a persistent risk. The charts of 1138 patients who underwent tonsillectomy with or without adenoidectomy from 7-1-89 to 6-30-93 were reviewed. Post-tonsillectomy hemorrhage occurred in 36 patients (3%). Preoperative, intraoperative and postoperative risk factors were assessed. Postoperative bleeding occurred more often in older patients (69% over age 11 years). Seventy-five per cent of these patients were operated on for chronic tonsillitis as compared to 11% operated on for upper airway obstruction. The majority of these patients presented after postoperative day 1 (83%). Four patients required blood transfusions. Postoperative hemorrhage occurred in 14% of patients with elevated postoperative mean arterial pressures. Intraoperative blood loss that exceeded 50 cm3 was also a significant risk factor for post-tonsillectomy hemorrhage. It is concluded that older age, a history of chronic tonsillitis, excessive intraoperative blood loss and elevated postoperative mean arterial pressure are significant risk factors for post-tonsillectomy hemorrhage. An awareness of these risk factors can help identify patients with potential to bleed postoperatively.

Bone-screw mandible fixation: An intraoperative alternative to arch bars

ABSTRACT OBJECTIVES: Bone-screw mandible fixation (BSMF) is evaluated as an alternative to intraoperative arch-bar maxillomandibular fixation before plating of mandibular fractures. BSMF is achieved by wire ligation of opposing bone-screws placed in the maxilla and mandible. METHODS: A retrospective evaluation of 23 patients with 40 mandibular fractures who underwent man-dibular fracture repairs. BSMF was used instead of arch bars to ensure proper dental occlusion. All fractures were then plated, after which BSMF was removed before termination of anesthesia. RESULTS: Normal occlusion was observed in 21 patients (91.3%), Class II malocclusion was noted in 1 patient (4.3%), and 1 patient was edentulous. No complications related to the use of BSMF were observed. CONCLUSION: BSMF can serve as a viable alternative to arch-bar maxillomandibular fixation for obtaining temporary intraoperative occlusion. BSMF produces acceptable malocclusion rates and offers the advantages of decreased intraoperative time, lower risk for percutaneous and mucosal wire punctures, and ease of use.

Primary Salivary Gland Amyloidosis Causing Sicca Syndrome

Sicca syndrome (SS), consisting of xerostomia and xerophthalmia, may be caused by various disease processes. We present a unique case of SS secondary to primary amyloidosis. Amyloidosis is a rare but definite cause of SS and should be included in the differential diagnosis of any patient who presents with sicca symptoms. A literature review comparing amyloidotic patients with SS and patients with amyloidosis only demonstrates that both of these groups of patients present similarly with regard to symptoms. However, the majority of patients with SS present with sicca symptoms initially in addition to symptoms of amyloidosis. These SS patients also present with proteinuria and negative serology test results. Therefore, patients presenting with sicca symptoms, proteinuria, and negative serologic findings should be suspect for amyloidosis. The importance of distinguishing the diagnosis of Sjögrens syndrome from SS in these patients cannot be overemphasized. There is a significantly higher incidence of developing a lymphoma in Sjögrens syndrome patients. This has important implications for the head and neck surgeon treating these patients.

Acute intracranial complications of temporal bone trauma

Temporal bone trauma can be disastrous for the individual and his or her family. With the increase in violent crime throughout our society, the number of intracranial complications associated with temporal bone injury has increased significantly. Although multiple reports concerning the diagnosis and management of temporal bone trauma have been published, few studies on its intracranial complications have been addressed. In this study, we assessed the cases of 43 patients treated for temporal bone fractures between January 1992 and December 1994. The number of temporal bone fractures increased from 6 in 1992 to 21 in 1994. Twenty-one patients (49%) presented with decreased mental status. Significant alcohol and drug use was documented in 28% and 58% of patients, respectively. The most common radiologic finding was skull and intracranial injury. Thirty-six patients (84%) had at least one abnormal intracranial finding; of these patients, 14 (39%) had more than one abnormal finding on computed tomography. Cerebral midline shift, subarachnoid hemorrhage, subdural hemorrhage, and cerebral edema were the most common radiologic findings. Nineteen patients (44%) required an open neurosurgical procedure, and almost all patients with more than one abnormal radiologic finding underwent neurosurgery (86%). Seven patients required further institutional care after discharge. Four patients died (9% mortality); all the deaths were neurologically related. Mean hospital charges increased from

Fracture of a synthetic fenestrated tracheostomy tube: Case report and review of the literature

30,900 in 1992 to

Miniature Disc Battery in the Nose: A Dangerous Foreign Body

63,000 in 1994.

Battle's Sign in Temporal Bone Trauma

Frequently patients require a tracheostomy tube over a prolonged period of time. A number of complications have been reported with the chronic use of tracheostomy tubes including granulation tissue formation, subglottic stenosis, and tracheomalacia. Reports of a tracheostomy tube fracture are rare. Many of these tubes were made of metal such as silver, zinc, and copper.‘.’ It was thought that corrosion of the metal predisposed the tubes to fracture.l With the advent of synthetic tracheostomy tubes in the 196Os, it was hoped that these tubes would be free of the problem of fracture. However, the first report of a synthetic tube fracture was documented in 197X3 Thereafter, several other reports have described synthetic tracheostomy tube fracture. Most of these fractures occurred at the neck plate site. In this article the first case of a fracture in a synthetic fenestrated tracheostomy tube is reported and the literature is reviewed. This case may suggest that the fenestration in the tube may be a weak point and that fracture at that site may occur, particularly after prolonged wear. The patient was subsequently lost to follow-up until his visit to the ear, nose, and throat clinic 4 years later. The patient had not changed his tube during this time period. The patient presented with a foul smell from the tracheostomy tube and a mass under his tube. He had no shortness of breath and no hemoptysis. The patient had a no. 8 fenestrated Shiley tracheostomy tube with a nonfunctional cuff. There was a large amount of peristomal granulation tissue which partially pushed out the tracheostomy neck plate. The patient was brought to the operating room for tracheostomy tube change and excision of peristomal granulation tissue. Under local anesthesia, the tracheostomy tube was inspected. It was noticed that two fractures, approximately 1 to 2 cm in length, were present at the site of the fenestration (Fig 1). The granulation tissue had grown through the fenestration preventing removal of the tube. Excision of the granulation tissue was performed with electrocautery. The tracheostomy tube and fracture site were both grasped and removed with a clamp. A new no. 8 cuffless nonfenestrated Shiley tracheostomy tube was inserted. The patient was discharged with two sets of tracheostomy tubes. He is closely followed up in clinic for tracheostomy tube changes.

Resection of a recurrent nasal tumor via Le Fort I osteotomy approach

Advances in technology have created a popular market for disc batteries to power such devices as watches, calculators, and toys. Because of the current popularity of disc batteries, they are becoming more common as ear, nose, and throat foreign bodies, particularly in children. The small size and shiny surface of the batteries make them attractive to children. Their size, 0.5-1.5 cm in diameter, lends them to easy insertion into the

Clinical PhotographsCervicocutaneous sarcoidosis

A 61-year-old woman was involved in a motor vehicle accident and sustained blunt head trauma to the left postauricular region. She had decreased hearing in the left ear and vertigo. Physical examination revealed left postauricular ecchymosis (BattleÕs sign) (Fig. 1) and hemotympanum. Facial nerve function was normal. A CT scan demonstrated a left longitudinal temporal bone fracture. An audiogram showed a left moderate conductive hearing loss. The patient was treated in the hospital for severe vertigo with antiemetics and meclizine. After 2 months of outpatient observation, she had resolution of the hemotympanum with a near-normal audiogram.

Intraoral cortical bone-screw fixation: An alternative to arch bars

(Editorial Comment: The authors describe another approach to the nasal cavity. The Le Fort osteotomy is commonly used to expose the clivus on nasopharynx. The nasal cavity is most often exposed with either a lateral rhinotomy or midface degloving. Surgeons must consider the relative merits and difficulties inherent in selecting any surgical approach.) Pleomorphic adenoma most commonly affects the major salivary glands. The minor salivary glands are involved in only 8% of cases,l whereas most cases involve the palate. Nasal cavity involvement may be difficult to treat because of inadequate exposure that may lead to recurrence of the tumor. Compagno and Wang’ reviewed the files of the Armed Forces Institute of Pathology and found a 10% recurrence rate following conservative resection of