Alaa Gaafar

Chronic subglottic and tracheal stenosis: endoscopic management vs. surgical reconstruction

Laryngotracheal stenosis has been and remains one of the most vexing problems in the field of head and neck surgery. Two treatment modalities prevail, endoscopic and external. The indication for each modality is not yet clearly defined. This undefined situation motivated our current work, and we decided to assess laser-assisted endoscopy (with or without stenting) vs. open surgery for treating chronic laryngotracheal stenosis. Our study included 28 cases of chronic laryngotracheal stenosis that were classified according to treatment in two main groups: group I included 13 patients who were endoscopically treated and group II included 15 patients with surgical reconstruction. The mean follow-up period was 12.58 months for group I and 27.43 months for group II. Respiratory function tests (RFT) were carried out preoperatively, 1-month postoperatively and on completion of follow-up. Except for age, which was significantly higher in group I ( P <0.001), there was no significant difference between both groups. Although the incidence of complications was higher in group I (69%) than in group II (47%), it was nonsignificant. The postoperative RFT improved significantly in both groups. Although the improvement was higher in group I than group II, the difference was nonsignificant. The correlation between preoperative stridor and all other variables demonstrated that preoperative stridor correlated with the diameter of the stenosed segment ( r s=−0.631, P <0.001) and the peak expiratory flow rate (PEFR) ( r s=−0.488, P =0.030). Our results indicate that open surgery is the treatment of choice. Compared with endoscopic treatment, it provides a higher success rate and better functional results, especially long term. However, if contraindications to open surgery exist, whether local or general, laser-assisted endoscopy with stenting can offer good palliative results.

Rhinoscleroma: An updated experience through the last 10 years

Abstract Conclusion: Rhinoscleroma is a chronic, specific, granuloma of the nose and other parts of the respiratory system. The disease is endemic in Egypt and many other countries. The causative organism is Klebsiella rhinoscleromatis bacillus, proved by fulfilling Kochs postulates. The mode of infection is not known and its worldwide irregular geographical distribution is not understood. Lines of treatment are unsatisfactory and a tendency for recurrence is the rule. Objectives: Our aim was to study the clinical presentation, microbiology, pathological staging, follow-up, and lines of treatment of new rhinoscleroma patients admitted or seen at Alexandria Main University Hospital from January 1999 until January 2009. Methods: Demographic data and the results of clinical, bacteriological, and histological examinations were reviewed. Medical and surgical treatments were evaluated. Follow-up as regards the results of treatment and incidence of recurrence was assessed. Results: Fifty-six patients were included in the study. There were 26 males and 30 females, and 85% of patients presented in the third and fourth decades of life. The nose was affected in 100% of patients. Other regions affected were the nasopharynx in 13 patients, palate in 7 patients, skin in 2 patients, larynx in 3 patients, trachea in 17 patients, nasolacrimal duct in 2 patients, and premaxilla in 1 patient. No lymph node affection was reported. Klebsiella rhinoscleromatis strain III was isolated from 100% of patients. Antibiotics used were a combination of trimethoprim-sulfamethoxazole 400 mg and rifampicin 300 mg twice daily for 3 months. Since 2003, this was replaced by ciprofloxacin 500 mg twice daily for 3 months. Surgical procedures performed were removal of nasal granulations, bronchoscopic dilatation, bipolar coagulation of skin lesions, tracheostomy, and repair of pharyngeal stenosis. Results were disappointing, as a large number of patients did not attend for follow-up. A high incidence of recurrence was found, reaching up to 25% within 10 years.

Temporalis Myofascial Flap for Primary Cranial Base Reconstruction after Tumor Resection

OBJECTIVE To evaluate the use of the temporalis myofascial flap in primary cranial base reconstruction following surgical tumor ablation and to explain technical issues, potential complications, and donor site consequences along with their management. DESIGN Retrospective case series. SETTING Tertiary referral center. PARTICIPANTS Forty-one consecutive patients receiving primary temporalis myofascial flap reconstructions following cranial base tumor resections in a 4-year period. MAIN OUTCOME MEASURES Flap survival, postoperative complications, and donor site morbidity. RESULTS Patients included 37 males and 4 females ranging in age from 10 to 65 years. Two patients received preoperative and 18 postoperative radiation therapy. Patient follow-up ranged from 4 to 39 months. The whole temporalis muscle was used in 26 patients (63.4%) and only part of a coronally split muscle was used in 15 patients (36.6%). Nine patients had primary donor site reconstruction using a Medpor((R)) (Porex Surgical, Inc., Newnan, GA) temporal fossa implant; these had excellent aesthetic results. There were no cases of complete flap loss. Partial flap dehiscence was seen in six patients (14.6%); only two required surgical débridement. None of the patients developed cerebrospinal leaks or meningitis. One patient was left with complete paralysis of the temporal branch of the facial nerve. Three patients (all had received postoperative irradiation) developed permanent trismus. CONCLUSIONS The temporalis myofascial flap was found to be an excellent reconstructive alternative for a wide variety of skull base defects following tumor ablation. It is a very reliable, versatile flap that is usually available in the operative field with relatively low donor site aesthetic and functional morbidity.

Partial Laser Arytenoidectomy in the Management of Bilateral Vocal Fold Immobility: A Modification Based on Functional Anatomical Study of the Cricoarytenoid Joint

OBJECTIVE: To establish the anatomical relationships between the arytenoid and cricoid cartilages and apply these findings to design an arytenoidectomy based on a sound anatomical basis. STUDY DESIGN: In 50 patients the length of the vocal process and the distance between vocal process tip and upper border of the cricoid cartilage were endoscopically measured. Twenty-five total laryngectomy specimens were sagittally and axially sectioned to verify the position of the arytenoids and their relation to the cricoid. The anatomical findings led to the design of laser partial arytenoidectomy and cordotomy (L-PAC), which was used in 45 patients with bilateral cord paralysis in adduction. RESULTS: The anatomical findings showed that the cricoarytenoid joint did not contribute to the airway in any of the measured specimens. Using L-PAC, 100% of the patients were decannulated and no patient needed a postoperative tracheostomy at any time. Only 3 patients experienced minimal postoperative aspiration to liquids (6.7%). Reasonable phonation was achieved as regarded by a speech analysis battery. Three patients (6.7%) needed a contralateral L-PAC. CONCLUSIONS: The shape of the cricoid and the location of its axis of maximum width ought to dictate the technique of glottic widening to be used in bilateral cord immobility in adduction. The present extra-articular technique, L-PAC, showed its versatility in providing an effective balance between the protective, the respiratory, and to lesser extent the phoniatory functions. EBM rating: C-4

Deep Neck Infections of Congenital Causes

Objectives. To review cases of deep neck infections with underlying congenital etiology with special emphasis on their clinical presentations and the computed tomographic findings and to discuss the various therapeutic modalities employed for such lesions. Study Design. Case series with chart review. Settings. Alexandria University Hospital, Egypt. Subjects and Methods. The authors retrospectively reviewed the clinical, imaging, and operative records of deep neck infection cases presented to their department in the past 10 years. Deep neck infection cases due to congenital causes were included in the study. Results. Of the 249 cases of deep neck infections admitted to the authors’ department in the past 10 years, 39 patients were diagnosed with deep neck infections due to congenital causes. Patients were classified into 2 groups. In group 1 (29 patients), computed tomography revealed the presence of infected cystic swelling in the neck that was classified as second branchial cyst (16 patients), third and fourth branchial cysts (8 patients), and thyroglossal cyst (5 patients). Group 2 (10 patients) presented with recurrent attacks of deep neck infection with a history of incision and drainage several times. Radiological and operative findings revealed the presence of congenital pyriform fossa sinus. Conclusion. Computed tomography is helpful in diagnosing infected congenital cysts and its types. Infected congenital cysts could be excised completely under an umbrella of antibiotics. Recurrence of deep neck infections should alert the physician to the possibility of underlying congenital lesions. Thorough clinical and radiological assessment is mandatory to rule out the possibility of a congenital pyriform fossa sinus.

Inhalation mitomycin-C in the management of laryngeal fibrosis: rationale, benefits, and pitfalls

This study has pursued the development of animal model to assess the efficacy and safety of administrating mitomycin-C (MMC) by inhalation route for management of laryngeal fibrosis with the potential of human application. Glottic trauma was created in 10 mongrel dogs aiming at scaring and web formation. Eight dogs were randomized to receive a single daily dose of inhalation MMC using a mixture of 1 cm3 of 0.5 mg/ml MMC and 2 cm3 of normal saline. The remaining two dogs were left untreated and assigned as controls. A blood sample was withdrawn from the MMC group before trauma, on the 14th, and 28th day. Direct microlaryngoscopy (DML) was performed in all animals on the 14th and 28th day to allow clinical evaluation and photodocumentation. Immediately after 28 days, all animals were painlessly euthanized. The larynx, trachea, lung, liver, kidney, and spleen were harvested and studied for possible pathologic changes. Vocal granuloma and glottic webbing were documented in the controls. The inhalation MMC group demonstrated significant inhibition of fibrosis and scar formation. No local or systemic toxic effects were documented. Our study submits the technique of inhalation MMC as a simple, non-invasive adjuvant to the therapeutic tool for the management of laryngeal stenosis.

Microdebrider in Management of Obstructive Laryngeal Tumors

Objective: 1) To determine the efficacy of the powered endoscopic microdebrider as a tool in the management of obstructive laryngeal tumors. 2) To compare the histopathological diagnosis between a biopsy taken using the laryngeal forceps and the resected tissue from the microdebrider. Method: This study is a prospective randomized study. Eighteen patients presented with obstructive laryngeal tumors to the outpatient clinic or emergency room of Alexandria Main University Hospital in 12 months duration starting from November 2010 till November 2011. Tumor debulking was done using laryngeal microdebrider. Results: All cases presented with moderate to severe stridor, the lesion obstructing more than 50% of the lumen of the larynx. In all cases tracheotomy could be avoided until a definitive therapy was initiated. No significant bleeding was encountered during these procedures. The operating time was directly dependent on the volume of the tumor. Both biopsies (one taken by forceps and the other from tissues resected by microdebrider) gave the same diagnosis except in 1 patient, as there were artifacts in microdebrider collected tissues. Conclusion: Endoscopic debulking of laryngeal tumors using the microdebrider is a safe, accurate, and reliable method, thus preventing tracheotomy in most cases. The use of microdebrider does not preclude the submission of tissue for histological analysis. These preliminary results are encouraging and worthy of further evaluation and comparison with other techniques.