Andrew J. Lerrick

Subglottic Air Escape Causing Subcutaneous Emphysema

Objectives: Closure of a tracheocutaneous fistula risks air escape into the anterior neck. Vocal cord augmentation establishes a subglottic pressure gradient during exhalation. We present a patient who underwent these procedures concurrently in whom subcutaneous subsequently developed. Methods: A 66 year-old female developed a neck abscess following a dental procedure. She presented to the ER with a compromised airway, requiring intubation. She underwent two separate neck abscess drainage procedures by OMFS. Prolonged intubation necessitated a tracheotomy, performed by cardiothoracic surgery. She was subsequently weaned and decannulated. Results: She was referred for dysphonia and a micro-tracheocutaneous fistula. Laryngoscopy revealed left vocal cord paralysis, not thought to be iatrogenic. Fistula closure with vocal cord augmentation was proposed. Fistula tract excision was followed by a two-layer muscle and skin closure. An air-tight seal was confirmed on high-pressure ventilation. Gelfoam was injected into the left vocal cord. She was discharged the morning after surgery. Twelve hours later she returned to the ER with rapid onset of cervicofacial subcutaneous emphysema. A pressure dressing was applied to the anterior neck. The subcutaneous emphysema subsided, being sub-totally resorbed within 24 hours. Conclusions: Despite the delay in onset, once conditions developed a percentage of subglottic air preferentially escaped through the small defect in the anterior tracheal wall, rather than exclusively through the larger hemi-glottic aperture, causing subcutaneous emphysema. Caution should be exercised in performing these procedures simultaneously.

Repair of Parotidectomy Defects Using Layered Meshed Allogenic Grafts

Objectives: Cervicofacial deformities following parotidectomy are commonly repaired using autologous tissue and allogenic grafts. Using two layers of allogenic material, oriented perpendicularly after meshing, and accented by eccentric spindle-shaped gaps, affords a more favorable outcome with respect to appearance and healing. Methods: Following parotidectomy, the defect is measured and the allogenic tissue cut to size, using sterile paper as a template, if desired. A duplicate graft is prepared using either the first graft or the template. Each graft is oriented with ink, then meshed 1.5:1. The critical step is to orient the second graft on the mesher platform by 90 degrees. This maneuver creates spindle-shaped holes oriented perpendicularly once each graft is placed. The meshed grafts are thinner and more pliable than the original material, facilitating in-setting. The deep and superficial grafts are placed, taking into account the orientation of the spindles. Both grafts are trimmed in situ. The spindle sizes are altered by varying the tension, achieved by peripheral trimming. The superficial graft is tacked down beyond the deeper graft to provide a smoother transition zone. A suction drain is placed superficial to the grafts. Results: The integrity of each graft protects the facial nerve, affords precise contouring, and avoids donor site morbidity. Graft porosity facilitates drainage, expediting healing. Fibrinous in-growth exceeds that of non-porous tissue. The overlapping spindles inhibit neural in-growth, reducing the likelihood of gustatory sweating. Conclusions: Allogenic grafts with eccentrically-overlapping spindles provide an optimal setting for healing following parotidectomy.

P192: Topographic Tongue Reduction in Obstructive Sleep Apnea

lapse. 2. Understand how to apply an office-based surgical procedure for correction of nasal valve collapse. METHODS: Retrospective case series of 45 patients undergoing an office-based surgical procedure for the correction of nasal valve collapse between September 2003 and October 2006. The practice setting is a multispecialty clinic. A simple, novel office surgery to correct nasal valve collapse is described in detail, and the indications and overall patient satisfaction are discussed using visual analog scales. RESULTS: There were no complications. The patients reported overall good to excellent long-term (at least 6 months) results regarding nasal obstruction. Only one patient felt the external appearance of the nasal tip was changed. All patients tolerated the procedure well in the office without sedation. CONCLUSIONS: This in-office surgical technique to correct nasal valve collapse is applicable to the majority of patients complaining of nasal obstruction due to a narrow or closed nasal valve.

P047: Contralateral Tonsillectomy in Staging Tonsil Lymphoma

OBJECTIVES: Lymphomas represent the second most common type of tonsil malignancy. Ten percent of lymphomas occur in the head and neck, of which 40% arise in the tonsils. The contralateral tonsil may harbor occult disease, as evidenced by this study. METHODS: A 49-year-old male presented with two months of right-sided odynophagia caused by an ulcer along the medial aspect of the right tonsil. He lacked constitutional and leftsided symptoms. A neck CT demonstrated parapharyngeal soft-tissue fullness and confirmed a palpable 1.3 cm jugulodigastric node. Chest CT revealed mediastinal nodes measuring up to 1.5 cm and a 2.8 x 1.6 cm epigastric mass. PET scan showed metabolic FDG-activity in the right parapharyngeal region (16.0), right cervical lymph node (3.2), mediastinum (3.0), and at the epigastric site (20.6). The left tonsil had no activity. Biopsies, including a contralateral tonsillectomy, were planned, implementing a lymphoma protocol. RESULTS: The right tonsil biopsy revealed a “malignant neoplasm with extensive necrosis.” Additional tissue was requested, warranting a tonsillectomy. A large cell lymphoma was identified. The right tonsil cytology was consistent with a follicular lymphoma that had transformed to a large B-cell lymphoma. Regional biopsies, demonstrating squamous mucosa with underlying “reactive” and “atypical” lymphoid infiltration, were negative for malignancy. Unexpectedly, the clinically normal left tonsil contained a follicular lymphoma. Adjuvant chemoradiotherapy is planned to treat this patient with Stage III disease. CONCLUSIONS: A contralateral tonsillectomy is justified during the staging of malignant neoplasms, even in the absence of clinical or radiologic findings, as the result may reveal occult disease.

P059: Prevention of Frey’s Syndrome Using Soft-Tissue Barriers

where along the gastrointestinal tract. Their origin is thought to be derived from misplaced embryonal rests. Of the few reported head and neck cases, colonic heterotopia is rarely described. This report presents (1) the clinical picture and treatment of a rare embryologic anomaly with late presentation that has not previously been reported in the literature, and (2) the histological features of enteric duplication and colonic heterotopia as they pertain to head and neck anomalies. METHODS: A single case at a tertiary care hospital is reported. A 38-year-old male presented with an enlarging symptomatic neck mass. Multiple attempts at FNA were nondiagnostic. Imaging identified a cystic mass occupying the entire prestyloid parapharyngeal space. Surgical methods and outcomes are discussed, including a histopathologic analysis of enteric duplication. RESULTS: The first known published case of cystic colonic heterotopia isolated to the prestyloid parapharyngeal space in an adult is presented. Tissue biopsy, CT and MRI were crucial for preoperative planning. Surgical excision with lateral pharyngotomy was curative. The likely developmental origin of this anomaly was the suprahyoid tongue base. CONCLUSIONS: This case demonstrates that enteric duplication of the head and neck may be present and asymptomatic until adult life. When tissue biopsy is benign and not consistent with lymphangioma, late presentation of enteric duplication must be considered in the differential diagnosis.

P005: Piggyback Vascular Boost to Enhance Flap Survival

and complications of augmentation rhinoplasty with alloplastic material implantation are two of the most challenging clinical problems. The purpose of this study is to present the experience in augmentation rhinoplasty with costal cartilage graft by open rhinoplasty in the Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital. METHODS: Fifty consecutive patients with severe saddle nose or complications of silicone implantation underwent surgical correction by open rhinoplasty between January 1, 2004 and May 1, 2005. They all were treated using the autogenous costal cartilages to correct the unfavorable nasal dorsal profile. These cases were retrospectively reviewed. RESULTS: All patients (32 males and 18 females) underwent open rhinoplasty under general anesthesia. Their ages ranged from 18 to 56 years with a mean age of 28 years. Most of the costal cartilage graft was harvested for the right seventh costal cartilage. The postoperative recoveries were uneventful except one patient experienced postoperative wound infection, which was solved after conservative treatment; and one patient complained of noticeable warping of the costal cartilage graft, which was corrected postoperatively within a year. CONCLUSIONS: This technique to harvest the costal cartilage for augmentation rhinoplasty, which can efficaciously prevent the warping of the graft and lead to highly satisfactory outcomes, is recommended by the presenters. The autogenous costal cartilage can be the first choice of graft material in treating severe saddle nose, posttraumatic nasal deformity, and revision rhinoplasty, especially the complications from the alloplastic material in Asian rhinoplasty.

Lateral advancement flaps in obstructive sleep apnea

Abstract Objectives: Palatal and pharyngeal soft tissue laxity and redundancy contribute to upper airway obstruction and obstructive sleep apnea. Hypertrophic tonsils exacerbate the condition. Uvulopalatopharyngoplasty with-or-without tonsillectomy is the procedure of choice to correct the disorder. In some instances, however, excision of the excess lateral soft tissues creates a faucial arch defect that cannot be closed primarily. We present our technique using laterally-advanced full-thickness pharyngeal muscular-mucosal flaps to achieve tension-free closure of the tonsillar fossae. Methods: Open lateral wall defects in the oropharynx heal by secondary intention. Drawbacks with this approach include excess scar tissue deposition, contracture of the fauces, and decreased mobility of the pharyngeal arch, which contribute to a poor surgical result. Coincidentally, too tight a closure causes the same result. To avoid these complications, we undermine the lateral free edge of the posterolateral pharyngeal wall to include a thick cuff of muscle and overlying mucosa. The thickest flaps expose the prevertebral fascia. The flaps can be elevated unilaterally or bilaterally. The blood supply is random, primarily based on terminal branches of the ascending pharyngeal arteries, arising inferiorly. The venous plexus is sufficiently dense to provide adequate vascular drainage. Results: The vascular integrity and elasticity of the pharyngeal musculature permits medially based lateral soft tissue advancement sufficient to allow reapproximation to the palatoglossus. Defects approaching 50% of the flap’s length have been closed. Conclusion: In complex cases, primary, tension-free closure of the faucial arch using soft tissue advancement flaps from the posterior pharynx reduces the likelihood of infection and scar contracture, facilitates healing, and improves surgical results.

Rhabdomyolysis complicating acute bacterial epiglottitis

ral center of a geographic region with high tobacco and alcohol consumption and with the incidence of upper aerodigesfive tract tumors among the highest in Europe. Seventy-five were treated only by radiotherapy (25 for unresectable locoregional extension, 24 for poor performance status, 20 for multiple associated unresectable primary tumors, 3 for distant metastases, and 3 for refusal of demolitive surgery); only 1 of these patients is still alive and free of disease. The other 153 patients (88% pyriform sinus, 8% posterior wall, 4% postcricoid area) underwent surgery (_+ radiotherapy). During the aforementioned period the policy for hypopharyngeal SCC did not change. Results: With univariate analysis of survival T and N, the mobilities of N, pT, and pN display prognostic significance. With multivariate analysis only T, N, pT, and pN are confirmed as prognostic factors. The 5-year specific disease survival was 68%, the disease free survival was 67%, and the crude survival was 47%. Compared with other series, the present is characterized by earlier stages, better related prognosis, and a high number of multiple malignancies (only 45% of patients of this series had a single tumor). In fact, 22.2% of hypopharyngeal SCCs were diagnosed during the staging procedures for a synchronous different head and neck SCC and 13.7% during the follow-up for a previous SCC of the upper aerodigestive tract. The majority of these endoscopically detected hypopharyngeal SCCs were asymptomatic, earlystage lesions and were treated with a curative aim. Conclusion: The systematic endoscopy of the upper aerodigestive tract during the staging and the follow-up of a primary head and neck SCC has allowed the detection of a huge percentage of asymptomatic hypopharyngeal SCCs in early stages. Treating these patients with a curative aim by surgery with or without radiotherapy and treating all hypopharyngeal SCCs by an aggressive approach (radical surgery researching the microscopically free margins, hemithyroidectomy for pyriform sinus lesions, bilateral neck dissection, recurrential dissection, postoperative radiotherapy if indicated), the prognosis may be better than previously reported.

162: Respiratory Distress Precipitated by a “Contralateral” Mediastinal Goiter

linkage analysis, the inherited gene for NF-2 has been localized to the long arm of chromosome 22. It is the loss of tumor-suppressive genetic material that is thought to predispose to the formation of multiple tumors in the central and peripheral nervous systems. Individuals with NF-2 are at r isk not only for acous t i c neu romas but also for meningiomas, spinal ependymomas, astrocytomas, and facial nerve neuromas. NF-2 has an incidence of 3 cases per 100,000 population and affects nearly 1 in 40,000 people in the United States. Identical (monozygotic) twins occur approximately once in every 300 births among white North Americans. Interest ingly, since the init ial descript ion of NF-2 by Wishart in 1822, no twins with bilateral acoustic tumors have been reported. With discordant phenotypic presentation and the necessary disparate management undertaken, we present the first reported case of identical twins with NF-2.

Flaps and Grafts in Head and Neck Surgery: A 40-Year Update

Educational objectives: To understand the indications for traditional and current reconstructive techniques and to learn the step-wise advances that led to one-stage, vascularized tissue transfer.