Anthony J. Reino

Management of embossment following the frontal osteoplastic operation

The deformity in the bony contour of the forehead following the osteoplastic flap procedure on the frontal sinus, termed embossment, occurs in a small but definite number of cases. This complication arises from the combined processes of resorption and deposition of bone following disturbance of the periosteum in performing the operation. A simple and highly reliable method of cosmetic correction employing acrylic cranioplasty has been successfully utilized in a series of cases without complications. The details of the operative technique will be outlined.

The silicone columellar strut.

&NA; The placement of a silicone columellar strut serves to correct columellar retraction, to improve the nasolabial angle, and to increase tip projection by elevating the medical crura of the lower lateral cartilages. The potential complications of extrusion, infection, and migration are minimal if the implant is placed in a separate watertight compartment with a tension‐free closure and no impingement on the nasal dome. (Plast. Reconstr. Surg. 97: 938, 1996.)

Upper Airway Distress in Crack-Cocaine Users

Crack , an impure free-base form of cocaine, is manufactured by combining cocaine hydrochloride with an alkaline substance. The hydrochloride salt is mixed with a solution of water and sodium bicarbonate, baking soda, or lye, and is brought to a boil. This process dissolves the salt and leaves an uncharged cocaine moiety that separates from the solution and solidifies into small pieces called rock.’ Free-base is the pure ether form of cocaine that melts at 980” C and vaporizes at still higher tempera t u r e ~ . ~ ’ ~ Consequently, crack cocaine can be smoked in cigarettes or heated and inhaled from pipes or other vaporizing paraphernalia because of its heatstable chemical structure. The attraction of the coca plant has been known for centuries. The natives of the Andean countries have chewed and sucked coca leaves to increase endurance and promote a sense of well-being.’ However, since the appearance of crack as an illicit street drug in 1986, the abuse of this cocaine derivative has become epidemic in the urban areas of this country. The addicting potential and popularity of crack cocaine are traceable to three factors. First, the euphoria produced by smoking crack is virtually immediate and is extremely intense because of absorption from the vascular bed of the lung.”3 The “high” lasts approximately 20 minutes, but it is followed by a dysphoric “crash.” The crash triggers intense cravings to reestablish the euphoria by smoking more crack. Second, the drug is inexpensive; users report that a puff from a crack pipe costs only about a dollar in most crack houses. In addition, the popularity of crack is related to its

Factors in the Pathogenesis of Tumors of the Sphenoid and Maxillary Sinuses: A Comparative Study†

Objectives/Hypothesis To explain the processes that lead to the development of tumors in the maxillary and sphenoid sinuses.

Inflammatory Pseudotumor of the Maxillary Sinus: Case Reports and Review of the Literature

The term inflammatory pseudotumor (IPT) has been applied to a benign, reactive, non-neoplastic and inflammatory space occupying lesion that clinically and radiographically mimics a neoplasm. Histologically, IPT is composed of polymorphous inflammatory cell infiltrates and variable fibrous stroma containing thick walled blood vessels. Aggressive pseudotumors must be distinguished from malignancy to avoid unnecessary surgery or irradiation. Some cases can be differentiated from neoplasms by their dramatic response to oral steroid therapy. Because of the diverse cellular proliferation, diagnosis can be difficult, especially on frozen section study. Primary pseudotumor of the maxillary sinus is an extremely rare entity. An extensive review of the literature has produced only four reported cases. We describe six cases of pseudotumor of the maxillary sinus that had clinical and radiographic findings suggesting neoplasia. The purpose of this paper is to report these new cases of maxillary sinus pseudotumor and to better define its natural history, criteria for diagnosis, and selection of treatment.

Three Dimensional Video Imaging for Endoscopic Sinus Surgery and Diagnosis

Technological advances in video imaging over the last decade have resulted in remarkable additions to the armamentarium of instrumentation for the otolaryngologist. The use of video cameras and computer generated imaging in the operating room and office is invaluable for documentation and teaching purposes. Despite the obvious advantages of these systems, problems are evident, the most serious of which include image distortion and inability to judge depth of field. For more than 6 decades 3D imaging has been neither technically nor commercially successful. Reasons include alignment difficulties and image distortion. The result is “visual fatigue,” usually in about 15 minutes. At its extreme, this may be characterized by headache, nausea, and even vomiting. In this study, we employed the first 3D video imager to electronically manipulate a single video source to produce 3D images; therefore, neither alignment nor image distortions were produced. Of interest to the clinical surgeon, “visual fatigue” does not seem to occur; however, with prolonged procedures (greater than 2 hours) there exists the potential for physical intolerance for some individuals. This is the first unit that is compatible with any rigid or flexible videoendoscopic system and the small diameter endoscopes available for endoscopic sinus surgery. Moreover, prerecorded 2D tapes may be viewed in 3D on an existing VCR. The 3D image seems to provide enhanced anatomic awareness with less image distortion. We have found this system to be optically superior to the 2D video imagers currently available.

Transverse Infrahyoid Approach to Bilateral Glottic Tumors

Glottic exposure and entry for vertical partial laryngectomy procedures has traditionally been through the subglottis. Although this approach is generally satisfactory for the resection of unilateral vocal cord lesions, it may be unsafe in cases in which tumors extend across the midline and/or subglottically. In these instances, we prefer the superior transverse infrahyoid approach to the glottis, which transects the petiole of the epiglottis and reflects the contents of the preepiglottic space posterior and superior. This improved visualization of the larynx has permitted precise tumor excision without sacrifice of uninvolved segments of the vocal cords. This procedure has been performed 35 times over a 15-year period at our institution for the resection of bilateral glottic tumors, with and without subglottic extension. In none of the cases in which it has been employed was there a positive surgical margin.

The Riedel Procedure - An Analysis of 22 Cases

Objectives: To report one institution’s experience with 22 cases of the Riedel procedure in order to establish a profi le for those patients with chronic frontal sinusitis who develop chronic osteomyelitis.

The SNaP Wound Care System for Head and Neck Wound Closure

Objective: Vacuum-assisted closure of head and neck wounds has been previously described. Negative pressure wound therapy, although efficacious, has practical limitations in the outpatient setting. The purpose of this study is to describe a novel method of treating complex head and neck wounds using an ultraportable mechanical vacuum wound care system. Method: A cohort study at 2 tertiary care centers. All head and neck patients with complex, low to moderately exudative wounds were treated by the senior author using the SNaP Wound Care System. Patient comorbidities, wound etiology, site, length of treatment, outcomes, and ancillary procedures were recorded. Results: A variety of wounds was treated with this system and included mucocutaneous fistulas, a tracheocutaneous fistula, soft tissue defects of the head and neck, and tendon exposure of a radial forearm free flap donor site. Outpatient SNaP therapy was utilized in five patients with 6 small- to medium-sized wounds. This system was successful in obtaining wound closure in all patients. These patients were able to complete routine activities of daily living, participate in public social settings, and tolerate therapy without adverse events. One patient required an adjunctive procedure of split thickness skin grafting. Conclusion: This study demonstrates a novel use of the first FDA-approved ultraportable, mechanical negative pressure device in the treatment of several complex head and neck wounds. The device has utility in the outpatient setting for adjunctive closure of wounds with minimal disturbance to patients’ activities of daily living and lifestyle.

Rhinotomy Approaches to the Paranasal Sinuses and Anterior Skull Base

Educational objectives: To understand and apply the three rhinotomy approaches for extirpation of benign and malignant diseases of the sinonasal cavity, skull base, and anterior cranial fossa.