Brad Millman

Cervical thymic anomalies

Because of its infrequent occurrence, cervical thymic tissue is rarely considered in the differential diagnosis of neck masses. Consequently, diagnosis is most often made by pathologic examination of the excised specimen. The preponderance of reported patients have been children and adolescents, typically asymptomatic. The clinical presentation, evaluation and surgical management of five new cases of cervical thymic anomalies ranging from infancy to adulthood are described. The authors also review the embryology and histopathology of these lesions and discuss their recommended approach to the evaluation and management of cervical thymic anomalies.

Isolated congenital internal auditory canal atresia with normal facial nerve function

The internal auditory canal forms as a result of mesoderm enveloping the eighth cranial nerve in the developing embryo. The mesoderm eventually transforms into cartilage and ultimately ossifies around the nerve, forming the internal auditory canal. It is theorized that atresia or stenosis of the internal auditory canal results from altered cochleovestibular nerve development secondary to faulty chemotactic mechanisms or a lack of end organ targets. Unilateral internal auditory canal anomalies are frequently seen in conjunction with other inner ear anomalies and occasionally with middle or external ear anomalies. Infrequently, it will occur as either an isolated or bilateral finding, but rarely simultaneously. The few citations of isolated, unilateral or bilateral internal auditory canal anomalies that are reported in the literature are usually associated with other systemic developmental anomalies, such as, cardiac septal defects, polycystic kidney disease, skeletal deformities and duodenal atresia. We present a case report of a patient with bilateral, congenital, internal auditory canal atresia and cochleovestibular deficits but, normal facial nerve function. A review of the literature is discussed as well as diagnostic considerations and treatment options including audiologic and communication rehabilitation.

Alar batten grafting for management of the collapsed nasal valve

Objective The purpose of the study is to describe a commonly overlooked etiology of nasal airway obstruction. Collapse of the nasal valve can be corrected with precise placement of cartilage grafts. This study demonstrates the surgical technique, rarely described in the literature, of placing a contoured cartilage graft in the nasal valve region for the improvement of the nasal airway.

Nodular thyroid disease in children and adolescents

Thyroid nodules in children are extremely uncommon. Most thyroid nodules, both benign and malignant, present as asymptomatic neck masses. A thyroid nodule in a child is significant because of the risk of malignancy. A review of medical records at our institution demonstrated 71 patients 20 years of age and younger with surgically managed thyroid nodules, of which 45 were benign and 26 were malignant. Our diagnostic workup, including serum thyroid studies, radiologic evaluation, and fine-needle aspiration, is discussed. Because of the possibility of malignancy, we recommend that all solitary thyroid nodules be excised in children unless fine-needle aspiration definitively determines a benign histology. The extent and type of surgical management is controversial and is still subject to much debate. Partial thyroidectomy appears adequate for benign disease, but even though there is no statistical difference in survival, we recommend total thyroidectomy for the management of malignant disease.Thyroid nodules in children are extremely uncommon. Most thyroid nodules, both benign and malignant, present as asymptomatic neck masses. A thyroid nodule in a child is significant because of the risk of malignancy. A review of medical records at our institution demonstrated 71 patients 20 years of age and younger with surgically managed thyroid nodules, of which 45 were benign and 26 were malignant. Our diagnostic workup, including serum thyroid studies, radiologic evaluation, and fine-needle aspiration, is discussed. Because of the possibility of malignancy, we recommend that all solitary thyroid nodules be excised in children unless fine-needle aspiration definitively determines a benign histology. The extent and type of surgical management is controversial and is still subject to much debate. Partial thyroidectomy appears adequate for benign disease, but even though there is no statistical difference in survival, we recommend total thyroidectomy for the management of malignant disease.

The Potential Pitfalls of Concurrent Rhinoplasty and Endoscopic Sinus Surgery

Objective As the largest portion of the population is becoming middle aged and our society becomes increasingly interested in youth and appearance, so does the number of esthetic surgeries. Rhinoplasty is being performed with increased frequency in recent years. Many surgeons are performing rhinoplasty combined with endoscopic sinus surgery as a means to decrease operating times, healing times, as well as patient cost. Many surgeons may be unaware of several potential life‐threatening complications when these two safe procedures are performed concurrently.

Long-term follow-up of Stapedectomy in Children and Adolescents

Otosclerosis presenting in children and adolescents is uncommon. Typically, otosclerosis presents as a slowly progressive conductive hearing loss in the third to fourth decade. Many well-documented studies have demonstrated excellent long-term hearing results with stapedectomy. Although stapedectomy is highly effective, the rare complications may be devastating. Thirty-one patients, 21 years or younger, underwent 40 stapedectomies for otosclerosis at our institution. The average age at surgery was 16 years, with a range of 7 to 21 years. Postoperative results showed an average improvement in air-bone gap of 22 dB. Clinical and audiologic data were collected over a mean follow-up period of 25 years. There was no statistically significant difference in air-bone gap when comparing the immediate postoperative gap (measured 2 months after stapedectomy) with the last gap recorded (mean, 25 years after stapedectomy). Fifty percent of the ears operated on maintained an air-bone gap within 10 dB at the last follow-up, and an additional 40% maintained a 10- to 20-dB gap. There were no significant relationships between demographic or clinical factors and “success” (gap ≤ 10 dB) or long-term gap closure. Our data demonstrate that stapedectomy is an effective method for closing the air-bone gap in children and adolescents with otosclerosis, and long-term results parallel those of adults, showing maintenance of excellent gap closure. This review represents the largest population with the longest follow-up in children who underwent stapedectomy for the treatment of otosclerosis.

The island rotation flap: a better alternative for nasal tip repair.

The use of the island rotation flap for the repair of small and medium-sized partial-thickness defects of the nasal tip and soft triangle has led to extremely favorable aesthetic results far superior to that of full-thickness skin grafts. The color and thickness match have been excellent, and the complication rate was negligible. The aesthetic results and reliability, coupled with the single stage and single operative site, make this flap an excellent option for nasal tip reconstruction. It is our procedure of choice for the reconstruction of small and medium-sized nasal tip and soft triangle defects.

Cholesterol granuloma of the frontal bone

Cholesterol granuloma is a chronic inflammatory process with associated foreign body reaction to hemorrhage-related cholesterol crystals. In the head and neck region, cholesterol granulomas most frequently occur in the middle ear and mastoid, but they only rarely have been reported in the paranasal sinuses and the frontal bone. Those lesions involving the frontal bone typically occur in the lateral aspect of the supraorbital ridge and more commonly affect men.1,2 We present a case of a middle-aged woman with a cholesterol granuloma of the medial frontal bone in close proximity to her frontal sinus. The diagnosis and management of this lesion are discussed.

Strobovideolaryngoscopy in the management of acute laryngeal trauma.

Surgical intervention in the management of acute laryngeal trauma can sometimes pose a difficult decision. The objective of this study is to evaluate the effectiveness of strobovideolaryngoscopy (SVL) in determining the course of management for patients sustaining acute laryngeal trauma. A 20-year retrospective study of patients presenting with acute laryngeal trauma was performed in order to determine if the addition of SVL during the study period changed the management of certain acute laryngeal injuries. Patients sustaining blunt laryngeal trauma evaluated at our institution from 1981 to the present were reviewed. There were 40 patients identified that were grouped by severity according to the Schaefer classification. Analysis included mechanism of injury, clinical presentation, assessment, treatment, and outcome. Group 1 injuries were the most common, with motor vehicle accident (MVA) the most frequent mechanism of injury. Initial assessment included fiberoptic laryngoscopy and computed tomography (CT) imaging in all patients not requiring immediate exploration. SVL was used in 20 patients, with 7 undergoing stroboscopy within 24 hours of presentation. All 7 patients were managed conservatively without surgical intervention or the need to establish an alternative airway. SVL improves the clinical assessment of patients with acute laryngeal injury. This study supports its use and found it to be an important factor in determining the need for surgical intervention. SVL may also shorten the hospital stay in these patients.

2: Comparison of Transconjunctival versus Subcillary Incisions for Orbital Fractures:

Objective: Myringotomy and tube placement in children and sometimes in adults has traditionally required general anesthesia. Risks of general anesthesia and costs of even outpatient surgery have led to a search for alternatives. This study demonstrates the safety and effectiveness of nitrous oxide conscious sedation as a supplement to local anesthesia for myringotomy and tube placement in children and adults. Methods: Nitrous oxide was used as conscious sedation for 595 cases of myringotomy and tube placement in children and 789 cases of myringotomy and tube placement in adults. These cases were retrospectively reviewed. Results: Nitrous oxide was effective as an agent for conscious sedation in conjunction with local anesthesia for office myringotomy and tube placement. There were no significant complications in 1384 cases. Conclusion: Nitrous oxide conscious sedation used as a supplement to local anesthesia is effective and safe as a method of office myringotomy and tube placement.