Daniel B. Kuriloff

Sarcoidosis of the sinonasal tract: A new staging system☆☆☆★

Sarcoidosis is a chronic multisystem granulomatous disease that has a predilection for pulmonary and upper respiratory tract involvement. Because the initial signs and symptoms of sarcoidosis may be identical to those of other forms of chronic sinonasal inflammatory disease, these patients will often first seek treatment from an otolaryngologist. We present a series of 28 patients whose primary symptoms was involvement of a sinonasal tract. A new staging system is proposed to categorize the severity and sites of involvement and to guide the aggressiveness of therapy. Sarcoidosis should be considered in the differential diagnosis of inflammatory sinonasal disease.

The nasolabial cyst-nasal hamartoma.

The nasolabial cyst is an uncommon midfacial cyst. Twenty-six patients with nasolabial cysts were treated at the New York Eye and Ear infirmary from 1969 to 1986. Most of these lesions manifested facial deformity, unilateral nasal obstruction, and pain when infected. The nasolabial cyst is often unrecognized or confused with other intranasal masses, or fissural and odontogenic cysts. Infection of these lesions—which occurred in 50% of the patients—may mimic facial cellulitis, periodontal abscess, acute maxillary sinusitis, or nasal furuncies. This cyst is considered to be a hamartoma because of its developmental origin from entrapped epithelium in an embryonic fusion plane. Simple aspiration invariably leads to recurrence, and complete surgical excision is the accepted treatment. The nasolabial cyst should be considered in the differential diagnosis of intranasal masses, midface infections, and swelling in the nasolabial area.

Risk Factors for Intubation Injury of the Larynx

The endolaryngeal structures are subjected to insult from prolonged endotracheal intubation. Factors that may exacerbate this injury include intubation technique, duration of intubation, tube geometry and constitution, frequency of reintubation, and patient-related factors such as concomitant medical diseases. The contribution of underlying medical disease to laryngeal intubation injury was studied prospectively by sequential endoscopy from the time of tracheotomy. Diabetes mellitus, congestive heart failure, and a history of stroke or tuberculosis increased the likelihood of severe laryngeal injury. The association of these disorders with severe laryngeal injury should lead to consideration of earlier tracheotomy in such patients.

Rapid intraoperative localization of parathyroid glands utilizing methylene blue infusion

OBJECTIVE: To review a single surgeons experience utilizing an intraoperative methylene blue infusion (IMBI) to identify parathyroid glands during neck exploration for primary hyperparathyroidism. STUDY DESIGN AND SETTING: Retrospective review of 35 patients who underwent bilateral neck exploration utilizing an IMBI at a dose of 7.5 mg/kg following the induction of general anesthesia. RESULTS: All patients reverted to normocalcemia with a mean follow-up of 17 months. IMBI facilitated the identification of abnormal parathyroid tissue in 34/35 patients (97%). A dark blue-purple staining was observed in 33/37 stained adenomas (89%). Four adenomas and four hyperplastic glands stained a lighter shade of blue-green. Among 89 normal glands, 41(46%) stained a pale green-grey color. CONCLUSIONS: IMBI is a safe, readily available, cost-effective, and underutilized technique that facilitates rapid identification of parathyroid adenomas, helps distinguish normal glands from hyperplastic glands, and helps to locate ectopic glands. An overall reduction in operative time, especially for bilateral neck exploration, can be anticipated. Since parathyroid glands are often inconspicuous, their identification can be a challenging problem when performing neck exploration for the treatment of hyperparathyroidism. Normal parathyroid glands can be a few millimeters in size (especially when suppressed by hypercalcemia), of variable color, and supernumerary. They may also be surrounded by or imbedded in adipose tissue or confused with small paratracheal lymph nodes. When thyroid surgery is performed by experienced surgeons, inadvertent parathyroidectomy may be as high as 9%. 1 Abnormal parathyroid glands may be concealed beneath the thyroid capsule, intrathyroid, intrathymic, or inside the carotid sheath. Other ectopic locations in the neck or anterior mediastinum are also encountered. Furthermore, the distinction between true double adenomas and asymmetric hyperplasia continues to challenge even the most seasoned endocrine surgeon. It has been argued that with the exception of a mediastinal parathyroid adenoma, localizing studies (eg, technetium-99m-sestamibi [Tc-MIBI] imaging, MRI, CT, and ultrasound [US]) add little to the overall success of parathyroidectomy, especially for primary explorations in the hands of experienced endocrine surgeons. However, for the less experienced surgeon, preoperative localization studies have been helpful in directing the side of the neck for initial exploration, and for reducing operative times and frustration. Revision parathyroidectomy, after a failed initial neck exploration, can be an exercise in futility without some form of localizing study, the cost of which is then always justified. Recent extramural pressures to perform “minimally invasive surgery,” limiting both the scope and duration of parathyroidectomy and reducing hospital length of stay, have popularized the use of preoperative parathyroid localizing studies. Over the past decade, Tc-MIBI imaging has become the “gold standard” for preoperative localization because of its high sensitivity and specificity, and its use has become routine in many centers. Intraoperative procedures such as Tc-MIBI localization using a hand-held gamma probe, intraoperative circulating iPTH assay (Nichols Institute Diagnostics, San Juan Capistrano, CA, USA), have evolved to permit a more limited “minimally invasive” unilateral neck exploration. However, this approach is limited to patients for whom a preoperative Tc-MIBI strongly suggests the presence of a single adenoma. Even with this positive finding, Tc-MIBI will miss double adenomas and asymmetric four-gland hyperplasia in a significant number of patients. The additional radiation exposure to patient and personnel with radioguided surgery, the need for more than one scan, and complex scheduling issues for appropriate timing of the radiopharmaceutical administration may represent other disadvantages.

Squamous Cell Carcinoma of the Thyroid: A Diagnostic Dilemma:

Four cases of primary squamous cell carcinoma of the thyroid gland are reported. Thorough evaluation confirmed these lesions to be of primary thyroid origin rather than from metastasis or direct invasion from contiguous structures. These cases illustrate the aggressive nature of the disease and the propensity for local and distant metastases. The clinicopathologic data presented here underscore the challenge in diagnosis and treatment of this rare entity.

Laryngotracheal injury following cricothyroidotomy

Airway complications following elective cricothyroidotomy were reviewed in 48 adult cardiothoracic surgery patients. A 52% incidence of airway complications was found and manifested by failed or delayed decannulation, extensive subglottic granulation tissue, stenosis, vocal cord paralysis, and aspiration pneumonia. The most common cause for decannulation difficulty was subglottic stenosis (50%).

Delayed neck infection following anterior spine surgery

Pharyngoesophageal perforation and neck abscess formation is a rare complication of anterior cervical spine surgery. This complication usually manifests itself within the early postoperative period and is associated with soft tissue trauma at the time of surgery.

Delayed airway obstruction and neck abscess following manual strangulation injury.

Few reports describing manual strangulation injury to the neck are found in the otolaryngologic literature. Since most victims sustain immediate fatal asphyxiation, brain anoxia, or cardiac arrest, they are usually examined by a forensic pathologist. When strangulation attempts are nonfatal, neck injuries can lead to delayed airway obstruction. If not managed in a timely fashion, these injuries can be fatal or cause permanent laryngotracheal sequelae. We describe a patient who 36 hours following manual strangulation developed acute upper airway obstruction and neck abscess necessitating tracheotomy, neck exploration, and drainage. Patients suffering this unique type of compression injury may present initially with deceptively benign symptoms and signs. We discuss the overall management of these patients, stressing the need for early imaging studies, endoscopic assessment, and continued airway monitoring in an intensive care unit.

Prefabricated microvascular autograft in tracheal reconstruction.

Tracheal reconstruction continues to be a challenge in head and neck surgery. Numerous techniques, Including the use of alloplasts, composite grafts, and staged laryngotracheal troughs, have met with limited success because of Implant exposure, Infection, persistent granulation tissue, and eventual restenosis. With recently introduced techniques for soft-tissue molding, bone induction with bone morphogenetic protein, and microvascular free tissue transfer, a rodent model was developed to create a well-vascularized tracheal autograft. In this model, a rigid tube having the same dimensions and flexibility as the native trachea was created by wrapping a cylindrical silicone tracheal mold with a layer of vascularized adductor thigh muscle pedicled on the femoral vessels in the groin. Tracheal rings were created by filling transverse troughs in the muscle bed with bone morphogenetic protein—primed demineralized bone matrix before wrapping around the silicone mold. Grafts harvested at 2 weeks demonstrated rigid skeletal support provided by heterotopic bone formation in the form of rings and a smooth inner lining produced by fibroplasia. Bone transformation was controlled and restricted to the muscle troughs, allowing intervening regions of soft tissue and thus producing a flexible neotrachia. With this model, a homologous, vascularized tracheal autograft capable of microvascular free tissue transfer was fabricated based on the femoral vessels. Prefabrication of composite grafts, through the use of soft-tissue molding, bone Induction, and subsequent free tissue transfer, has an unlimited potential for use in head and neck reconstruction.

Detection of Gastroesophageal Reflux in the Head and Neck: The Role of Scintigraphy

Patients with gastroesophageal reflux (GER) present to the head and neck specialist with a myriad of nonspecific complaints that may be manifestations of pharyngoesophageal or upper airway involvement. Numerous diagnostic tests for GER have been used in the past with varying success. In the present study, gastroesophageal scintigraphy using 99mtechnetium-sulfur colloid was used to evaluate 28 patients with head and neck manifestations of GER. The role of gastroesophageal scintigraphy as an accurate and noninvasive method of detecting GER is discussed in the context of other current diagnostic modalities.