Garrett R. Griffin

Potential of an Electric Prosthesis for Dynamic Facial Reanimation

Chronic facial paralysis is a devastating condition with severe functional and emotional consequences. The current surgical armamentarium permits the predictable reestablishment of a protective blink as well as good resting symmetry. Yet the ultimate goal of symmetric, spontaneous emotional expression remains elusive despite significant progress in the areas of peripheral nerve grafting and free tissue transfer. This commentary explores the possibility of an implantable electrical prosthesis for facial reanimation. It reviews animal studies supporting this concept as well as recent human data suggesting that such an implant could rescue denervated facial musculature, thus overcoming a major hurdle for existing reanimation techniques.

Outcomes Following Temporalis Tendon Transfer in Irradiated Patients

OBJECTIVE To compare objective outcomes and complications following temporalis tendon transfer in patients with and without a history of radiation to the parotid bed. METHODS Retrospective medical chart review comparing dynamic movement of the oral commissure and resting symmetry achieved in 7 irradiated patients (group R) and 7 nonirradiated patients (group N) after temporalis tendon transfer for unilateral facial paralysis. RESULTS There were no significant differences between the 2 groups of patients in terms of age, additional facial reanimative procedures, baseline lip position, or follow-up time. Postoperatively, good resting symmetry was achieved in both groups. The mean commissure excursion was significantly inferior in the irradiated group of patients (-1.5 mm in group R vs 2.1 mm in group N; P < .05). Two patients in the irradiated group experienced surgical site infections requiring hospital admission and eventual debridement of their tendon transfers. CONCLUSIONS Temporalis tendon transfer seems to produce less dynamic movement in patients who have received radiation to the parotid bed, and these patients may also be at higher risk of postoperative infection. Temporalis tendon transfer can achieve good resting symmetry in both irradiated and nonirradiated patients.

Outcomes Following V-Y Advancement Flap Reconstruction of Large Upper Lip Defects

OBJECTIVE To characterize revision surgery following V-Y subcutaneous tissue pedicle advancement flap repair of large upper lip skin defects. METHODS Retrospective review of upper lip skin defects at least 3.0 cm(2) in area that were reconstructed with a V-Y subcutaneous tissue pedicle advancement flap at an academic tertiary care center. Depth and area of the defect, as well as involvement of the vermilion and nasal ala, were recorded as independent variables. Revision techniques were analyzed to identify patterns. RESULTS Thirty patients were identified as having upper lip skin defects with a mean (range) area of 7.0 (3.0-14.0) cm(2) (median, 6.25 cm(2)). The defect involved the nasal ala in 4 cases and the vermilion in 3 cases. At least 1 revision surgery was performed in 14 patients (47%). Alar or vermilion involvement was a significant factor in revision by χ(2) analysis (P = .03). Larger defect size did not predict a need for revision, even among cases where the defect did not involve the ala or vermilion (P = .68). CONCLUSIONS Reconstruction of large upper lip skin defects with a V-Y subcutaneous tissue pedicle advancement flap is associated with a 47% revision rate, and when the defect involves the ala or vermilion, the revision rate is increased. Defect size alone cannot be used to predict the need for revision surgery. Revision techniques are demonstrated.

Auricular tophi as the initial presentation of gout

Tophaceous gout is generally considered to be the end result of long-standing hyperuricemia, and is usually preceded by arthritis and several acute attacks. We present the unusual case of a man with no history of gout who presented with primary gouty tophi of the bilateral auricles. A 47-year-old man with a history of hypercholesterolemia and alcohol abuse presented with a six-month history of increasing numbers of gradually enlarging nodules of the auricle. The largest lesion was becoming more painful with pressure while sleeping. The patient denied bleeding, pruritis, or drainage. He denied a history of similar lesions, podagra, or arthritis. Lovastatin was his only medication and he infrequently used NSAIDs. He worked in construction and had significant sun exposure but had no history of skin cancers. He consumed on average five alcoholic beverages per day. On physical exam there were several pale, nontender nodules measuring 2 to 10 mm in diameter over both auricles, primarily the helix and antihelix. These were very superficial, well-circumscribed, and with no surrounding erythema or ulceration (Fig 1). The Institutional Review Board does not require approval for single case reports at our institution. Clinically, the differential diagnosis included elastotic nodules, rheumatoid nodules, and tophaceous gout. These lesions are easily confused with basal cell carcinoma, and given the patient’s complaints of pain, the patient was consented for excisional biopsy of the largest lesion from the left antihelix. During excision, it separated easily from the surrounding tissues and did not invade the perichondrium. The pathology revealed tophaceous gout. The patient’s serum uric acid level was found to be elevated at 7.8 mg/dL. Allopurinol was initiated, which moderately decreased the size of the tophi.

Interpolated subcutaneous fat pedicle melolabial flap for large nasal lining defects

Full‐thickness nasal deformities are a reconstructive challenge. Restoration of a reliable internal lining is critical for a successful reconstruction. Septal hinge flaps are the workhorse for internal lining defects. However, these and other intranasal mucosal flaps are sometimes unavailable due to prior harvest or previous oncologic resection. We present the two‐stage interpolated subcutaneous fat pedicle melolabial flap for lining large defects when traditional intranasal flaps are unavailable. This approach is particularly useful when one forehead flap has already been expended, preserving the patients remaining forehead tissue for external cover. Laryngoscope, 2012

A new member of the multidisciplinary ALS team: The otolaryngologist

Abstract The multidisciplinary approach to treatment of amyotrophic lateral sclerosis (ALS) has improved the overall care of patients suffering from this disease (12). This approach typically has included neurologists, physiatrists, occupational therapists, respiratory therapists and speech therapists. Dysphonia, dysarthria, and dysphagia are three of the most common bulbar manifestations of ALS, and are often the presenting symptoms in bulbar-onset patients. Despite this, otolaryngologists are often not included in ALS management until a tracheostomy is considered. The otolaryngologist can play an important role in early diagnosis and subsequent management of bulbar manifestations of ALS, and would be a valuable member of the multidisciplinary team.

Transmastoid labyrinthectomy for disabling vertigo in a patient with internal auditory canal pathology

Objective: Document the use of transmastoid labyrinthectomy to treat disabling vertigo secondary to a lesion in the internal auditory canal. Patient: A 69-year-old man with nonserviceable left hearing experienced disabling attacks of vertigo refractory to medical measures. Magnetic resonance imaging revealed a small left intracanalicular lesion with an irregular configuration and modest enhancement, suggesting either an unusual acoustic neuroma or a cavernoma. Tumor size remained stable on serial imaging, and the patient declined microsurgical resection, stereotactic radiation, or intratympanic gentamicin therapy. Intervention: Transmastoid labyrinthectomy followed by a customized vestibular rehabilitation program. Main Outcome Measure: Comparison of patient symptoms preoperatively and at 5 and 8 months after surgery. Results: Complete relief of vertigo was achieved, but the patient has moderate imbalance postoperatively. Conclusion: Transmastoid labyrinthectomy alone may be a viable treatment option in patients with an internal auditory canal neoplasm causing disabling attacks of vertigo.

Campomelic dysplasia: Airway management in two patients and an update on clinical-molecular correlations in the head and neck

Campomelic dysplasia is a rare and historically lethal skeletal dysplasia with a variable but recognizable phenotype; it affects the long bones and is associated with a variety of head and neck anomalies. Mutations in or around the SOX9 gene have been identified as the molecular origin in most patients. We briefly present 2 children who meet the diagnostic criteria for campomelic dysplasia to illustrate the various clinical manifestations. Many patients with campomelic dysplasia have airway obstruction at multiple levels. We describe our approach to managing the airway in these patients, and review recent advances in understanding how SOX9 mutations lead to the spectrum of abnormalities seen in the head and neck.

Development of a moderate fidelity neck-dissection simulator

INTRODUCTION Selective neck dissection can be viewed as a ‘‘keystone’’ operation, mastery of which essentially proves the ability to work safely around cranial nerves and the great vessels, access deep neck space infections, and perform smaller ‘‘component’’ procedures like submandibular gland excision. It is a relatively complicated surgery with potentially severe complications including incomplete lymphadenectomy with persistent/ recurrent malignancy, cranial nerve injury, stroke, and high-flow chyle leak. We feel that traditional reading alone is inadequate preparation for a trainee’s first several neck dissections as resident surgeon. The tortuous three-dimensional anatomy and process of removing the lymphatic package en bloc are difficult to grasp from text and two-dimensional drawings. A moderate-fidelity neck dissection simulator (NDS) was created to augment book learning.

Neurologic late effects associated with radiologic evidence of vertebral osteoradionecrosis after salvage laryngectomy: A syndrome associated with survivors of laryngeal and hypopharyngeal cancer

Delayed nonspecific posterior neck pain after pharyngeal instrumentation can be associated with a syndrome of rapidly progressive neurologic embarrassment. We present this cohort to help define the syndrome and aid in early detection.