J. Dale Browne

Tracheobronchial foreign bodies

A retrospective review of 88 cases of foreign body aspiration was undertaken. The patients ranged in age from 5 months to 73 years; the peak incidences of foreign body aspiration occurred in children less than 3 years of age and in adults older than 50 years. Sixty‐one of the 88 patients were male. Physical examination was abnormal in 61% of patients. The most common radiographic abnormality was inspiratory‐expiratory abnormality, seen in 27% of patients. Rigid endoscopy under general anesthesia was the preferred method for removal of the aspirated material. Multiple foreign bodies were found in 5% of the patients. Tracheobronchial foreign bodies should, therefore, be strongly suspected in susceptible patient populations who present with a suggestive history, even when no physical or radiographic evidence can be seen. Patients should be carefully examined for multiple foreign bodies at the time of rigid endoscopic removal.

Evaluation of airway obstruction using virtual endoscopy.

Objectives: This study examines the use of virtual endoscopy (VE) in the evaluation of patients with upper airway obstruction. The utility of VE compared with actual endoscopy was investigated with respect to accuracy of diagnosis and reproduction of endoscopic images.

Benefits of routine maxillectomy and orbital reconstruction with the rectus abdominis free flap

Maxillary defects lead to functional and cosmetic deficiencies, especially with tumor invasion of the orbit and cribriform plate. Additionally problematic is the near-total palatal resection in patients with poor dentition (ie, not useful for anchoring obturators) and the desire for return of deglutition and useful speech. A series of 12 patients is presented in whom a rectus abdominis free flap was used for reconstruction of the palate, maxilla, and/or orbit. Nine of 12 free flaps were used to reconstruct defects involving the maxilla and orbit; all were successful in restoring hard palate continuity and function without the use of an obturator. The remaining 3 patients underwent successful repair of defects involving the orbit and medial maxilla without complication. Four of those 9 patients with palatal reconstruction augmented their dental rehabilitation with either their existing upper denture plate or the use of a cosmetic appliance anchored to their remaining dentition. Objectively, the rectus abdominis myocutaneous free flap proved to be a reliable and expeditious method of restoring function and acceptable cosmesis. We believe this technique should be routinely considered in the reconstruction of these defects.

Swallowing Dysfunction is a Common Sequelae After Chemoradiation for Oropharynx Carcinoma

Introduction:A retrospective review of all patients with advanced oropharynx cancer from a single institution was performed. Methods:Sixty-seven patients with stage III/IV oropharynx cancer were treated with definitive radiotherapy with or without concurrent chemotherapy from 1990 to 2004. Follow-up ranged from 6 to 91 months with a median of 32 months. Results:Patients treated with concurrent chemotherapy had a statistically significant benefit for control above the clavicles, primary control, disease-free survival, and overall survival but no difference in distant control at 3 years. Cox proportional regression model demonstrated the use of concurrent chemotherapy to be the only independent variable that reached significance for control above the clavicles, primary control, and overall survival. Complete dysphagia for solids and/or gastrostomy tube dependence was observed in more patients who were treated with chemoradiation than those treated with radiation alone; 18% and 0%, respectively (P = 0.04). Conclusions:Concurrent chemotherapy decreases the recurrence at the primary site and above the clavicles. The most notable difference in sequelae between the 2 groups was the increase in swallowing dysfunction with concurrent chemotherapy.

Desmoplastic Malignant Melanoma of the Oral Mucosa An Underrecognized Diagnostic Pitfall

Although cutaneous desmoplastic malignant melanoma (DMM) has been well characterized, those arising from the oral mucosa have been less well defined.

Clinical, histopathologic, and radiographic indicators of malignancy in head and neck paragangliomas.

OBJECTIVE: The goal of this study is to review our series of head and neck paragangliomas to identify factors that may help in predicting malignancy. STUDY DESIGN: Case series with chart review. SETTING: Academic medical center. SUBJECTS AND METHODS: Subjects with head and neck paragangliomas at our institution from 1976 to current were reviewed. In addition to statistical comparisons of epidemiologic factors, pathologic and radiographic characteristics were reviewed. RESULTS: Of the 84 subjects, there were seven malignant paragangliomas (8%). Age was found to be significantly different between the benign and malignant subgroups, with an average age of 54 ± 16 and 40 ± 12 years, respectively (P = 0.02). Pain was a presenting complaint in five patients with benign disease (6%), and five of the seven malignant patients (71%) presented with pain, showing a significant association between pain and disease type (P <0.0001). The odds ratio for a patient with pain having a malignant tumor was 36 (95% CI: 5.5–234). Enlarging neck mass was noted in all cases of malignant disease, but only in 31 percent of cases of benign disease (P < 0.0001). In a secondary analysis of carotid body tumors alone, enlarging neck mass was not found to be significant between benign and malignant disease (P = 0.14). However, pain continued to be significantly different, with 67 percent of malignant lesions demonstrating pain, compared with only 11 percent of benign lesions (P = 0.01). CONCLUSION: This study suggests that pain, a rapidly enlarging neck mass, and younger age are predictive factors of underlying malignancy, which should prompt one to consider an aggressive diagnostic and management approach.

Parathyroid hormone early percent change: an individualized approach to predict postthyroidectomy hypocalcemia☆

PURPOSE The purpose of this study is to evaluate a percent change model of postoperative parathyroid hormone level in thyroidectomy patients as a predictor of hypocalcemia. MATERIALS AND METHODS Chart review was completed on patients who had undergone total or completion thyroidectomy over a 22-month period in our department. Only those patients with a preoperative ionized calcium and parathyroid hormone (PTH) level and at least 1 postoperative result were included. Ionized calcium levels served as an internal control. The Student t test was used to compare PTH level between the normocalcemic and hypocalcemic groups at each time point. Logistic regression analysis was used to predict hypocalcemia based on the diagnostic criteria. Receiver operator curves were used to maximize sensitivity. RESULTS Fifty-two patients met the inclusion criteria during the study period. A total of 22 patients (42%) experienced hypocalcemia. We were unable to maximize both sensitivity and specificity at the same time point. When comparing preoperative to 6-hour postoperative PTH percent change, patients with a greater than 44% decrease are likely to have hypocalcemia, with a sensitivity of 100%. Likewise, in those patients without a greater than 44% decrease at 6 hours, early discharge can be considered safe, given the negative predictive value of 100%. CONCLUSION In our series, patients with a greater than 44% PTH decrease from preoperative to 6-hour postoperative are very likely to develop hypocalcemia. We would propose that these patients need further inpatient monitoring to progress to safe discharge. Likewise, patients with a less than 44% decrease at the 6-hour time point are unlikely to develop hypocalcemia and may be considered safe for discharge.

Dural arteriovenous fistula: diagnosis, treatment, and outcomes.

The objective of this study is to determine the sensitivity of computed tomography angiography (CTA) and magnetic resonance angiography (MRA) compared to the gold standard, conventional carotid angiography, in the diagnosis of a dural arteriovenous fistula (DAVF). Further objectives include identifying outcomes of treatment and complications as a function of pretreatment radiologic classification.

Functional outcomes and suitability of the temporalis myofascial flap for palatal and maxillary reconstruction after oncologic resection

The temporalis myofascial flap (TMF) is a method of palatal reconstruction that offers a single‐stage, reliable, and functional technique to repair oncologic defects involving the oral cavity following tumor removal. It is hypothesized that both speech and swallowing function are preserved following TMF.

The midfacial degloving procedure for nasal, sinus, and nasopharyngeal tumors

The midfacial degloving approach is more technically involved than a lateral rhinotomy and requires a basic level of proficiency and understanding of closed rhinoplasty incisions and anatomy of the nose, paranasal sinuses, and skull base structures. Current applications of the midfacial degloving procedure have allowed expansion of indications for this technique through the use of complementary endoscopic and subcranial approaches, permitting the exposure and removal of extensive skull base lesions without disfiguring facial incisions. Fundamental in these approaches is the basic midfacial degloving exposure, which is discussed in this article, along with the applications for treatment of skull base lesions.