James Chan

Intracapsular tonsillar reduction (partial tonsillectomy): reviving a historical procedure for obstructive sleep disordered breathing in children

OBJECTIVE We sought to reintroduce a historical procedure-intracapsular tonsillar reduction (partial tonsillectomy or tonsillotomy)-for tonsillar hypertrophy causing obstructive sleep disordered breathing (OSDB) in children, as well as to determine whether partial tonsillectomy, compared with conventional (total) tonsillectomy when performed by more than one surgeon, is equally effective for the relief of OSDB while resulting in less pain and more rapid recovery. STUDY DESIGN We conducted a retrospective case series at a tertiary childrens hospital. The charts of children who underwent partial tonsillectomy and total tonsillectomy (1998 through 2002) for postoperative complications were reviewed. The caregivers were surveyed to assess postoperative pain, rapidity of recovery, and effectiveness of surgery for relieving symptoms of OSDB. RESULTS Two hundred forty-three children underwent partial tonsillectomy and 107 children underwent total tonsillectomy. There were no significant differences in immediate and delayed complications between the groups. Both operations were equally effective in relieving OSDB. Children who had partial tonsillectomy had significantly less postoperative pain and significantly more rapid recovery. CONCLUSION Intracapsular tonsillar reduction with an endoscopic microdebrider relieves OSDB as effectively as conventional tonsillectomy, but results in less postoperative pain and a more rapid recovery.

Power-Assisted Adenoidectomy: Total and Partial Resection

Objective To describe the surgical technique for power‐assisted adenoidectomy and review the safety and effectiveness of the procedure.

Functional outcomes following chemoradiotherapy for head and neck cancer

OBJECTIVE: To study functional outcomes following concurrent chemoradiotherapy of head and neck cancer. METHODS: A retrospective chart review assessed diet, feeding tube use, and tracheotomy pretreatment and 3, 6, 12, and 24 months posttreatment. RESULTS: Of 196 patients who underwent chemoradiotherapy between 1990 and 2002, 148 (76%) required feeding tubes immediately posttreatment; 150 (77%) required nutritional support at 3 months. By 12 months, 92% were tube-free and 83% resumed near-normal diet. Of 17 patients (9%) with tracheotomy posttreatment, 71% were decannulated by 6 months. Stage IV disease strongly predicted prolonged feeding tube use and slow recovery of diet; age ≥60 also predicted slow recovery. Primary site, gender, and radiotherapy schedule did not predict functional recovery after adjusting for stage and age. CONCLUSION: Few patients required tracheotomy before or during chemoradiotherapy. Many patients required feeding tubes and nutritional support for several months following therapy, but most were tube-free and eating near-normal diets within 1 year. EBM rating: C.

Occult supraglottic lymphatic malformation presenting as obstructive sleep apnea.

Sleep disordered breathing and obstructive sleep apnea is commonly encountered in the pediatric population. In many cases, it is the result of oropharyngeal obstruction secondary to adenoidal or adenotonsillar hypertrophy. We describe an unusual case of a child with adenoidal hypertrophy who had an occult supraglottic lymphatic malformation that manifested as obstructive sleep apnea. The management of this lesion is discussed including the use of endoscopy, carbon-dioxide laser, and the decision to avoid a tracheotomy. Occult supraglottic lymphatic malformations (LMs) are a rare cause of obstructive sleep apnea, the diagnosis of which will be missed without fiberoptic laryngeal examination. They are challenging to manage because of the airway involvement and propensity to recur.

Investigation of a Novel Cross-Linked Hyaluronan Hydrogel for Use as a Soft-Tissue Filler

Objective: To investigate an innovative tyramine-based hyaluronan (TB-HA) biomaterial for soft-tissue augmentation. Specifically, to test: (1) the ability of the TB-HA biomaterial to be injected subcutaneously; and (2) to test the in vivo response of the TB-HA biomaterial in an immunocompetent animal model. Introduction: Hyaluronan (HA) is a normal component of most tissues and, as such, is nonimmunogenic, nontoxic, and noninflammatory. Cross-linked hydrogels are formed from HA by substitution (approximately 5%) with tyramine followed by enzymatic cross-linking with peroxidase in the presence of very dilute hydrogen peroxide. From a single formulation of tyramine-substituted HA (TS-HA), a full spectrum of biomaterial properties can be produced by varying the HA concentration before cross-linking. The properties of these biomaterials ranged from a soft, optically clear hydrogel (6.25 mg/mL), suitable for soft-tissue augmentation as an injectable material, to a paste-like material (12.5–25.0 mg/mL). Materials and Methods: The hydrogel was evaluated in vivo as an injectable material (6.25 mg/mL). The material was injected into the subcutaneous tissue of an adult Sprague-Dawley rat, harvested at 8 weeks, and evaluated grossly and histologically. The specimens were paraffin embedded, sectioned on a microtome, and stained with hematoxylin and eosin. Results: In vivo analysis of the TB-HA hydrogels at 8 weeks revealed that they were resistant to degradation. Histological analysis revealed no evidence of rejection or tissue inflammatory response. Conclusions: Novel enzymatic cross-linking of HA enables the development of a versatile new biomaterial that can be used for soft-tissue augmentation. Preliminary in vivo analysis in an immunocompetent rat model revealed that the hydrogel material resisted degradation and did not elicit a host inflammatory response.

Temporal Mandibular Joint Reconstruction Using Vascularized Bone Graft with Alloderm

Objectives: Vascularized free bone grafts have been used extensively for reconstruction of the mandible. When surgical resection includes the temporal mandibular joint, definitive management remains controversial. We describe a novel technique that involves the use of a fibula free flap with alloderm to reconstruct the lateral hemimandible and temporal mandibular joint capsule. Methods: Retrospective case series at an academic center. Patients undergoing composite resection of the lateral hemimandible including the condyle, or with disruption of the temporal mandibular joint were evaluated in this study. Results: There were 6 patients (5 male, 1 female) with a mean age of 53.7 years. Indications for surgery were carcinoma (n = 4) and osteoradionecrosis (n = 2). Mean follow-up was 12 months. All patients reported improved facial symmetry, decreased trismus, adequate jaw opening, and improved occlusion. The majority of patients demonstrated good postoperative speech and swallowing. All but one patient was able to chew and tolerate a normal diet. There were no flap failures, infections, or complications. Conclusion: The lateral hemimandible and temporal mandibular joint can be resected and successfully reconstructed using a fibula free flap with alloderm. Improved cosmesis, decreased trismus, adequate jaw opening, minimal jaw drift, and the ability to chew were achieved in the majority of patients treated in this manner.

Permeability of the blood-labyrinth barrier in mice following acoustic injury

Abstract Problem: The blood-brain barrier is a well-described structure that excludes the transport of molecules from the blood stream into the brain. The cochlea has been demonstrated to maintain a similar barrier with the intravascular space, termed the blood-labyrinth barrier (BLB). Its presence has been established with the use of radio-labeled proteins and ions, showing that a gradient exists between the serum and the perilymph. However, an anatomic study of the permeability gradients in different regions of the cochlea has not been performed. The purpose of this study is, therefore (1) to assess the presence of a BLB in the cochlea using Evans blue (EB), and (2) to investigate the effects of acoustic injury on the integrity of such a barrier. Methods: Normal control and noise-exposed mice were intravascularly injected with EB and after 20 minutes, brain and cochlea were harvested. EB staining was viewed under fluorescence microscopy. Results: In the cochlea, EB fluorescence demonstrated areas of high permeability including the bone marrow and blood vessels within the stria vascularis. There were also areas of moderate permeability such as the intra-strial compartment of the stria vascularis. Finally there were areas of relative impermeability found in the cochlear duct, spiral ligament, spiral limbus, scala vestibuli, and scala tympani. In this experiment we demonstrated that acoustic injury can change the permeability characteristics of the cochlea and causes leakiness of the BLB in the spiral ligament. Conclusion: The EB dye test is a technique that can be applied to assess the integrity of the BLB. Within the inner ear, there are specific regions that demonstrate high permeability, moderate permeability, and relative impermeability to EB. Significance: Acoustic trauma causes changes in the intrinsic properties of the BLB and results in leakiness of the BLB in the spiral ligament, precisely in the location where inflammatory cells migrate in response to acoustic injury. Support: This study was funded by the American Academy of Otolaryngology-Head and Neck Surgery resident research grant award.