Lance Oxford

Complications of Acute Sinusitis in Children

OBJECTIVE: To review the demographic, microbiologic, and outcome data for children with complications of acute sinusitis. STUDY DESIGN AND SETTING: Retrospective review of children admitted with complications of acute sinusitis from January 1995 to July 2002 to a tertiary care childrens hospital. RESULTS: One hundred four patients were reviewed with the following complications: orbital cellullitis (51), orbital abscesses (44), epidural empyemas (7), subdural empyemas (6), intracerebral abscesses (2), meningitis (2), cavernous sinus thrombosis (1), and Potts puffy tumors (3). Sixty-six percent were males (P < 0.001), and 64.4% presented from November to March (P < 0.001). Patients with isolated orbital complications were younger than patients with intracranial complications (mean, 6.5 versus 12.3 years), had a shorter stay (mean, 4.2 versus 16.6 days), and had shorter duration of symptoms (mean, 5.4 versus 14.3 days; all P < 0.0001). Complete resolution was documented for 54/55 patients with restricted ocular motility, 7/8 with visual loss, 3/3 patients with a nonreactive pupil, 7/7 with neurological deficits, and 2/4 with seizures. The most common organism isolated was Streptococcus milleri (11/36 patients with surgical cultures). No mortalities occurred, and persistent morbidity occurred in 4 patients (3.8%). CONCLUSIONS: Despite significant deficits on presentation, permanent morbidity was low. Streptococcus milleri is a common pathogen with complications of sinusitis in children.

Hydroxyapatite Cement in Craniofacial Reconstruction

OBJECTIVES: To evaluate the long-term efficacy of hydroxyapatite cement in craniofacial reconstruction, specifically examining the role (if any) of radiation, implant location, and cement type. STUDY DESIGN: A retrospective chart review was conducted of all patients presenting to the senior surgeon (Y.D.) for craniofacial reconstruction from September 1997 to April 2004. METHODS: Data were collected including type of cement used, size of defect, complications, need for removal of cement, reason for defect, and pathologic results of examination of removed cements. RESULTS: One hundred two patients were identified who underwent craniofacial reconstruction with hydroxyapatite cements, 7 of whom required complete implant removal (6 Norian and 1 Mimix), and 4 (2 Norian and 2 Bone source) of whom required partial implant removal for foreign body reaction. Five of the removals were in patients who underwent postoperative radiation. CONCLUSIONS: Hydroxyapatite cements are safe in craniofacial reconstruction. The highest risk of implant infection comes from reconstruction in the area of the frontal sinus, immediately beneath coronal incisions, and in patients who receive postoperative radiation treatment. Based on our results, there does appear to be a statistically significant difference in rates of infection and foreign body reaction between the different types of hydroxyapatite cement. We would not recommend implantation of this material in contact with the frontal sinus. Caution should be exercised when it is placed directly beneath an incision or in patients receiving postoperative radiation, particularly if a boost dose is given. EBM RATING: C

Transoral Approach to the Superomedial Parapharyngeal Space

OBJECTIVES: To present our early experience with the transoral approach to the superomedial parapharyngeal space (PPS) and describe our technique for removal of these neoplasms. STUDY DESIGN: Consecutive case series by one author (Y.D.). METHODS: Eight patients with various neoplasms of the superomedial PPS were retrospectively reviewed for type of neoplasm, size, success with the transoral approach, need for conversion to another approach, length of hospitalization, and complications. RESULTS: The transoral approach described herein safely allowed for en bloc resection of benign neoplasms with intraoperative control and exposure of the internal carotid artery. The most common pathology encountered was that of schwannoma. All patients were started on liquid diet on postoperative day 1. Average length of stay was 3.2 days (range, 2 to 5). Mean tumor size was 3.3 cm (range, 1.5 to 7 cm). No significant complications were felt to be related to the approach itself and visualization was felt to be excellent in each case without the need for conversion to a more extensive approach. CONCLUSIONS: The transoral approach safely provides access to superomedial PPS lesions with decreased morbidity compared with traditional approaches. This technique is indicated for neoplasms with benign appearance on preoperative imaging or fine needle aspiration. This approach alone may not provide adequate access for resection of malignant lesions especially those with extension intracranially or to more inferior or laterally placed lesions of the parapharyngeal space. EBM rating: C-4

Differential diagnosis and treatment options in paranasal sinus cancers.

Paranasal sinus malignancies are challenging to treat. Most patients present with advanced lesions, often with intracranial or intraorbital extension, and have a poor overall prognosis. Given the low incidence and diverse pathologies of paranasal sinus cancers, it is extremely difficult to perform prospective, randomized clinical trials to compare different treatment approaches. Improving the prognosis of these cancers continues to be a difficult task, even in light of advances in surgical techniques,radiation delivery techniques, and new chemotherapeutic agents. Cranio-facial resection techniques developed in the past few decades have cured many patients with skull base invasion, who would have been considered unresectable in the past. Furthermore, improvements in radiation therapy can allow more accurate administration to the desired region, with decreased damage to surrounding structures such as the orbit and brain. Aggressive and oncologically sound surgical resection combined with radiation therapy remains the treatment of choice for most patients.Finally, advances in the diagnosis and staging by use of molecular or DNA markers of tumor behavior may allow for more directed therapy.

Intraoperative Evaluation of Cortical Bony Margins with Frozen-Section Analysis

OBJECTIVES: To describe and evaluate the efficacy of frozen-section analysis of cortical bone margins in surgery of the craniofacial skeleton. STUDY DESIGN: Retrospective analysis of a consecutive series of patients undergoing oncologic resection of various head and neck neoplasms with osseous involvement by the senior author (Y.D.) from 1998 to 2003. RESULTS: Frozen-section analysis of cortical bone was performed in 38 patients. Adequate specimens for histological analysis were obtained in all patients. Frozen sections were positive in 21 of 22 patients with bone invasion on decalcified specimens. After validating our technique for frozen analysis of cortical bone in 13 patients, the method had a sensitivity of 89% and a specificity of 100% in 25 patients. Malignancies diagnosed on frozen cortical bone specimens included squamous cell carcinoma (15), mucoepidermoid carcinoma (3), and sarcoma (3). Frozen cortical margins altered the extent of bony resection in 8 patients. CONCLUSION: A simple technique for analysis of cortical bone involvement by neoplasm is presented and reviewed. It allows for frozen-section analysis with standard equipment and appears to be a reliable method to evaluate bony margins intra-operatively. EBM rating: C-4

Proximal peroneal perforator in dual-skin paddle configuration of fibula free flap for composite oral reconstruction.

Background: Composite defects of the oral cavity are often the result of trauma or advanced-stage tumor extirpation. The resultant deformity frequently requires a three-dimensional reconstruction of bone and soft-tissue. The fibula free flap is the preferred method of reconstruction, with various modifications focused on providing supplemental soft-tissue coverage. The objective of this study was to ascertain both anatomic and clinical data regarding the proximal peroneal perforator and its contribution to the evolution of the fibula free flap. Methods: Ten cadaver lower extremities were dissected to isolate the most proximal perforator supplying skin over the proximal lateral lower leg. Data were recorded regarding perforator presence, location, and course. Furthermore, review of clinical cases in which the proximal perforator was used in fibula free flap design was performed for operative data collection. Results: Cadaveric dissections revealed the proximal perforator to be present in 90 percent of specimens. Most commonly, the perforator, originating from the peroneal artery, traveled a short intramuscular course through the soleus muscle prior to supplying the overlying skin. In all clinical cases, the perforator was easily located with Doppler prior to incision, and there were no cases of flap failure or skin paddle loss. Flap inset was found to be optimal in all cases, with no tethering or undue tension. Conclusions: The proximal peroneal perforator was found to be anatomically reliable and clinically useful in composite oral cavity reconstruction following tumor removal. The gained separation between skin paddles allows for greater versatility in flap design and inset. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Retrograde Balloon Dilation of Complete Cervical Esophageal and Hypopharyngeal Strictures

OBJECTIVES To evaluate and describe retrograde endoscopic dilation of 100% strictures of the cervical esophagus and hypopharynx. METHODS AND MATERIALS All patients who presented to the senior author (Y.D.) from September 1997 to September 2003 with strictures of the cervical esophagus and hypopharynx were retrospectively reviewed. RESULTS Six patients with 100% strictures of the cervical esophagus and hypopharynx were available for review. Eighty-three percent of these patients were successfully treated endoscopically with the outlined technique. All were able to handle their secretions successfully, and four were no longer dependent on a gastrostomy tube. CONCLUSIONS Retrograde dilation of complete strictures of the hypopharynx and cervical esophagus appears to be safe, reliable, and associated with a high rate of ultimate success. It should be considered a first-line treatment prior to open approaches, which may be reserved for failures.

Transcervical elective superior mediastinal dissection for thyroid carcinoma

OBJECTIVES To review our results with elective superior mediastinal dissections for thyroid carcinomas. STUDY DESIGN Retrospective review. METHODS We searched operative case logs for all patients with thyroid carcinoma treated with an elective superior mediastinal dissection by the senior author (Y.D.) during a 6-year period. Charts were reviewed for demographic information and pathologic results. Elective superior mediastinal dissections were performed when the frozen section was consistent with anaplastic or medullary carcinoma or with a well-differentiated carcinoma when there was fixation of the primary tumor to the laryngotracheal complex, there was overt clinically evident paratracheal and/or cervical adenopathy, or the primary tumor measured greater than 2.0 cm in dimension. RESULTS Thirty-one patients meeting the above criteria were reviewed, and superior mediastinal disease was present in 19 patients (61.3%). Superior mediastinal nodes were positive in 13 (65%) of 20 patients with papillary carcinoma, 0 of 4 with follicular thyroid carcinoma, 4 of 5 patients with medullary thyroid carcinoma, and 2 of 2 patients with anaplastic thyroid carcinoma. Patients with follicular carcinoma had a lower incidence of mediastinal disease (0%) compared with nonfollicular thyroid carcinoma (70.4%), P = .02. Patients with cervical metastasis had an increased incidence of superior mediastinal disease (100% vs 53.3%). CONCLUSIONS Elective transcervical superior mediastinal dissection was commonly positive in patients with papillary, medullary, and anaplastic thyroid carcinomas. A transcervical approach may be safely performed without sternotomy to the level of the brachiocephalic vein. Further studies are required to determine if performing elective superior mediastinal lymph node dissections will have an impact on survival.

Elective transcervical superior mediastinal lymph node dissection for advanced laryngeal and level 4 N3 squamous cell carcinoma.

Objectives: To review our results with elective superior mediastinal lymph node dissections in patients with advanced laryngeal squamous cell carcinoma (SCCA) and overt level 4 adenopathy.

Congenital Tracheocutaneous Fistulas

Objective To outline two cases of congenital tracheocutaneous fistula and discuss the potential pathogenesis of this previously unreported developmental abnormality.