Maisie L. Shindo

Necrotizing Fasciitis of the Face

Necrotizing fasciitis (NF) is a rapidly progressive soft tissue infection with high morbidity and mortality rates. Its occurrence in the head and neck region is uncommon, the majority of reported cases being limited to involvement of the neck, usually from infections of dental or pharyngeal origin. Involvement of the face from NF is rare; only 35 such cases have been reported in the literature since 1960. It is not only associated with a high mortality but can also result in severe disfigurement of the face, posing challenging reconstructive problems. Successful management of facial NF requires early diagnosis, prompt institution of broad spectrum antibiotics, aggressive surgical debridement to control the infection, and reconstruction of the resultant soft tissue defects. This report describes four additional cases of facial necrotizing fasciitis. One of the four patients died as a result of sepsis and multi‐organ system failure. Two of the three surviving patients had significant facial disfigurement. A comprehensive review of the facial NF cases reported in the literature is also provided. Based on our experience with facial NF and the results of all previous case reports, the clinical manifestations, pathogenesis, and management of this disease are discussed.

Safety of thyroidectomy in residency: A review of 186 consecutive cases

A retrospective review was performed to assess the surgical complications of thyroidectomy performed by otolaryngology residents under close supervision by faculty. One hundred eighty‐six consecutive cases of thyroidectomy performed by the residents in the Department of Otolaryngology—Head and Neck Surgery at the University of Southern California were reviewed. Sixty‐nine percent of thyroidectomies were performed for malignant or possible malignant diseases, and 31% were performed for benign conditions. Transient (less than 2 weeks in duration) hypocalcemia occurred in 26% of the patients; the vast majority of cases resolved within the first week. Five percent of the patients developed persistent hypocalcemia requiring prolonged replacement therapy. The incidence of unexpected postoperative permanent vocal cord paralysis was 0.9%. These complication rates are comparable to those in previously published large series on results of thyroidectomy. Thyroidectomy performed in an otolaryngology residency training program is a safe procedure when closely supervised by experienced faculty.

Sensory recovery in noninnervated free flaps for head and neck reconstruction.

Recent studies have reported sensory recovery in innervated (“sensate”) microvascular free flaps used for oromandibular reconstruction. To evaluate the efficacy of sensate free flaps used for head and neck reconstruction, the natural outcome of noninnervated flaps must be known. Data on the natural recovery of sensation in noninnervated head and neck free flaps are lacking in the literature. This study evaluates the degree of spontaneous sensory reinnervation in noninnervated microvascular free flaps used for reconstruction of a variety of head and neck defects. Eighteen flaps were evaluated–9 fibula osseocutaneous and 9 radial forearm. The fibula flapswere used to reconstruct composite defects of the mandible and oral cavity mucosa. The radial forearm flaps were used to reconstruct defects resulting from floor of mouth resection (3), total glossectomy (2), pharyngectomy (1), full‐thickness cheek (1), and facial skin (2). Sensation to pinprick, light touch, and temperature discrimination were tested over the skin paddle at time intervals ranging from 6 to 24 months. The pattern of sensory reinnervation in these noninnervated flaps over time and by location is discussed.

Management of thyroid nodules during pregnancy

Guidelines for the management of thyroid nodules discovered during pregnancy have not yet been established. The authors reviewed the records of 23 patients with thyroid nodules that were first detected during pregnancy. These patients were divided into three groups according to how they were managed. Seven patients who presented early in pregnancy had their work‐up completed during pregnancy, 11 patients underwent biopsy after delivery, and 5 patients were managed with observation alone. The incidence of malignancy in the series was 39%. Four patients underwent surgery during pregnancy, and 7 patients were operated on in the postpartum period. No fetal morbidity or mortality occurred.

Management of traumatic hypopharyngeal injuries

Violation of the hypopharynx by external penetrating trauma is an uncommon occurrence that may lead to life‐threatening infectious complications if not recognized promptly and treated appropriately. A retrospective review of 48 such injuries seen during a 10‐year period showed that flexible fiberoptic endoscopic examination is the best screening tool for recognition of a possible hypopharyngeal mucosal violation. Direct laryngopharyngoscopy is the best method of definitively diagnosing the injury. Size of the visualized mucosal violation alone is not sufficient information on which to base the decision for medical management versus surgical intervention (i.e., immediate exploration and drainage). Rather, the size, exact site of injury, and mechanism of the injury must be considered to have equal importance. Associated vertebral body fractures may negatively influence acute outcome if diagnosis and treatment of the hypopharyngeal injury are delayed by the cervical spine injury.

Dynamic Properties of the Posterior Cricoarytenoid Muscle

The aim of this research was to investigate the contractile properties of the posterior cricoarytenoid (PCA) muscle. Simultaneous measurements were made of the isometric force, temperature, and electromyographic activity of the dorsal cricoarytenoid muscle of anesthetized dogs during supramaximal stimulation of the recurrent laryngeal nerve for twitch and tetanic contraction. The conduction delay between stimulation of the recurrent nerve at the level of the larynx and the onset of the muscle action potential averaged 2.0 ± 0.2 milliseconds (ms), and the latent period between the onset of electrical activity of the muscle and the onset of contraction had a mean duration of 3.3 ± 0.8 ms. The mean of isometric contraction times found was 33.3 ± 2.0 ms, shorter than most previous studies of canine PCA muscle. Tetanic frequency defined as smooth contraction was higher than previous estimates. Considerations of scaling of physiological time based on animal mass were applied to analysis of the experimental findings to make possible systematic comparison of previous findings across species and animal size.

Complications of Anesthesia for Head-Neck and Reconstructive Surgery

URGERY of the head and neck region involves sharing the airway. There may be an acute sympathetic response caused by airway manipulation or use of epinephrine or cocaine for vasoconstriction. Common causes of dysrhythmia during head and neck surgery include vagal reflexes, carotid sinus stimulation, epinephrine and volatile anesthetics agents interaction, hypoxia, hypercapnia, and inappropriate anesthetic depth] Head and neck surgery may be associated with substantial and rapid blood loss, for example, radical neck dissection for cancer of head and neck, epitaxis ligation, tonsillectomy, glottic tumors.