Mark C. Royer

Sculpting Resection of Rhinophyma Using the Shaw Scalpel

BACKGROUND Rhinophyma is a disfiguring disorder of the nasal skin characterized by hypervascularity, sebaceous gland hyperplasia, occluded sebaceous ducts, and dermal fibrosis. It has no known effective medical treatment; however, a myriad of surgical treatments have been reported. We report an effective, efficient, and safe approach to treat this disorder using the Shaw scalpel to surgically sculpt the nose. OBJECTIVE To evaluate the efficacy and safety of using the Shaw scalpel to treat rhinophyma. METHODS We performed a retrospective review of 7 male patients (age range, 58-81 years) who underwent primary surgical treatment of rhinophyma with the Shaw scalpel. RESULTS A good to excellent outcome was noted in all 7 patients. No perioperative complications occurred. Essentially no blood loss was noted during or after the procedures. CONCLUSION Use of the Shaw scalpel as the sole surgical instrument and method is a safe, efficient, and effective means to treat rhinophyma.

Otolaryngology Consult Carts: Maximizing Patient Care, Surgeon Efficiency, and Cost Containment.

Objective: The objective of this study was to develop an otolaryngology consult cart system to ensure prompt delivery to the bedside of all the unique equipment and medications required for emergent and urgent otolaryngology consults. Method: An otolaryngology practice responsible for emergency room and hospital consult coverage sought to create a cart containing all equipment, medications, and supplies for otolaryngology consults. Meetings with hospital administration and emergency room, nursing, pharmacy, central processing, and operating room staff were held to develop a system for the emergent delivery of the cart to the needed location, sterilization and restocking of equipment between uses, and appropriate billing of supplies. Results: Two months were required from conception to implementation. All equipment was purchased new, including flexible scopes and headlights. The cart is sterilized, restocked, and maintained by central processing after each use. The equipment is available to handle all airway emergencies as well as all common otolaryngology consults and is delivered bedside in less than 5 minutes. Conclusion: The development of a self-contained otolaryngology consult cart requires coordination with a wide variety of hospital departments. This system, while requiring initial monetary and time investment, has resulted in improved patient care, cost containment, and surgeon convenience.

Rapid mandible margins for intraoperative assessment

OBJECTIVES To determine the feasibility of a rapid method of processing mandible bone margins for intraoperative histopathologic examination and to assess the relative value of fine, coarse, and core specimens in assessing bone margins. STUDY DESIGN Prospective histologic controlled study. SETTING A tertiary level academic medical center histopathology laboratory. SUBJECTS AND METHODS Multiple bone samples were collected from fresh (<12 hours post-mortem) human cadaveric mandible using a 1) standard 4mm otolaryngologic cutting drill bit 2) diamond drill bit and 3) cutting core biopsy trocar. The specimens were placed in one of three decalcifying solutions (Decal A, Calex, EDTA Decal) from 15 to 75 minutes or control (fixation in 10% formalin). After each designated decalcification time period, specimens were cryosectioned or paraffin embedded and subsequently reviewed by a head and neck surgical pathologist. The specimens were assessed for overall quality, adequacy of decalcification, soft tissue quality, marrow quality, and presence of artifact. RESULTS Bone margin specimens collected with a 4mm burr and processed with EDTA Decal for 30 minutes yielded the highest quality histopathologic slides compared to the other methods in a similar time frame. The adequacy of decalcification directly impacted the quality of histopathologic assessment. CONCLUSIONS Mandible bone margins can be rapidly and safely prepared and adequately evaluated with only 30 minutes of decalcification. This method may provide acceptable intraoperative assessment of bone margins in patients with tumors which involve or approximate bone. We plan to examine this model in a prospective clinical study of patients with cancer invading mandibular bone.

Improvising a Posterior Nasal Pack with Equipment in a Basic First Aid Kit

Posterior epistaxis is a serious condition that can be difficult to treat in a wilderness setting. The initial standard of care involves packing the affected nostril with a 7 to 9 cm nasal pack to tamponade the bleed. These packs are often unavailable outside of the emergency or operating room. This study set out to determine whether a posterior nasal pack could be constructed from the supplies present in a basic first aid kit in order to control massive nasal hemorrhage in a wilderness setting. A basic first aid kit was utilized to construct a posterior nasal pack that was inserted into an anatomical model and visibly compared with the Rapid Rhino (Posterior, 7.5 cm; Smith & Nephew, Austin, TX) nasal packing. The shape, size, and anatomical areas of compression (ie, into nasopharynx and posterior aspect of inferior turbinate) of this pack was similar to the commercially available posterior nasal pack. Placement in an anatomical model appears to provide similar compression as the commercially available posterior pack. This technique may provide short-term hemorrhage control in cases of serious posterior nasal hemorrhage where standard treatment options are not available.

Brief report: Sound output of infant humidifiers

The sound pressure levels (SPLs) of common infant humidifiers were determined to identify the likely sound exposure to infants and young children. This primary investigative research study was completed at a tertiary-level academic medical center otolaryngology and audiology laboratory. Five commercially available humidifiers were obtained from brick-and-mortar infant supply stores. Sound levels were measured at 20-, 100-, and 150-cm distances at all available humidifier settings. Two of 5 (40%) humidifiers tested had SPL readings greater than the recommended hospital infant nursery levels (50 dB) at distances up to 100 cm. In this preliminary study, it was demonstrated that humidifiers marketed for infant nurseries may produce appreciably high decibel levels. Further characterization of the effect of humidifier design on SPLs and further elucidation of ambient sound levels associated with hearing risk are necessary before definitive conclusions and recommendations can be made.

A Novel Approach to Tracheocutaneous Fistula Closure

Objective: 1) Describe a novel, 3-stage approach to closure of a large tracheocutaneous fistula (TCF) and augmentation of an adjacent area of tracheal stenosis. 2) Present pre-, intra-, and postoperative photographs to illustrate surgical technique. 3) Discuss postoperative patient care considerations. 4) Review other techniques described for similar defects. Method: Case report of patient receiving treatment from May 2010 to present. The patient presented with a 1.4 by 1.6 cm TCF and adjacent tracheal stenosis. This was repaired in a 3-stage approach culminating in radial forearm free flap (RFFF) with banked conchal cartilage and buccal mucosal graft for tracheal closure. Results: This case resulted in successful closure of a 1.4 by 1.6 cm TCF in a previously radiated patient using a novel, 3-stage approach. The initial stage involved implanting a conchal cartilage graft in the left radial forearm. During the second stage a buccal mucosal graft was implanted to cover the conchal cartilage graft after removing the hair-baring skin. The third stage involved transfer of the RFFF with cartilage and mucosal graft for closure of the TCF, augmenting the support with an absorbable miniplate. The patient had no issues with breathing, speaking, or wound healing immediately or at four months postoperative. Conclusion: Large TCFs in irradiated patients present a unique surgical challenge. This case illustrates successful closure of an extensive TCF involving anterior trachea and partial bilateral sidewalls. The unique graft allowed for structural support with hairless mucosal lining on a fasciocutaneous flap.

Facial Nerve Localization Is Triangulation the Key

framework that provides residents and practitioners with a reliable and surgically relevant method for identifying the facial nerve trunk (CNVII) after exiting the skull base during parotidectomy and to describe the effect on Otolaryngology Residents’ dissection time, accuracy and confidence when taught this technique compared to traditional methods and their baseline competency. Methods: The currently available literature and textbooks do not completely address the challenges trainees encounter in learning how to identify CNVII during parotidectomy. In response to this gap in the literature and potential associated deficits in surgical training, we developed an approach that integrates multiplanar intersections (based on mathematical principles) with surgical anatomy to create a reliable method for CNVII identification during parotidectomy. This method was then taught to residents randomly divided into groups and their confidence, accuracy and dissection times were subsequently recorded. Results: The multiplanar intersections shown via our medical illustrations and surgical photography demonstrate the application of the triangulation concept to improve the accuracy and efficiency in surgical localization of CNVII. The prospective arm showed no significant difference in cadaveric dissection time, but did result in a subjective increase in confidence for safely, efficiently and accurately identifying the facial nerve.