Mark K. Wax

CONTEMPORARY MANAGEMENT OF CEREBROSPINAL FLUID RHINORRHEA

Management of patients with cerebrospinal fluid rhinorrhea (CSF) remains controversial. Most studies recommend either an endoscopic or an external extracranial approach, depending on the surgeons preference. Eighteen patients with CSF rhinorrhea have been managed at our institution since 1990. The causes of the CSF rhinorrhea consisted of functional endoscopic sinus surgery (7), lateral rhinotomy with excision of a benign nasal tumor (3), spontaneous rhinorrhea (7), and secondary repair after intranasal ethmoidectomy (1). In 11 patients the CSF leak was recognized at the time of surgery; in 10 of these patients it was repaired during the primary surgery, whereas one patient underwent secondary repair after failure of conservative management of his CSF fistula. Seven patients underwent exploration for spontaneous CSF rhinorrhea. Four patients had computer tomography scans that showed the leak, and two patients had cisternography to localize the leak. One patient underwent magnetic resonance cisternography. Both of these leaks were identified with cisternography and were then confirmed intraoperatively. Repair methods included a pedicled septal mucosal flap (4), a free mucosal graft from the septum (7), and a middle turbinate (5). Two patients had obliteration of the sinus with muscle/fascia and fibrin glue. Eight patients were repaired endoscopically. The remainder underwent repair through external approaches. Seventeen patients (at a minimum 1 year follow-up) remain free from leakage. One patient required a second repair 8 months after surgery. Iatrogenic trauma remains the most common cause of CSF rhinorrhea. Management at the initial setting is the least morbid approach and is successful in 95% of cases. Whether an endoscopic or external approach is used depends on surgical expertise and experience.

Value of preoperative prothrombin time/partial thromboplastin time as a predictor of postoperative hemorrhage in pediatric patients undergoing tonsillectomy

OBJECTIVEnHemorrhage after tonsillectomy is a potentially lethal complication. Preoperative assessment consisting of prothrombin time (PT) and activated partial thromboplastin time (PTT) has been used to identify patients at risk for hemorrhage after tonsillectomy and adenoidectomy. We sought to assess the value of PT/PTT screening as a predictor of posttonsillectomy hemorrhage.nnnDESIGNnA retrospective chart review was carried out with a minimum of 1 month follow-up.nnnSETTINGnTertiary academic referral center.nnnPATIENTSnBetween January 1992 and June 1995, 382 patients undergoing tonsillectomy were examined; 339 patients with a minimum of 1 month follow-up were reviewed for this study.nnnMAIN OUTCOME MEASUREnNormal and prolonged PT/PTT values were examined. Bleeding in the intraoperative, immediate postoperative, and delayed phases of healing was examined.nnnRESULTSnTwo-hundred and twenty-two patients had normal PT/PTT, 39 had prolonged PT/PTT, and 78 had no preoperative studies performed. Bleeding occurred in 2.7%, 2.6%, and 3.3%, respectively, of patients. Eight patients had positive family histories of bleeding tendencies. One patient (12.5%) with a normal PT/PTT experienced a delayed posttonsillectomy bleed. Of 39 patients with abnormal coagulation studies, 30 were borderline elevations with no repeat studies done; one patient experienced postoperative hemorrhage. Nine abnormal results were repeated; three returned to normal, three remained prolonged but underwent tonsillectomy with no intervention, and three received hematology consultations. One patient had lupus anticoagulant, one had Hageman Factor deficiency, and one was cleared for surgery with no diagnosis. All patients underwent tonsillectomy with no episodes of postoperative bleeding.nnnCONCLUSIONSnPreoperative PT/PTT provides no additional information than does a bleeding history for the general pediatric population undergoing tonsillectomy. This should only be done in selective cases where warranted by history.

Outcome and Changing Cause of Unilateral Vocal Cord Paralysis

Unilateral vocal cord paralysis (UVCP) is relatively common, and previously, thyroidectomy used to be the leading cause. We retrospectively reviewed 98 cases of UVCP. The left vocal cord was involved in 70% of the cases and the right vocal cord in 30%. The cause was neoplastic in 32%, surgical in 30%, idiopathic in 16%, traumatic in 11%, central in 8%, and infectious in 3% of the cases. Only 4 cases were the result of thyroid surgery. Evaluation consisted of a review of the history, a physical examination, and computerized scanning or magnetic resonance imaging, as needed. The functional recovery rate as related to the cause was as follows: surgery 31%, idiopathic 19%, traumatic 18%, and neoplastic 0%. Thirty-five percent of patients required medialization Iaryngoplasty or Teflon injection. Lung and skull base tumors and their surgical treatment are the most common causes of UVCP.

Epistaxis: A comparison of treatment

Epistaxis is a common condition as well as a frequent otolaryngologic emergency, with up to 60% of people experiencing one episode in their lifetime and 6% seeking medical attention. Treatment is controversial, with many options being available. We retrospectively reviewed the hospital course and management of 65 patients who experienced epistaxis from January 1, 1986, to October 31, 1991, to compare medical and surgical treatment methods. Fifty-one patients were managed medically. Of these, 36 patients required one treatment (group 1), 10 required multiple treatments (group 2), and seven required multiple admissions (group 3). The mean lengths of hospitalization were 3.27, 4.90, and 5.57 days respectively. Fourteen patients were managed surgically. The preoperative stay of nine patients who underwent unsuccessful medical management at our institution (group 4) was 3.9 days, with an average postoperative stay of 7.3 days. The difference in length of stay was statistically significant between surgical and medical groups and the postoperative stay of group 4 was different from the length of stay of group 1 patients. The remaining five patients were initially treated elsewhere (group 5). Seventeen (33.3%) medical and only 1 (7%) surgical patients underwent unsuccessful initial therapy. Complication rates were not statistically different for each group. Transfusion requirements were evaluated as a possible predictive factor. Eighteen patients (35.3%) in the medically managed group required transfusions, compared with 11 patients (78.6%) treated surgically (p < 0.01). The medical group received an average of 0.91 units, compared to the surgical group that received 2.93 units preoperatively (p < 0.01). Group 4 required the most preoperative transfusions (3.89). Hypertension, NSAID usage, and coumadin usage did not significantly increase the length of hospital stay in either surgically or medically treated patients. The majority of patients respond to simple nonsurgical measures. Patients who require multiple interventions over a 72-hour period to control hemorrhage and require three or more units of red blood cells should be considered for surgical intervention.

Completion thyroidectomy in the management of well-differentiated thyroid carcinoma.

Completion thyroidectomy is the removal of any thyroid tissue that remains after less than total thyroidectomy. At our center, completion thyroidectomy is used when, on permanent sectioning, a frozen section diagnosis is revised from benign to malignant. We reviewed our experience with completion thyroidectomy to examine its indications and complications. We found that the carcinoma was misdiagnosed in 32 of 244 (13%) of cases. Twenty-five of these were initially designated follicular adenomas. The completion proved to be no more technically difficult than a routine hemithyroidectomy. There was one case of permanent hypoparathyroidism (3%). Transient vocal cord palsy occurred in one patient (3%) and transient hypocalcemia occured in five patients (15%). Complete recovery occurred in all six of these patients. Focal areas of residual carcinoma were found in 8 of 32 (25%) of glands removed at completion. We found completion thyroidectomy to be a safe procedure with minimal morbidity. We recommend its use in those instances of well-differentiated thyroid carcinoma in which the frozen section diagnosis differs from the permanent section.

Fine-needle aspiration of head and neck masses in children

PURPOSEnHead and neck masses in children are common. Suspicious or persistent masses are referred to the otolaryngologist who is faced with the dilemma of deciding which ones require surgical excision. Fine-needle aspiration (FNA) in adults helps distinguish lesions requiring excision from those that do not. Few reports exist of its use in childrennnnPATIENTS AND METHODSnBetween January 1991 and December 1994, 67 FNAs were performed on children, 29 of which (43%) were for head and neck masses. Based on the FNA findings, 16 patients underwent surgery.nnnRESULTSnIn 13 patients, the final pathology was consistent with the FNA findings: granulomatous diseases (3), branchial cysts (3), acute/chronic lymphadenitis (3), thyroglossal cyst, hemangioma, Hodgkins lymphoma, and Castlemans disease (one each). There was one misdiagnosis, no false positives, and two nondiagnostic specimens. Based on the results of FNA, surgery was not performed in the remaining 10 patients. The cytology was: cervical lymphadenopathy (7), abscess formation (1), lymphangioma (1), and leukemia (1).nnnCONCLUSIONnWe conclude that FNA in an extremely useful tool in the management of head and neck masses in children. It is very well-tolerated by children, and we did not encounter any complications.

Traumatic Retropharyngeal Hematoma: A Case Report

We describe a case of retropharyngeal hematoma after a cervical hyperextension injury in an elderly man. Progressive hoarseness, dysphagia, and dyspnea were the early signs that necessitated oral endotracheal intubation and, ultimately, tracheostomy. The hematoma was explored and drained through a lateral cervical approach, and a bleeding vessel in a small tear in the anterior spinous ligament was noted and cauterized. The patient recovered uneventfully.

Small Cell Carcinoma of the Tonsil

Extrapulmonary small cell carcinomas are rare tumors of the APUD system. They are most commonly seen in the esophagus with rare cases reported in the head and neck. We present the sixth reported case of primary small cell carcinoma of the tonsil. These tumors are usually widely disseminated initially. Aggressive locoregional treatment with radiation is the treatment of choice. Systemic treatment is needed for presumed metastatic disease. Surgery may be an adjunct treatment used for locoregional control.

Tracheostomal stenosis after laryngectomy: Incidence and predisposing factors

Laryngectomy for carcinoma of the larynx has been performed since it was first described in 1880. Since that time the complication of tracheostomal stenosis has plagued both surgeons and patients. The reported incidence of tracheostomal stenosis ranges from 4% to 42%. At West Virginia University Hospitals from 1976 to 1994, 106 patients undergoing laryngectomies on the head and neck oncology service were analyzed. The charts of patients treated before 1991 were reviewed retrospectively; a prospective analysis was initiated in 1991. Only patients with a minimum of 6 months of follow-up were included in this study. The male-to-female ratio was 3:1, with an age range of 28 to 86 years (mean, 58 years). The overall rate of stenosis was 28.4%. The incidence of tracheostomal stenosis was higher in women (46.4%) than in men (21.6%) (p < 0.05). Since 1991 a plastic type of closure was used in 25 patients. The stenosis rate was 0% in these patients. Before 1991 a bevel or circle technique was used, with stenosis rates of 33% and 75%, respectively (p < 0.05). Infection at the site of the stoma, fistula, steroid use, neck dissection, pectoralis major myocutaneous flap usage, primary tracheoesophageal puncture, and radiotherapy did not correlate with an increased incidence of stenosis. The most important factor in prevention of stomal stenosis after laryngectomy is attention to detail while forming the stoma. With good technique and a plastic-type closure to break up the suture line, a minimal rate of stenosis should be encountered.

Malignant melanoma of the lacrimal sac.

m l t n December 1999, a 55-year-old woman, who was nder observation in another institution with the diagosis of chronic dacryocystitis, was admitted to our ospital for a planned dacryocystorhinostomy. She preented a 10-month history of painless swelling in the ight medial canthal area with epiphora and occasional loodstained tearing. Physical examination revealed a rm and well-circumscribed mass in the medial canthus onsistent with enlargement of the lacrimal sac. During he surgical procedure, the lacrimal sac was found to ontain a brown-pigmented soft tissue, which on frozen ection analysis revealed undifferentiated malignant ells, without a conclusive histologic diagnosis. The acrimal sac was then excised, and intraoperative bipsy samples were taken from the lateral nasal wall and nferior meatus, pending final pathology reports. On ermanent section, immunohistochemical staining for arcinoembryonic antigen and cytokeratines was negaive, whereas positive immunoreactivity for S-100 proein and HMB-45 supported the diagnosis of malignant elanoma of the lacrimal sac. Subsequent computed omography scanning and magnetic resonance imaging tudies of the region demonstrated a soft-tissue mass in he lacrimal fossa expanding the nasolacrimal duct, ith no bone erosion or orbital involvement (Fig 1). owever, no metastatic disease was evident on chest adiograph or hepatic ultrasound scan. These clinical and radiologic findings led to definiive surgery 4 weeks later, which consisted of a comlete removal of the tumor through a lateral rhinotomy pproach, with excision of the entire lacrimal system, nferior total turbinectomy, partial medial turbinecomy, and endoscopic ethmoidectomy. Surgical exploation did not show satellite lesions in nasal and ocular ucosa, and the histopathologic study confirmed the iagnosis of lacrimal melanoma (Fig 2).