Michael Rontal

Surgical Anatomy of the Orbit

When operating in and around the orbit, the key to a successful operative result is precise, anatomic localization. This study was constructed to give pertinent anatomic measurements to which the maxillofacial surgeon may refer. The safe distances noted from this study are: 1) medially 30 mm from the anterior lacrimal crest; 2) inferiorly 25 mm from the infraorbital foramen; 3) superiorly 30 mm from the supraorbital notch; and 4) laterally 25 mm from the frontozygomatic suture.

Bacteriologic Findings from the Nose, Ethmoid, and Bloodstream during Endoscopic Surgery for Chronic Rhinosinusitis: Implications for Antibiotic Therapy:

This study addresses the bacterial flora of chronic rhinosinusitis at the time of endoscopic sinus surgery. We used the consensus definition of chronic rhinosinusitis as the presence of paranasal sinus inflammation present for greater than 12 weeks. In our patient study group, all cases of chronic rhinosinusitis had failed to respond to antibiotic therapy and had not been treated previously with surgery. By microscopic examination, chronic inflammatory changes were confirmed in the resected sinus lining of all study patients. Intraoperative cultures were obtained from the nasal vestibule, the middle meatus, ethmoid lining, and peripheral blood during and after the endoscopic procedure. We found approximately 30% of the patients with sterile sinuses, 50% with coagulase-negative staphylococci, and the remainder with a mixed group of “nonpathogenic” organisms. Anaerobes were conspicuously rare. The blood cultures were positive in 7% of cases and were consistent with an organism of the operative site. This is the first time bacteremia has been reported in association with endoscopic sinus surgery. The results suggest that chronic rhinosinusitis is not a bacterial disease, but rather the result of chronic inflammation produced by a previous acute inflammation. The incidence of positive blood cultures, while relatively low and cleared quickly, should alert the physician for the possible need for prophylactic antibiotics in patients with cardiac, prosthetic, or systemic conditions that could lead to metastatic infection.

Arytenoid cartilage dislocation caused by a laryngeal mask airway treated with chemical splinting.

S ore throat and hoarseness after laryngoscopy and short-term endotracheal intubation is not uncommon. The incidence ranges from 16% to 100% (1,2). The cause of postintubation hoarseness is multifactoral including pharyngeal and laryngeal trauma, hematoma and edema, vocal cord paralysis, and arytenoid cartilage dislocation (3-5). As of 1994 there were only 57 cases of arytenoid dislocation or subluxation reported in the world literature (6). The laryngeal mask airway (LMA) is an airway management device which was introduced in 1988 (7). It is an alternative to endotracheal intubation for certain routine anesthetics and is an adjunct in emergency airway management (8). The LMA does not necessitate direct laryngoscopy for insertion and, therefore, should limit the airway trauma sometimes caused by instrumentation with rigid laryngoscopes. We present the first report of arytenoid cartilage dislocation secondary to LMA insertion. Treatment was by mechanical reduction and chemical splinting.

Objective evaluation of vocal pathology using voice spectrography.

Permanent objective evaluation of vocal changes associated with laryngeal pathology is a goal which has been difficult for the laryngologist and speech pathologist to attain. Most attempts at achieving objective records have focused on direct visual examination of the larynx using techniques such as high speed photography, x-ray studies or histologic sectioning. However, the important subjective qualities of the voice are difficult to translate into objective visual patterns. In order to produce these patterns, certain individual components of the voice (i.e., breathiness, periodicity and formant structure) must be analyzed. Recently, modifications of the sound spectrograph have enabled the clinician to objectively visualize these components. The patterns produced by the spectrograph may be applied to a variety of clinical situations. For example, the technique aids greatly in determining the success or failure of medical and surgical management for vocal cord lesions. Secondly, voice spectrography can readilv show improvements or deficiencies in vocal rehabilitation for functional dysphonia. Lastly, this method provides an objective, permanent record of the voice which may be useful from a medicolegal standpoint. Sound spectrographic analysis of vocal pathology is an important diagnostic tool for the clinician. Its future use should be encouraged as a more precise aid in the evaluation of the voice.

Endoscopic laryngeal surgery for bilateral midline vocal cord obstruction.

There are a number of treatment regimens for bilateral laryngeal paralysis, ranging from tracheostomy to external microscopic approaches. None has become the standard because of their unpredictable results and/or the need for an external approach. Recently, the use of micro-trapdoor flaps and suturing done via a laryngoscope has shown a possibility of correcting the airway problem, allowing a predictable result, with a completely endoscopic approach. This paper presents our experience with a group of 10 patients who had at least one treatment attempt that failed and were treated by endoscopic laryngoplasty. Eight have been decannulated.

The use of sialodochoplasty in the treatment of benign inflammatory obstructive submandibular gland disease

One of the most common causes of submandibular gland enlargement is benign inflammatory disease. The usual cause is ductal outflow obstruction due to either a calculus or stenosis allowing stasis and retrograde movement of the saliva into the acinar structures leading to an inflammatory response and gland enlargement.

Vocal cord injection in the treatment of acute and chronic aspiration.

The problem of maintenance of proper tracheobronchial toilet is frequently a determining factor in the morbidity and mortality of patients with vocal cord paralysis. Aspiration from an incompetent glottis can cause pneumonitis and its attendant complications.

The use of spectrograms in the evaluation of vocal cord injection.

The utilization of voice spectrography can be an important adjunct to the assessment of vocal cord function by both laryngologists and speech pathologists. It is especially useful in determining the effectiveness of vocal cord Teflon paste injection procedures. Dysphonic characteristics are made visible, and their improvement can be monitored. As such, spectrographic analysis should be considered as a useful tool for the laryngologist.

Jet insufflation anesthesia for endolaryngeal surgery

The ideal anesthetic in endolaryngeal surgery provides a quiet completely unobstructed larynx in a patient who is comfortable and has respiratory functions maintained. Dissatisfaction with the intubation and venturi techniques has led to the use of a high pressure jet insufflation method. The results of this study have shown that anesthetically this technique is safe for a wide range of patients and endoscopic procedures. Laryngologically, the absence of glottic obstruction has broadened the scope of endoscopic procedures performed under general anesthesia.

Studying whole-mounted sections of the paranasal sinuses to understand the complications of endoscopic sinus surgery

Endoscopic techniques for paranasal sinus surgery have allowed detailed and complete removal of sinus disease while promising minimum distress to the patient. The telescopic view of the operative field shows detail of the sinus anatomy and its disease, not possible in earlier transnasal techniques. Several articles document the serious complications seen with the endoscopic surgery. To understand the paranasal sinuses and their relationships to the orbit and cribriform plate, blocks of cadaver heads that included the orbit and paranasal sinuses were whole sectioned. It has been possible to see areas of the cribriform and orbital wall that are at risk to produce cerebrospinal fluid rhinorrhea and orbital complications. At the same time, landmarks for avoiding these complications can be defined to guide the surgeon during this dissection as seen through the endoscope.