Robert H. Maisel

Cervical necrotizing fasciitis

Nine cases of cervical necrotizing faciitis are presented. Five were odontogenic, three were pharyngeal in origin, and one developed from a soft‐tissue spider bite. The bacteriology represented a polyculture of gram‐positive, gram‐negative, as well as anaerobic bacteria, and initial medical treatment by third‐generation cephalosporin and metronidazole or clindamycin was successful and is recommended. Airway control is necessary early, as is a wide exploration of the fascial spaces of the neck, with frequent reexploration in either the operating room or at the bedside to evaluate the effects of treatment and to prevent further progression of the disease. Intensive medical support is crucial, and hyperbaric oxygen is advised for patients who are deteriorating under standard therapy.

Diagnosis and treatment of deep neck space abscesses

Objective: To review our experience with deep neck abscesses and identify unique trends in our patient population. Study Design: Case series with chart review. Subjects and Methods: Evaluation of patients with deep neck space abscesses between 2001 and 2006. Peritonsillar abscess, superficial craniocervical infection, and salivary gland infections were excluded from selection of study population. A total of 106 cases were reviewed. Results: Dental infections were the most common cause of deep neck abscesses (49.1%). Comorbidities included substance abuse (53.7%), psychiatric illness (10.4%), hypertension (9.4%), head and neck cancer (6.6%), and diabetes mellitus (5.7%). All patients received systemic antibiotics, eight patients required tracheotomy, 85 patients underwent surgical drainage in the operating room, and 11 had bedside drainage. Median and lower quartile of time in hospital was 2 and 3 days, respectively, whereas upper quartile was 4 days (range, 1 to 27 days). Patients with comorbidities or concurrent illness tended to stay longer (P < 0.05, Mann-Whitney test). There were six complications and no mortality. Conclusion: Substance abuse and poor orodental hygiene are important predisposing factors to deep neck abscesses. Appropriate management continues to favor a combination of early surgical drainage and systemic antibiotics.

The Long-Term Evaluation of Tracheostomy in the Management of Severe Obstructive Sleep Apnea†

Objective To determine the long‐term success and morbidity of tracheostomies for patients with severe obstructive sleep apnea.

Necrotizing sialometaplasia involving the nasal cavity

Nectrotizing sialometaplasia is a disease process which affects minor salivary glands. It may clinically and microscopically resemble squamons cell or mucoepidermoid carcinoma but is histologically benign. Thirteen patients with this process occurring on the hard palate have been reported in the past two years. We describe two cases in the nasal cavity and propose that compromise of the blood supply contributed to the occurrence of these lesions. This apparently benign lesion may represent nonspecific reaction of salivary and mucous glands to ischemic injury and must be distinguished from carcinoma.

Indications for performing hemithyroidectomy for tumors requiring total laryngectomy.

To determine the necessity of performing a hemithyroidectomy in patients who require a total laryngectomy, the pathologic reports and clinical courses of 261 patients who underwent total laryngectomy were reviewed. Twenty-four percent of the specimens demonstrated transcartilaginous invasion, with the highest incidences occurring in glottic (31 percent) and subglottic (60 percent) tumors. Epidermoid tumor invading the thyroid gland occurred in 5 percent of the specimens. All of these showed invasion by direct extension, were palpable at the time of surgery and were associated with transcartilaginous invasion. Ninety percent of these tumors were primarily glottic or subglottic and 70 percent demonstrated subglottic extension greater than 1.5 cm. Furthermore, the prognosis of patients with tumorous invasion of the thyroid gland was dismal, with local recurrence or distant metastasis occurring within 10 months of curative resection. In patients who had laryngectomies, hypothyroidism was found in 70 percent of those who underwent radiotherapy and hemithyroidectomy, in 38 percent of those who underwent radiotherapy alone, in 23 percent of those who underwent hemithyroidectomy alone, and in 20 percent of those who did not undergo hemithyroidectomy or radiotherapy. Based on these results, we advocate ipsilateral or total thyroidectomy for palpably suspicious thyroid glands seen intraoperatively, subglottic tumors, glottic tumors with more than 1 cm of subglottic extension, T4 endolaryngeal tumors with transcartilaginous invasion, and T4 pyriform sinus tumors.

Free Jejunal Autograft Reconstruction of the Pharyngoesophagus: Review of a 10-year experience

Seventeen patients underwent free jejunal autograft reconstruction of the pharyngoesophagus after ablative surgery for Stage III and IV squamous cell carcinoma of the cervical esophagus and hypopharynx. Postoperative complications included three perioperative deaths, three graft failures, six transient fistulas, and two early and one late fistula. The 5-year survival rate of patients with Stage III and IV hypopharyngeal carcinoma was 20% (one of five). The 4-year survival rate for patients with cervical esophageal carcinoma was 33% (one of three). This method of reconstruction is advocated as a reliable palliative procedure for patients with a dismal long-term survival.

Surgical debridement and adjunctive hyperbaric oxygen in cervical necrotizing fasciitis

Objective: To review our management of cervical necrotizing fasciitis (CNF) with the use of adjunctive hyperbaric oxygen therapy (HBO). Study Design: Case series with chart review. Subjects and Methods: Evaluation of ten patients with CNF between 2001 to 2006. Results: There were five male and six female patients. Mean age was 43 ± 11 years. Eight cases resulted from an odontogenic source. Comorbidities included diabetes mellitus, hypertension, and substance abuse. All patients had computed tomography scans performed, received intravenous antibiotics, and underwent surgical debridement. Eight patients underwent surgery within 24 hours. The average number of debridements was 2.2 ± 0.8. Hospitalization was twice as long for diabetic patients (15.5 ± 8.16 days) compared with nondiabetic patients (7.5 ± 1.6 days, P = 0.029). Nine patients had HBO therapy. Combined data revealed a possible decrease in length of hospitalization with HBO therapy (P < 0.001). No mortality was documented. Conclusion: In addition to early and aggressive medical management and surgical debridement, this study suggests that HBO therapy is a beneficial adjunct by potentially decreasing length of hospitalization. Randomized trials are still needed to demonstrate its efficacy.

Choosing the optimal wound dressing for irradiated soft tissue wounds

This article reviews the healing state of the previously irradiated wound, the tenets for optimal wound care, and the choices of wound dressings now available for its management. The goal in assisting a previously irradiated surgical wound to heal is to transform its chronic wound state into an acute wound state. This transformation encourages wound healing to proceed. Six major moisture-retentive dressing categories exist to optimize its healing. They are classified into the alginates, foams, gauzes, hydrogels, hydrocolloids, and transparent films. Optimal wound care management for previously irradiated wounds involves (1) adequately debriding and cleansing the local wound, (2) accurately assessing the wound, (3) choosing the appropriate dressing based on the wound assessment, and (4) encouraging granulation tissue formation and reepithelialization.

Malignant teratoma of the thyroid: review of literature and report of a case.

(Editoria] Comment: This review is essential reading for any clinician faced with an unusual fibroid neoplasm.) Teratomas comprise the most common extragonadal germ cell tumors in childhood. 1 The head and neck accounts for 5% of all benign and malignant germ cell tumors and for 6% of all teratomas, 1 where the most common sites of involvement are the soft tissues of the neck, thyroid, superficial facial structures (most commonly, infratemporal fossa and zygoma), oral cavity, nasopharynx, and orbit. 2 Most teratomas involving the thyroid are benign and occur in children. 3 Malignant teratomas of the thyroid are rare, and only 19 cases have been reported in the literature (Table 1). 4-20 Given its rarity, no certain treatment modality has been established for this tumor. We report the case of a patient with malignant teratoma of the thyroid and describe a previously unreported treatment method. CASE REPORT

Subglottic laryngeal paraganglioma.

Objectives To review the clinical and pathological picture of laryngeal paragangliomas and compare laryngeal paragangliomas with the three other types of laryngeal neuroendocrine neoplasms.