Yadranko Ducic

Hydroxyapatite Cement in Craniofacial Reconstruction

OBJECTIVES: To evaluate the long-term efficacy of hydroxyapatite cement in craniofacial reconstruction, specifically examining the role (if any) of radiation, implant location, and cement type. STUDY DESIGN: A retrospective chart review was conducted of all patients presenting to the senior surgeon (Y.D.) for craniofacial reconstruction from September 1997 to April 2004. METHODS: Data were collected including type of cement used, size of defect, complications, need for removal of cement, reason for defect, and pathologic results of examination of removed cements. RESULTS: One hundred two patients were identified who underwent craniofacial reconstruction with hydroxyapatite cements, 7 of whom required complete implant removal (6 Norian and 1 Mimix), and 4 (2 Norian and 2 Bone source) of whom required partial implant removal for foreign body reaction. Five of the removals were in patients who underwent postoperative radiation. CONCLUSIONS: Hydroxyapatite cements are safe in craniofacial reconstruction. The highest risk of implant infection comes from reconstruction in the area of the frontal sinus, immediately beneath coronal incisions, and in patients who receive postoperative radiation treatment. Based on our results, there does appear to be a statistically significant difference in rates of infection and foreign body reaction between the different types of hydroxyapatite cement. We would not recommend implantation of this material in contact with the frontal sinus. Caution should be exercised when it is placed directly beneath an incision or in patients receiving postoperative radiation, particularly if a boost dose is given. EBM RATING: C

Adult Epiglottitis in a Canadian Setting

The objective of this study was to determine stable estimates of the incidence, case fatality, and epidemiologic features of adult epiglottitis, and risk factors for intubation. The authors designed a retrospective cohort combined with a nested casecontrol study, followed by detailed analysis of cases from two tertiary care institutions. Among 813 cases, the incidence was 2.02 cases/105 population per year. Ten recorded deaths constituted a case fatality rate of 1.2% (95% confidence interval [CI]: 0.5% to 1.9%). The eight fully documented deaths indicated no sudden episodes of catastrophic upper airway obstructions without previous dyspnea. A detailed review of 51 cases revealed that 18% of patients underwent expeditious intubation. Patients managed without initially requiring intubation did not need emergency airway interventions. Only the presence of dyspnea (noted in 29% of patients) at the time of admission ( P < 0.001) predicted the need for intubation. A low case fatality rate in a conservatively managed cohort and the absence of sudden upper airway catastrophes in patients without dyspnea suggest that prophylactic intubation and intensive care unit monitoring is not warranted in all patients. An early complaint of dyspnea may safely discriminate between patients requiring invasive airway management and close observation.

METASTATIC HEAD AND NECK CARCINOMA TO A PERCUTANEOUS ENDOSCOPIC GASTROSTOMY SITE

Percutaneous endoscopic gastrostomy (PEG) tube placement is a safe and widely accepted alternate route for enteral alimentation in the head and neck cancer patient population. Cancer metastatic to a PEG tube exit site is a rare but serious complication of this procedure. We sought to determine the route of spread responsible for PEG site metastases such that we may prevent further occurrences of this highly morbid condition. We also report a case of PEG site metastasis at our institution.

Transoral Approach to the Superomedial Parapharyngeal Space

OBJECTIVES: To present our early experience with the transoral approach to the superomedial parapharyngeal space (PPS) and describe our technique for removal of these neoplasms. STUDY DESIGN: Consecutive case series by one author (Y.D.). METHODS: Eight patients with various neoplasms of the superomedial PPS were retrospectively reviewed for type of neoplasm, size, success with the transoral approach, need for conversion to another approach, length of hospitalization, and complications. RESULTS: The transoral approach described herein safely allowed for en bloc resection of benign neoplasms with intraoperative control and exposure of the internal carotid artery. The most common pathology encountered was that of schwannoma. All patients were started on liquid diet on postoperative day 1. Average length of stay was 3.2 days (range, 2 to 5). Mean tumor size was 3.3 cm (range, 1.5 to 7 cm). No significant complications were felt to be related to the approach itself and visualization was felt to be excellent in each case without the need for conversion to a more extensive approach. CONCLUSIONS: The transoral approach safely provides access to superomedial PPS lesions with decreased morbidity compared with traditional approaches. This technique is indicated for neoplasms with benign appearance on preoperative imaging or fine needle aspiration. This approach alone may not provide adequate access for resection of malignant lesions especially those with extension intracranially or to more inferior or laterally placed lesions of the parapharyngeal space. EBM rating: C-4

Use of endoscopically placed expandable nitinol tracheal stents in the treatment of tracheal stenosis.

Objective: To evaluate the potential utility of a new endoscopically placed expandable tracheal stent in the treatment of benign symptomatic stenoses of the cervical trachea. Study Design: Pilot study utilizing a prospectively followed case series. Methods: An initial group of six patients undergoing stent placement was examined with rigid and flexible endoscopy under anesthesia immediately following stent placement and at postoperative 6 to 8 weeks. Subsequently each patient was followed clinically for a minimum of 6 months. Results: All stents were well tolerated with no observed complications. Immediate reversal of symptomatic airway obstruction without the need for adjunctive tracheotomy was noted in every patient. At 6 weeks, endoscopic confirmation of complete intraluminal mucosalization without formation of any granulation tissue or scar bands within the stented areas was noted in each case. Conclusions: This preliminary pilot study supports the use of nitinol expandable tracheal stents as an alternative in the treatment of benign symptomatic tracheal stenoses.

The versatile extended pericranial flap for closure of skull base defects.

OBJECTIVE: We sought to demonstrate the technical aspects of the extended pericranial flap and its versatility in reconstruction of a variety of skull base defects. STUDY DESIGN: We conducted a retrospective chart review of 32 patients who underwent reconstruction of skull-base defects with an extended pericranial flap by the senior author (Y.D.) from September 1997 to July 2003. METHODS: Patients with skull base defects after trauma or extirpative surgery were reconstructed with either a lateral- or an anterior-based vascularized extended pericranial flap. Variables and outcomes measured included: the size and anatomical location of the defect, need for other flaps, preoperative and/or postoperative radiation therapy and/or chemotherapy, bone flap necrosis, hardware exposure, wound dehiscence, postoperative cerebrospinal fluid (CSF) leak, and meningitis. RESULTS: There was no evidence of flap failure, 2 cases of transient (3 to 4 days) CSF leak without resultant meningitis, 3 patients with hardware exposure, and 2 patients with hydroxyapatite infection. The 2 transient cases of CSF leak both resolved without further surgical intervention or the placement of a lumbar drain. CONCLUSION: Both the lateral and anteriorly based extended pericranial flaps are reliable and versatile flaps associated with minimal morbidity and a low rate of complications when used to reconstruct defects of the anterolateral skull base. (Otolaryngol Head Neck Surg 2004;130:704-11.)

Frontal Sinus Obliteration Using a Laterally Based Pedicled Pericranial Flap

Objective: Fractures of the frontal sinus represent one of the more uncommon injuries of the maxillofacial skeleton. In an effort to avoid potential mucocele formation, frontal sinus obliteration has been put forward as the treatment of choice when there has been significant disruption of normal frontal sinus drainage. Traditionally, sinus obliteration has been accomplished with nonvascularized free adipose tissue or bone grafts and a variety of alloplastic materials. We developed a laterally based pedicled pericranial flap to accomplish frontal sinus obliteration.

Endoscopic transantral repair of orbital floor fractures

Objective: To review our technique of endoscopic transantral repair of orbital floor fractures. Study Design: Case series with chart review. Methods: All orbital floor fractures treated with the outlined technique from 1998 to 2007 were reviewed in a retrospective fashion. Demographic data, surgical outcomes, and complications were gathered from available patient charts. Results: A total of 63 patients were treated with the described technique (44 male, 19 female). Thirty-nine patients underwent autograft placement from the anterior maxillary sinus wall harvest/exposure. Fourteen patients underwent placement of various alloplasts, and the remaining 10 patients underwent reduction of the contents and floor repositioning. Two patients underwent repeat repair due to inadequacy of initial repair. Both of these complications occurred in the subgroup of patients who underwent simple repositioning. There were no cases of blindness, permanent new diplopia, ectropion, entropion, or new infraorbital anesthesia. Conclusions: The described technique of endoscopic repair of orbital floor fractures represents a precise method of fracture repair that results in excellent outcomes with minimal morbidity in the majority of patients. It allows for immediate fracture repair without the need to wait for periorbital edema to settle. It also allows for clear visualization of the entire fracture for precise graft placement.

Treacher Collins Syndrome: The genetics of a craniofacial disease

OBJECTIVES The molecular underpinnings of Treacher Collins Syndrome (TCS) are diverse. This article codifies the most recent findings in this complex area of research to further current understanding of the disease process. Elucidating the genetic causes of the disorder can be useful in earlier detection and better treatment planning. DESIGN Articles from 1991 to 2013 were selected and reviewed by five researchers utilizing the most recent literature of the genetics and pathophysiology of TCS. RESULTS Mutations in TCOF1, POLR1C and POLR1D have all been implicated in causing TCS. The association of the TCOF1 gene product, Treacle, and gene products of POLR1C and POLR1D with ribosome biosynthesis suggests that a loss of function mutation in these genes disrupts ribosome biosynthesis in constituent neural crest cells and neuroepithelium leading to apoptosis. However, recent data illustrating that P53 heterozygosity is protective against TCS, and that P53 and TCOF1 hemizygous embryos do not affect ribosomal function, implicates P53 or elements downstream of P53 as playing a role in TCS pathogenesis. CONCLUSION Our study codified nascent findings of the molecular determinants of TCS. These findings add to a burgeoning database of TCS-associated mutations, and as such, can be used to establish TCS diagnosis and further clarify TCS pathogenesis.

Management of Osteomyelitis of the Anterior Skull Base and Craniovertebral Junction

OBJECTIVES: The study goals were to determine the patient demographics, identify predisposing factors, and determine efficacy of treatment for nonotologic osteomyelitis of the skull base and craniovertebral junction. STUDY DESIGN: All patients with a biopsy-proven diagnosis of osteomyelitis of the skull base treated by the author from 1997 through 2001 were retrospectively evaluated. RESULTS: Six patients were identified on review. The average age at presentation was 56.7 years (age range, 38 to 70 years), and all except one patient had an underlying immunocompromising condition (diabetes mellitus, human immunodeficiency virus infection, steroid use). Most presented with neurologic deficits associated with a destructive lesion of the osseous skull base. Aggressive debridement of involved bone enabled through the use of broad field standard skull base approaches was associated with clinical resolution of symptoms in each case. Systemic antibacterial/antifungal therapy and medical optimization remain important adjuncts in the treatment of this group of patients. CONCLUSION: The diagnosis of this entity may be difficult to discern from neoplastic involvement of the skull base. Standard skull base approaches are useful for both the diagnosis and the treatment of nonotologic osteomyelitis.