Role of UPPP
Given the currently available technology for OSA and considering the significant health implications of this disorder, I tend to use the algorithm shown in Figure 12-1 to provide a basis for managing these patients. In general, after a thorough discussion of OSA and its clinical implications, the success rate and nonsurgical nature of nasal CPAP is emphasized to the patient. I encourage all patients to seriously consider this alternative. However, many patients cannot or will not use the nasal...
Other Surgery
Every year another operation or two is advocated for Meniere's disease. Many procedures for Meniere's disease have come and gone. The Cody tack operation, the Fick procedure, cryosurgery, and ultrasound proved less reliable than other methods. 7. Derebery MJ. Allergic and immunologic aspects of Meniere's disease. Otolaryngol Head Neck Surg 1996 114 360-365 8. Soliman AM. A subpopulation of Meniere's patients produce antibodies that bind to endolymphatic sac antigens. Am J Otol 1996 17 76-80 9....
Skin Resurfacing Laser or Peel
Structure and surface should be analyzed separately and then melded into a therapeutic plan for the individual facing you across the consultation room. Since the mid 1990s, laser-assisted skin resurfacing has rapidly replaced chemical peels and physical dermabrasion as the most common means of skin exfoliation. Remarkably this has taken place with alarming rapidity and despite the lack of comparative trials. Evidence-based medicine has taught us the value of comparative trials. Without these we...
Why The Maxillary Sinus
Although the frontal and sphenoid sinuses have long been recognized as occasional sites of clinically important disease, the maxillary sinus has traditionally been the focus for defining bacterial sinusitis. Emphasis on the OMC has only recently shifted new attention to the importance of the eth-moidal cells. In retrospect, it was our ability to image the maxillary sinuses satisfactorily with standard radiographic equipment, that led to that site as the gold standard for assessing the...
Nasopharyngeal Cancer
Nasopharyngeal cancer is a highly radioresponsive tumor. This is especially true for the World Health Organization (WHO) class II and III (nonkeratinizing and undifferentiated squamous cell carcinoma). In the United States, however, 30 to 50 of patients will have WHO class I (keratinized squamous cell carcinoma), which is associated with alcohol and tobacco use and is much less radiosensitive.77 Advanced-stage disease is associated with poor 5-year survival rates, within a range of 10 to 40...
Background
Historically, rhytidectomy began during the early twentieth century as a very limited procedure involving minimal subcutaneous undermining and excision of redundant skin.5 The modern concept of facelift surgery began in 1974, when Skoog6 described a subplatysmal technique in a deeper anatomic plane of the face that he believed was useful for facelift surgery. The research conducted by Mitz and Pey-ronie,7 which identified and clarified the relationship and dynamics of the superficial...
Systemic Factors
In addition to the local factors reviewed previously, there are several systemic considerations that impact on a patient's ability to heal. Many of these systemic factors are related directly to the risk factors that predispose to head and neck cancer itself heavy alcohol use and smoking. Patients who continue to smoke until surgery often not only suffer from compromised pulmonary status but are at increased risk of wound breakdown due to poor distal vascular perfusion caused by a direct...
Primary Cancer Sites Based on Neck Node Location
The primary cancer sites based on neck node location are as follows Level 1. submandibular submental lips, buccal mucosa, anterior nasal cavity, soft tissues of the cheek, oral cavity Level 2. upper jugular oral cavity, oropharynx, nasopharynx, supraglottic larynx, hypopharynx Level 3. mid jugular larynx, hypopharynx, thyroid Level 4. lower jugular larynx, thyroid, esophagus, lung, upper GI tract Level 5. posterior triangle of neck nasopharynx, thyroid, cervical esophagus When assessing...
Brief History of Pediatric Sinusitis
Before the 1980s, pediatric sinusitis, especially in the young child or infant, was rarely entertained as a distinct clinical entity. Most cases were apparently dismissed as an unimportant allergy or a cold and were rarely treated with anything beyond decon-gestants or antihistamines, or both, perhaps not an altogether bad approach. Through a series of well-designed and executed studies, Dr. Ellen Wald and her associates in Pittsburgh established a logical framework for diagnosing and treating...
Staging and Stratification
The challenge of developing outcomes management systems rests in adequately defining and stratifying starting points and in accurately quantifying endpoints. In sinusitis, for example, a great deal of attention has been focused on the appropriate method to stage a preoperative computed tomography (CT) scan of the paranasal sinuses. Yet, the factors that comprise a good staging system (i.e., validity, reliability, statistical distribution, comprehensiveness, and the ability to predict outcome)...
Objective Outcome Measures and Staging Systems
In an effort to objectify the severity of chronic rhinosinusitis and the response to medical therapy, numerous staging systems have been proposed. Theoretically, a uniform reporting scheme and a uniformly accepted staging system would improve scientific and accurate communication between otolaryngologists. Such a staging system might also permit the subsequent re-staging of patients after therapeutic intervention and thus become a management tool. To date, however, such a staging system has...
Intraarterial Chemotherapy
In the treatment of advanced tumors, higher rates of complete tumor response are difficult to achieve because of dose-limiting toxicity. In theory, much higher drug concentrations within a tumor can be achieved by delivering the drug directly to the tumor through its arterial blood supply. The theoretical advantage of intra-arterial chemotherapy over standard intravenous (IV) chemotherapy is that a higher concentration of the drug can be delivered directly to the tumor bed than to other organs,...
Lipodissection
Before making incisions, flap elevation with lipodissection is accomplished. The term is derived from the use of liposuction cannulas used for dissection rather than suction. In fact, very little liposuction is even completed. We have found from past experience that the technique of aggressive facial liposuction, although often providing good initial results, often led to later changes that were undesirable as patients aged. Patients who were followed for long periods have an excessive loss of...
Endoscopic Sinus Surgery
When prolonged maximal medical therapy and adenoidectomy both fail to provide adequate relief in a child with at least 6 months of severe symptoms of chronic rhinosinusitis, the child may be a potential candidate for functional endoscopic sinus surgery (FESS).78,85 The Caldwell-Luc procedure is essentially contraindicated in young children due to the potential for damage to unerupted teeth.29,44 Indications for FESS in pediatric rhinosinusitis remain poorly defined and shrouded in...
Posterior Petrosectomyneurotologist
After completion of the cervical exposure, our neurotologist performs the posterior petrosectomy. This is performed under the operating microscope with continuous irrigation and a variety of cutting and diamond bits on a high-speed drill. Transcanal Postauricular Postauricular Postauricular Traditional skull base Traditional skull base Modified infratemporal Modified and or extended infratemporal Figure 82-3 Positioning for the craniocervical approach. The patient is placed supine with the head...
Histologic Effects of Photoaging and Skin Resurfacing
Most patients seeking evaluation for skin rejuvenation have a history of significant sun exposure. Clinical signs of actinic damage include the development of coarse rhytids, rougher skin texture, pigmentary mottling, and the development of solar lentigines and actinic keratoses. Histologically, changes in the epidermis and dermis of patients with sun-damaged skin develop as well. Epidermal dysplasia occurs, indicated by thickened epidermis and the appearance of dysplastic cells. Clinically,...
Conservative Treatment
In the absence of complications, such as sensorineural hearing loss, treatment of active, uncomplicated PLFs should always begin with conservative treatment. About 85 of patients will improve with 6 weeks of bed rest.62 The goal of bed rest is to minimize movement across the defect causing PLF. This immobilization technique is accomplished by minimizing changes in intracranial, intrathoracic, and or intra-abdominal pressure and is analogous to the principles of wound healing employed by all...
Controversies in Surgical Management of Sleep Apnea
One of the more controversial issues in otolaryngology deals with the sleep-obstructive patient. This spectrum ranges from patients with the noise-only snore, to patients who frequently awaken with sleep interruption disorder of snoring, to patients with full-blown apnea with documented obstruction and desaturation. Several standards are established for the criteria for apnea, on the basis of frequency of pauses and degree of oxygen desaturation stated as the clinical parameters of sleepiness....
Conclusion
Patients presenting with metastatic disease in the neck from an occult primary tumor remain a diagnostic and therapeutic challenge. However, many patients presenting with squamous cell carcinoma, especially those with early stage disease, may be offered effective treatment with the prospect of a favorable outcome. It is essential that a thorough evaluation be undertaken before definitive therapy. Careful physical examination, imaging studies, and endoscopy with biopsies will detect the primary...
Chronic Drainage
After topical or oral antibiotics, or both, have been given for initial treatment, the patient is reexamined at 10 days. If drainage is greatly improved but not yet resolved, the same antibiotics can be continued for another 10 days. However, if drainage is no better, several causative factors must be considered. First, chronic drainage can persist because the bacteria are resistant to the antibiotic. Frequently this implies that the infection is caused by Pseudomonas aeruginosa, which is...
Management of the Unilateral Atretic
No one would argue that surgery for congenital aural atresia has the same potential for hearing restoration as does stapedectomy few middle ear procedures involving the middle ear ossicles do. But is the success rate so modest that unilateral cases are best observed, at least until the individual is an adult and can make his or her own decision We cannot overemphasize the importance of complete audiologic evaluation even in the child with unilateral atresia with or without microtia. The routine...
Discussion
Extranasal lateral rhinotomy or maxillary degloving with eth-moidectomy and medial maxillectomy are the gold standard operations for extensive inverting papilloma involving the ethmoid and maxillary sinuses. These procedures and the positive results reported in treating inverting papilloma were developed after years of inadequate intranasal and extranasal procedures. The only reason to change management philosophy depends on equivalent or improved management techniques. Endo-scopic diagnosis...
Eve Bluestein
In general, most children with retrognathia have some degree of airway obstruction as part of their anomaly. In managing these children, physicians should attempt to minimize any airway obstruction present while promoting normal neurologic development and ensuring appropriate weight gain. Although positioning may be successful in some patients, alternative measures have been necessary in other children in order to enable retrognathic children to grow and develop normally. The literature is...
Problems And Complications Of Pess
For most sinus surgeons, the scope of PESS has been reduced sufficiently that it is now a relatively safe and well-tolerated procedure. Some concerns remain. Most importantly, the surgery may not achieve the expected results. For example, we have seen many children who have undergone one or more sinus surgeries with a period of improvement, only to exhibit similar radiographic and clinical findings again, and to become surgical candidates once again. In these cases, what are the goals of...
Factors Related to Tympanostomy Tube Otorrhea
The development of otorrhea after tympanostomy tube insertion is probably of multifactorial etiology. These factors can be considered to overlap those for otorrhea in chronic otitis media patients. Preoperatively recognizable patient characteristics and comorbidities, the surgeon's operative findings, the surgeon's operative choices, and the postoperative management may all influence the development of drainage through the tube. PATIENT CHARACTERISTICS, COMORBIDITIES, AND BEHAVIORS There is...
Hnc Qol Perspective Where Are We Going
The number of articles addressing QOL in the HNC literature should heighten the awareness of practitioners as to the importance of such considerations, although the current focus is largely still on the rather basic and incomplete aspect of functional status accompanying various cancer treatments. The mind-body-spirit connection is being addressed in the QOL literature at large, although such factors are still largely absent in the HNC literature. Several examples are included in this...
Trichloroacetic Acid Peels
TCA is perhaps the best single agent for skin resurfacing. It exhibits unique properties that afford the cosmetic surgeon tremendous flexibility and versatility in treating a variety of clinical conditions. When properly used, TCA has an overall decreased morbidity as compared with other agents. It allows patients to achieve a predictable result with the benefit of disrupting their lives to a lesser degree. Although TCA is the most popular and most widely used chemical peeling agent, proper...
Future Directions
Meticulous postoperative debridement and medical therapy are the best manner in which to achieve a successful objective and subjective outcome in the long-term. However, the cost-effectiveness of such a management strategy has never been demonstrated. Intuitively, avoidance of revision surgery with its associated costs and risks would seem advantageous. However, aggressive postoperative follow-up and the use of prolonged systemic steroid therapy and antibiotics are not without risk and cost. It...
Some Patient Concerns That Influence Satisfaction Dissatisfaction
independence Fear, anxiety, depression, anger, loneliness SOURCE Arrzouman JM, Dudiss S, Farance CE, et al. Quality of life of patients with sarcoma post-chemotherapy. Oncol Nurs Forum 1991 18 889-894. her destiny. There is increasing need to recognize that treatment decisions are not up to the physician rather, they are the patient's decision. Treatment managers often lose sight of this. A rapidly expanding new literature suggests that patient satisfaction may directly relate to the degree to...
General Approach to Facelift Surgery
In the senior author's practice, which spans a career in facelifting of 25 years, the biplane facelift has become the workhorse operation and is used for most patients. Newer innovations, including the use of laser dissection and the skin-sparing tech nique described later in this chapter, basically have not altered the approach that has been in use for more than 15 years. In patients who are seeking additional upper facial rejuvenation, the biplane facelift can easily be combined with either a...
Indications for UPPP in Snoring
UPPP is highly effective for the treatment of snoring. The suc cess rate of this technique has ranged from 76 to 94 , and, in most series, is greater than 90 .23 Although highly efficacious, UPPP is associated with considerable morbidity and thus is fre quently unacceptable to many patients. It requires a general anesthetic and hospital admission, often to the intensive care unit. Postoperative pain is moderate to intense and often unremitting for days in most cases, a narcotic is required for...
Stepwise Summary of Assessment Management and Management of Uncomplicated Chronic Pediatric Rhinosinusitis
Step 1 Thorough history and physical examination suggesting chronic rhinosinusitis Cardinal symptoms 18 chronic nasal congestion purulent nasal discharge, head, pain, cough, fetid breath, postnasal drainage, behavioral changes Boggy edematous turbinates with obstruction polyposis posterior pharyngeal cobbling postnasal discharge tender cervical adenopathy Symptom duration of 12 weeks or more Step 2 Evaluation for predisposing factors and concomitant diseases, with treatment of positive findings...
Management of Inverting Papilloma
Intranasal approaches have been fraught with recurrences because these tumors are usually bulky, creating a difficult exposure. However, otolaryngologists have been gradually extending the indications for minimally invasive intranasal operations, including endoscopic techniques. Does endoscopic sinus surgery have the potential to lower the high recurrence rate associated with the intranasal approach to that of external techniques, on a consistent basis The only reason to change management...
TABLE 302 Glogau Classification
Mild pigmentary changes No keratoses Minimal wrinkles Patient age 20s or 30s Minimal or no makeup Minimal acne scarring Early to moderate photoaging Early senile lentigines visible Keratoses palpable but not visible Parallel smile lines beginning to appear Patient age late 30s or 40s Some foundation usually worn Mild acne scarring Obvious dyschromia, telangiectasias Visible keratoses Wrinkles present even when not moving Patient age 50s or older Acne scarring present makeup does not cover...
Factors Involved in Treatment Algorithm for Chronic Otitis Media
The initial evaluation of patients with chronic otitis media should include a thorough otologic and general medical history. The otologic history must include careful documentation of symptoms and previous treatment, both medical and surgical. The general medical history should include documentation of potential predisposing factors including upper respiratory allergy, smoking, diabetes mellitus, and possible immunologic compromise. Examination should include a thorough otologic and complete...
Info
Assessment and Management of the Unknown Primary with Neck Disease Suspicious areas of mucosa e.g., leukoplakia, erythroplasia, or mucosal irregularities seen on prior physical examination or on imaging studies should be biopsied. If no such lesions are seen, random biopsies should be performed on mucosal sites with the known highest probability of harboring a tumor i.e., nasopharynx, tonsil, tongue base, pyriform sinus. The routine use of CT or MRI for the purpose of attempting to identify a...
Examples of Computed Tomography Staging Systems
Staging system proposed by Kennedy 0 Anatomic abnormalities, all unilateral sinus disease, bilateral disease limited to ethmoidal sinuses Bilateral ethmoidal disease with involvement of one dependent sinus Bilateral ethmoidal disease with involvement of two or more dependent sinuses on each side Staging system proposed by Gliklich and Metson Harvard System 4 0 Normal lt 2 cm mucosal thickening on any sinus wall 1 All unilateral disease or anatomic abnormality II Bilateral disease limited to...
Laser Resurfacing
Although laser physics was first described by Albert Einstein in 1917, laser technology did not appear until the 1960s. Only in recent times have the CO2 and erbium lasers found their way into the cosmetic surgeon's armamentarium as skin resurfacing tools. These high-energy lasers have revolutionized the treatment of photoaged skin. In contrast to other forms of skin resurfacing, laser resurfacing has captured the attention of many people worldwide. When referring to laser resurfacing, the...
Management of Synkinesis and Hyperkinesis
Injection of botulinum toxin can be quite helpful for patients who develop hyperkinesis following reinnervation e.g., after XII to VII cross-innervation . It may also be helpful for patients who have severe synkinesis that results in excessive facial twitches. The toxin is injected into the orbicularis oculi muscle for eyelid spasms and into the zygomaticus major muscle for midfacial spasms. EMG may be helpful in localizing the muscle for injection. An initial dose of 5 to 10 U can be injected...
Phenol Peels
Phenol represents the most common deep chemical peeling agent. It leads to dramatic results by producing a controlled chemical burn to the level of the upper reticular dermis. As healing occurs, new stratified collagen is laid down, resulting in younger-appearing skin. Phenol is an extremely effective agent for reversing facial wrinkling and irregular pigmentary changes related to sun exposure and the natural aging process. The most commonly used phenol preparation is the BakerGordon formula,...
Introduction to the Opportunistic Biplane Facelift
The biplane facelift described in this chapter is based on principles that increase aesthetics and longevity with limited morbidity. Facial aging is most pronounced from changes occurring in the deeper musculofascial plane that result in ptosis of the malar fat pad, jowl region, nasolabial folds, and neck. Precise elevation and rotation of this plane is accomplished using this biplane facelift technique. We call the operation opportunistic, because there is no set anatomic limit to the...
Laser Technique
Although beyond the primary scope of this chapter, it is worthwhile to briefly discuss our laser technique when combined with deep-plane facelifting. We classify our laser technique as moderately aggressive. Because settings vary from instrument to instrument, it is important to realize that wise surgeons will always start at low intensities until they are familiar with the effects of their unit. We use a Luxar CO2 laser. Before surgery, we mark the deepest lines of the patient. After prepping,...
Static Rehabilitation Procedures
A static sling procedure is generally indicated when the patient does not desire restoration of facial motion or is not medically fit to undergo a more extensive procedure under general anesthesia. Although static sling procedures do not restore facial motion, they do improve facial aesthetics for the patient by providing facial symmetry at rest and often will improve oral incompetence. Traditionally, a fascial graft, such as fascia lata from the thigh, is harvested and anchored from the...
Is Selective Neck Dissection Appropriate for the Treatment of the N0 Neck
It is generally accepted today that a radical neck dissection is not indicated for surgical treatment of the N0 neck.30 However, the preference between selective neck dissection and the modified radical neck dissection type III MRND-III , in which the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve are preserved, remains controversial. Some surgeons, particularly in Europe, advocate this type of MRND as the treatment of choice for the NO neck, whereas in...
