Faculty Bibliography

Silent sinus syndrome is a known clinical entity caused by negative sinus pressure from acquired obstruction of the maxillary sinus ostium with resulting enophthalmos and hypoglobus. We present a case in which, after septorhinoplasty, a patient developed progressive enophthalmos and hypoglobus. His evaluation was consistent with silent sinus syndrome. This case illustrates the complex reconstructive challenges of repairing an orbit in the setting of fistulization of the orbit with the maxillary sinus cavity. In particular, we highlight the inferior fornyx transconjunctival approach with simultaneous intranasal endoscopic maxillary sinus aeration.

OBJECTIVE: To elucidate the advantages and disadvantages of the anterolateral thigh flap (ALTF) for pharyngoesophageal reconstruction, we assessed this donor site and compared it with the radial forearm free flap (RFFF). DESIGN: Retrospective medical chart review. SETTING: Tertiary care referral center. SUBJECTS: Twenty-three consecutive patients who underwent pharyngoesophageal reconstruction using an ALTF or RFFF. INTERVENTION: Pharyngoesophageal reconstruction. MAIN OUTCOME MEASURES: Patient medical charts were assessed for age, histopathological diagnosis, preoperative treatment, surgical defect, tracheoesophageal speech, flap survival, donor and recipient site complications, and swallowing function. RESULTS: Twenty-three patients (12 who underwent reconstruction with ALTF and 11 with RFFF) were included in the study. Both donor sites provided adequate tissue for pharyngoesophageal reconstruction; however, the RFFF group demonstrated a higher rate of postoperative donor site complications including skin graft loss and extremity edema and stiffness. Postoperatively, the ALTF group demonstrated no gait disturbance and no donor site complications. All 23 patients in both groups were able to tolerate an unrestricted oral diet; however, 3 patients who underwent reconstruction with an RFFF experienced cervical esophageal stenosis, whereas only 1 patient with an ALTF experienced stenosis. CONCLUSION: In this preliminary series, the ALTF represents an excellent source of tissue for pharyngoesophageal reconstruction and is associated with a lower rate of donor site morbidity and anastomotic stenosis compared with the RFFF donor site.

There has been a great deal of controversy regarding the appropriate method of management of oral cavity and oropharyngeal tumors that invade the mandible. The inability to acquire intraoperative bone margins can make the decision process complex. Preoperative imaging offers several advantages, however, there is no single modality that has proven accurate. Intraoperative assessment has been suggested as a method of evaluation, however, this approach does not allow for preoperative planning. The following is a review of the current literature regarding mandibular invasion and the indications for a marginal mandibulectomy.

PROBLEM: Several studies have evaluated the effect of intravenous gammaglobulin (IVIG) in women with unexplained recurrent spontaneous abortions (RSA). Data regarding the underlying immunologic abnormalities in these patients is scant. This study reports the pregnancy outcome and immunologic changes observed in a large group of women with RSA associated with well-defined alloimmune and autoimmune abnormalities treated with IVIG. METHODS: Thirty-five patients with three or more recurrent miscarriages were studied. None of the patients had identifiable alloimmune response to paternal lymphocytes. Twenty-four patients had anti-thyroid antibodies, ten patients had high levels of circulating immune complexes, and six patients had anti-cardiolipin antibodies. Five patients had Hashimoto's disease, one had immune thrombocytopenic purpura, and one had Crohn's disease. Twenty-three patients had more than one autoimmune abnormality. All patients received IVIG infusions (200-250 mg/kg) every 3 weeks during the first 8 months of pregnancy. RESULTS: Twenty-eight patients (80%) had a successful pregnancy. Decrease of the level of autoantibodies and circulating immune complexes was observed in all patients who had a successful pregnancy. Only three of these patients developed measurable alloimmune response to paternal antigens. CONCLUSIONS: This preliminary study suggests that IVIG may be of benefit to patients with recurrent pregnancy associated with combined alloimmune and autoimmune abnormalities. This benefit was seen in spite of lack of detectable correction of the alloimmune abnormality in the majority of patients.