Faculty Bibliography

OBJECTIVE: The reasons why adenotonsillectomy (AT) is less effective treating obese children with obstructive sleep apnea syndrome (OSAS) are not understood. Thus, the aim of the study was to evaluate how anatomical factors contributing to airway obstruction are affected by AT in these children. METHODS: Twenty-seven obese children with OSAS (age 13.0 +/- 2.3 y, body mass index Z-score 2.5 +/- 0.3) underwent polysomnography and magnetic resonance imaging of the head during wakefulness before and after AT. Volumetric analysis of the upper airway and surrounding tissues was performed using commercial software (AMIRA(R)). RESULTS: Patients were followed for 6.1 +/- 3.6 mo after AT. AT improved mean obstructive apnea-hypopnea index (AHI) from 23.7 +/- 21.4 to 5.6 +/- 8.7 (P < 0.001). Resolution of OSAS was noted in 44% (12 of 27), but only in 22% (4 of 18) of those with severe OSAS (AHI > 10). AT increased the volume of the nasopharynx and oropharynx (2.9 +/- 1.3 versus 4.4 +/- 0.9 cm(3), P < 0.001, and 3.2 +/- 1.2 versus 4.3 +/- 2.0 cm(3), P < 0.01, respectively), reduced tonsils (11.3 +/- 4.3 versus 1.3 +/- 1.4 cm(3), P < 0.001), but had no effect on the adenoid, lingual tonsil, or retropharyngeal nodes. A small significant increase in the volume of the soft palate and tongue was also noted (7.3 +/- 2.5 versus 8.0 +/- 1.9 cm(3), P = 0.02, and 88.2 +/- 18.3 versus 89.3 +/- 24.4 cm(3), P = 0.005, respectively). CONCLUSIONS: This is the first report to quantify volumetric changes in the upper airway in obese children with OSAS after adenotonsillectomy showing significant residual adenoid tissue and an increase in the volume of the tongue and soft palate. These findings could explain the low success rate of AT reported in obese children with OSAS and are important considerations for clinicians treating these children.

Robotic surgical systems have been developed to augment the capabilities of the surgeon when applied to limited access surgical situations. The adaption of robotic technology to the management of oropharyngeal pathology may represent a paradigm shift in the management of early stage oral malignancies that have commonly been treated with chemoradiation due to the morbidity associated with standard open surgical techniques. The creation of a surgical defect with this approach also creates the need to develop and adapt techniques for reconstruction. Fortunately, the surgical robot is easily applied to the transposition of local flaps to meet these reconstructive needs. © 2013 Elsevier Inc.

Transoral robotic surgery (TORS) for oropharyngeal and laryngohypo-pharyngeal tumors is not only a functionally but also a cosmetically excellent approach. However, visible cervical scars for elective neck dissection (ND) or therapeutic ND cannot be avoided. In our experience, using the conventional neck dissection resulted in long neck scars in patients with high risk of nodal metastases. Robot-assisted neck dissection (RAND) through transaxillary approach in a well-differentiated thyroid carcinoma with lateral neck node metastasis was first reported. Complete ND of the upper neck including level I is frequently required in the surgical management of head and neck squamous cell carcinoma, so we hypothesized that a retroauricular approach could provide the surgical field required for upper ND. Initially, we developed robot-assisted selective ND through a transaxillary and retroauricular approach to hide an apparent scar and to remove lateral or posterior neck compartments after TORS in patients with pharyngeal carcinomas. From accumulation of additional experiences with RAND, we have recently attempted performing level IV and V as well as level I-III dissections through a modified facelift or retroauricular approach without an axillary incision in head and neck cancers. © 2013 Elsevier Inc.

Malignant tumours of the sinonasal tract comprise approximately 3% of the malignancies that arise in the upper aerodigestive tract. Approximately 10% of tumours that arise in the sinonasal tract originate in the ethmoid and/or frontal sinuses, and are likely to involve the anterior cranial base. The route of spread of tumours originating in the anterior skull base and paranasal sinuses is determined by the complex anatomy of the craniomaxillofacial compartments. These tumours may invade laterally into the orbit and middle fossa, inferiorly into the maxillary antrum and palate, posteriorly into the nasopharynx and pterygopalatine fossa, and superiorly into the cavernous sinus and brain. Recent improvements in endoscopic technology now allow the resection of the majority of benign neoplasms and some early malignant tumours with minor dural involvement. For advanced-stage malignant tumours and benign tumours with frontal bone involvement, the classical open approaches remain viable surgical techniques. In this paper, we review the open surgical resection approaches used for resections in the craniomaxillofacial area.

Schmorl nodes represent displacement of intervertebral disc tissue into the vertebral body and have been considered as an asymptomatic incidental radiological finding on plain radiographs, computed tomography and magnetic resonance imaging (MRI). Although uncommon, acute symptomatic Schmorl nodes causing severe back pain do occur. We report here an unusual case of acute painful Schmorl node in a young healthy woman, with no previous trauma, presenting with a sudden significant localized back pain within hours accompanied by characteristic findings on a MRI scan. We reviewed all reports of symptomatic Schmorl nodes known in the literature, focusing mainly on MRI findings, and recent treatment options.

IMPORTANCE: Understanding age-related changes is important when considering cartilage-based implants or grafts during rhinoplasty and nasal reconstructive surgery. OBJECTIVE: To characterize the cellular and architectural changes in human nasal cartilage with aging. DESIGN: Laboratory study. PARTICIPANTS: Nasal septal cartilage was harvested from 50 consecutive patients undergoing septoplasty, rhinoplasty, or septorhinoplasty. INTERVENTION: Cartilage specimens were stained with hematoxylin-eosin (H&E) and safranin O for cartilage. MAIN OUTCOME MEASURES: A modified Mankin histologic grading scale was used to analyze each cartilage sample for H&E findings and safranin O staining. Higher H&E scores indicated more degenerative changes, while higher safranin O scores indicated reductions in proteoglycan content within the cartilage matrix, representing decreased active chondrocyte activity. Correlation between H&E and safranin O scores and patient age was determined. RESULTS: There was positive correlation between safranin O staining scores and age, with higher scores seen with advancing age (P = .01). A linear regression best-fit equation was determined to calculate a potential safranin O staining score for a given age. CONCLUSIONS AND RELEVANCE: We have quantitatively determined that advancing age is positively correlated with reductions in cartilage proteoglycan content and active cartilage growth. This finding not only enhances our current understanding of the natural changes that occur in cartilage with aging but may also affect surgical decision making when cartilage grafting is considered during functional, reconstructive, and aesthetic rhinoplasty. LEVEL OF EVIDENCE: NR.

IMPORTANCE: The effect of different rhinoplasty maneuvers on alar retraction remains to be elucidated. OBJECTIVE: To determine the etiology and treatment of alar retraction based on a series of specific rhinoplasty maneuvers. DESIGN: Retrospective review of a single surgeon's rhinoplasty digital photo database, examining preoperative alar retraction from January 1, 2002, to December 31, 2005, in 520 patients. Patients with more than 1 mm of alar retraction on preoperative photographs were identified. Postoperative photographs were examined to determine the effect of specific rhinoplasty maneuvers on the position of the alar margin; these maneuvers included cephalic trim, cephalic positioning of the lower lateral cartilage, composite grafts, alar rim grafts, alar batten grafts, and overlay of the lower lateral cartilage. SETTING: Tertiary care academic health center. PARTICIPANTS: Forty-five patients with alar retraction met inclusion criteria, resulting in 63 nasal halves with alar retraction. MAIN OUTCOMES AND MEASURES: Intraoperative findings, postoperative results. RESULTS: Forty-seven percent of the patients (n = 21) had prior surgery; 47% also had cephalically positioned lower lateral cartilages. Among patients with less than 4 mm of cartilage width at the outset, 46% of those who received supportive grafts achieved target correction vs only 7% for patients who did not undergo supportive cartilage grafting. In patients who underwent more than 4 mm of cephalic trim, those who received supportive grafts achieved 46% of target correction vs 11% among those who did not. Ninety-five percent of composite grafts, 69% of alar strut grafts, 47% of alar rim grafts, 43% of vertical lobule division, and 12% of alar batten grafts achieved their target correction values. CONCLUSIONS AND RELEVANCE: Alar retraction is a highly complex problem. It can be seen de novo and is associated with cephalically positioned lower lateral cartilages. Structurally supportive grafting-including composite grafts, alar strut grafts, alar rim grafts, vertical lobule division, and alar batten grafts-can improve alar retraction. LEVEL OF EVIDENCE: 4.

IMPORTANCE: Free-tissue transfer for head and neck reconstruction has evolved since the mid-1950s. A variety of different recipient arteries and veins have been described for use in head and neck reconstruction. In our experience, the internal mammary artery (IMA) and internal mammary vein (IMV) have become increasingly important for achieving successful microvascular reconstruction. OBJECTIVE: To illustrate the efficacy of the IMA and IMV recipient vessels in head and neck reconstruction, highlighting the different techniques used to harvest these vessels and outline decision making when approaching a neck where commonly used vessels are unavailable. DESIGN: Retrospective medical record review. SETTING: Outpatient clinic setting. PARTICIPANTS: All free-tissue transfers performed between 2005 and 2011. All patients in whom the IMA or IMV recipient vessels were used were included. INTERVENTIONS: Twelve cases were performed with IMA and IMV harvest. MAIN OUTCOMES AND MEASURES: Donor site, flap used, recipient artery and vein, success of transfer, flap survival, and presence of donor site complications. RESULTS: The IMA and IMV were harvested in 12 patients, with 11 successful free-tissue transfers. In 1 patient, the vessels were unusable, and a regional tissue transfer was performed. CONCLUSIONS AND RELEVANCE: The IMA and IMV are excellent recipient vessels for use in head and neck reconstruction and should be considered for use in challenging reconstructive cases.

OBJECTIVES: Surgical resection of oral cancer can result in altered speech, swallowing, and quality of life (QOL). To date, the oral outcome variables of tongue strength, tongue and jaw range of motion, and saliva production have not been extensively assessed. This pilot study was done to assess tongue strength along with other oral outcomes and their relationship to performance status for speech, swallowing, and QOL after partial glossectomy. Our aim was to create a norm for what should be considered a normal tongue strength value in this population. We hypothesized that patients with tongue strength of 30 kPa or greater would perform better on the performance status scale and various QOL measures than do patients with tongue strength of less than 30 kPa. METHODS: We used a cross-sectional design in this study. The postoperative assessment included 1) Performance Status Scale and Karnofsky Performance Status Scale; 2) oral outcome variables of tongue strength, jaw range of motion. and saliva production; and 3) patient-rated QOL ratings via Eating Assessment Tool, M. D. Anderson Dysphagia Inventory, EORTC-H&N35, and Speech Handicap Index. RESULTS: Patients with tongue strength of at least 30 kPa performed better on the performance status scales and various QOL measures. The cutoff score of 30 kPa for tongue strength measures revealed a trend in predicting performance on the scales and QOL measures. CONCLUSIONS: The oral outcome variables correlated with performance status for speech, swallowing, and QOL. We propose a norm for tongue strength in this population, based on the trend seen in this group of patients, as none previously existed. Future studies are under way that incorporate a larger sample size to further validate this norm. Future studies will also examine oral functional outcome measures in a larger population by inclu'ding other oral and oropharyngeal sites to help predict speech and swallow performance status and QOL.