Faculty Bibliography

OBJECTIVE: To review the background, case characteristics, and outcomes of malpractice litigation resulting from surgical injury of the spinal accessory nerve. DESIGN: Retrospective review of indemnity insurance cases (part 1) and court trials (part 2) between January 1, 1985, and January 1, 2007. In part 1, records of the Medical Liability Mutual Insurance Company identified 41 lawsuits in New York State; part 2 was a review of a national legal database (WestLaw) that identified 81 court trials. Case details were analyzed, and awards were adjusted for inflation. RESULTS: For part 1, of 41 indemnity insurance cases, 39 (95%) involved a posterior triangle lymph node biopsy. Defendants were mainly general surgeons and otolaryngologists. Most lawsuits against surgeons (22 of 34 [65%]) were settled before trial, and only 4 of 34 (12%) were discontinued. Of these 34 cases, 28 (82%) ultimately compensated the plaintiff. The mean inflation-adjusted pretrial settlement was $264 395, and the mean settlement at trial was $443 538. Cases reaching trial received significantly higher settlements (P = .01). For part 2, 81 cases of alleged surgical injury to the spinal accessory nerve were identified. Defendant physicians were mainly general surgeons and otolaryngologists. Most operations were cervical lymph node biopsies (55 [68%]), followed by sebaceous cyst excisions (6 [7%]), neck dissections (4 [5%]), and other procedures (12 [15%]). Morbidity included weakness (81 patients [100%]), pain (30 patients [37%]), inability to work (20 patients [25%]), need for a nerve repair procedure (16 patients [20%]), deformity (9 patients [11%]), and numbness (4 patients [5%]). Types of malpractice alleged included negligent surgical technique (79 cases [98%]), lack of informed consent (17 cases [21%]), and failure to diagnose the injury (16 cases [20%]). Thirty-seven cases (46%) were decided for the defendant, 32 (40%) were decided for the plaintiff, and 12 (15%) were settled (percentages do not total 100 because of rounding). The mean inflation-adjusted settlement was $356 132, and the mean jury award was $515 968. Jury awards were significantly higher than settlements (P = .003). CONCLUSIONS: Unintended injury to the spinal accessory nerve after head and neck surgery is a significant source of malpractice litigation. Timely diagnosis and treatment of this complication are essential. Regardless of whether the medical community considers careful surgical technique and nerve preservation to be the standard of care, the legal system clearly treats it as such, awarding compensation in 82% of cases. Strategies for optimal surgical care and litigation risk reduction are discussed

Objective: To compare the extent of exposure and surgical maneuverability provided by facial translocation and transtemporal approaches for access to the infratemporal fossa and anterolateral skull base. Materials and Methods: Surgical procedures were performed on five fresh frozen adult cadavers (ten sides) with no known pathology. Facial transfacial approaches with and without a mandibulotomy and transtemporal approaches were evaluated. Objective measures were (1) the distance from the surgical plane to designated anatomic landmarks and (2) the surgical angle of exposure. Results: Distances from the surgical plane to the anatomic reference points were comparable for most of the access procedures (3 to 6 cm). The extended midfacial translocation and bilateral facial translocation approaches did, however, provide a shorter operative distance (1 to 3 cm) for access to the infratemporal fossa and contralateral structures, respectively. The transtemporal approaches facilitate a better angle of exposure (74 to 84 degrees) to the petrotemporal region, while the transfacial approaches were superior for access to the infratemporal structures. Conclusions: Based on the results, we propose a clinical algorithm for selecting a surgical approach based on the position and extent of an infratemporal or petrotemporal lesion

Although recent studies indicate that regional dura mater influences the fate of the overlying cranial suture, little is known about the assembly of extracellular matrix (ECM) molecules within the patent and fusing murine cranial suture complexes. Confocal laser scanning microscopy was used to study ECM assembly within patent and fusing cranial suture complexes. Coronal sections (20 microm thick) of patent sagittal (SAG) and fusing posterior frontal (PF) sutures from postnatal 8-, 14-, and 18-day-old Sprague-Dawley rats were scanned in 0.5-microm increments, and images were collected consecutively to create a z-series for three-dimensional reconstruction. Spatial and temporal collagen arrangements were compared between SAG and PF sutures by measuring interfiber distance, fiber thickness, and total collagen surface area at each time point.We demonstrate that on day 8 (before the onset of suture fusion), collagen bundles are randomly arranged in both the SAG and PF sutures. By day 14 (midfusion period), there was a statistically significant reduction in total collagen surface area (80.5% versus 67.4%; P < 0.05) as the collagen bundles were organized into orthogonal lattices along the anterior and endocranial margins of the PF suture. Furthermore, new bone matrix deposition was observed along the edges of these organized collagen bundles. In contrast, collagen within the SAG suture remained randomly arranged and unossified. By day 18 (late fusion period), the PF suture was completely fused except for the posterior-ectocranial portion. This patent section of the PF suture contained a highly organized mineralizing orthogonal collagen lattice. The total collagen surface area in the day-18 PF suture continued to decline compared with the day-8 PF suture (80.5% versus 55.6%; P < 0.05). In the day-18 SAG suture, the collagen bundles remained randomly arranged, and the total surface area did not change. The same analysis was performed in a human pathologic fusing and patent suture. Similar results were observed. The total collagen surface area significantly decreased in the pathologic fusing human suture compared with the patent suture (92.8% versus 60.6%; P < 0.05). Moreover, the pathologically fusing suture contained a highly organized mineralizing orthogonal collagen lattice. This is the first analysis of collagen patterns in patent and fusing cranial sutures

CONTEXT: Adults who live in rural areas of the United States have among the highest smoking rates in the country. Rural populations, including Appalachian adults, have been historically underserved by tobacco control programs and policies and little is known about their effectiveness. PURPOSE: To examine the end-of-class quit success of participants in A Tobacco Cessation Project for Disadvantaged West Virginia Communities by place of residence (rural West Virginia and the urban area of Greater Charleston). METHODS: This collaborative program was implemented in 5 underserved rural counties in West Virginia and consisted of 4 intervention approaches: (1) a medical examination; (2) an 8-session educational and behavioral modification program; (3) an 8-week supply of pharmacotherapy; and (4) follow-up support group meetings. FINDINGS: Of the 725 program participants, 385 (53.1%) had successfully quit using tobacco at the last group cessation class they attended. Participants who lived in rural West Virginia counties had a lower end-of-class quit success rate than those who lived in the urban area of Greater Charleston (unadjusted odds ratio [OR]= 0.69, 95% confidence interval [CI]= 0.48, 0.99), even after taking into account other characteristics known to influence quit success (adjusted OR = 0.58, 95% CI = 0.35, 0.94). CONCLUSIONS: Tobacco control programs in rural West Virginia would do well to build upon the positive aspects of rural life while addressing the infrastructure and economic needs of the region. End-of-class quit success may usefully be viewed as a stage on the continuum of change toward long-term quit success.

Dermal lymphatic malformations are rare congenital hamartomas of superficial lymphatics characterized by high recurrence rates after excision. The standard therapy for a single lesion is surgical excision with wide margins, which reduces recurrence but can have a potentially unacceptable aesthetic outcome. A case of a 24-year-old woman with a 6 cm x 5 cm dermal lymphatic malformation on her right thigh, diagnosed by clinical history, physical examination, magnetic resonance imaging and pathological findings, is reported. The patient underwent wide local excision with split-thickness skin grafting. After pathological examination revealed negative margins, the patient underwent tissue expander placement and excision of the skin graft with primary closure. The lesion did not recur, and the patient achieved a satisfactory aesthetic result. The present case represents the first report of the use of tissue expanders to treat dermal lymphatic malformations in the lower extremity and demonstrates a safe, staged approach to successful treatment.

Sclerosing sweat duct carcinoma is a rare, locally aggressive adnexal tumor that frequently occurs on the face of middle-aged adults, invades deeply, and has a propensity to recur. We report a rare instance of sclerosing sweat duct carcinoma occurring in a 6-year-old African American child and review the literature of this infrequently observed neoplasm.