Faculty Bibliography

BACKGROUND: In the neck, the recipient vessels most frequently used for microsurgical reconstruction are compromised by prior surgery and radiation. METHODS: We conducted a retrospective chart review of all patients who underwent microvascular reconstruction between July 2001 and June 2005. Donor vessels, vein grafts, and flap survival were examined. RESULTS: Fourteen of 197 patients (7%) were identified with a vessel-depleted neck. All patients had undergone a prior neck dissection and radiation (100%) or chemoradiation (42%). Free flap revascularization was achieved using the transverse cervical artery with a vein graft and a cephalic vein (4 patients), thoracoacromial artery and cephalic vein (3 patients), internal mammary artery and vein (3 patients), and inferior thyroid artery and cephalic vein (1 case). In 3 patients, the reverse flow thoracodorsal artery and cephalic vein were used to vascularize the scapular flap. CONCLUSION: The cephalic vein, transverse cervical, internal mammary, and thoracoacromial vessels represent reliable alternatives in the vessel-depleted neck.

OBJECTIVE: Various energy delivery systems have been utilized to treat superficial rhytids in the aging face. The Intense Ultrasound System (IUS) is a novel modality capable of transcutaneously delivering controlled thermal energy at various depths while sparing the overlying tissues. The purpose of this feasibility study was to evaluate the response of porcine tissues to various IUS energy source conditions. Further evaluation was performed of the built-in imaging capabilities of the device. MATERIALS AND METHODS: Simulations were performed on ex vivo porcine tissues to estimate the thermal dose distribution in tissues after IUS exposures to determine the unique source settings that would produce thermal injury zones (TIZs) at given depths. Exposures were performed at escalating power settings and different exposure times (in the range of 1-7.6 J) using three IUS handpieces with unique frequencies and focal depths. Ultrasound imaging was performed before and after IUS exposures to detect changes in tissue consistency. Porcine tissues were examined using nitro-blue tetrazolium chloride (NBTC) staining sensitive for thermal lesions, both grossly and histologically. The dimensions and depth of the TIZs were measured from digital photographs and compared. RESULTS: IUS can reliably achieve discrete, TIZ at various depths within tissue without surface disruption. Changes in the TIZ dimensions and shape were observed as source settings were varied. As the source energy was increased, the thermal lesions became larger by growing proximally towards the tissue surface. Maximum lesion depth closely approximated the pre-set focal depth of a given handpiece. Ultrasound imaging detected well-demarcated TIZ at depths within the porcine muscle tissue. CONCLUSION: This study demonstrates the response of porcine tissue to various energy dose levels of Intense Ultrasound. Further study, especially on human facial tissue, is necessary in order to understand the utility of this modality in treating the aging face and potentially, other cosmetic applications

OBJECTIVE: To assess word recognition and pitch-scaling abilities of cochlear implant users first implanted with a Nucleus 10-mm Hybrid electrode array and then reimplanted with a full length Nucleus Freedom array after loss of residual hearing. BACKGROUND: Although electroacoustic stimulation is a promising treatment for patients with residual low-frequency hearing,a small subset of them lose that residual hearing. It is not clear whether these patients would be better served by leaving in the 10-mm array and providing electric stimulation through it, or by replacing it with a standard full-length array. METHODS: Word recognition and pitch-scaling abilities were measured in 2 users of hybrid cochlear implants who lost their residual hearing in the implanted ear after a few months. Tests were repeated over several months, first with a 10-mm array, and after, these patients were reimplanted with a full array. The word recognition task consisted of 2 50-word consonant nucleus consonant (CNC) lists. In the pitch-scaling task, 6 electrodes were stimulated in pseudorandom order, and patients assigned a pitch value to the sensation elicited by each electrode. RESULTS: Shortly after reimplantation with the full electrode array, speech understanding was much better than with the 10-mm array. Patients improved their ability to perform the pitch-scaling task over time with the full array, although their performance on that task was variable, and the improvements were often small. CONCLUSION: 1) Short electrode arrays may help preserve residual hearing but may also provide less benefit than traditional cochlear implants for some patients. 2) Pitch percepts in response to electric stimulation may be modified by experience

OBJECTIVE: To assess the change in disease-specific quality of life (QOL) in pediatric patients with obstructive sleep-disordered breathing (OSDB) secondary to adenotonsillar hypertrophy after powered intracapsular tonsillectomy and adenoidectomy. DESIGN: Prospective outcomes study. SETTING: Hospital-based pediatric otolaryngology practice. PATIENTS: Fifty children with a mean age of 4.5 years who had a clinical diagnosis of OSDB. INTERVENTIONS: A caregiver of qualifying patients completed a validated QOL survey of pediatric obstructive sleep apnea, the OSA-18 (Obstructive Sleep Apnea-18), preoperatively and 3 months and 1 year postoperatively. MAIN OUTCOME MEASURE: The OSA-18 mean change scores. RESULTS: The mean (SD) total OSA-18 change score at the 3-month follow-up visit was 2.3 (1.2) and at the 1 year follow-up visit was 2.2 (1.3). The total and individual domain change scores were significantly improved at both postoperative intervals (P<.001 for all). There were no significant changes in the total or domain change scores between the intervals. The total change score was not significantly associated with either tonsil size or tonsil position. CONCLUSION: The OSDB-related QOL is significantly improved after powered intracapsular tonsillectomy and adenoidectomy, and this improvement remains stable even after 1 year

Manganese-enhanced MRI (MEMRI) has been developed to image brain activity in small animals, including normal and genetically modified mice. Here, we report the use of a MEMRI-based statistical parametric mapping method to analyze sound-evoked activity in the mouse auditory midbrain, the inferior colliculus (IC). Acoustic stimuli with defined frequency and amplitude components were shown to activate and enhance neuronal ensembles in the IC. These IC activity patterns were analyzed quantitatively using voxel-based statistical comparisons between groups of mice with or without sound stimulation. Repetitive 40-kHz pure tone stimulation significantly enhanced ventral IC regions, which was confirmed in the statistical maps showing active regions whose volumes increased in direct proportion to the amplitude of the sound stimuli (65 dB, 77 dB, and 89 dB peak sound pressure level). The peak values of the activity-dependent MEMRI signal enhancement also increased from 7% to 20% for the sound amplitudes employed. These results demonstrate that MEMRI statistical mapping can be used to analyze both the 3D spatial patterns and the magnitude of activity evoked by sound stimuli carrying different energy. This represents a significant advance in the development of MEMRI for quantitative and unbiased analysis of brain function in the deep brain nuclei of mice

The complex architecture of the auricle makes it one of the most challenging structures for the reconstructive surgeon to re-create. Overlying the ear's unique cartilage framework are layers of varied soft tissues forming a three-dimensional organ, which is distinctively positioned on the head. Arguably, the most challenging auricle to reconstruct is third-degree microtia due to a near-total absence of native tissue and a need for lifelong durability of the reconstruction. Many methods of reconstruction have been studied; autogenous costal cartilage reconstruction has been one of the more traditional methods, with favorable long-term results reported by several surgeons. However, this technique requires tremendous artistic and technical skill on the part of the surgeon-sculptor to construct a realistic-appearing ear. High-density porous polyethylene (Medpor) is a stable, alloplastic implant that can integrate with host tissues, is resistant to infection, and has been successfully applied to reconstruction of the head and neck. For auricular reconstruction, Medpor--enveloped in a temporoparietal fascial flap with full-thickness skin graft coverage--is a durable and aesthetically gratifying alternative in microtic patients. This alternative surgical technique reduces surgical time and morbidity, standardizes results among surgeons, and facilitates an aesthetic, natural-appearing reconstruction of the auricle

BACKGROUND: Radiation is a known risk factor for poor wound healing. Patients undergoing intraoperative radiation therapy (IORT) typically receive higher cumulative doses to their wound beds than patients treated with conventional radiation therapy. We review our experience with IORT in patients undergoing resection of head and neck cancer and flap reconstruction. Logistics of delivery and outcomes are discussed. METHODS: A retrospective chart review was performed on all patients at Beth Israel Medical Center who underwent IORT for head and neck cancer between 2000 and 2007. Twenty-one patients receiving 22 treatments involving flap reconstruction were identified. The results of these reconstructions were evaluated for complications and functional outcome. RESULTS: All patients had complex surgical wounds of the face, upper aerodigestive tract, or neck who received IORT in conjunction with pedicled or free flap closure. Twenty-five flaps in 21 patients were performed in the setting of IORT. All patients received between 10 and 15 Gy of IORT administered directly to the wound bed. There were no perioperative mortalities. Wound breakdown occurred in three cases, all of which were treated successfully by operative revision. Functionally, most patients did well and performed similarly to historic controls for their type of reconstruction. CONCLUSIONS: Reconstruction using flaps in the context of IORT can be achieved with expectation of good wound healing in the majority of cases despite heavy cumulative doses of radiation to recipient wound beds.

BACKGROUND: Stomal stenosis after laryngectomy is a common and distressing complication. Once sets in, it is generally progressive, causes problems and needs active intervention. AIM: To evaluate effectiveness of new simple method of stomaplasty in solving troublesome complication of stoma stenosis. SETTINGS AND DESIGN: Charts of eight patients who underwent modified stomaplasty and completed 1 year were reviewed. MATERIALS AND METHODS: A modified anterior advancement flap and lateral splaying of trachea for stoma plasty are described. This involves excision of scar tissue of the anterior two-third of trachea and interposition of the defect with an inferiorly based triangular skin flap. The tracheo-esophageal-prosthesis (TEP) site is left untouched. STATISTICAL ANALYSIS: Outcome were measured in relation with need for further stenting or any other revision procedure required and ability to use TEP for speech production. RESULTS: Eight patients underwent stoma revision surgery. Median preprocedure stoma diameter was 10 mm vertically (range 8-12 mm) and 6 mm horizontally (range 5-10 mm). This could be improved to 25 mm (range 22-30 mm) vertically and 16 mm (range 14-20 mm) horizontally after stoma revision. At 1-year follow-up, the median measurements were 20 mm (range 16-26) vertically and 14 mm (range 12-18) horizontally. Postprocedure, one patient required intermittent stenting at nighttime. All patients could use the TEP effectively. One patient who underwent salvage laryngectomy following chemoradiotherapy developed flap dehiscence. CONCLUSIONS: This is a simple and effective technique for stomaplasty. All patients treated with this technique had adequately large stoma for breathing and use of TEP.

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