Faculty Bibliography

PURPOSE/OBJECTIVE:This cadaver dissection studied the relationship of the buccal branch of the facial nerve to the parotid duct and its relevance to surgical procedures in this area. MATERIALS AND METHODS/METHODS:Ten cadaveric heads (twenty sides) were dissected. The superficial tissues were removed, and the buccal branch of the facial nerve and the parotid duct were identified. The vertical and horizontal relationships were recorded and analyzed. RESULTS:Eighty-five percent of the cadavers had a single buccal branch of the facial nerve, whereas 15% had two branches. In 75% of cases, the nerve was inferior to the duct as it emerged from the parotid gland, whereas in 25% of cases the nerve crossed the duct, usually from superior to inferior. CONCLUSION/CONCLUSIONS:The buccal branch of the facial nerve has a close relationship with the parotid gland for over 2.5 cm after it emerges from the parotid gland; it normally lies inferior to the duct. This relationship is of importance in performing parotid gland surgery, parotid duct surgery, and some facial cosmetic surgery.

OBJECTIVE: To determine if elective cosmetic septorhinoplasty impacts on nasal air flow resistance over the long-term. DESIGN: Case series. Mean postoperative follow-up period was 41.5 months (range, 16 to 77 months). PATIENTS: A consecutive sample of 200 patients having undergone cosmetic open septorhinoplasty by one of us (P.A.A.) before July 1992 were contacted by telephone; 50 agreed to participate, and 27 actually participated in the study. INTERVENTIONS: Open cosmetic septorhinoplasty performed by one of us (P.A.A.). MAIN OUTCOME MEASURES: Comparison of preoperative and postoperative nasal resistance values by headout body displacement plethysmography; correlation of preoperative and postoperative nasal valve anatomy with nasal resistance values; and correlation of postoperative nasal resistance values with subjective evaluation of nasal air flow as reported on a 10-point analogue scale. RESULTS: Of the 27 patients, 10 had normal preoperative nasal resistance values and 17 had elevated resistance values. Preoperative Normal Group: Four of the 10 patients' mean resistance values exceeded normal limits postoperatively. One of these four patients reported subjective nasal obstruction. Preoperative Abnormal Group: Of the 17 patients, surgery resulted in normal resistance values postoperatively in six, decreased but still above normal resistance values in eight, and no decrease in postoperative resistance values in three. CONCLUSIONS: (1) Patients with normal nasal resistance values may suffer long-term, asymptomatic increase in nasal resistance values after cosmetic open septorhinoplasty, often with no quantifiable change at the nasal valve. (2) Patients with elevated nasal resistance measurements generally improve with open septorhinoplasty. Patients with isolated septal deformities improve with septoplasty. Patients with upper lateral cartilage collapse improve with spreader grafts. The lasting objective improvement on the nasal valve using spreader grafts is reported herein for the first time. (3) Subjective estimations of nasal patency do not correlate well with objective measures of patency, namely nasal resistance measurements. (4) Cosmetic septorhinoplasty can alter nasal patency. Continued care must be exercised when manipulating the nasal framework for cosmetic purposes, as slight changes to the nasal valve may result in significant alterations in nasal air flow resistance

Ectopic thyroid tissue can be found anywhere between the foramen cecum and the normal position of the thyroid gland. Although very uncommon, it is most often found in the region of the foramen cecum, in patients in whom the gland fails to descend. Extralingual thyroid tissue is most commonly located in the anterior cervical area, the region of the thyroglossal duct. It must be differentiated from thyroglossal duct cyst, in that it frequently represents the only source of thyroid tissue. In the majority of patients with lingual thyroid tissue, this is the only functioning thyroid. We present the case of a thirteen year old male child with a midline cervical mass first noted at one year of age. Since its early presentation, this midline mass had increased and decreased in size, and over the last three months had been associated with odynophagia and anterior neck swelling. A presumptive diagnosis of thyroglossal duct cyst was made. A preoperative thyroid scan revealed that this midline mass was in fact the only functioning thyroid tissue; therefore no surgery was performed. This case demonstrates the essential role of a thyroid scan in the preoperative evaluation of a midline neck mass. Recognizing that ectopic thyroid tissue may present as a thyroglossal duct cyst and may be the only functioning thyroid avoids subjecting the child to inappropriate surgery and a life of replacement therapy.

Choroid plexus papillomas are rare tumors, representing less than 1% of all intracranial neoplasms in our review of the English literature. Derived from the neuroepithelial cells of the choroid plexus, these tumors recapitulate the structure of the normal choroid plexus, often demonstrating a well-developed papillary architecture. This tumor most commonly affects children and typically arises in the lateral ventricles. Before 1992, 26 cases have been reported arising in the cerebellopontine angle. We describe an example of choroid plexus papilloma of the cerebellopontine angle that was initially diagnosed as metastatic papillary carcinoma. A metastatic disease workup revealed a right thyroid lobe nodule. Fine needle aspiration biopsy of this nodule yielded a few atypical cells, but no evidence of papillary carcinoma. We performed additional laboratory investigations to rule out the possibility of a primary papillary carcinoma of the thyroid gland and to make a definitive diagnosis of a choroid plexus papilloma. This article reviews choroid plexus papilloma of the cerebellopontine angle and demonstrates the use of immunohistochemistry to differentiate this benign primary neoplasm from well-differentiated metastatic papillary carcinoma.

While both prophylactic antibiotics and tympanostomy tube insertion have a role in the treatment of recurrent acute otitis media (AOM) and otitis media with effusion (OME) in children previous work has shown that patients in our urban clinic are not compliant with prophylactic antibiotics. Concerned about the potential for decreased compliance in a non-compliant population, we performed a retrospective review to assess the incidence of complications from the insertion of tympanostomy tubes in the same pediatric clinic population. A total of 391 tubes were placed in 165 patients. Follow-up ranged from 0-49.4 months with a mean of 21.3 months. Three ears (1.14%) had persistent perforations. Tympanosclerosis was found in 30 ears (11.1%). No ear showed a chronic retraction or cholesteatoma. Six ears (1.70%) developed postoperative otorrhea. Thirty-five patients had at least one episode of otorrhea outside of the perioperative period, and a total of 60 episodes (19.6% of ears) occurred during the study period. The mean pure tone average prior to tube placement was 25.0 dB, with tubes in place was 2.44 dB and after the last set of tubes had extruded was 6.97 dB. Our study shows that the incidence of complications of tympanostomy tubes was minimal in our inner city clinic population

The performance of tonsillectomy and adenoidectomy in an ambulatory setting is controversial. However, most current studies show that with adequate criteria for patient selection and careful postoperative observation, these procedures can be safely done as outpatient surgery. This study was undertaken to reassess the safety of outpatient tonsillectomy and adenoidectomy surgery and to reevaluate the current recommendations for postoperative care. A prospective study was undertaken to relate the incidence of significant complications, including hemorrhage, protracted emesis, and fever, to each postoperative hour. The study included 534 pediatric patients (age 14 or less) undergoing tonsillectomy with or without adenoidectomy. All 534 patients were observed for 5 postoperative hours, and 175 of the 534 patients were observed for 6 postoperative hours. To assess complications occurring in the first postoperative week, all attending surgeons involved in this study were asked to anonymously report the occurrence of hemorrhage, protracted emesis, and/or fever from the time of discharge through the seventh postoperative day. In this study, no complications were encountered during the fifth or sixth postoperative hours. These results indicate that it is both safe and appropriate to perform tonsil and adenoid surgery in the ambulatory setting. Furthermore, the current recommendation that patients remain under postoperative recovery room observation for 6 hours appears to be excessive. This observation period may be safely reduced to 4 hours