The objective of this study was to assess the value of preoperative fiberoptic nasopharyngoscopy with the Müller maneuver (FNMM) and cephalometric radiography in predicting response to uvulopalatopharyngoplasty (UPPP) in patients with obstructive sleep apnea syndrome. Fifty-three such patients having significant obstruction at the soft palatal level and variable degrees of obstruction at the base-of-tongue level underwent both diagnostic procedures before UPPP. Outcome was assessed by the apnea-plus-hypopnea index (AHI) as determined by polysomnography, which was performed before and after surgery. As a group, patients exhibited a significant 10-point reduction in AHI (46.5 to 36.7). However, 17 (32.1%) were judged to be responders as defined by a reduction of the AHI by an increment of 50% or greater with respect to baseline. Of all the cephalometric variables assessed, soft palate length was the only one that differed between responders and nonresponders (45.5 mm versus 42.6 mm, respectively). However, this difference only approached significance (P = .067). Similarly, FNMM results did not discriminate between responders and nonresponders. These results indicate that preoperative cephalometric radiography and FNMM cannot be reliably used to enhance surgical success.
\s=b\Nasal packing is considered routine by most physicians and patients at the completion of nasal and septal surgery.Yet the rationale for this maneuver is not clearly defined by reported investigation or logical analysis. We discuss 75 consecutive nasal surgical procedures completed without packing. There were two postoperative episodes of bleeding, both from pyriform aperture incisions for lateral osteotomy and both managed in the recovery room with an absorbable gelatin sponge. Technical refinements such as scrupulous preoperative history taking, through-and-through suturing of the entire septal flaps, small-caliber osteotomy, meticulous closure of all intranasal incisions, and proper application of a conforming dressing are essential for hemostasis. We offer specific procedural guidance to minimize the risk of postoperative nasal bleeding.
Granular cell tumors are rare neoplasms that arise in different regions of the body. Their cell of origin is still debated among many pathologists, but recent authors consider them to be neurogenic. These tumors are believed to be benign; however, local recurrences after excision and multifocality arouse suspicions for malignancy. In the head and neck, granular cell tumors occur most frequently in the tongue. In the laryngotracheobronchial tree, most tumors reported have been in the larynx and the next most in the bronchi. Only six cases of true tracheal occurrences have been reported previously; two additional cases are reported in this paper. The literature of the cell of origin of these tumors is reviewed, the different theories are presented, and diagnosis, treatment, and follow-up are discussed.
Radiation therapy is an integral part of treatment for head and neck cancer, but its use is not without complications. We describe the first reported sternoclavicular-tracheal fistula resulting from osteoradionecrosis (ORN) at the medial clavicle. This ORN resulted from definitive radiation therapy for a primary pyriform sinus squamous cell carcinoma. The diagnosis of ORN was made by fiberoptic bronchoscopy. The physiologic damage of ORN is based on a compromised blood supply and altered metabolism of bone formation secondary to effects of ionizing radiation. Treatment requires meticulous hygiene, antibiotics, and debridement as conservative therapy. Radical surgery and reconstruction may be indicated in refractory cases. A thorough preirradiation assessment of patients is mandatory to decrease the incidence of radiation-induced ORN.
REPORTK D. is a 36-year-old male with a diagnosis of • chronic undifferentiated schizophrenia and a history of previous self-mutilation, including multiple superficial stabbings of the abdomen and extremities. The patient had been released from a state chronic care facility approximately 1 month before presentation. K.D. had been noncompliant in taking his psychotropic medications and he had not returned for any of his scheduled outpatient psychiatric appointments at the state facility. The patient presented to the emergency ward of Thomas Jefferson University Hospital after an acute psychotic episode of unclear etiology in which he • Assistant Professor,Am J Rhinology attempted to assault other family members with a pair of household sewing scissors. The patient's attack was unsuccessful and it was reported that he became extremely "frustrated and then stabbed himself in both eyes with the scissors".Upon arrival in the emergency ward, the patient had stable vital signs, and was intermittently calm and cooperative to direct commands. He did, at times, exhibit flight of ideas, echolalia, loose associations, and grandiose ideation. No active hemorrhage or excessive blood loss was noted at the scene or during transport to the hospital. PHYSICAL EXAM P hysi.calexamin~tion re~ealed~disheveled male with ObVIOUS metalhc foreign objects protruding from the inferior portion of each orbit (Fig. la, b c). The left foreign body lay in what appeared to be a transverse plane and extended approximately 1-2 mm anteriorly from the interior portion of the conjunctiva of the left eye. The right foreign body lay in a slightly more vertical plane and entered the lateral portion of the right lower lid conjunctiva. No additional details as to size or orientation of the metallic objects could be obtained by physical examination. Ophthalmologic exam revealed bilateral complete ocular entrapment in all fields of gaze by forced duction testing. Pupils were briskly reactive and fundoscopic examination was normal. Vision was 20/40 OU by near card. Neurologic exam showed no focal, motor, or sensory deficits. The remainder of a detailed head and neck, and general physical examination was normal. 53
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