Removal of a Frontal Sinus Osteoma and Reconstruction by a Custom-Made Implant with Neuronavigation Assistance

Cranial Maxillofac Trauma Reconstruction
DOI: 10.1055/s-0037-1607066

The authors report the surgical treatment of an extensive right frontal sinus osteoma assisted by neuronavigation and reconstruction by a hydroxyapatite custom-made implant. The patient presents with ptosis, hypoglobus, and proptosis of the right eye, without any visual impairment. Computed tomographic (CT) scan showed a very large bony mass involving right frontal sinus and displacing the orbital roof. A stereolithographic model–guided planning was carried out to obtain a practical simulation of the surgical operation and it was submitted to a new CT scan to acquire the reference point to realize the neuronavigation assistance, and to achieve the template to realize the hydroxyapatite custom-made implant. Intraoperatively, with the help of neuronavigation assistance, osteotomies were performed by piezoelectric device. The reconstruction was made using a hydroxyapatite custom-made implant. The procedure was damage free, the bony mass was excised, and the orbital roof was repaired without any adverse effects. Postsurgical CT scan and scintigraphy showed a good reconstruction and a good-quality osteoblasts activity on the borders of the implant. Osteoma is a benign slow-growing bone tumor, usually involving the frontal sinus. Navigational assistance offers a very important help to perform safe osteotomies. Hydroxyapatite custom-made implant seems to be an excellent reconstructive method.
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Thromboprophylaxis in Head and Neck Microvascular Reconstruction

Cranial Maxillofac Trauma Reconstruction
DOI: 10.1055/s-0037-1607068

Head and neck patients undergoing microvascular reconstruction are at high risk for thromboembolism. While the prevention of thromboembolism has become an essential aspect of care, within the field of microsurgery, concern for anastomotic complications have hindered the creation of an accepted regimen. The aim of this review was to evaluate the risks and benefits of prophylactic agents for thromboprophylaxis. A literature search was conducted in MEDLINE, Cochrane Library, and PubMed/NCBI databases. Articles discussing thromboprophylaxis in otolaryngology, head and neck surgery, or microvascular reconstruction were considered in the review from the past 30 years. The majority of patients undergoing microvascular surgery have multiple risk factors for thrombus formation. Several consensus guidelines exist for the prophylaxis in patients who are critically ill, undergoing surgery, or with malignancy. Significant evidence supports the routine use of mechanical means, such as early mobilization and pneumatic compression along with subcutaneous heparin. Low-molecular-weight heparin is also frequently utilized, although results are largely divided. Data on aspirin remain equivocal. Studies on microvascular failure and flap loss have demonstrated little to no association with chemoprophylaxis. The evidence for postoperative thromboprophylaxis regimens in patients undergoing head and neck free tissue transfer is variable. Multiple studies have supported the use of unfractionated heparin or low-molecular-weight heparin. There appears to be an expert consensus for the combined use of mechanical prophylactic methods and chemical prophylaxis. Prospective randomized trials are required to validate the most effective combination of chemoprophylaxis agents.
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Pseudoaneurysm Following Endoscopic-Assisted Repair of Subcondylar Fracture

Cranial Maxillofac Trauma Reconstruction
DOI: 10.1055/s-0037-1607064

Pseudoaneurysms are a known complication following facial trauma and orthognathic surgery. Few reports exist of this clinical entity following traditional open techniques of repair, and none have been associated with endoscopic-assisted open reduction and internal fixation (ORIF) of a subcondylar fracture. We present a case of a 33-year-old man who developed pseudoaneurysm after endoscopic-assisted ORIF as well as a review of the literature on this topic. While uncommon, this is a potential complication that should be recognized with the use of endoscopic-assisted repair of mandibular fractures.
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Traumatic Anterosuperior Dislocation of the Intact Mandibular Condyle into the Temporal Fossa

Cranial Maxillofac Trauma Reconstruction
DOI: 10.1055/s-0037-1607067

Temporomandibular joint (TMJ) dislocation, or luxation, occurs when the condyle crosses the articular eminence in such a way that it does not return to its correct anatomical position, unless aided by a reduction in external forces for TMJ. The diagnosis of condylar luxation is clinical; however, image exams are important in classifying the types of condylar luxation and associated fractures. Displacement of the TMJ can occur due to either an exaggerated mouth opening or a forced opening and occasionally is associated with a high-impact trauma to the jaw, the latter being an extremely rare condition. Few cases of anterosuperior dislocation of the intact mandibular condyles into the temporal fossa (ADIMC) have been documented in medical literature, many of which are associated with craniofacial trauma. This study describes the case of an ADIMC of the left side combined with facial fractures, as well as the treatment performed. A review of cases found in the literature from 1969 to 2017 was conducted through a detailed bibliographical study.
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Cartilage Graft Donor Site Morbidity following Rhinoplasty and Nasal Reconstruction

Cranial Maxillofac Trauma Reconstruction
DOI: 10.1055/s-0037-1607065

Although surgical techniques for rhinoplasty and nasal reconstruction are well established, prospective research on postoperative morbidity remains limited. The aim of this pilot study was to assess costal and auricular cartilage donor site pain and morbidity in patients undergoing rhinoplasty and nasal reconstruction. In this prospective cohort study, we enrolled 55 patients undergoing nasal surgery that required costal or auricular cartilage harvest from February 2015 through May 2016. Each patient was given a symptom-specific patient survey that assessed general pain, nasal pain, graft donor site pain, graft donor site itching, color variation, skin stiffness and thickness, and graft donor site appearance at 1, 4, and 12 weeks after surgery. Our patient group was 55% female (n = 30); the mean age was 47 years. Rib cartilage graft patients had significantly greater nasal pain than cartilage donor site pain. There was no significant difference in rib versus ear cartilage donor site pain. Nearly all patients reported that they were not at all concerned about their scar appearance or ear shape and appearance. No prior studies compare cartilage donor site morbidity in patients undergoing nasal surgery. Our findings challenge the conventional wisdom that utilizing auricular and costal cartilage results in high levels of donor site pain. Surgeons should have a low threshold to harvest rib or ear cartilage when it can improve surgical outcome.
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A Novel Approach for the Management and Prevention of Self-Induced Masticatory Lingual Trauma in the Neurologically Injured Patient

Cranial Maxillofac Trauma Reconstruction
DOI: 10.1055/s-0037-1606300

Self-induced masticatory trauma is an unfortunate complication of a variety of neurologic disorders, including epileptic seizures, cerebral palsy, mental retardation, psychiatric disease, and brain trauma, in addition to other described etiologies. While single or occasional occurrences of tongue biting are relatively benign, recurrent self-injury can pose major issues and predispose a patient to chronic, severe complications. To prevent the complications associated with ongoing trauma to the tongue, steps must be taken to protect individuals from chronic self-injurious behavior. Often, these interventions cause significant morbidity to the patient, such as elective removal of the dentition or complications in gaining access to the oral cavity/airway associated with maxillomandibular fixation. In the neurologically impaired patient, immobilization of the jaws is frequently associated with higher rates of agitation, aspiration, or development of complicating infections of the gingival tissues. We report a case of self-induced masticatory trauma managed with the fabrication of a custom-fabricated oral appliance. This treatment modality successfully prevents the recurrence or incidence of self-induced masticatory trauma to the tongue. The benefits of this modality are that it allows access to the oral cavity, prevents immobilization of the jaws, has minimal to no morbidity, and is completely reversible.
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Figi’s Issues Recall Alert Due to Undeclared Allergen (Milk) in Dark Chocolate Gingersnaps

Figi's Companies, Inc of Marshfield, WI is recalling the following 2 products that are related to the GKI FOODS LLC Dark Chocolate Products recall because it may contain undeclared milk allergen. People who have an allergy or severe sensitivity to milk run the risk of serious or life- threatening allergic reaction if they consume these products.

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Osseointegrated Implants and Prosthetic Reconstruction Following Skull Base Surgery

Seminars in Plastic Surgery 2017; 31: 214-221
DOI: 10.1055/s-0037-1607201

Rehabilitation following ablative skull base surgery remains a challenging task, given the complexity of the anatomical region, despite the recent advances in reconstructive surgery. Remnant defects following resection of skull base tumors are often not amenable to primary closure. As such, numerous techniques have been described for reconstruction, including local rotational muscle flaps, pedicled flaps with skin paddle, or even free tissue transfer. However, not all patients are appropriate surgical candidates and therefore may instead benefit from nonsurgical options for functional and aesthetic restoration. Osseointegrated implants and biocompatible prostheses provide a viable alternative for such a patient population. The purpose of this review serves to highlight current options for prosthetic rehabilitation of skull base defects and describe their indications, advantages, and disadvantages.
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Locoregional and Microvascular Free Tissue Reconstruction of the Lateral Skull Base

Seminars in Plastic Surgery 2017; 31: 197-202
DOI: 10.1055/s-0037-1606556

The goals of reconstruction following any oncologic extirpation are preservation of function, restoration of cosmesis, and avoidance of morbidity. Anatomically, the lateral skull base is complex and conceptually intricate due to its three-dimensional morphology. The temporal bone articulates with five other cranial bones and forms many sutures and foramina through which pass critical neural and vascular structures. Remnant defects following resection of lateral skull base tumors are often not amenable to primary closure. As such, numerous techniques have been described for reconstruction including local rotational muscle flaps, pedicled flaps with skin paddle, or free tissue transfer. In this review, the advantages and disadvantages of each reconstructive method will be discussed as well as their potential complications.
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Skull Base Reconstruction

Seminars in Plastic Surgery 2017; 31: 175-176
DOI: 10.1055/s-0037-1607277

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Yadranko Ducic, MD

Seminars in Plastic Surgery 2017; 31: 173-174
DOI: 10.1055/s-0037-1607276

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Skull Base Trauma: Clinical Considerations in Evaluation and Diagnosis and Review of Management Techniques and Surgical Approaches

Seminars in Plastic Surgery 2017; 31: 177-188
DOI: 10.1055/s-0037-1607275

Traumatic injuries to the skull base can involve critical neurovascular structures and present with symptoms and signs that must be recognized by physicians tasked with management of trauma patients. This article provides a review of skull base anatomy and outlines demographic features in skull base trauma. The manifestations of various skull base injuries, including CSF leaks, facial paralysis, anosmia, and cranial nerve injury, are discussed, as are appropriate diagnostic and radiographic testing in patients with such injuries. While conservative management is sometimes appropriate in skull base trauma, surgical access to the skull base for reconstruction of traumatic injuries may be required. A variety of specific surgical approaches to the anterior cranial fossa are discussed, including the classic anterior craniofacial approach as well as less invasive and newer endoscope-assisted approaches to the traumatized skull base.
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Endoscopic Endonasal Reconstructive Methods to the Anterior Skull Base

Seminars in Plastic Surgery 2017; 31: 203-213
DOI: 10.1055/s-0037-1607274

The success of expanded endoscopic endonasal approaches (EEAs) to the anterior skull base, sellar, and parasellar regions has been greatly aided by the advancement in reconstructive techniques. In particular, the pedicled vascularized flaps have been developed and effectively cover skull base defects of varying sizes with a significant reduction in postoperative CSF leaks. There are two aims to this review: (1) We will provide our current, simplified reconstruction algorithm. (2) We will describe, in detail, the relevant anatomy, indications/contraindications, and surgical technique, with a particular emphasis on the nasoseptal flap (NSF). The inferior turbinate flap (ITF), middle turbinate flap (MTF), pericranial flap (PCF), and temporoparietal fascial flap (TPFF) will also be described. The NSF should be the primary option for reconstruction of majority of skull base defects following endonasal endoscopic surgery. In general, for the planum, cribriform, and upper two-thirds of the clivus, the NSF is ideal. For the lower-third of the clivus, the NSF may not be adequate and may require additional reconstructive options. Although limited in reach or more technically challenging, these reconstructive flaps should still be considered and kept in the surgical algorithm.
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Open Anterior Skull Base Reconstruction: A Contemporary Review

Seminars in Plastic Surgery 2017; 31: 189-196
DOI: 10.1055/s-0037-1607273

Skull base extirpative and reconstructive surgery has undergone significant changes due to technological and operative advances. While endoscopic resection and reconstruction will continue to advance skull base surgery for the foreseeable future, traditional open surgical approaches and reconstructive techniques are still contemporarily employed as best practices in certain tumors or patient-specific anatomical cases. Skull base surgeons should strive to maintain a working knowledge and technical skill set to manage these challenging cases where endoscopic techniques have previously failed, are insufficient from anatomical constraints, or tumor biology with margin control supersedes the more minimally invasive approach. This review focuses on the reconstructive techniques available to the open skull base surgeon as an adjunct to the endoscopic reconstructive options. Anatomic considerations, factors relating to the defect or patient, reconstructive options of nonvascular grafts, local and regional flaps, and free tissue transfer are outlined using the literature and author's experience. Future directions in virtual surgical planning and emerging technologies will continue to enhance open and endoscopic skull base surgeon's preparation, performance, and outcomes in this continually developing interdisciplinary field.
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Calvarial Reconstruction

Seminars in Plastic Surgery 2017; 31: 222-226
DOI: 10.1055/s-0037-1606557

Calvarial reconstruction is a challenge to reconstructive surgeons, especially considering protection of intracranial contents. In recent years, the advent of multiple reconstructive materials adds tools to the surgical armamentarium. Options include autologous split calvarial and rib grafts and alloplastic materials such as titanium mesh, methyl methacrylate, calcium hydroxyapatite, and polyetheretherketone. The most important aspect of cranial reconstruction still lies in finding the most aesthetic, safe, and reliable means of filling a defect.
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Complications of Skull Base Surgery

Seminars in Plastic Surgery 2017; 31: 227-230
DOI: 10.1055/s-0037-1607203

Approaches to surgical management of skull base pathology and reconstruction of skull base defects have evolved over the past several decades. The goal, however, remains the same—to effectively address the pathology with minimal complications. In this article, the authors try to explore multiple complications of skull base surgery, discussing their incidence, natural course, and prevention. This will prove beneficial in optimal management of patients with a myriad of skull base disorders.
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Auditive Verarbeitungs- und Wahrnehmungsstörung: Ist die Diagnose schon bei Erstklässlern möglich?

Laryngo-Rhino-Otol
DOI: 10.1055/s-0043-120580

Hintergrund Signifikante Leistungsunterschiede zwischen Kindern mit und ohne auditive Verarbeitungs- und Wahrnehmungsstörungen (AVWS) im 2., 3. und 4. Grundschuljahr wurden in einer eklektischen AVWS-Testbatterie für die meisten Diagnoseinstrumente festgestellt. Die aktuelle Studie erfolgte mit der Fragestellung, ob dies auch für Kinder der 1. Schulklassenstufe zutrifft. Material und Methoden Leistungen von 41 Kindern mit und von 37 ohne AVWS im 1. Regelgrundschuljahr (Alter: 6–8 Jahre) wurden in 14 spezifisch auditiven Tests miteinander verglichen. Ergebnisse Statistisch signifikante Gruppenunterschiede wurden in 12 Diagnoseinstrumenten aufgedeckt; lediglich in 2 PaTSy-Subtests (Tonfrequenzen; Tonintensitäten) war das nicht der Fall. Bzgl. der monauralen Ordnungsschwelle blieb die Signifikanz nach Bonferroni-Korrektur knapp erhalten. Non-AVWS-Kinder bewältigten die PaTSy-Subtests in 86–89 %, AVWS-Kinder in 73–83 % aller Fälle. Die Testwerte von Jungen bzw. Mädchen mit AVWS waren im Vergleich zu denen von Jungen bzw. Mädchen ohne AVWS durchweg reduziert. Schlussfolgerungen Auch Erstklässler mit „AVWS" ließen sich von solchen ohne „AVWS" statistisch signifikant unterscheiden. In der Tendenz waren bei Erstklässlern mit AVWS dieselben Leistungen gemindert wie bei Grundschülern in höheren Klassenstufen. Der Einsatz sprachfreier audiologischer Verfahren zur klinischen Diagnose von AVWS erscheint für die Altersgruppe 6–8 Jahre jedoch fragwürdig.
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Georg Thieme Verlag KG Stuttgart · New York

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Reduktion postoperativer Schmerzen durch Manuelle Medizin bei Erwachsenen nach Tonsillektomie

Laryngo-Rhino-Otol
DOI: 10.1055/s-0043-119885

Hintergrund Postoperativer Schmerz nach Tonsillektomie (TE) kann in der Regel durch die Gabe von Analgetika aus der Gruppe der nicht steroidalen Antirheumatika (NSAR) suffizient behandelt werden. Bei einigen Patienten besteht jedoch eine außergewöhnlich therapieresistente Schmerzsymptomatik, welche zudem häufig einseitig stärker ausgeprägt ist. Unsere klinisch praktische Erfahrung hat gezeigt, dass bei diesen Patienten häufig eine Blockierung der oberen Kopfgelenke vorliegt, die durch Manuelle Medizin (MM) erfolgreich therapiert werden kann. In dieser prospektiven, randomisierten, placebo-kontrollierten, einfach verblindeten Studie sollte deshalb untersucht werden, ob sich der schmerzlindernde Effekt dieser Therapie statistisch nachweisen lässt. Material und Methoden 52 erwachsene Patienten mit außergewöhnlich starken (VAS > 4) und / oder einseitigen Schmerzen nach TE (1. bis 4. Tag postoperativ) wurden hinsichtlich des Schmerzverlaufs mittels Visueller Analogskala (VAS) zu 4 Zeitpunkten untersucht: direkt vor (t0) und sofort nach der MM (t1), dann 4 Stunden nach MM (t2) sowie 24 Stunden nach MM (t3). Ergebnisse Die Ergebnisse zeigen eine signifikant höhere Schmerzreduktion (jeweils als Differenz zu t0) in der Verum- als in der Placebogruppe zum Zeitpunkt t1 und t3 (t1: p = 0,012, t3: p = 0,012, beides Bonferroni-adjustiert). Zum Zeitpunkt t2 war die Differenz mit p = 0,54 nicht signifikant. Schlussfolgerungen Anhand der Studie konnte die Wirksamkeit von Manueller Medizin zur Schmerzreduktion bei erwachsenen Patienten mit außergewöhnlich starken bzw. einseitigen Schmerzen nach TE und Hypomobilität der Halswirbelsäule nachgewiesen werden.
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Georg Thieme Verlag KG Stuttgart · New York

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Eine seltene Differentialdiagnose des jugulotympanalen Paraganglioms

Laryngo-Rhino-Otol
DOI: 10.1055/s-0043-118006

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Georg Thieme Verlag KG Stuttgart · New York

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Langzeitergebnisse und Patientenzufriedenheit nach Tympanoplastik mit Titan-Clip-Prothesen

Laryngo-Rhino-Otol 2017; 96: 698-703
DOI: 10.1055/s-0042-12450

Ziel der vorliegenden Arbeit ist die Evaluation der Langzeitergebnisse nach Ossikelkettenrekonstruktion mittels Titan-Clip Prothesen. Hierzu wurde eine retrospektive Analyse mit prospektivem Follow-up bei allen Patienten durchgeführt, bei denen in den Jahren 2002–2013 ein Clip-PORP implantiert wurde. Es erfolgten audiologische Messungen, otoskopische Untersuchungen sowie die Evaluation der Lebensqualität mittels Glasgow Benefit Inventory. 48 Patienten (51 Ohren, 29 Männer, 19 Frauen, Durchschnittsalter 44,1 Jahre) konnten für das Follow-up rekrutiert werden, der Nachbeobachtungszeitraum lag im Mittel bei 6,3 Jahren. Die Schallleitungskomponente wurde insgesamt (0,5–4 kHz) von präoperativ 22,8 dB auf 14,6 dB postoperativ reduziert (p≤0,001). Häufigste Operationsindikation waren Cholesteatome und -Rezidive (52%), gefolgt von chronischen Otitiden (12%), Radikalhöhlenrevisionen (8%) und Schallleitungsstörungen nach Voroperation (14%). In 47 Fällen war das Trommelfell verschlossen (92,2%), 4x (7,8%) bestand ein Defekt. Die Prothese war 39 Mal (75%) in situ, 6x (11,8%) lag eine Protrusion bzw. 2x (4%) eine Verkippung vor, 1x (2%) war die Prothese fehlend und 3x (5,9%) konnte es nicht beurteilt werden. Die postinterventionelle Patientenzufriedenheit wurde insgesamt positiv bewertet (8,4 Punkte), ebenso die allgemeine Unterskala während bei den Unterskalen soziale Unterstützung und körperliche Gesundheit keine Veränderung auftraten. Zusammenfassend ist die Ossikuloplastik mittels Titan-Clip Prothesen ein sicheres und etabliertes Verfahren. Auch langfristig werden gute und stabile audiologische Messresultate durch Reduktion der Schallleitungskomponente aufgezeigt. Die subjektive Lebensqualität ist insgesamt nachhaltig verbessert.
[...]

© Georg Thieme Verlag KG Stuttgart · New York

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