Biomedical subjects
A Komisar
Publications and source records attributed to A Komisar.
Basal cell adenocarcinoma of the parotid gland.
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The management of post-thyroidectomy hypocalcemia.
Postoperative hypocalcemia was studied in 40 patients undergoing total thyroidectomy for a malignancy or massive goiter. Parameters evaluated included serum calcium, phosphate and magnesium levels. All patients exhibited a postoperative decline in serum calcium, however, the lowest serum calcium level was not seen until 48 hours after surgery. Serum calcium levels returned to normal in five to six days after surgery in 37 patients. Five patients required calcium supplementation for either symptomatic hypocalcemia or serum calcium levels lower than 7.0 mg/dl. Only three of these five patients were discharged home on oral calcium supplements. In this series, we discovered that the critical period for monitoring of serum calcium was 24 to 96 hours after surgery. If serum calcium replacement was not needed in the first 72 hours after surgery, it would not be needed during the remainder of the patient's hospital course. In addition, we found that serum magnesium levels should also be monitored in the postoperative period and corrected if low.
Imaging quiz case 1. Thyroglossal duct cyst with intralaryngeal extension.
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Voice failure after tracheoesophageal puncture: management with botulinum toxin.
Primary or secondary tracheoesophageal puncture with a speaking prosthesis has provided rehabilitation of speech in most patients after total laryngectomy. Persistent constrictor spasm is thought to be responsible for a small percentage of these patients' inability to speak with the prosthesis. Management of these patients has included bougienage and pharyngeal myotomy and/or pharyngeal neurectomy. Botulinum toxin injections of the cricopharyngeus muscle complex in six patients have been successfully used diagnostically and therapeutically for tracheoesophageal puncture failures. The assessment, technique, and results are discussed.
Tongue paralysis following head trauma.
Paralysis of the tongue due to isolated bilateral hypoglossal nerve palsy is a rare occurrence. Due to a trauma the cause in our case may have been a traction injury to both hypoglossal nerves at the base of skull. In some cases a contributing factor may be malformation of the skull base. Most cases have a good prognosis for recovery.
Mandible preservation in cancer of the floor of the mouth. Anatomical and oncological considerations.
An extended marginal mandibulectomy can be performed in most T2-T3 carcinomas of the floor of the mouth that abut the anterior mandible if there is no radiologic evidence of bony invasion or clinical evidence of fixation. We propose a modification of the marginal mandibulectomy that maintains viability to the anterior mandibular remnant and thus decreases the morbidity associated with a loss of blood supply. This modification permits preservation of a viable mandibular remnant with significantly less loss of function than with the traditional segmental mandibular resection, while remaining oncologically sound.
Computer-generated presentations: current status and future directions.
The personal computer allows the user to create professional presentations as good as any created by commercially available services. With the new generation of inexpensive software, myriad fonts, layouts, graphics, and imported images can all be used by the novice. The technology is currently available that can project images directly from the computer, obviating the need for slides. This presentation will discuss the relative merits and costs of such systems and the problems that remain concerning implementation at a national level.
Ambulatory pH monitoring in the management of reflux.
Ambulatory pH monitoring is a useful tool in the diagnosis and treatment of different esophageal and pharyngeal complaints. We have studied its use in an office setting in 15 patients with suspected gastroesophageal reflux disease (GERD). The patients were monitored for at least 18 hours while wearing a two-channel probe at home. Data obtained confirmed severe GERD in 6 patients and chest pain without GERD in 2 patients. Two patients continued to have symptoms in spite of appropriate therapy, while 2 untreated patients had symptoms of GERD with normal pH studies. We feel this technique is relatively safe and cost-effective and causes minimal disruption of the patient's life-style, while enabling the physician to monitor therapy and help achieve a good therapeutic outcome.
Head and neck trauma in taxicabs. A growing urban problem.
The passage of mandatory seat belt legislation has markedly decreased the incidence of head and neck trauma to passengers in private automobiles. However, taxicabs are exempt from seat belt laws in many states. Seat belts, which are included as standard equipment by automobile manufacturers, are often made inaccessible by taxicab operators. We present five cases of head and neck trauma sustained by passengers in taxicabs in which seat belts were not accessible. Injuries included laryngeal fractures, maxillofacial trauma, and severe trauma to the cervical spine. All injuries could have been avoided by the use of an accessible safety belt. The nationwide scope of this problem and strategies for modification of existing laws for better protection of passengers in cars for hire are presented.
Achieving better functional outcome after maxillectomy: surgical and prosthetic considerations.
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Experience with the Wilkie procedure for sialorrhea.
Sialorrhea (drooling) is most commonly seen in children with cerebral palsy or mental retardation. Surgical procedures for the control of sialorrhea include salivary gland excision, parasympathetic nerve section, and salivary duct ligation and/or rerouting. Eighteen children between the ages of 5 and 17 years underwent bilateral submandibular gland excision and rerouting of Stensen's duct (Wilkie procedure). All children had severe drooling associated with cerebral palsy or mental retardation. Follow-up at 7 years showed satisfactory control of sialorrhea in 16 of 18 patients (89%). There was one major complication: xerostomia. Our results indicate that submandibular gland excision together with parotid duct retropositioning provides effective control of sialorrhea in most cases. Unfavorable head and mandibular posturing seemed to cause persistent sialorrhea in one case.
The functional result of mandibular reconstruction.
A study was performed to determine if patients who underwent mandibular reconstruction were functionally rehabilitated. Five parameters were evaluated: deglutition, mastication, cosmesis, diet, and the use of dentures. Deglutition was not improved in patients who had mandibular continuity restored. Problems with deglutition were related to soft tissue resection. Mastication was poorer in the reconstructed group due to scarring, loss of the muscles of mastication, and inhibition of compensatory mandibular motion. Cosmesis was improved in patients who had immediate restoration of mandibular continuity. Cosmesis was not improved in patients with delayed mandibular reconstruction due to previous scarring. Prosthetic rehabilitation was poor in both groups of patients. Reconstructed patients had a greater number of hospitalizations due to management of, or complications from reconstructive surgical procedures. The results of this study suggests that restoration of mandibular continuity does not enhance the functional rehabilitation of the majority of patients with oral-pharyngeal malignancy.
A critical analysis of immediate and delayed mandibular reconstruction using A-O plates.
Eleven patients who underwent mandibular reconstruction with A-O plates were followed up for as long as 40 months. The patients underwent either immediate or delayed mandibular reconstruction. Nine patients had free cortical bone grafts included in the reconstruction. Complications in patients who underwent immediate reconstruction included loss of the bone graft due to infection, external and intraoral exposure of the reconstruction plate, pain, and infection. In the patients with immediate reconstruction, more than 50% of the bone grafts resorbed. There were less complications and minimal bone graft resorption in patients who underwent delayed reconstruction. The cosmetic results were initially good in both immediate and delayed reconstruction but deteriorated as more surgery was required for management of complications. At 40 months, 7 of 11 patients (5 of 9 with immediate reconstruction) had died of local recurrence, distant metastasis, or another primary tumor. No patients were rehabilitated prosthetically. We conclude that while A-O plating is technically easy and has a low perioperative morbidity rate, the long-term morbidity rate is high. This must be weighed against the benefits of the procedure and the probability that the patients will have a poor functional outcome.
The histopathologic diagnosis of head and neck tumors by special stains.
Various histochemical and immunocytochemical stains were useful in the diagnosis of six unusual head and neck neoplasms that included spindle-cell squamous carcinoma, synovial sarcoma, mucoepidermoid carcinoma, melanoma, T-cell lymphoma, and B-cell lymphoma. Close cooperation with a pathologist ensured rapid diagnosis and the initiation of appropriate therapy. Three cases required special histochemical stains to make a diagnosis or determined tumor differentiation. The three other cases would have been identified as poorly-differentiated tumors of unknown origin without the use of special immunocytochemical stains. These latter findings influenced our final therapeutic strategy, which emphasizes the uses of special stains and studies to accurately identify tumors of the head and neck.
Nasal obstruction due to benign and malignant neoplasms.
Nasal obstruction can be the first symptom of an obstructing neoplasm originating in the paranasal sinuses, nasopharynx, nasal skin, or nasal chamber. Several standard approaches permit access to these lesions for surgical removal, and these are outlined here.
Malignant fibrous histiocytoma of the mandible.
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Complications of midline mandibulotomy.
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