Ludwig angina: a review of current airway management.
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Anti-Bacterial Agents↗
Biomedical subjects
W W Shockley
Publications and source records attributed to W W Shockley.
External laryngeal trauma analysis of 392 patients.
BACKGROUND: External laryngeal trauma (ELT) is a rare but clinically important injury. OBJECTIVE: To perform the first population-based, time series analysis of the epidemiology, management, and outcomes of ELT using an 11-state, inpatient sample database containing more than 54 million patients. PATIENTS: Three hundred ninety-two patients with a primary or secondary diagnosis of ELT were identified. Over a 5-year period, the incidence of ELT in this series was 1/137,000. The mean (+/-SD) age was 37 (+/-7) years, and the overall mortality rate was 2.04%. Two hundred forty-eight patients required surgical intervention. RESULTS: The average length of stay for 67 patients not requiring surgical intervention for any injury was 3 (+/-2) days, with no mortality. One hundred eighty patients underwent endoscopy, with 14 requiring tracheotomy alone and 57 requiring tracheotomy plus laryngeal repair. The average length of stay and the mortality rate were higher in these latter groups. Overall, 139 patients underwent tracheotomy, with a mortality rate of 5%, while 96 patients underwent laryngeal repair, with a mortality rate of 1%. Surgical treatment was performed in 140 patients with ELT within 24 hours after presentation, while another 60 received treatment within 48 hours. Associated injuries included skull base or intracranial injury (13%), open neck injury (9%), cervical spine injury (8%), and esophageal or pharyngeal injury (3%). CONCLUSION: External laryngeal trauma is a rare injury, with most patients requiring surgical intervention.
Adult↗
Transient vocal fold immobility.
Temporary vocal fold immobility resolving in 4 weeks or less is considered a transient immobility. Many different disorders may lead to this type of laryngeal motion impairment. It is important for otolaryngologists to be familiar with the differential diagnosis for transient vocal fold immobility in order to optimize the management of these unusual cases.
Adult↗
Effect of stenting on graft vascularization after laryngotracheoplasty.
The management of pediatric airway stenosis has been an important topic of debate over the last few decades as prolonged intubation has become more common in the neonate. Although many surgical options are available, most would agree that use of expansion techniques (laryngotracheoplasty) with cartilaginous grafting is the procedure of choice for the severely stenotic airway. Controversy persists, however, regarding the role of stents. Advocates feel that stents serve to counteract scar contracture and support the newly constructed airway. In contrast, recent studies suggest that stenting results in impaired wound healing and an increased complication rate. The present study addresses the effect of stenting on the vascularization of cartilaginous grafts in an animal model. Thirty-six New Zealand white rabbits were evaluated after laryngotracheoplasty with autogenous cartilage grafting. Half of the animals were stented with a 2-cm section of an endotracheal tube that was secured just below the glottis. Three rabbits from each group were then painlessly sacrificed on days 4, 6, 8, 10, 14, and 21. Gross and histologic comparisons of the stented and nonstented specimens revealed similar wound healing. Measurements of graft vascularization were obtained with a computerized image measurement program, and a comparison was made regarding the rate of vascularization. There was a statistically significant increase in the rate of vascularization in the stented group (mean 73% versus 55% at day 10; p < .05). This analysis suggests that stenting does not inhibit early wound healing and specifically graft vascularization after laryngotracheoplasty.
Animals↗
Composite graft survival. An auricular amputation model.
OBJECTIVE: To study the effects of corticosteroids and fibroblast growth factor on composite graft survival using a rabbit model of auricular amputation and reimplantation. DESIGN: Randomized, "blinded," placebo-controlled, prospective animal study. SETTING: Animal laboratory in tertiary care center. INTERVENTION: Amputation of the distal 2 cm of the rabbit ear as a composite graft and reimplantation with simple 6-0 prolene sutures. All animals underwent the same surgical procedure and were randomized into the following four groups: (1) surgical reimplantation alone; (2) 30 mg/kg intramuscular methylprednisolone sodium succinate for 5 days, starting immediately postoperatively; (3) topical basic fibroblast growth factor for 5 days postoperatively; and (4) delayed reimplantation with corticosteroids. In group 4, the ears of the animal were amputated, placed in iced saline containers for 90 minutes, and given 30 mg/kg intramuscular methylprednisolone for 5 days, with the first dose starting immediately prior to reimplantation. MAIN OUTCOME MEASURES: Percentage graft survival and histologic characteristics of viable and nonviable composite graft tissue. RESULTS: The groups that received corticosteroids and delayed reimplantation with corticosteroids had a statistically significant increase in percentage of graft survival compared with the control group (P < .003 and P < .006, respectively). The growth factor group showed no significant difference from the control group. CONCLUSION: Neovascularization occurred in the viable grafts, thus suggesting its role in graft survival. This study establishes the efficacy of corticosteroids in enhancing composite graft survival.
Administration, Cutaneous↗
The influence of arterial insufficiency and venous congestion on composite graft survival.
A rabbit auricular amputation model was used to study the relative effects of arterial insufficiency (AI) and venous congestion (VC) on composite graft survival. The percentage of graft survival was significantly greater for the AI group (45.8%) than for the VC group (15.9%) 2 weeks postoperatively. The percentage of graft survival at 3 weeks for the VC, AI, and noligation groups were not statistically different. All three groups were statistically different from the control group, which had both the central artery and vein ligated. The VC group also exhibited significantly more graft edema, as measured by maximal graft thickness, than the other three groups. The impact of AI and VC on composite graft survival is investigated and discussed. These results suggest that venous congestion is more detrimental to early graft survival than arterial insufficiency.
Animals↗
Orbital osteology: a study of the surgical landmarks.
This study was conducted to re-examine the osteological anatomy of the orbit. Previous studies examined dried human skulls; this study looks at cadaveric specimens in a population that more closely resembles the population in the United States. Measurements were made of the bony orbit to define safe distances for surgical intervention and to identify distances to intraorbital fissures, canals, and foramina. Safe distances to the optic nerve were identified by subtracting 5 mm from the shortest measured specimen. The safe distances were as follows: medial quadrant, 29 mm; inferior quadrant, 39 mm; superior quadrant, 38 mm; and lateral quadrant, 36 mm. Staying close to the bony wall, not exceeding these parameters, and careful identification of anatomical structures should keep the surgeon from inadvertent damage to the intraorbital structures.
Cadaver↗
Unilateral supraglottitis in adults: fact or fiction.
Supraglottitis and epiglottitis have been described for many years by various authors. Haemophilus influenzae type b is the primary cause of childhood epiglottitis, which classically appears between the ages of 2 and 4 years. Onset is usually acute and the presentation can be dramatic with drooling, high temperatures, and stridor. Compared to childhood supraglottitis, adult supraglottitis usually pursues a more indolent course with no significant airway compromise and no identifiable pathogen. Rarely, adult supraglottitis can resemble its childhood counterpart with acute respiratory compromise secondary to H. influenzae infection. Although most incidences of adult supraglottitis are infectious in origin and involve the entire supraglottitis and epiglottis, we present two cases of unilateral supraglottitis caused by inhalation of a hot wire screen used as a filter for smoking crack cocaine.
Administration, Inhalation↗
Tracheal vascular response to hypertonic and hypotonic solutions.
One of the major roles of the upper respiratory mucosa is to humidify inspired air. This function requires the coordinated activity of respiratory epithelium and mucosal vasculature. It has been difficult to study this relationship in vivo. In the present study, we investigated the effects of osmolarity on the vessel diameter of mucosal vessels via a specially constructed chamber that allows direct visualization of the rat trachea microvasculature. With use of an anesthetized and instrumented rat preparation, the luminal surface of the dorsal wall of the trachea was superfused with physiological solutions at 37 degrees C. The osmolarities were varied by removing or adding NaCl or mannitol (200, 290, and 500 mosM). The mucosal vessels dilated when the airway surface was superfused with hypertonic solutions and constricted when superfused with hypotonic solution. The largest changes occurred in the arterioles (51 +/- 5.6 microns diam), which constricted by 10 +/- 2.18 microns (P = 0.0001) when exposed to a 200 mosM solution and dilated by 11 +/- 1.55 microns (P = 0.0001) when exposed to a 500 mosM NaCl-enriched solution. Smaller changes of similar pattern were seen in venules. The changes in vessel diameter were readily reversible upon replacement of the hypo- or hypertonic solutions by an isotonic solution. We conclude that increase or decrease of solution osmolarity on the epithelial surface of the trachea can regulate diameter of mucosal blood vessels.
Animals↗
Timing and dosage of postoperative radiotherapy for squamous cell carcinoma of the upper aerodigestive tract.
Seventy patients who received postoperative irradiation (PI) after curative surgery for stage III or IV squamous cell carcinoma of the upper aerodigestive tract were studied retrospectively to compare the rate of local and regional recurrence (LRR) and the effect of total dose on LRR rate in patients irradiated timely (n = 40) with those who were not (n = 30). Overall, the LRR rate was higher when PI was delayed than when timely (37% vs 20%). No advantage resulted from increasing total dose when PI was delayed; the LRR rate in the primary site and upper neck was 18% with less than 60 Gy and was 26% with 60 Gy or more; the LRR rate in the lower neck was 13% with 50 Gy or less and was 14% with more than 50 Gy. These data seem to corroborate the findings of other investigators regarding the importance of initiating timely PI, but not the observation that a pronounced delay is not detrimental provided higher tumoricidal doses are used.
Adult↗
Statistical considerations for cross-sectional data relating to tracheal reconstruction over time.
Complementary statistical analyses are performed on data concerning tracheal reconstruction in rats. The principal response criterion is vessel area as defined by the area of a graft onto the trachea covered by blood vessels. Postoperatively, this vessel area changes in a nonlinear fashion over time. Starting at 0% immediately postoperation, the vessel area increases to a peak and then sharply decreases to a certain level at which it remains. A total of 64 independently observed cross-sectional pairs (postop day, vessel area) are distributed among four treated groups. Analysis consists of two-way analysis of variance and piecewise linear regression under the usual assumptions of normality and variance homogeneity. Other analyses that relax these assumptions are also considered; treatment differences are established by nonparametric tests, and a quasi-likelihood analysis of the piecewise linear regression model is applied under the assumption of a binomial-like variance function. The resulting fit of the normal-theory-based piecewise linear model is compared to that of a nonlinear model whose shape is that of a gamma function integrand.
Analysis of Variance↗
Special problems associated with carcinoma of the nose.
Because of its prominent location on the face, the nose is the primary target for sun-induced skin cancers. The unique anatomical features of the nose account for the unusually high rate of recurrence of tumors at this site. The reasons are multifactorial and have been discussed. Special care must be undertaken in managing cutaneous neoplasms arising in this region, for failure to control disease can lead to catastrophic events and eventually to the demise of the patient. Likewise, tumor recurrence and multiple therapeutic endeavors are associated with progressive facial deformity that impacts significantly on the patient's self-image and ability to interact socially. Reconstruction of nasal defects must be predicated on complete tumor ablation and documented by histologic evidence. Patients with high-risk lesions or in whom tumor margins are in question should undergo a period of observation before definitive reconstruction is contemplated. Although multiple reconstructive options are available, decisions relating to timing, advisability, and appropriate technique must be individualized. These judgments are based on the experience and bias of the surgeon as well as the goals and concerns of the patient.
Carcinoma↗
Prognostic factors in the recurrence of stage I and II squamous cell cancer of the oral cavity.
Stage I and II squamous cell cancers of the oral cavity have a high recurrence rate given their size and relative amenability to surgical resection. It has been suggested that one way to decrease this recurrence rate is to augment the surgical resection of these tumors with either elective neck dissection or radiation therapy. However, this would expose a significant number of patients to the unnecessary morbidity associated with either of these modalities. In an attempt to identify those patients most at risk for recurrence, we retrospectively determined the clinical and histologic factors that were associated with recurrence in 49 patients with stage I and II oral cavity cancer. Multiple regression analysis revealed that when various interactions between variables were controlled for, only the presence of a positive surgical margin or a tumor depth greater than 5 mm was significantly associated with recurrence. Each individually increased the likelihood of recurrence almost threefold.
Adult↗
Thyroid paraganglioma.
Paraganglioma of the thyroid gland is a rare neoplasm. Only eight cases have previously been reported. The neoplasm was confined to the thyroid in all but two patients; laryngeal involvement was seen in one and tracheal involvement in another. A review of these previously reported cases is presented along with the details of an additional case with laryngeal involvement. Laryngeal and thyroid paragangliomas are compared and contrasted. The anatomic and embryologic basis of these tumors and the diagnosis and treatment are discussed. We suggest changing the nomenclature and reporting of these lesions on the basis of their apparent common origin. Surgery remains the treatment of choice in most paragangliomas, including those involving the larynx and thyroid. Although the number of reported cases is small, there have been no cases of distant metastases or local recurrence after adequate surgical removal.
Adult↗
Acquired von Willebrand's syndrome. Therapeutic and diagnostic implications.
Acquired von Willebrand's syndrome is a newly recognized bleeding diathesis thought to be caused by autoantibodies to the von Willebrand factor. Acquired von Willebrand's syndrome has been reported in association with lymphoproliferative disorders and benign monoclonal gammopathies. Clinical features and laboratory abnormalities of this disease are similar to congenital von Willebrand's disease, but the optimal treatment may differ. We describe a 75-year-old man with chronic lymphocytic leukemia and recurrent epistaxis and also discuss the pathogenesis, diagnosis, and treatment of both the congenital and acquired disorders.
Aged↗
Immediate mandibular replacement using reconstruction plates.
Mandibular reconstruction at the time of tumor resection remains a surgical dilemma. Primary reconstruction allows for immediate reconstitution of mandibular form and function. Various methods have been attempted, but none enjoys uniform success. With advances in the field of microvascular surgery have come numerous options in replacing these defects. These procedures, however, require special surgical teams and are associated with an increase in operative time as well as morbidity at the donor site. An alternative method involves the use of mandibular reconstruction plates to bridge the defect between segments. This review focuses on 19 patients whose jaws were reconstructed in this fashion. Although not free of complications, mandibular plate reconstruction offers the advantages of (1) lack of donor site morbidity, (2) expediency, (3) excellent mandibular contour, and (4) the ability to reconstruct the condyle when necessary. The technique, results, and complications associated with this procedure are discussed.
Adult↗
Management of animal and human bites in the head and neck.
Management of bites requires both local wound and systemic considerations. The authors will highlight their experience in 32 cases. Interestingly in this series, human bites were more common than animal bites. The bacteriology, antimicrobial therapy, and surgical treatment of human and animal bites will be reviewed. A management protocol that we use is based on whether the bite was inflicted by a human, dog, or other animal. The discussion will include cases demonstrating immediate and delayed reconstruction. Long-term follow-up was possible for a number of these patients.
Adolescent↗
Frontal sinus fractures: some problems and some solutions.
Head trauma can result in serious injuries leading to life-threatening situations. Often accompanying these injuries are fractures involving the frontal sinus. Some fractures are subtle and difficult to diagnose, while others are massive and difficult to treat. The experience at this institution in the management of frontal sinus fractures is examined. Particular emphasis is placed on the problematic cases. These include fractures that were nearly overlooked, those that were associated with massive CSF leaks, and those which were extensively comminuted. In treating some of the most severe compound injuries, a frontalis myofascial flap has been used successfully to "plug" the site of CSF leakage. The review will include the types of fractures encountered, associated injuries, errors in diagnosis, the treatment rendered, and the complications which resulted. As encountered in other studies relating to trauma, adequate follow-up has been a serious shortcoming. The protocol presently used in the management of these injuries will be outlined.
Adolescent↗