Diego V. Bohorquez, PhD

• Assistant Professor in Medicine
• Assistant Professor in Pathology
• Assistant Research Professor in Neurobiology
• Faculty Network Member of the Duke Institute for Brain Sciences

https://medicine.duke.edu/faculty/diego-v-bohorquez-phd

There is diffuse failure of epithelial desquamation and migration creating a laminar keratin plug that widens the diameter of the ear canal allergy testing supplies order 5 mg zyrtec otc. When performing canaloplasty for either disease condition allergy symptoms vs common cold buy zyrtec with amex, drilling of the medial posteroinferior canal wall may expose the mastoid segment of the facial nerve allergy shots tiredness cheap zyrtec 10 mg buy online. Exposed mastoid air cells need to be obliterated with fascia or adipose tissue to avoid persistent otorrhea or fistula formation resulting in recurrent cholesteatoma formation allergy buster buy 10 mg zyrtec visa. Physical Examination An examination of the ear using a microscope is the most important part of the physical examination for both conditions allergy testing hurt buy zyrtec 10 mg with mastercard. Widening of the bone wall of the ear canal secondary to constant circumferential pressure induced by the keratin plug resulting in bony resorption, without focal erosion of the bone c. Invasion of squamous tissue into a localized area of the bony canal with localized osteitis, focal erosion, and bone sequestration5 b. Trapping and tunneling of epithelium may occur beneath the skin of the external auditory canal. A and B, Views of the external auditory meatus showing complete obstruction with a keratin plug. Identify the extent of disease invasion into the mastoid from the erosion and destruction of the posterior bony external auditory canal. Inflammatory granulation tissue in the external auditory canal that requires a biopsy to rule out other pathologies, including carcinoma of the auditory canal or malignant otitis externa. Greater risk when surgery is performed in the only hearing ear Preoperative Preparation 1. Local: rarely performed as the ear canal is too sensitive for the patient to tolerate local anesthetic injection without any sedation 4. Positioning Supine: the patient is positioned on his/her back, and the head is turned away from the surgeon placing the ear under direct microscopic view. Operating microscope Middle ear set Otologic surgery drill and drill bits Suction and irrigator Dermatome for harvesting a split-thickness skin graft Key Anatomic Landmarks 1. The external auditory canal is divided into a medial twothirds with the bony canal covered by a very thin layer of skin adherent to the underlying periosteum and a lateral one-third cartilage canal covered with thick skin. This division connects at the isthmus (narrowest portion), and the ear canal terminates at the tympanic membrane. The mastoid segment of the facial nerve can be located just medial to the posterior inferior tympanic annulus. Familiarity with the temporal bone, external auditory canal, and middle ear anatomy 2. Experience with the ossicular chain and facial nerve pathway in the temporal bone 3. Otoscopic view of exposed and eroded bone after removal of a cholesteatoma matrix. Use of cutting and diamond burs to remove sequestrum and expose fresh, viable bone. After exposing the bony canal erosion defect, the transition between healthy and unhealthy tissue is demarcated. Unhealthy tissue is débrided, and healthy skin adjacent to the defect is elevated for optimal exposure of the healthy underlying bone. Using appropriately sized cutting and diamond drill burs, devitalized bone of the ear canal is carefully removed until healthy bleeding bone is encountered. Consequently, a transcanal approach in which the nerve is not definitively identified may present greater risk for facial nerve paralysis. The sac extending into the mastoid air cells must be completely excised in order for the operation to be curative. Sometimes, a canal wall down tympanomastoidectomy is necessary if reconstruction of the canal wall cannot be achieved. After removal of diseased skin and bone, the final surgical step is relining the denuded area of the exposed bony canal. If minimal coverage is required, temporalis fascia can be used to line the bony canal tucking the edge of the fascia beneath the surrounding healthy skin. If large aerated mastoid air cells are exposed after performing a tympanomastoidectomy, fascial or adipose tissue should be used to obliterate the air cells prior to applying a skin graft. This will enhance survival of the graft, minimize potential development of a draining fistula from the mastoid air cells, and diminish the risk of recurrent cholesteatoma. Elevated healthy adjacent canal skin is replaced, and the conchal or vascular strip is returned to its original position. A strip of silk or rayon mesh is laid over the skin graft to protect it and prevent movement. The postauricular canal incision is closed in the usual manner, followed by a mastoid dressing. It should be repaired with adipose tissue, fascia, a cartilage graft or hydroxyapatite reconstruction to avoid a fistula from the ear canal to the mastoid. Larger defects may require converting the procedure to a canal wall down tympanomastoidectomy. It is important to assure that the edges of a split-thickness skin graft are laid flat and not folded upon itself. Occasionally, formal tympanomastoid surgery and canalplasty (as described above) will be necessary for more extensive disease. On follow-up visits, Gelfoam packing can be débrided, and the silk mesh will be removed. Simple débridement of skin edges may be carried out in the office until healing is complete, which normally occurs within 6 to 10 weeks. Desquamation from the skin graft is common and may continue even after appropriate healing. Topical mineral oil or antibiotic ointment may lessen the accumulation of desquamated epithelium and make serial débridement easier. Pain medication, including narcotics, should be provided for postoperative pain management. Given that they are disorders of the skin of the ear canal they may create difficulty in definitively diagnosing the processes. Thickening of the keratin layer of the skin in the ear canal can also involve the epithelial layer of the tympanic membrane. This may present with a sensation of fullness in the ear and a conductive hearing loss. Complete ear canal involvement results in a cast outlining the contour of the ear canal and tympanic membrane, which, when extracted, can appear as a cylindrical bullet casing. Fortunately, the use of emollient oils or topical steroid drops can decrease the adhesiveness of the desquamated lining that fails to properly migrate. Removal of the cast reveals the widened ear canal and better visualization of the tympanic membrane. Topical ear drops can reduce the surrounding inflammation and granulation tissue, which may result in otorrhea and bleeding. Some patients can tolerate local curettage following an injection of local anesthetic. Conservative treatment with meticulous removal of the lesion may be all that is necessary to maintain control. Often patients must be taken to the operating room for additional sedation and comfort. Discrete areas of epithelial burrowing and erosion can be removed with a curette for débridement and biopsy. A small microdrill can be used through an ear speculm to smooth and contour irregularities of the bone or spicules created by the erosive skin. As described, this exposed bone must be covered with fascia or a split-thickness skin graft. It can erode the bony canal posteriorly entering into the mastoid or more rarely anteriorly into the glenoid fossa. Such aggressive invasion should not be managed conservatively and merits operative removal and reconstruction. This may be due to poor surgical exposure or deep extension of the disease into the mastoid cells and will result in persistence or recurrence of disease. Erosion or aggressive drilling into the mastoid air cell system may require a canal wall down tympanomastoidectomy. Appropriate management options depend on the type and degree of facial nerve injury. This will require reconstruction of the tympanic membrane using a fascial graft and ossicles using an incus interposition or prosthesis. Large bony canal defect requiring reconstruction with a cartilage graft or hydroxyapatite 5. Exposed bony external auditory canal secondary to failure of the skin graft to take 6. External auditory canal stenosis secondary to scar formation requiring a revision canaloplasty procedure Alternative Management Plan 1. Surgical intervention to remodel the external auditory canal may be necessary for intractable cases. Keratosis obturans and external ear canal cholesteatoma: how and why we should distinguish between these two conditions. Clinical characteristics of keratosis obturans and external auditory canal cholesteatoma. What imaging modality is helpful to differentiate between the two disease entities What important key feature(s) on the imaging study helps to differentiate between the two disease entities What important landmark needs to be monitored to avoid facial nerve injury when performing a canalplasty Lateralization of the inferior turbinate with a Freer elevator or serial balloon dilations can improve access of the posterior nasal cavity in narrow passageways. The catheter in eustachian tuboplasty should not extend beyond the isthmus at the time of dilation. Presence of fever, otalgia, otorrhea, headaches, nausea and vomiting, anorexia, sleepless nights, ear tugging, subjective hearing loss, and balance disturbance b. Presence of ear popping, fullness, discomfort with barometric challenge, or autophony c. Prior treatment: Previous history of antibiotic, allergy desensitization, nasal steroid, nasal antihistamine, oral antihistamine, oral steroid, or use of a topical or oral decongestant b. Medical illness: Concurrent rhinitis, rhinosinusitis, adenoid hypertrophy, laryngopharyngeal reflux, craniofacial disorders, syndromes, ciliary dysfunction, granulomatous disease, tympanic membrane rupture or perforation, cholesteatoma and tympanic membrane retraction, and atelectasis c. Social history: Exposure to tobacco smoke directly or through second-hand exposure f. Tympanostomy tubes are placed in the pars tensa of the tympanic membrane away from the posterior superior quadrant to avoid injury to the ossicular chain and chorda tympani nerve. Physical Examination Examination may reveal a normal tympanic membrane, retraction pocket with or without cholesteatoma, severe atelectasis, or adhesive otitis media. Endoscopic view of the nasopharyngeal opening of a left eustachian tube showing significant peritubal inflammation. Pneumatic otoscopy and otomicroscopy: this is the gold standard test for otitis media. Videoendoscopy is helpful to differentiate obstructive disease from dynamic dysfunction. Having the patient repeat the letter "K" and swallow or yawn causes contraction of the levator veli palatini. During the active phase, the resting S-shaped lumen opens to a more rounded patent one. Myringotomy and Tube Placement Tympanostomy tube insertion is the most common ambulatory surgery performed in children in the United States. Common indications include persistent otitis media with effusion resulting in hearing loss, recurrent otitis media, or persistent otitis media that fails to resolve with conservative treatment. Ventilation of the middle ear aims to lateralize the tympanic membrane off the promontory and ossicles. Balloon Eustachian Tuboplasty · Supine position with the head turned slightly toward the surgeon. Perioperative Antibiotic Prophylaxis Tympanocentesis · Clean-contaminated surgery · Perioperative antibiotic prophylaxis is not recommended. Myringotomy and Tube Placement · Clean-contaminated surgery · Perioperative antibiotic prophylaxis is not recommended. Anesthesia contraindications Balloon Eustachian Tuboplasty · Clean-contaminated surgery · Perioperative antibiotic prophylaxis is not recommended. Anesthesia contraindications Myringotomy and Tube Placement · None necessary Preoperative Preparation Audiogram and tympanogram Balloon Eustachian Tuboplasty · Cardiac monitoring is recommended. Tuberculin syringe and 18-gauge needle with the need for prolonged middle ear ventilation. Cup forceps; cerumen loops; curettes, 3, 5, and 7F suction; and cotton-tipped applicators for removal of ear canal debris and cerumen 4. Alligator forceps for tympanostomy tube guidance into the ear canal and myringotomy site 6. Curved pick and right-angled hook for completion of tube insertion and orientation 7. When advancing a balloon catheter, the isthmus can be felt as an area of resistance. Tympanostomy Tube Options Tympanostomy tubes are typically made of plastic, although silicone, metal, and hydroxyapatite tubes are still used. Short-term tubes are typically retained from 6 to 12 months and long-term tubes retained more than 12 months. They may have the configuration of an hourglass (Shepard-type tube) or have beveled inner flanges (Armstrong-type tube). Long-term tubes are typically T-tubes with long inner flanges to prevent early extrusion and are placed in patients who have a history of early extrusion or in patients Prerequisite Skills 1.

Reassess: At this point allergy medicine infants zyrtec 10 mg buy cheap, another intraoperative assessment of the septum is carried out to get a better sense of the nature of the septal deformity and which deforming forces must be overcome to correct the septal alignment allergy shots bee stings discount zyrtec online american express. Correcting the septum: Working sequentially from the posterior nasal airway toward the caudal septum is preferred allergy medicine overdose symptoms cheap 10 mg zyrtec mastercard. Because alterations or manipulation of the caudal septum is potentially more disruptive to tip support allergy treatment germany discount 10 mg zyrtec visa, it is better to address those last and reconstruct that area as needed without the need to do more work farther back in the nose allergy testing needles purchase zyrtec overnight, which might destabilize a reconstructed caudal septum at that point. Intraoperative checklist: In every case, the same system is consistently applied to analyze the nasal airway as the surgery proceeds. Having a system in place will focus attention in a deliberate way and reduce the chance of leaving a persistent deflection unattended or overlooked. Specifically, as the surgery proceeds from back to front, the author evaluates the following: a. If the root of the middle turbinate can be easily visualized without having to pass a speculum too far into the nasal cavity or without opening the nasal speculum too forcibly, then one can be reassured that airflow will move easily through the internal nasal valve. This is a common site of failure, and even modest deviations in the valve region should be addressed. Is the nose open along the floor (typically spurs of maxillary crest or displacements of quadrangular cartilage over crest) Is the caudal septum straight and maintaining a tension-free position in the midline Separate the quadrangular cartilage from the bony septum: Applying steady pressure with the Cottle elevator, the quadrangular cartilage will separate from the bony septum (perpendicular plate of the ethmoid) posteriorly. Removal of the deflected perpendicular plate of ethmoid and vomer: If the bone is at all off-center, the rigid nature of the bone will overpower the softer more pliable nature of the attached cartilage, tethering it into a sustained nonmidline position. Bone removal must therefore be as complete as deemed necessary rather than overly conservative. Whenever possible, superior cuts in the bone should be made sharply to avoid the very rare complication of fracturing the cribriform plate and creating a cerebrospinal fluid fistula. Cartilage removal: If there is a persistent deviation of the quadrangular cartilage, incisions are made and cartilage removal proceeds as necessary. Under direct vision and using a number 15 blade, one incision is made in the cartilage paralleling the nasal dorsum and another incision is made paralleling the caudal septal edge/columella, outlining the segment of cartilage to be removed. At a minimum, cartilage removal should preserve at least a 1-cm dorsal septal strut and a 1-cm caudal septal strut. This is critical to maintain adequate support to the nasal tip and dorsum to minimize the risk of postoperative settling of the supratip dorsum (saddle deformity). If a determination is made preoperatively that a clinically significant curvature or angulation exists within the dorsal 1 cm of the quadrangular cartilage, then the surgeon should consider correcting the nasal airway through an external functional septorhinoplasty approach or referring this patient to a surgeon who is capable of such. An external rhinoplasty approach gives the surgeon maximal exposure to correct, divide, excise, and/or reconstruct the dorsal septal strut as needed. Removed cartilage segments that are reasonably straight (but were off the midline and hence excised) can be replaced between the septal flaps for added septal support prior to quilting the mucosal flaps. In such cases the returned segment should be positioned above the caudal strut and behind the dorsal strut to minimize inadvertent obstruction that might arise from an overlap. Left image: separation of quadrangular cartilage (being displaced to the left of the speculum) from the perpendicular plate of ethmoid bone (edge indicated by arrow). Right image: high and low bone cuts (arrows) with removal of intervening bony segment. Removal of inferior bony septal spurs (maxillary crest): the surgeon must decide whether a spur or localized deviation of the maxillary crest is of a magnitude that might contribute to airway compromise. Smaller deviations toward the floor of the nose are often asymptomatic, unlike smaller deviations dorsally toward the internal nasal valve. Larger spurs, spurs that contact the inferior turbinate, or crest deviations that create a secondary deviation of the overlying quadrangular cartilage should be removed. Bilateral elevation of the mucoperiosteum over the lateral aspect of the crest can be tedious and must be done carefully because the mucosa tends to be thinner and more adherent to the bone as compared to cartilage. The deviated crest can then be removed with a double-action rongeur or a 4- to 6-mm chisel or osteotome. Correction of caudal septal deformities: Severe angulation or rotation of the caudal strut off the midline sagittal plane should be readily identifiable at the preoperative consultation. Routine palpation of the caudal septum provides valuable insight over and above anterior rhinoscopy and will distinguish those deformities that would not be correctable with "traditional" excisional surgery or submucous resection. An external functional septorhinoplasty approach should be considered for more extreme caudal septal deformities to minimize the likelihood of surgical failure, patient dissatisfaction, and the need for more difficult revision surgery in the future. The caudal septum that is tilted or displaced off the anterior nasal spine or gently bowed or curved is very amenable to an endonasal correction. Likewise, if there is a mild to moderate angulation (as opposed to curvature) in the midportion of the caudal septum, where the caudal edge of the septum is still directed inferiorly and the apex of the fracture is directed laterally, this can be addressed endonasally. On the other hand, if the fracture/angulation extends along an anteroposterior vector through the junction of the caudal and dorsal septum, the caudal septal segment may be completely rotated off the axis of the dorsal septum. In this circumstance the caudal edge of the septum will not be directed inferiorly but will be oriented laterally toward the nasal sidewall and inferior turbinate instead. This type of caudal septal deviation can always be identified preoperatively with a thoughtful and thorough examination. A more radical caudal septal deviation such as this may require complete transection (explanting) of the caudal septum from the dorsal septum with reorientation and restabilization of the native segment or replacement of that segment with a separate free cartilage replacement graft and then restabilization. This can be done endonasally (but it is very challenging and requires significant experience to execute) or through an external rhinoplasty approach. Such cases can jeopardize dorsal and tip support and as such are best attended to by surgeons experienced in reconstructive nasal airway surgery and comfortable with external approach reconstructive rhinoplasty. Caudal septal deformities are better appreciated and more readily corrected with the benefit of bilateral mucosal flap elevation. The goal is to allow the caudal strut to sit tension-free right over (in contact with) the anterior nasal spine but not to hang well above it. This reduces the chance of posterior settling of the supratip dorsum and a visible dorsal depression. If the reduction is inadequate, however, the tilt or curve may persist, or the patient may complain that there is movement and "clicking" in that region as the posterior septal edge contacts or moves across the spine. For the caudal septum that is angulated (as one might see with a prior fracture), removing a small wedge above the anterior nasal spine and crest as described previously does nothing to remove the angulation and will therefore prove to be inadequate. In such cases the surgeon must transect the caudal strut along a cephalocaudal vector, through the apex of the fracture line. The caudal septum thus becomes two segments, one anterior (contiguous with the dorsal strut) and one posterior (attached at the nasal spine). The excess length will allow the two segments to be overlapped and suture secured to one another to strengthen the caudal strut. When the caudal septum is tilted/displaced over the anterior nasal spine (A), excising a small wedge of cartilage-incrementally and conservatively-will allow the caudal strut to move into a midline position immediately atop the nasal spine (B). Conservatively shortening the gently curved or bowed caudal septum above the anterior nasal spine (A) will allow the bowed segment to release, straighten, and assume a midline position (B). The anterior and posterior segments can then be overlapped and suturesecured to one another. Alternatively, the overlap can be excised and the two segments aligned end to end and stabilized with a sutured-in-place batten (reinforcement) graft (B). An alternative to overlapping is to excise the excess cartilage so that the two segments rest end to end. Septal flaps: the septal flaps from either side are quilted to one another with a running through-and-through 4-0 plain gut suture. The hemitransfixion incision is closed with simple interrupted 5-0 plain gut, through-andthrough 4-0 plain gut septocolumellar sutures, or a combination thereof. Placement of Doyle splints: Doyle splints are placed on either side of the septum and stabilized with a throughand-through 3-0 Prolene suture. The location of the traversing incision is measured with an intranasal view from the nasal columella to the site just anterior to the deviation using the Cottle elevator. The deviated portion of the cartilaginous septum is removed with a Ballenger swivel knife or through-cutting straight Blakesley forceps taking care to preserve the cartilaginous strut. Deviation of the bony septum is removed by creating a cut superiorly with double-action scissors. The double-action scissors should be introduced into the flap with the jaws oriented in a vertical fashion to prevent injury laterally to the middle turbinates. The axilla of the middle turbinate can now be visualized, which allows for access to the paranasal sinuses, especially to the frontal sinus. A to C, Localized flaps can be raised to remove obstructive bony spurs, obviating the need for large flap elevation. The anterior hemitransfixion incision is closed with a series of interrupted 5-0 fast-absorbing suture, and the septal flaps are reapproximated with a quilting 4-0 plain gut suture. The middle turbinates can also be included in the quilting suture by pexy to the septum to prevent lateralization. Doyle splints are then placed into the nose bilaterally and secured anteriorly with 3-0 Prolene. The endoscope is used to ensure that the splints do not cause lateralization of the middle turbinate. The most superior/posterior portion of the splint can be trimmed to ensure that the splint does not disrupt the pexy suture. Inadequate resection of the bony deviation leading to persistent septal deviation 4. Inattention to septal shift dorsally or caudally leading to persistent septal obstruction at the internal or external valve, respectively 6. Patients are instructed to irrigate the intranasal splints with a high-volume (8 oz) saline solution 3 to 4 times daily. After each rinse, the nasal vestibule is cleaned of any loose/ clotted blood with a cotton swab soaked in hydrogen peroxide, following which an over-the-counter antibiotic ointment is applied inside the nares to moisturize the nose. This regimen helps keep the splints clear, thus maximizing comfort and enabling the patient to breathe through the splints. An unrecognized hematoma can lead to pressure ischemia, loss of the remaining septal cartilage, and a saddle nose deformity. Toxic shock syndrome: this has been reported in patients with and without nasal packing following nasal septoplasty and is thought to be due to colonization of the nasal packing by S. There does not appear to be an absolutely certain way to prevent this complication. If a patient reports early fever, serious diarrhea, or ischemia of the limbs, evaluation for toxic shock syndrome should be done immediately. The packing should be removed and cultured, antistaphylococcal antibiotics should be administered, and careful observation and intervention should be done as needed. Nasal packing post septoplasty is rarely necessary, however, with the availability of silastic splints. This can be avoided by not avulsing any bone or cartilage unless a superior cut has already been made from the perpendicular plate of the ethmoid bone. Anosmia: this condition is rare and spurious, with a quoted incidence of 1 in 1,000,000. Need for secondary/revision surgery: Such surgery might be required for persistent symptomatic obstruction. Change in external appearance: Loss of height of the dorsal septum (mild saddle deformity) can result from disarticulation of the quadrangular cartilage from the perpendicular plate of the ethmoid bone at the keystone area (rhinion), from posterior settling of the caudal and dorsal septal struts, or from overly aggressive reduction of dorsal strut height. Although infrequent, a crushed cartilage onlay graft placed over the dorsal septum through an intercartilaginous incision can camouflage the external deformity. Screening and evaluation for allergic rhinitis or inferior turbinate hypertrophy b. Trial of a topical nasal steroid spray and oral antihistamine if a history of allergic rhinitis is present c. Patients whose conditions warrant exception from a preoperative trial of medical therapy include those without obvious history of inflammatory disease and a significant anatomic deformity that suggests that surgical correction would be best suited for the patient. Excess postoperative bleeding: Bleeding may respond to a topical vasoconstrictor spray. Continued bleeding will require splint removal and cauterization if the focal site is identifiable or exploration in the operating room. Sinusitis: Should the patient develop sinusitis, culturedirected antibiotics are preferable. If not available, amoxicillin-clavulanate is recommended per current guidelines or, in penicillin-allergic patients, doxycycline. Septal perforation: this is generally preventable with meticulous elevation of intact mucosal flaps and repair of any incidental mucosal tear. Septal hematoma: Suture quilting the septal flaps from one side to the other eliminates the surgical dead space and minimizes the chance of septal hematoma. If intraoperative bleeding or oozing between septal flaps is felt to be excessive, a small venting stab incision should be made in the septal mucosa posteriorly if there are no inadvertent mucosal tears. Should a hematoma develop, as suggested by increasing pain, nasal congestion, and visible bilateral distention or swelling of the septum, aspiration with an 18-gauge needle is reasonable in an effort to evacuate the hematoma. Prior to 2004, most reports of outcomes of septal surgery were limited by study design: They were often retrospective, relied only on chart reviews or telephone follow-up surveys, depended on physician-rated outcomes rather than patientreported satisfaction, and used nonvalidated outcome measures. As with any operation, however, proper patient selection and an individualized surgical plan are paramount. The section on endoscopic septoplasty will be of particular interest to surgeons not familiar with this approach. Gillman and Lee have written a very practical and useful review of the endonasal and endoscopic approach to septoplasty.

Benign and malignant tumors of salivary gland origin may be covered by mucosa allergy forecast mckinney tx buy zyrtec 5 mg otc, and incisional biopsy is usually necessary in such cases for accurate diagnosis allergy shots help asthma 10 mg zyrtec buy visa. In the presence of a malignant tumor allergy medicine kroger buy genuine zyrtec on line, determine the need for ipsilateral or bilateral neck dissection allergy testing wilmington nc purchase zyrtec 10 mg on-line. Preoperative medical clearance must be secured for patients with significant medical comorbidities allergy symptoms lasting months safe 5 mg zyrtec. Informed consent should include: bleeding; infection; need for local, regional, or microvascular reconstruction; possible use of a dental prosthesis; evaluation by a prosthodontist; and potential cosmetic deformity. Early admission is recommended for detoxification in patients with known alcohol abuse. Squamous cell carcinoma is the most commonly encountered cancer of the hard palate. Flexible fiberoptic laryngoscopy: Evaluation of the remainder of the upper aerodigestive tract is performed to exclude the possibility of a second primary cancer, because second primaries may occur in 20% to 25% of patients with squamous cell carcinoma of the oral cavity and oropharynx. General anesthesia is indicated for most procedures involving the maxilla for airway protection and patient comfort. Surgery is the first-line treatment of all benign and malignant tumors of the palate. Benign tumors may be removed without resecting bone and there is no requirement for reconstruction. Malignant tumors will require resection of part or all of the hard palate or maxillary alveolus (or both) to remove bone that is obviously involved along with at least a 1-cm margin. Adjuvant chemoradiation is beneficial when there is bone invasion, perineural invasion, two or more positive lymph nodes, or extracapsular spread. Bilateral selective neck dissections should be performed for tumors involving the midline. The patient is placed in the supine position with the head of the bed turned 90 or 180 degrees away from the anesthesiologist. Microvascular free tissue transfer may require repositioning based on the donor site of the flap and will be governed by the reconstructive surgeon. Antibiotics covering for oral flora (gram positive, gram negative, and anaerobic bacteria) such as ampicillin-sulbactam or clindamycin for penicillin-allergic patients Contraindications 1. Very advanced local disease (T4b) involving the masticator space, pterygoid plates, skull base, or encasement of the carotid artery 3. Transoral Inferior Maxillectomy 229 Instruments and Equipment to Have Available 1. The hard palate separates the oral cavity from the nasal cavity and maxillary sinuses. The pterygopalatine and infratemporal fossae are located posterior to the maxilla. Gingivobuccal incision and anterior maxillotomy with visualization of the maxillary sinus floor and infraorbital rim. Creation of defects larger than anticipated without proper preoperative preparation Surgical Technique 1. Approaches to the surgical management of cancer limited to the hard palate and alveolar ridge include: a. Partial lateral maxillectomy: Surgical approach for tumors of the hard palate that involve the maxillary sinus and nasal cavity c. Inferior maxillectomy: Surgical approach for tumors of the hard palate that do not involve the floor of the maxillary sinus and nasal cavity d. Approach to benign mucosal tumors of the palate (Biopsy-confirmed benign tumors only involving the mucosa. Reconstruction 1) A palatal island rotational flap or rotational flap based on either the greater palatine or ascending palatine arteries is used to cover the site of the defect. Hands-free cheek retractor, a bite block, or a side-biting mouth gag is placed to gain access to the oral cavity. Elevate the soft tissue in the subperiosteal plane of the front and lateral walls of the maxillary antrum to the level of the infraorbital nerve with a Freer elevator or a 9 Molt periosteal elevator. Enter the maxillary antrum using a small osteotome and remove the anterior wall with a Kerrison rongeur sparing the infraorbital nerve. A sagittal saw with reciprocating or sagittal blades is used to make osteotomies with at least 1-cm bony margins from the edge of the tumor along the frontal and lateral walls of the antrum. Transect the palate into the maxillary sinus with care to avoid entering the nasal cavity if the tumor margins allow. Once the pterygoid plates are fractured, brisk bleeding is expected from the pterygoid plexus and internal maxillary artery. Performing this cut last allows for removal of the tumor, and hemorrhage from the pterygopalatine fossa cannot be adequately controlled until the tumor is removed. Obtain frozen section analysis from the left tissue margins of the specimen that are concerning for residual tumor or are too close to be oncologically sound. Remove the entire mucosa from the maxillary sinus to avoid contamination by oral cavity microorganisms and prevent resultant edema and inflammation that can interfere with the fit of the oral splint. Pack the defect tightly with Xeroform gauze to close off dead space and compress the skin graft to the underlying tissue to ensure graft survival. The presence of the surgical splint allows the patient to swallow and speak during the immediate postoperative period. Retract the lips with a hands-free cheek retractor, a bite block, or a side-biting mouth gag to gain access to the oral cavity. Incisions are made in a manner similar to that described for tumors of the alveolar ridge. The osteotomy is usually completed with the osteotome at the level of the pterygoid plates. The nasal cavity is entered and the septum is transected with heavy curved Mayo scissors 1 to 2 cm superior to the floor of the nose. The soft palate is transected with electrocautery, and any residual soft tissue attachments are transected with scissors. After the mucosa of the maxillary antrum is removed as previously described, the inferior turbinate is also removed to prevent infection and edema, which would interfere with the application of a palatal prosthesis. More extensive tumors limited to the hard palate and alveolar ridge can be removed by simply extending the osteotomies. Once the specimen is removed, it is sent to the pathology laboratory for frozen section diagnosis and assurance of clear surgical margins. Management of the neck in squamous cell carcinoma of the hard palate and alveolar ridge a. A high incidence of cervical metastasis (30%) in the subsites of tongue and floor of the mouth cancer has been well documented. Dissect the neck before the oral cavity because resection of the neck is considered clean. If the primary tumor does not involve the midline, we perform a unilateral selective neck dissection. Midline lesions or lesions involving the entire hard palate require bilateral neck dissections. If metastasis in the neck is present, N1 to N2, a selective neck dissection is performed. Once the neck dissection is completed, we re-drape and isolate the neck dissection wound from the oral cavity procedure. An anterior maxillotomy is made to visualize the entire floor of the maxillary sinus. Positive margins Postoperative Management Rehabilitation of a Patient With Loss of Oral-Nasal Separation Patients treated by inferior maxillectomy require a means of restoring the oral-nasal separation lost by removal of the palate and alveolar bone. Not doing so results in patients who can neither speak nor swallow, which gives rise to an unacceptable quality of life. A comprehensive midface and maxilla classification system has been established incorporating both vertical and horizontal defects. Dental prosthetic management: A patient with a limited lesion of the alveolar ridge alone or the alveolar ridge and palate that does not involve more than half the hard palate can be rehabilitated relatively easily. Local flaps: the palatal island flap for reconstruction of palatal lesions is a single-stage mucoperiosteal flap that is a reliable source of regional vascularized soft tissue that obviates the need for prosthetic rehabilitation. The temporalis muscle is an attractive option for reconstruction for the following reasons: 1) the donor site and the defect are within the same operative field and therefore the need for more complex free tissue transfers can be avoided. Microvascular free tissue transfer: Reconstruction of defects after inferior maxillectomy are well summarized under the theme of functional palatomaxillary reconstruction. Horizontal classification: a-palatal defect only, not involving the dental alveolus; b-less than or equal to ½ unilateral; c-less than or equal to ½ bilateral or transverse anterior; d-greater than ½ maxillectomy. Letters refer to the increasing complexity of the dentoalveolar and palatal defect and qualify the vertical dimension. Patient with a removable denture that restores good oral-nasal separation and provides for a good cosmetic appearance. Transfer to a dedicated head and neck cancer unit with nurses trained in the care of head and neck patients. There is usually no need for intensive care unit­level of care for this surgery unless microvascular reconstruction is employed. If microvascular reconstruction is performed, the reconstructive surgeon dictates the level of care. Pain medication: Opioid pain medication such as oxycodone 5 to 10 mg every 4 hours as needed should provide adequate analgesia in the perioperative period. Meticulous oral hygiene with chlorhexidine mouthwash swish-and-spit after every meal is essential to help prevent infection. Prosthetic rehabilitation and local or regional flap 1) Full liquid or pureed diet starting on postoperative day 1 c. This is used in the interim while the final prosthesis is delayed until the maxillectomy cavity matures. If there are plans for adjuvant radiation therapy, the final prosthesis may have to be delayed until after completion of radiation to ensure a proper fit. Early ambulation with or without physical therapy is essential for postoperative rehabilitation. Patients who have undergone neck dissection in conjunction with resection of the primary cancer will have the neck wound managed as described in the chapter on neck dissection (see Chapter 87). Patients with bone invasion (T4 lesions) or with highgrade salivary gland cancers are referred for postoperative radiation therapy. Patients who have perineural involvement in their primary tumor or positive resection margins should always be referred for radiation therapy. Similarly, patients who have more than two positive nodes or extracapsular spread in one or more nodes will be referred for chemoradiation therapy. B, After total inferior maxillectomy, the defect was reconstructed with a temporalis muscle flap, which quickly became mucosalized. It has now been 15 years since the patient completed his surgery, and he is asymptomatic despite the stable lung metastasis. Perforation of soft tissue on the nasal side of the palate with removal of palatal bone as a deep margin b. Repair intraoperatively with soft tissue via a prosthesis, local, regional, or microvascular free flap. Meticulous oral hygiene and perioperative antibiotic prophylaxis will prevent most infections. Treat with postoperative antibiotics covering for oral flora (gram-positive, gram-negative, and anaerobic bacteria) such as ampicillin-sulbactam or clindamycin for penicillin-allergic patients with pus and systemic signs of infection (fever or leukocytosis) Alternative Management Plan 1. Nonsurgical management: the patient who is not a surgical candidate due to the site of the tumor or due to medical comorbidities can be referred for radiation therapy. The palliative care physicians discuss issues such has symptom management (pain, hunger, thirst) and the details of hospice care. Editorial Comment: Inferior Maxillectomy the hard palate and alveolar ridge give rise to a wide variety of conditions ranging from necrotizing sialometaplasia, a benign condition, to squamous cell carcinoma, which is the most frequently encountered malignant tumor. Malignant tumors and most benign conditions are treated surgically because radiation applied to bone structures can result in osteoradionecrosis. When I was first introduced to the inferior maxillectomy it was carried out through a lateral rhinotomy approach, which provides wide exposure but at the price to the patient of a conspicuous scar. I soon realized that most tumors arising in the area of the palate could be removed successfully through a transoral approach, and I abandoned the lateral rhinotomy incision. Loss of oronasal separation, which is fundamental to both swallowing and speaking, was managed with a prosthesis except in cases of a total inferior maxillectomy, which was reconstructed with a temporalis muscle flap. Reconstruction of the palate with free tissue transfer introduced more recently was not embraced fearing that closing the defect would preclude cancer surveillance. Another major step forward in the management of patients with squamous cell carcinoma is the management of the neck. It was believed that cancers of the hard palate and alveolar ridge, which occurred much less frequently than cancer in other sites such as the tongue and the floor of the mouth, had a different pattern of metastasis. I became aware of a study done at the University of Virginia in which the members of the Department of Otolaryngology observed a rate of metastasis of approximately 35%, which is the same as in other sites in the oral cavity. A subsequent study performed in our department7 validated the findings of the aforementioned study. Based on this study, we adapted the use of the selective neck dissection, bilateral or unilateral based upon the location and extent of the primary. When combined with radiation or chemoradiation, depending on the presence or absence of extracapsular spread, we have been able to establish excellent local regional control in patients undergoing inferior maxillectomy. Cancer of the hard palate and maxillary alveolar ridge: technique and applications. Cervical metastasis from squamous cell carcinoma of the maxillary alveolus and hard palate. Management of the neck in a patient with squamous cell carcinoma involving the left maxillary alveolus extending to midline includes which levels According to the Brown and Shaw maxillary defect classification, a maxillary defect involving the orbital rim, but preserving the eye and involving greater than half of the palate falls into which of the following classes A maxillary defect not involving the orbit and less than half of the hard palate is best reconstructed with which of the following

Trauma to the duct If severe allergy testing san francisco buy zyrtec 5 mg, this may lead to stricture and recurrent obstructive sialadenitis; stent placement may mitigate risk of stricture allergy testing utah county zyrtec 10 mg purchase mastercard. Vasovagal reaction this may be due to patient factors or overinfusion of lidocaine solution allergy vodka symptoms purchase zyrtec 5 mg on-line. It is seen in posterior floor of mouth cutdown procedures allergy testing rules generic zyrtec 10 mg with mastercard, typically with deep dissection allergy testing queensland purchase generic zyrtec from india. Increasingly, ultrasound has become an extension of the physical exam of head and neck patients. Salivary endoscopy is increasingly finding its way into the office as well, for the diagnosis and treatment of certain obstructive salivary pathologies. Barry Schaitkin Evidence-Based Medicine Question: Is Sialendoscopy Effective in the Management of Salivary Pathology A meta-analysis revealed weighted pooled success rates of 86% (endoscopy alone) and 93% (endoscopy with combined procedure) for patients undergoing sialendoscopy for obstructive disease. Limited distal sialodochotomy to facilitate sialendoscopy of the submandibular duct. Fine-needle aspiration biopsy versus ultrasound-guided fine-needle aspiration biopsy: cost-effectiveness as a frontline diagnostic modality for solitary thyroid nodules. Sialendoscopy for the management of obstructive salivary gland disease: a systematic review and meta-analysis. Operating room procedure Patients may not tolerate the procedure from a pain or vasovagal reaction standpoint. Excision of the gland If the patient is refractory to endoscopic therapy or the stone cannot be removed, gland excision is an effective treatment option. Submandibular stone size does not determine candidacy for an office-based procedure d. Walvekar Salivary endoscopy is a minimally invasive technique for the treatment of a variety of inflammatory salivary gland pathologies. The small high-resolution telescopes are in their fifth generation of development and now incorporate rinsing and instrumentation capabilities. Patients most commonly present with meal-time obstructive symptoms of swelling of the gland and discomfort with provocation. The inflammatory processes can have more constant symptoms not associated with meals. It is also a dynamic study and can be done with concurrent salivary stimulation with food. It is also possible to do the study with intraoral palpation to further delineate calculi. It is not useful for most cases of stenosis unless the duct is dramatically dilated. Contrast should be used in cases where a neoplasm remains in the differential diagnosis. For some hybrid procedures and bilateral cases, nasal intubation may provide better exposure in the oral cavity. Prerequisite Skills · Endoscopic skills · Basic open head and neck surgery skills · Patience 88 Positioning · Supine: the patient is positioned the same as any endoscopic sinus procedure with the head turned slightly toward the surgeon. Operative Risks · Failure to retrieve the calculus or eliminate the pathologic process · Perforation of the duct by penetrating the duct with the scope · Avulsion of the duct by pulling too hard on an impacted calculus · Blocked basket requiring an open procedure to retrieve the basket stuck on a salivary calculus · Stenosis of the duct from instrumentation, laser thermal injury, or combined approach incisions · Airway obstruction from irrigation · Cranial nerve injury to the lingual or buccal branch of the facial nerve during hybrid procedures · Bleeding from an injured vessel. No risk of these during purely endoscopic procedures · Failure of the procedure and the need for excision of the salivary gland Perioperative Antibiotic Prophylaxis Not all surgeons use perioperative or postoperative antibiotics for a routine type of procedure. However, if there has been recent infection or for a combined approach with some degree of opening through the mucosa combined with an endoscopy, antibiotics are recommended. There is no evidence that it improves outcomes, and we do not use such monitoring. Submandibular Gland · Patients are selected for local, monitored anesthesia care, or general anesthesia based on patient factors, pathology, and comorbidities. Salivary Endoscopy 595 · A variety of interventions are then possible after this access has been obtained. After the stenosis is dilated or the calculus is removed, the duct can be visualized by endoscopy via the natural ostium to go past the area of pathology into the more proximal duct, followed by placement of a guidewire and stent. Usually, if the duct has been incised, it is repaired at this time over the stent. Botox injection of the parotid parenchyma should be a consideration to prevent sialoceles. The duct is dissected from the buccal space to retract it into the oral cavity. The distal duct can then be excised (usually 1 to 2 cm) and the remnant proximal duct sutured to the buccal mucosa to complete the sialodochoplasty. Alternative Management Plan the alternatives to gland-preserving approaches that involve salivary endoscopy and hybrid approaches are either observation or excision of the gland. Patients in whom salivary endoscopy has not been helpful in mitigating symptoms should consider excision of the gland. The premise of salivary endoscopy was the ability of the procedure to permit return of flow and afford gland preservation. The authors denote that up to 66% of glands demonstrate stable or increased salivary flow as judged by scintigraphy after removal of submandibular hilar stones. The study provides objective evidence that validates endoscopic gland-preserving techniques. The latter are often responsible for salvage gland excision after successful endoscopic intervention. Common Errors in Technique · Inability to dilate the papilla · Making punctures with injection needles, dilators, or guidewires that look like the papilla opening · Not staying central in the lumen and so no real view · Pushing without visualization and perforating the duct · Continuing to irrigate after perforating the duct · Basketing a fixed calculus and having the basket trapped- "trapped basket syndrome" · Breaking the salivary endoscope by excessive force or bending it over the teeth · Too much irrigation, consequently overinflating the gland or causing ductal injury and extravasation of irrigation into the floor of the mouth or buccal space, causing swelling of the floor of the mouth or cheek, respectively Editorial Comment Inflammatory disease of the salivary gland traditionally involved removal of the gland. With the addition of hybrid techniques, gland retrieval can be used to rescue a small percentage of cases of inflammatory and obstructive diseases of the salivary glands. A comparison of parotid imaging characteristics and sialendoscopic findings in obstructive salivary disorders. A combined endoscopic and external approach for extraction of large stones with preservation of parotid and submandibular glands. Glandular function after intraoral removal of salivary calculi from the hilum of the submandibular gland. Complications · Perforation of the duct is usually managed with antibiotics, occasionally by stenting the duct. Calculi may need to have hybrid approaches or fragmentation of calculi if they are a. Walvekar, Rachel Barry A ranula is an extravasation mucocele that arises in the floor of mouth secondary to trauma to the sublingual gland or obstruction of the salivary ducts. These lesions are classified into two types: oral or simple ranulas and cervical or "plunging" ranulas. Plunging ranulas are pseudocysts, meaning that the wall of the ranula is lined with granulation or connective tissue and lacks an epithelial lining. Various methods have been described, including marsupialization and excision of the ranula with or without excision of the sublingual gland for oral ranulas. Others have described a transcervical approach and excision of the submandibular gland in the management of a plunging ranula. More recent literature supports the excision of the sublingual gland with transoral drainage of the plunging component as the modality with the fewest complications and recurrences. Complete excision of the sublingual gland is associated with the fewest recurrences of ranulas. History of recurring lesions with formation of cysts with resolution being pathognomonic of a ranula. Mass effect can cause impairment of submandibular salivary flow, leading to swelling and pain in the gland after eating. Plunging ranulas present with an enlarging, painless mass in the neck, with or without accompanying swelling of the floor of the mouth. Medical comorbidities that may impact eligibility for or viability of surgical intervention 5. A, Bilateral floor of mouth ranula; the asterix showing a prominent floor of mouth ranula. Computed tomography scan (coronal view) showing ranula involving sublingual space and expanding beyond the mylohyoid sling into the upper neck spaces. Sublingual gland or space may be replaced by radiolucent material suggestive of extravasated saliva, typical of ranula formation. The submandibular gland is often displaced or surrounded by the radiolucency making it difficult at times to decipher if the gland is the origin of the pathology or is being affected as a consequence of it. Hyperintense cystic lesion on T2-weighted images, low to intermediate intensity on T1-weighted images 3. Ultrasound has also been shown to successfully evaluate cystic lesions in the submandibular space, as well as evaluate areas of dehiscence in the mylohyoid muscle. Ultrasound can be a valuable tool intraoperatively as well as to ensure complete drainage of the plunging component of the ranula. Serum amylase: the diagnosis of a ranula is a clinical and radiological diagnosis; however, in cases where there is a question regarding the origin of the cyst, a raised serum amylase level in cyst aspirate can confirm salivary origin. Ranulas causing airway obstruction or compromise require immediate treatment with either incision and drainage or excision. Bimanual palpation of the floor of the mouth must be performed to rule out coincidental salivary calculi. In the case of a plunging ranula, external pressure on the neck mass often makes the corresponding sublingual fossa prominent. An effort must be made to identify and check the function of the submandibular duct. These steps facilitate cannulation of the submandibular duct if placement of a stent is considered and also facilitates early decision making to perform a marsupialization of the submandibular duct if the submandibular papilla is stenotic. Giant ranulas can extend to also involve parapharyngeal space or to the level of the clavicles. Patient with medical comorbidities precluding administration of general anesthesia 2. Anesthesiology 1) A coordinated effort is important to plan the management of the airway for large obstructing ranulas that may distort the anatomy or make for a difficult airway. Essential in cases of plunging ranula to determine cervical extent and relationships prior to operative management b. Prerequisite Skills · Experience with salivary gland and salivary duct surgery Positioning · Supine · Intraoral and extraoral betadine prep may be considered. Operative Risks Risks of general anesthesia Bleeding Infection Recurrence of the lesion Injury to the lingual nerve: sensory loss to anterior twothirds of the tongue, tongue numbness, or metallic taste in the mouth · Submandibular duct injury/papillary stenosis: obstructive sialadenitis or salivary leakage subsequently requiring excision of the submandibular gland if not resolved · Need for additional procedures · · · · · Perioperative Antibiotic Prophylaxis · Perioperative administration of antibiotics to cover oral flora is recommended; usually clindamycin. Monitoring · Routine anesthesia monitoring; nerve monitoring is not indicated in these procedures Surgical Techniques · There are varying surgical procedures described to manage ranula. The most common ones include excision of the floor of the mouth cyst and marsupialization of the cyst to the floor of the mouth. This article will focus on the comprehensive technique that is associated with the lowest recurrence rate, that is, excision of the sublingual gland with excision or drainage of the floor of the mouth ranula or drainage of the plunging component of the ranula. After appropriate dilation, the duct is cannulated with a salivary duct stent to assist with identification and preservation during the procedure. If the opening of the submandibular duct is abnormal and the duct cannot be cannulated easily, this step can be deferred. If expertise and instrumentation are available, a diagnostic endoscopy of the submandibular duct to ensure that there is no coincidental submandibular duct pathology is reasonable and will also allow identification of the duct for cannulation or repair. The submandibular duct runs in an anterior-superior direction from the submandibular gland to its papilla on the floor of mouth, and it makes contact with the medial surface of the sublingual gland. Since the plunging ranula is a pseudocyst, merely draining the cyst will allow for the resolution of the cyst as long as the source of the saliva is removed, that is, the sublingual gland. The sublingual gland is the smallest of the three major salivary glands and lies in the sublingual space. This potential space is bounded anterolaterally by the medial surface of the mandible, medially by genioglossus muscle, and posteriorly by the submandibular gland. The inferior boundary is the mylohyoid muscle, and the superior boundary is the mucosa of the floor of the mouth. The submandibular duct passes adjacent to the sublingual gland and, in its distal 10 to 15 mm, lies just deep to the mucosa of the floor of the mouth. In this position, the duct is liable to be injured during resection of the sublingual gland. Consequently, some surgeons routinely stent the submandibular duct prior to excision of the sublingual gland in an effort to protect it from injury. The lingual nerve must also be identified as its terminal branches pass beneath the sublingual gland and course below the submandibular duct to innervate the tongue. In contrast to the parotid and submandibular glands, the sublingual gland lacks a surrounding capsule. Drainage of the gland into the floor of the mouth occurs through 8 to 20 small ducts of Rivinus. However, if a salivary stent is left in place to manage a damaged submandibular duct, a course of postoperative antibiotics for 10 to 14 days is recommended. The stent is usually left in place for 10 to 14 days and can be removed as an in-office procedure. However, overnight observation may be required if there is significant edema of the floor of the mouth with concern for airway compromise; in our experience this is a very rare occurrence. If the submandibular duct has been interrupted, it should be marsupialized by suturing the edges of the duct mucosa to the edges of the floor mouth mucosa or the wound, whichever is possible without adding excessive tension to the sutures. If persistent, diagnostic salivary endoscopy and stent and/or Botox injection with ultrasound guidance. In recalcitrant cases, submandibular gland excision · Stricture or stenosis: sialendoscopy with dilation and stent placement, duct marsupialization, or excision of the submandibular gland Alternative Management Plan · Marsupialization can be performed under local anesthesia in patients unable to undergo general anesthesia; this is, however, associated with higher recurrence rates. The proposed mechanism is denervation of parasympathetic nerve endings responsible for saliva production. The stent in the submandibular duct can be removed at the conclusion of the procedure.

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