Thiersch skin grafting and postoperative care of otologic patients.

Postoperative care is as important as the actual surgical procedure, if not more important. Thiersch skin grafting remains an excellent technique to ensure proper healing in the mastoid cavity and ear canal. Successful surgical outcomes depend on a well-coordinated effort by the surgical team and the patient. Preoperative planning, intraoperative surgical technique, and postoperative care and follow-up are discussed in this article.     

Skin grafts

The techniques of partial-thickness and full-thickness skin grafting are reviewed, including choice of donor site, preparation of recipient site, graft harvesting, and postoperative dressings and care. A review of the basic principles of skin graft healing is included to increase understanding of the reasons these techniques are used and to show how to avoid complications associated with skin grafting. The areas of usefulness of skin grafts are discussed in relation to the face, head, and neck.     

Head and neck complications of epidermolysis bullosa

Epidermolysis bullosa is a rare congenital skin disease which is characterized by easy formation of traumatic skin bullae. The disease is usually detected in early infancy due to the recurrent bullae. Prognosis is dependent on the histological variant which is present. A case of autosomal recessive epidermolysis bullosa is presented, which demonstrates many of the head and neck complications of the disease. Traditional skin care modalities as well as multiple surgical procedures such as skin grafts and the use of amniotic membrane were used without success. Limited natural healing, which was possibly promoted by oral phenytoin, has occurred.     

Use of allogenic dermis for radial forearm free flap donor site coverage

OBJECTIVE: The radial forearm free flap has become the method of choice for reconstruction of head and neck defects following oncologic ablation. Harvesting of a radial forearm free flap leaves a donor site defect. This is most commonly closed with a split-thickness skin graft. Morbidity, most commonly owing to a lack of graft take over the tendons, can be quite high. Recently, an acellular matrix (Alloderm) has been advocated to decrease complications at the radial forearm donor site, as well as obviate taking a split-thickness skin graft from the thigh. MATERIAL AND METHODS: Tertiary referral academic centre. Retrospective chart review of 15 patients. Five patients received allogenic dermis, 10 patients received split-thickness skin grafting to the radial forearm donor site. RESULTS: Patients with allogenic dermis took between 12 and 16 weeks to heal completely. Patients undergoing split-thickness skin graft were completely healed within 4 to 6 weeks. Cosmesis was judged to be marginally better in the allogenic dermis group. Allogenic dermis placement had a greater impact on hand function owing to prolonged healing, whereas patients with split-thickness skin graft required wound care at the thigh for a 2- to 3-week period owing to the harvesting of the skin graft. CONCLUSIONS: Allogenic dermis may be a viable alternative to split-thickness skin grafting and radial forearm free flap donor sites. Prolonged healing with subsequent increased health care services use needs to be addressed.     

In vitro testing for allergy diagnosis

The measurement of specific IgE antibodies has progressed so that highly reproducible, accurate, and quality-controlled tests are available [62]. These tests can certainly assist all physicians in evaluating allergic problems and are likely to be used widely in the future. Continued research is allowing the refinement of these tests as well as increasing the understanding of allergens and allergic disease. In vitro testing techniques are major assets to allergy care. Either in vitro or skin methods are appropriate modalities for the diagnosis of allergic rhinitis [45]. When the merits of the allergy skin test and in vitro tests for diagnosis of specific allergens are compared, the following statements are considered to be correct at this time: 1. Optimally performed skin tests and in vitro tests detect IgE E antibody accurately and reproducibly. 2. Results of both tests correlate equally well with allergic signs and symptoms produced by exposure to the specifically tested allergen. 3. Both tests can be used as grounds for instituting avoidance therapy and immunotherapy efficiently and economically.     

Temporalis pericranial muscle flap for reconstruction of the lateral face and head

Large ablative surgical tissue defects of the lateral face and head can pose a difficult task for the reconstructive surgeon who must choose from among a large variety of possible reparativce techniques. In many situations the temporalis pericranial muscle flap offers the outstanding feature of providing a large amount of soft tissue at no direct expense of donor site skin cover. It is easily obtained and results in negligible functional loss. With care taken to preserve the neurovascular pedicle, this flap may be rotated in multiple directions and even overturned as either surface can receive surface skin closure. The amount of operative time and effort required is much less than for many of the more elaborate reconstructive flaps. Five representative cases are presented.     

Initial presentation and fatal complications of linear IgA bullous dermatosis in the larynx and pharynx

Two cases of linear IgA bullous dermatosis initially presenting as ulcerative lesions in the larynx and pharynx are reported. It was difficult to diagnose and treat the lesions, but they were finally diagnosed from the histopathological findings of accompanying skin lesion specimens. One of the patients required a tracheostomy due to increased airway stenosis by a laryngeal lesion. Despite general corticosteroid administration this could not be completely resolved, although partial opening of the glottis was observed, and the patient died of accidental tracheostomy tube complications during home care. Although there are no reports of this disease in the otolaryngological field, these rare diseases involving the skin and entire body should be considered in the differential diagnosis of laryngeal and pharyngeal ulcerative lesions, including airway stenosis. Furthermore, simple and safe procedures for relieving airway stenosis should be selected for rare and difficult-to-diagnose airway disease, prior to the final diagnosis.     

Intraoperative infectious disease exposure to otolaryngology operating room personnel

Health care workers are at risk of exposure to serious infectious diseases. Since the seroconversion rate is approximately 0.4% for human immunodeficiency virus and may be greater than 20% for hepatitis exposure, these risks are substantial. To assess body fluid exposure to otolaryngology operating room personnel, elective operations were prospectively analyzed over 2 months. Statistical evaluation was made between types of cases and length of procedures. Thirty-eight contaminations occurred in 228 operations with 26 torn gloves, 1 soaked gown, 6 skin scratches, 4 skin punctures, and 1 ocular exposure. Exposure was more likely in cases longer than 3 hours. Independent of procedure length, head and neck operations carried the greatest risk, followed by otologic procedures, as compared to general, endoscopic, pediatric, and elective trauma cases. The impact of potential operative exposure and universal precautions is emphasized.     

Rhinoplasty in the elderly

Though psychological and anatomical conditions are less suitable, cosmetic rhinoplasty in the elderly patient is possible when indicated in selected patients. Their motivations should be looked for. The ones that have been delayed for other reasons are most convenient. The nasal deformities have nothing in particular. Decreased skin elasticity due to ageing is the point to be considered. When this change is moderate, usual surgical technics can be used for mild corrections. Otherwise, cutaneous resections should be limited to the root of the nose in order to carry out an elevation of the skin and a nasal lift. When it's conducted with care, rhinoplasty in the elderly patient deserves its rank in palliative treatment of ageing.     

Kryochirurgie in der Hals-Nasen-Ohrenfachpraxis mit einem Lachgasger?t — einj?hrige Erfahrung

Summary On 78 superficial lesions of the skin of head and neck as well as the mucosa of nose and mouth 108 cryosurgical procedures were done. The sequence of frequency of these lesions was: in the skin warts, small benign tumors, basal cell carcinoma; in the mucosa stomatitis aphthosa, nosebleed, benign tumors of the palate and the tongue, lateral lymphatic hyperplasia of the pharynx, leukoplakia and precancerous lesions. — Best results were obtained in pedicled papillomas of the palate, stomatitis aphthosa, nosebleed (only one session necessary). Most resistant were keratinized lesions of the skin. In single cases also the shortened ligament of the tongue and the glossitis rhomboidea mediana have been treated cryosurgically. Scarring was also in the treatment of abundant leukoplakia minimal. Before cryosurgery of precancerous lesions a biopsy has to be taken. These patients must be followed up with special care.     

Symposium: Methods of reconstruction in tympanoplasty. III. The anterior canal wall bulge: indications and techniques for removal.

The bulge of the osseous anterior canal wall frequently prevents visualization not only of the margins of the perforation but also of the pathologic changes in the middle ear. In such instances, removal of this bone is absolutely necessary. In other instances, removal of the bulge facilitates both the surgical procedure and postoperative care. While the skin over the bulge may be sacrificed, it is preferable to preserve the skin by creating either a laterally or medially based flap. This provides access to the bone which is removed with motor driven burrs. The techniques are essentially the same whether the approach is through the canal or from behind the ear.     

Creation of a quality of life instrument for nonmelanoma skin cancer patients

Objective: Malignancies of the skin are the most common cancers among humans. The cervicofacial region is most affected by cutaneous malignancies, with approximately 80% of nonmelanoma skin cancers (NMSC) occurring in the head and neck. Treatment of cervicofacial skin cancers also is more likely to result in significant patient morbidity, because of the functional and cosmetic importance of this region. Unlike other malignancies, skin cancer has not been well investigated in terms of patient quality of life (QOL) assessment. Furthermore, no validated disease‐specific QOL instrument currently exists for skin cancer. The aim of this study was to construct a new QOL instrument, The Facial Skin Cancer Index (FSCI), that captures the relevant QOL issues for NMSC patients. Study Design: Cross‐sectional study of patients presenting to a dermatologic surgery clinic with NMSC of the head and neck. Methods: For stage I, item generation, a sample of 20 patients with cervicofacial NMSC and six health care providers specializing in the care of NMSC patients completed semistructured interviews. For stage II, item reduction, a second sample (n = 52) of NMSC patients rated the items in terms of their importance for QOL among skin cancer patients. Domains of the FSCI were evaluated in terms of data quality, item variability, internal consistency, and range and skewness of scale score on aggregation and floor and ceiling effects. Results: A total of 71 distinct items were generated in stage I. After using the outlined item reduction techniques in stage II, the FSCI was reduced from 71 to 36 items, representing 6 domains. With the exception of Physical Functioning (alpha = 0.63) that suggested adequate reliability, all subscale scores showed excellent reliability coefficients, with Cronbach's alpha ranging from 0.78 (Lifestyle) to 0.87 (Social/Family). Conclusions: A new disease‐specific QOL instrument for patients with NMSC of the head and neck has been created. Validation studies are currently underway. Future directions will include sensitivity analysis to determine whether the FSCI is sensitive to change over time among patients undergoing treatment for NMSC.     

Cost‐effectiveness of a topically applied pre‐operative tissue expansion device for radial forearm free flaps: a cohort study1

Clin. Otolaryngol. 2011, 36 , 345–351 Objectives: The objective of this study is to test the hypothesis that using a non‐invasive and inexpensive pre‐operative tissue expansion device (DynaClose) for radial forearm free‐flap donor sites will result in a significant reduction in the cost of both in‐hospital and out‐of‐hospital wound care compared with that of unexpanded radial forearm free‐flap donor sites. Design: A cohort study consisting of patients previously randomised in a randomised controlled trial. An intention to treat design was utilised. Setting: A large tertiary care centre in eastern Ontario, Canada. Patients: Thirty‐four patients presenting to Otolaryngology Head and Neck clinic were enroled. Of these patients, 29 were previously enroled in a randomised controlled trial, while an additional five patients were enroled and randomised for the purpose of this study. Interventions: Patients were randomised to either the treatment (pre‐operative tissue expansion, DynaClose Expansion System) or control group. Main outcome measures: Wound care costs (in US dollars) were calculated for all patients for both in‐hospital care and for patients requiring home care. Non‐parametric data analysis was utilised for statistical assessment. Results: There was a 93% reduction in the use of split‐thickness skin grafts in the treatment group. There was a significant reduction in total wound care cost for patients in the treatment group versus the control group (P < 0.0001). Patients in the treatment group required a mean (SD) total of $36.00 (23.50) per patient, while the control group required $277.00 (325.00) of wound care. After excluding the cost of home care, the treatment group continued to have a significant reduction in total and in‐hospital wound care costs compared with the control group (P < 0.001). Conclusions: Using a simple, inexpensive and non‐invasive method of pre‐operative tissue expansion results in a significant reduction in the costs of wound care for both in‐hospital and out‐of‐hospital treatment. The DynaClose dynamic skin expansion system results in a cost‐effective method to reduce the need of a split‐thickness skin graft for coverage of a radial forearm free‐flap donor site.     

Laser resurfacing of silicone-injected skin: the "silicone flash" revisited

OBJECTIVE: To determine whether prior silicone injection increases the risks associated with carbon dioxide laser resurfacing. DESIGN: Laboratory determination of the effect of laser energy on liquid silicone; histologic evaluation of silicone-injected skin after lasing; and histologic demonstration of silicone deposits in all layers of dermis years after injection of silicone as filler fluid. SETTING: Tertiary care medical center. PATIENT-RELATED DATA: Histologic examination of freshly excised skin injected with microdroplets of liquid silicone and subjected to application of carbon dioxide laser energy; histologic examination of skin excised years after silicone injection. INTERVENTIONS: High-speed clinical photographic imaging of the effect of laser energy on silicone fluid; histologic examination of hematoxylin-eosin-stained sections of skin injected with liquid silicone and subsequently lased. MAIN OUTCOME MEASURES: Response of liquid silicone to application of laser energy; effect of this response on surrounding normal skin. RESULTS: Exposure of microdroplets of liquid silicone to carbon dioxide laser energy produced flaring with frank flame. Flaring of dermal silicone caused collateral skin damage. CONCLUSIONS: Prior injection with liquid silicone is a relative contraindication to cutaneous resurfacing with the carbon dioxide laser. Surgical excision of silicone-injected skin may be preferable for many patients. A strenuous needs assessment should be done, alternatives for skin rejuvenation considered, and comprehensive informed consent obtained from the patient before embarking on laser resurfacing of silicone-injected skin.     

Care of pediatric tracheostomy in the immediate postoperative period and timing of first tube change

ObjectiveTo analyze the safety of a standardized pediatric tracheostomy care protocol in the immediate postoperative period and its impact on tracheostomy related complications.Study designRetrospective case series.SubjectsPediatric patients undergoing tracheotomy from February 2010–February 2014.MethodsIn 2012, a standardized protocol was established regarding postoperative pediatric tracheostomy care. This protocol included securing newly placed tracheostomy tubes using a foam strap with hook and loop fastener rather than twill ties, placing a fresh drain sponge around the tracheostomy tube daily, and performing the first tracheostomy tube change on postoperative day 3 or 4. Outcome measures included rate of skin breakdown and presence of a mature stoma allowing for a safe first tracheostomy tube change. Two types of tracheotomy were performed based on patient age: standard pediatric tracheotomy and adult-style tracheotomy with a Bjork flap. Patients were analyzed separately based on age and the type of tracheotomy performed.ResultsThirty-seven patients in the pre-protocol group and 35 in the post-protocol group were analyzed. The rate of skin breakdown was significantly lower in the post-protocol group (standard: p = 0.0048; Bjork flap: p = 0.0003). In the post-protocol group, all tube changes were safely accomplished on postoperative day three or four, and the stomas were deemed to be adequately matured to do so in all cases.ConclusionA standardized postoperative pediatric tracheostomy care protocol resulted in decreased rates of skin breakdown and demonstrated that pediatric tracheostomy tubes can be safely changed as early as 3 days postoperatively.     

Butylcyanoacrylate tissue adhesive for columellar incision closure

Cosmetic outcome of the columellar incision closure in external rhinoplasty patients has been a subject of discussion. This study was conducted to assess whether tissue adhesives provide an alternative option for sutureless closure of columellar skin incisions for cases utilizing open technique rhinoplastic surgery. One hundred and one patients undergoing external rhinoplasty were randomized to either topical application of butylcyanoacrylate or polypropylene sutures for columellar skin closure. The majority of tension on the wound edges was taken up using 5-0 chromic catgut. Cosmetic outcomes were evaluated by two otolaryngologists independently using visual analogue and Hollander wound evaluation scales in a blinded manner. There was no statistically significant difference in cosmesis between the surgeons' evaluation scores for either type or repair of the columellar incision. Since the tissue adhesive forms its own protective barrier, post-operative care is simplified. Closure with adhesives eliminates the need for post-operative suture removal requiring an extra visit that should lead to more efficient use of physician and patient time. Butylcyanoacrylate performs cosmetically as well as standard suture closure of columellar skin incision used for external rhinoplasty.     

Giant basal cell carcinoma of the forehead with extensive intracranial involvement

Basal cell carcinoma (BCC) is the most common malignant skin lesion and is frequently curatively treated with local excision. Improper removal or neglect of BCC is a particular problem for head and neck surgeons. We describe a case of a recurrent BCC that aggressively grew from the forehead skin through the skull and into the frontal lobe. We also present a review of the literature. Despite its fairly benign growth pattern, BCC should never be underestimated, and care should be taken not only in the complete primary excision but also in cancer surveillance.     

Injuries of the external ear

Ear injuries occur in people of all ages but predominate in active people such as wrestlers, boxers, and bike riders. The types and extent of injury are a function of the force causing the injury. Shearing forces of moderate intensity cause hematoma formation, whereas greater force causes lacerations or even amputation. Sharp objects cause lacerations determined by the force, direction, and point of impact. The high ratio of surface area to mass makes the auricle vulnerable to extremes of temperature. People participating in high-risk activities should wear protective headgear. The goal of treatment is to restore the normal contours while preventing infection. Hematoma results in disfigurement by organization or chondritis. Evacuation and pressure dressings using sterile technique correct the condition. Second-degree burns are treated by regular cleansing and application of topical antimicrobials. Deeper burns require debridement, biologic dressings, or burying the cartilage subcutaneously for later reconstruction. Simple lacerations are closed under aseptic technique using either skin-to-skin sutures only or sutures of the skin combined with intercartilage sutures. Extensive and complex lacerations require meticulous care to match all fragments and prevent infection or loss of tissue. Bare cartilage must be covered with vascularized tissue. The treatment of total amputation is controversial. Some advocate reattachment as a composite graft using intravenous low molecular weight dextrans and heparin as adjuvants. Mladick dermabrades the amputated pinna, reattaches it with sutures, and then slips it into a pocket of elevated postauricular skin for 2 weeks. Others urge microvascular reanastomosis of the small nutrient vessels. Brent and Byrd separate the cartilage from its overlying skin and envelope it first with vascularized temporoparietal fascia and then a split-thickness skin graft. Chondritis is the most feared complication of injury or surgery of the pinna. It is an aggressive process, and prompt removal of pus and necrotic cartilage is required. Exteriorization and removal of all cartilage is effective but disfiguring. Removal of only affected cartilage and constant irrigation with antibiotic solutions is effective but requires prolonged hospitalization. Iontophoresis of antibiotics into the auricle may be effective and conserve tissue. Traumatic deformities are corrected with composite grafts from the opposite ear, costal cartilage, and local pedicled flaps.(ABSTRACT TRUNCATED AT 400 WORDS)     

Endpoint titration and immunotherapy

Inhalant allergy, or "atopy" as it is now termed, is the best understood form of allergy today. In some circles, it is the only recognized form of allergy. While an overall picture of its effects on the body and a reasonable approach to its treatment now exist, many problems remain to be solved and much improvement in its treatment will probably occur within the next several years. Many new approaches to treatment of aeroallergens are now available; however, all are compared with the skin test, which is and has been the baseline for testing and treatment. Endpoint titration provides a quantitative means for undertaking treatment of aeroallergen sensitivity. In no other way does it differ from the forms of skin testing that have been widely used for generations. The practitioners of endpoint titration feel that this difference is highly significant in simplifying, validating, and shortening the necessary period of therapy. While the concept of endpoint titration is not difficult, it is by definition a quantitative form of testing and requires a degree of expertise in performing it correctly. While a good understanding of the method may be gained from the literature, adequate hands-on experience should be obtained by any physician prior to instituting the technique as a treatment modality. Once mastered, it becomes a reliable baseline for all forms of inhalant allergy care.     

Several cases of emergency repair of loss of skin substance in the child (author's transl)]

Traumatic loss of skin substance in the child is uncommon. There are three main causes: dog bites, scraping lesions and bullet wounds. In all cases, great attention is paid to initial and early treatment of the wounds (exploration, wound care) under general anaesthesia. Provided the operator is competent, dog bites may be completely repaired from the outset. Lesions due to scraping or bullet wounds should be treated more cautiously with emergency treatment not necessarily seeking to achieve closure at any price.