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Dehiscence of the greater palatine Nerve. A risk factor in inferior turbinectomy?
ABSTRACTS
163
into the nasopharynx by means of a catheter that is sutured to the end of the uvula. The authors point out the effectiveness of the transoral approach with soft palate retraction for lesions of first and second cervical vertebra without splitting of the soft palate. However, more inferior lesions have required midline labiomandibular glossotomy for exposure. The procedures were performed in conjunction with the actual resection of the lesion, which was performed by neurosurgical colleagues. The authors point out several significant complications that can occur, primarily dehiscence of soft-palate closure or posterior pharyngeal wound breakdown with the risk of meningitis. Illustrations in this article are well worth reviewing if performance of a procedure via this route is contemplated.
cific diagnosis accurate in 51%. The ability to exclude malignancy (ie, specificity) was 96% and the frozen-section diagnosis was more accurate for benign tumors. The authors review the literature and note that sensitivity for the detection of malignancy has been reported to be as high as 99%. They point out that the sensitivity of approximately 70°, in their series was more likely to represent what would be expected in the typical pathology laboratory. They also point out that similar difficulties are found with fine-needle aspiration and that the use of both modalities did not assure the correct final diagnosis. Despite the shortcomings of the procedure, they recommend the routine use of both fine-needle aspiration and intraoperative frozen section to provide the maximum amount of preoperative and intraoperative information.
Osseous Free Flaps for Orbit and Midface Reconstruction. MA Schusterman, GP Reese, MJ Miller. Am J Surg 166:341-345, 1993
Dehiscence of the Greater Palatine Nerve. A Risk Factor in Inferior Turbinectomy? JF Sharp, GO O’Grady. Clin Otolaryngol 18:253-256, 1993
Although mandibular free flap reconstruction is performed frequently, only rarely are bonecontaining free flaps used for orbit and midface reconstruction. The authors review their series of 10 patients who have defects of the orbit and midface reconstructed with bone-containing free flaps. Osseointegrated implants that are placed in the transfered bone were successfully used in three patients and resulted in a stable platform for a maxillary prosthetic. However, the authors suggest that if the use of an osseointegrated prosthesis is contemplated in a patient who must receive radiotherapy, then reconstruction should be delayed until the radiotherapy is complete. They point out that the radial forearm flap was most useful for management of orbital defects because of the requirement for only a small amount of bone, whereas larger bone segments were required for maxillary reconstruction. By this report, the authors have further advanced the state of the art in the reconstruction of midface defects.
The authors relate a case in which a patient treated with inferior turbinate out-fracture with subsequent anterior turbinectomy and in-fracture of the remaining bone sustained anesthesia over the hard palate as far forward as the premaxilla. This is the distribution of sensory innervation of the greater palatine nerve. They then studied 64 cadaveric lateral nasal walls and found a dehiscence rate of 22% of the greater palatine nerve in the posteriorinferior meatus. In an additional 55% of the nasal walls studied, there was only a minimal bony covering to the nerve. The dehiscences occurred exclusively in the inferior meatus just anterior to the posterior bony end of the inferior turbinate. Although this high rate of dehiscence is at odds with clinical experience of a very low incidence of nerve damage after turbinectomy, the authors point out that even when the bone is dehiscent, the mediolateral dimension of the canal is usually much greater than the anteroposterior dimension, and the nerve lies laterally within the canal and is usually protected from injury. Moreover, the canal is encompassed by hard bone that is able to resist lateral pressure, unlike the inferior turbinate, which is easily fractured. The authors present a thorough anatomic study of an unrecognized anatomic variant that explains an unusual complication of an often performed procedure. Care should be taken in surgical manipulations perpendicular to the posterior-lateral nasal wall in the inferior meatus to avoid injury to the often dehiscent greater palatine nerve.
Accuracy of Frozen Section in the Evaluation of Salivary Tumors. KS Heller, JN Attie, S Dubner. AmJ Surg 166:424-427,1993 Assessing pathological diagnosis from intraoperative biopsies of salivary gland tumors submitted for frozen section can be difficult. The authors of this report review 310 biopsies submitted for frozen section for 333 patients undergoing removal of salivary gland masses. The sensitivity for the detection of malignant disease was 69%, with the spe-
BERRYLIN J. FERGUSON, MD
163
into the nasopharynx by means of a catheter that is sutured to the end of the uvula. The authors point out the effectiveness of the transoral approach with soft palate retraction for lesions of first and second cervical vertebra without splitting of the soft palate. However, more inferior lesions have required midline labiomandibular glossotomy for exposure. The procedures were performed in conjunction with the actual resection of the lesion, which was performed by neurosurgical colleagues. The authors point out several significant complications that can occur, primarily dehiscence of soft-palate closure or posterior pharyngeal wound breakdown with the risk of meningitis. Illustrations in this article are well worth reviewing if performance of a procedure via this route is contemplated.
cific diagnosis accurate in 51%. The ability to exclude malignancy (ie, specificity) was 96% and the frozen-section diagnosis was more accurate for benign tumors. The authors review the literature and note that sensitivity for the detection of malignancy has been reported to be as high as 99%. They point out that the sensitivity of approximately 70°, in their series was more likely to represent what would be expected in the typical pathology laboratory. They also point out that similar difficulties are found with fine-needle aspiration and that the use of both modalities did not assure the correct final diagnosis. Despite the shortcomings of the procedure, they recommend the routine use of both fine-needle aspiration and intraoperative frozen section to provide the maximum amount of preoperative and intraoperative information.
Osseous Free Flaps for Orbit and Midface Reconstruction. MA Schusterman, GP Reese, MJ Miller. Am J Surg 166:341-345, 1993
Dehiscence of the Greater Palatine Nerve. A Risk Factor in Inferior Turbinectomy? JF Sharp, GO O’Grady. Clin Otolaryngol 18:253-256, 1993
Although mandibular free flap reconstruction is performed frequently, only rarely are bonecontaining free flaps used for orbit and midface reconstruction. The authors review their series of 10 patients who have defects of the orbit and midface reconstructed with bone-containing free flaps. Osseointegrated implants that are placed in the transfered bone were successfully used in three patients and resulted in a stable platform for a maxillary prosthetic. However, the authors suggest that if the use of an osseointegrated prosthesis is contemplated in a patient who must receive radiotherapy, then reconstruction should be delayed until the radiotherapy is complete. They point out that the radial forearm flap was most useful for management of orbital defects because of the requirement for only a small amount of bone, whereas larger bone segments were required for maxillary reconstruction. By this report, the authors have further advanced the state of the art in the reconstruction of midface defects.
The authors relate a case in which a patient treated with inferior turbinate out-fracture with subsequent anterior turbinectomy and in-fracture of the remaining bone sustained anesthesia over the hard palate as far forward as the premaxilla. This is the distribution of sensory innervation of the greater palatine nerve. They then studied 64 cadaveric lateral nasal walls and found a dehiscence rate of 22% of the greater palatine nerve in the posteriorinferior meatus. In an additional 55% of the nasal walls studied, there was only a minimal bony covering to the nerve. The dehiscences occurred exclusively in the inferior meatus just anterior to the posterior bony end of the inferior turbinate. Although this high rate of dehiscence is at odds with clinical experience of a very low incidence of nerve damage after turbinectomy, the authors point out that even when the bone is dehiscent, the mediolateral dimension of the canal is usually much greater than the anteroposterior dimension, and the nerve lies laterally within the canal and is usually protected from injury. Moreover, the canal is encompassed by hard bone that is able to resist lateral pressure, unlike the inferior turbinate, which is easily fractured. The authors present a thorough anatomic study of an unrecognized anatomic variant that explains an unusual complication of an often performed procedure. Care should be taken in surgical manipulations perpendicular to the posterior-lateral nasal wall in the inferior meatus to avoid injury to the often dehiscent greater palatine nerve.
Accuracy of Frozen Section in the Evaluation of Salivary Tumors. KS Heller, JN Attie, S Dubner. AmJ Surg 166:424-427,1993 Assessing pathological diagnosis from intraoperative biopsies of salivary gland tumors submitted for frozen section can be difficult. The authors of this report review 310 biopsies submitted for frozen section for 333 patients undergoing removal of salivary gland masses. The sensitivity for the detection of malignant disease was 69%, with the spe-
BERRYLIN J. FERGUSON, MD