- Email: [email protected]
The use of moderate therapeutic hypothermia for patients with severe head injuries: A preliminary report
650 recovered sixth-nerve palsies without further testing. All seven of the presented nerve palsies resolved completely at least once without reduction of the underlying tumor. Although the yield of finding abnormalities will be low, the authors suggest neuroimaging be considered in all patients with sixth-nerve palsy without vascular or inflammatory disease.-P.S. LAM Reprintrequeststo Dr Less& Department of Ophthalmology, Mas-
CURRENT LITERATURE
effects on acute derangements of cerebral physiology and metabolism caused by closed head injury (although data analysis did not show the differences to be statistically significant). They recommend additional multicenter studies in the future.-R.E. ALEXANDER Reprint requeststo Dr Marion: Department of Neurological Surgery, Room F948, Presbyterian University Hospital, 230 Lothrop St, Pittsburgh, PA 15213.
sachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02 114. Tongue Reconstruction: Concepts and Practice. Haughey BH.
Saah D, Elidan J, Braverman I, et al. Ann Otol Rhino1 Laryngol 102:729, 1993
Traumatic Macroglossia.
Traumatic macroglossia is significant because of the rapidity of tongue enlargement and the airway obstruction it may cause. It develops in tongue-biting, (eclampsia, hypertensive crises, epileptic seizures) and maxillofacial trauma. A case of eclampsia requiring tracheostomy and steroid and antibiotic therapy necessitated reducing and restraining the tongue to arrest the cycle of venous and lymphatic obstruction and congestion that leads to further edema and tongue swelling. The protruding tongue, strangulated between the teeth, was mobilized, returned into the oral cavity, and restrained, reducing swelling in 48 hours.-G.H. SPERBER Reprint requests to Dr Saah: Department of Otolaryngology, Hadassah University Hospital, Jerusalem, Israel. The Use of Moderate Therapeutic Hypothermia for Patients With Severe Head Injuries: A Preliminary Report. Marion
DW, Obrist WD, Carlier PM, et al. J Neurosurg 79354, 1993 Animal research data suggest that the use of moderate therapeutic hypothermia in the first 24 hours after injury may improve outcome after severe closed head trauma, but efficacy has not been established in humans. This study is the first controlled, randomized, clinical study of this therapeutic approach in humans. Forty consecutively treated patients between the ages of 16 and 75 years with closed head injuries and Glasgow Coma Scale scores of 3 to 7. treated over a period of 18 months, were randomly assigned (nonblinded) to either a normothermic or hypothermic group for management. There were no statistical differences between the groups. Cooling was begun within 6 hours of injury in the hypothermic patients, using cold saline gastric lavage and cooling blankets, until a brain temperature of 33°C was reached. Patients were maintained between 32” and 33°C for 24 hours (the period of peak vulnerability to posttraumatic brain ischemia), then slowly rewarmed to 37” to 38°C over the next 12 hours. Temperatures were measured with a catheter containing two microthermistors that was inserted into the frontal horn of the lateral ventricle. Patients were paralyzed to prevent shivering Intracranial pressure, cerebral blood flow, and cerebral metabolic rate for oxygen were monitored in all patients and the results analyzed. Using the Disability Rating Scale and the Glasgow Outcome Scale outcomes were assessed 3 months after injury. Hypothermia significantly reduced intracranial pressures (40%) and cerebral blood flow (26%) during the cooling period and neither parameter showed significant rebound during tbe rewarming period. Three months after injury 60% of the patients in the hypothermia group had moderate, mild, or no disabilities, as compared with 40% of the normothermia patients. The incidence of complications was identical in both groups of patients. Two patients died during the study, both in the normothermia group. The authors conclude that moderate therapeutic hypothermia is safe and has sustained favorable
Laryngoscope 103: 1132, 1993 This retrospective study presented the concepts and techniques of tongue reconstruction using various procedures as well as a new latissimus dorsi free-flap design. Fifteen patients undergoing total or partial glossectomy for squamous cell carcinoma were presented. Fourteen patients were reconstructed with latissimus dorsi flaps; of these 11 were microvascular free tissue transfers and 3 were transaxillary pedicled flaps. In one case a radial forearm free flap was used. A new technique of latissimus dorsi procurement was presented which oriented the muscle fibers transversely to the long axis of the neotongue, and created a “cupula” anteriorly by a wedge resection of the anterior aspect of the graft. The incorporation of the thoracodorsal artery and nerve into the graft allows for standard microvascular and microneural anastamoses. The graft inset is performed from posterior to anterior in the floor of the mouth, with suspension laterally with the pharyngeal constrictors and the medial pterygoids to form a sling. Reinnervation of the graft is by means of the hypoglossal stump; no attempts at sensory reinnervation are made. Only three flaps failed, two of which were pedicled flaps. Postoperative evaluation of airway, swallowing, and articulation was favorable. Two patients underwent videooropharyngography that showed adequate neotongue movement and effective swallowing. The study also compared the function of the pedicled pectoralis flap with their latissimus dorsi free-flap design. The authors contend that the innervated latissimus dorsi llap allows better rehabilitation including decanulation, oral alimentation, and intelligible speech.-J.M. WEES
Reprint requests to Dr Haughty: Director, Division of Head and Neck Surgical Oncology, Department of Otolaryngology, Washington University School of Medicine, 5 17 S Euclid, Box 8115, St Louis, MO63110. Resistance to Osteoradionecrosis
in Neovascularized
Bone.
Mirante JP, Urken ML, Aviv JE, et al. Laryngoscope 103: 1168, 1993 The use of vascularized composite free flaps has become a widely accepted method for primary reconstruction of oromandibular defects. Success rates have been reported to be in the 95% range. The authors discuss a case report and the efficacy of using vascularized bone grafts and osseointegrated implants in areas that have undergone radiation therapy. A 59-year-old white man who was diagnosed with well-differentiated squamous cell carcinoma of the anterior floor of the mouth underwent a composite resection with removal of the anterior segment of the mandible, the floor, and ventral surface of the tongue. Bilateral modified neck dissections were performed. Reconstruction was performed using a combined internal oblique-iliac crest osteomyocutaneous free flap. Endosteal osseointegrated implants were placed into the iliac bone at the time of reconstruction. After 9 months of radiotherapy during which the patient received 50.4 Gy, the patient
CURRENT LITERATURE
effects on acute derangements of cerebral physiology and metabolism caused by closed head injury (although data analysis did not show the differences to be statistically significant). They recommend additional multicenter studies in the future.-R.E. ALEXANDER Reprint requeststo Dr Marion: Department of Neurological Surgery, Room F948, Presbyterian University Hospital, 230 Lothrop St, Pittsburgh, PA 15213.
sachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02 114. Tongue Reconstruction: Concepts and Practice. Haughey BH.
Saah D, Elidan J, Braverman I, et al. Ann Otol Rhino1 Laryngol 102:729, 1993
Traumatic Macroglossia.
Traumatic macroglossia is significant because of the rapidity of tongue enlargement and the airway obstruction it may cause. It develops in tongue-biting, (eclampsia, hypertensive crises, epileptic seizures) and maxillofacial trauma. A case of eclampsia requiring tracheostomy and steroid and antibiotic therapy necessitated reducing and restraining the tongue to arrest the cycle of venous and lymphatic obstruction and congestion that leads to further edema and tongue swelling. The protruding tongue, strangulated between the teeth, was mobilized, returned into the oral cavity, and restrained, reducing swelling in 48 hours.-G.H. SPERBER Reprint requests to Dr Saah: Department of Otolaryngology, Hadassah University Hospital, Jerusalem, Israel. The Use of Moderate Therapeutic Hypothermia for Patients With Severe Head Injuries: A Preliminary Report. Marion
DW, Obrist WD, Carlier PM, et al. J Neurosurg 79354, 1993 Animal research data suggest that the use of moderate therapeutic hypothermia in the first 24 hours after injury may improve outcome after severe closed head trauma, but efficacy has not been established in humans. This study is the first controlled, randomized, clinical study of this therapeutic approach in humans. Forty consecutively treated patients between the ages of 16 and 75 years with closed head injuries and Glasgow Coma Scale scores of 3 to 7. treated over a period of 18 months, were randomly assigned (nonblinded) to either a normothermic or hypothermic group for management. There were no statistical differences between the groups. Cooling was begun within 6 hours of injury in the hypothermic patients, using cold saline gastric lavage and cooling blankets, until a brain temperature of 33°C was reached. Patients were maintained between 32” and 33°C for 24 hours (the period of peak vulnerability to posttraumatic brain ischemia), then slowly rewarmed to 37” to 38°C over the next 12 hours. Temperatures were measured with a catheter containing two microthermistors that was inserted into the frontal horn of the lateral ventricle. Patients were paralyzed to prevent shivering Intracranial pressure, cerebral blood flow, and cerebral metabolic rate for oxygen were monitored in all patients and the results analyzed. Using the Disability Rating Scale and the Glasgow Outcome Scale outcomes were assessed 3 months after injury. Hypothermia significantly reduced intracranial pressures (40%) and cerebral blood flow (26%) during the cooling period and neither parameter showed significant rebound during tbe rewarming period. Three months after injury 60% of the patients in the hypothermia group had moderate, mild, or no disabilities, as compared with 40% of the normothermia patients. The incidence of complications was identical in both groups of patients. Two patients died during the study, both in the normothermia group. The authors conclude that moderate therapeutic hypothermia is safe and has sustained favorable
Laryngoscope 103: 1132, 1993 This retrospective study presented the concepts and techniques of tongue reconstruction using various procedures as well as a new latissimus dorsi free-flap design. Fifteen patients undergoing total or partial glossectomy for squamous cell carcinoma were presented. Fourteen patients were reconstructed with latissimus dorsi flaps; of these 11 were microvascular free tissue transfers and 3 were transaxillary pedicled flaps. In one case a radial forearm free flap was used. A new technique of latissimus dorsi procurement was presented which oriented the muscle fibers transversely to the long axis of the neotongue, and created a “cupula” anteriorly by a wedge resection of the anterior aspect of the graft. The incorporation of the thoracodorsal artery and nerve into the graft allows for standard microvascular and microneural anastamoses. The graft inset is performed from posterior to anterior in the floor of the mouth, with suspension laterally with the pharyngeal constrictors and the medial pterygoids to form a sling. Reinnervation of the graft is by means of the hypoglossal stump; no attempts at sensory reinnervation are made. Only three flaps failed, two of which were pedicled flaps. Postoperative evaluation of airway, swallowing, and articulation was favorable. Two patients underwent videooropharyngography that showed adequate neotongue movement and effective swallowing. The study also compared the function of the pedicled pectoralis flap with their latissimus dorsi free-flap design. The authors contend that the innervated latissimus dorsi llap allows better rehabilitation including decanulation, oral alimentation, and intelligible speech.-J.M. WEES
Reprint requests to Dr Haughty: Director, Division of Head and Neck Surgical Oncology, Department of Otolaryngology, Washington University School of Medicine, 5 17 S Euclid, Box 8115, St Louis, MO63110. Resistance to Osteoradionecrosis
in Neovascularized
Bone.
Mirante JP, Urken ML, Aviv JE, et al. Laryngoscope 103: 1168, 1993 The use of vascularized composite free flaps has become a widely accepted method for primary reconstruction of oromandibular defects. Success rates have been reported to be in the 95% range. The authors discuss a case report and the efficacy of using vascularized bone grafts and osseointegrated implants in areas that have undergone radiation therapy. A 59-year-old white man who was diagnosed with well-differentiated squamous cell carcinoma of the anterior floor of the mouth underwent a composite resection with removal of the anterior segment of the mandible, the floor, and ventral surface of the tongue. Bilateral modified neck dissections were performed. Reconstruction was performed using a combined internal oblique-iliac crest osteomyocutaneous free flap. Endosteal osseointegrated implants were placed into the iliac bone at the time of reconstruction. After 9 months of radiotherapy during which the patient received 50.4 Gy, the patient