A Royal Pain in the Throat Tinnitus - ENT & Allergy Associates

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Vo c a l Pr o c e s s Gr a n u l o m a :A Ro y a l Pa i n i n th e Th r o a t !C h a n d r a Iv e y, M.D.Chronic throat pain is occasionallycaused by a poorly understood anddifficult to treat problem known asa vocal process granuloma. The symptomsof a vocal process granuloma seem to appear“overnight” then quickly become annoyinglypersistent. Patients are typically first seenby their primary care physician and treatedfor an infectious cause. Weeks later, whenthey are not better, they are referred to anotolaryngologist for evaluation. Patients areoften placed on an anti-reflux regimen andasked to come back in two to four months.When the symptoms continue to persist, theotolaryngologist begins to introduce wordslike “voice abuse”, “BOTOX”, and “surgery”,much to the dismay of the patient.I began to wonder what I could tell thesepatients in order to help them understandthis “chronic” condition that causes them toclear their throats constantly during the day,and to hope that the next time they speakthey will not feel that annoying “tug” in theirneck. More importantly, I began to evaluatewhich therapeutic approach is the most optimalto recommend? In this article, I sharewhat I have learned from my experience.Vocal process granuloma has been calledmany different things throughout history,including “contact ulcer” and “pepticgranuloma” in reference to the possibleetiology of the condition. Traumatic orinflammatory conditions involving thevocal process of the arytenoid cartilage maycause disruption of the epithelium, alongwith ulceration and/or focal deposition ofgranulation tissue (Figure 1). This portion ofthe vocal cord has thin mucoperichondriumand a relatively tenuous blood supply whichputs this area at risk for damage. The useof the word “granuloma,” however, ismisleading, as there are only occasionallymulti-nucleated giant cells present – the cellsthat are pathognomonic for true granulomaformation in mycobacterial infection orsarcoidosis. Instead, histologic analysis of thearea displays granulation tissue in association6with acute and chronic inflammatorycells, angioneogenesis and fibrocytes. Alesion may display a disrupted or ulceratedepithelium under the area of granulation(thus the term contact ulcer) or a thin intactepithelial surface expanded outward withdeposition of granulation underneath (thusthe rounded granuloma) 1 . These histologicabnormalities can be accompanied bysclerotic changes of the arytenoid cartilage,or degenerative chronic perichondritiswithin the cricoarytenoid joint. Thesecartilaginous changes may themselvescontribute to granuloma formation byaltering the joint movement or furtherworsening circulation. These underlyingchanges can also impact treatment, as theycannot be reversed and may contribute torecurrence despite appropriate managementat the mucosal level.Vocal process granuloma most often impactsthe cartilaginous portion (respiratory part)of the true vocal fold more than the membranousportion (vibratory part). Therefore,unless large, patients more commonly complainof throat clearing, globus sensation,cough, odynophonia and odynophagia sincethe granuloma may not disrupt the mucosalwave. However, a change in the quality ofvoice and fatigue while speaking can occasionallyoccur. If the area involved is small,patients may even be asymptomatic. A localizedsensation rather than a general burningor discomfort in the throat also suggestsgranuloma rather than other pathology

(such as LPR or sensory neuropathy). Anaccurate diagnosis is aided by a history ofa recent URI or severe cough, reflux, vocaltrauma/abuse, or recent intubation.The two main hypotheses for pathogenesisof vocal process granuloma – neither ofwhich is likely the full story – are (1) chemicalinjury, and (2) mechanical injury to thesite 2 . Research on chemical injury to the sitehas focused on the role of laryngopharyngealreflux in damaging the tissue of the posteriorglottis. In 1980, Ward et al describedpatients with granuloma as “hard driving,tense people who are likely to be late eaters,heavy drinkers, banquet attendees, andspeakers” 3 . One common thread betweenthese behaviors is the increased likelihood ofacid reflux. When asked, patients will oftengive a history of either having typical heartburnsymptoms or symptoms suggestinglong term reflux, such as globus sensation,chronic cough, throat clearing, and thickmucus. Dual pH probe testing has shownthat pharyngeal reflux is more likely to befound in patients with granuloma; 17 of 26patients with granuloma had positive exams(65%) versus five of 19 controls (26%) 4 . Itwas also found that those subjects with granulomahad more frequent reflux episodes,and that these episodes were predominantlywhile standing, not while lying supine. Perhapsthe most explicit evidence to supporta role for chemical injury was published byDelahunty and Cherry in 1968, where theauthors applied gastric juice to the vocalprocesses of dogs and were able to inducegranuloma formation 5 .While these studies helped to solidify therole of refluxate in the formation of vocalprocess granuloma, otolaryngologists oftensee patients with evidence of severe refluxwithout an accompanying granuloma orulcer. In addition, there are studies thatreveal that treating granulomas with protonpumpinhibitors, even in conjunction withother treatment modalities, is successful inless than 50% of cases 6 . Thus, reflux cannotalways be the primary etiologic factor.Mechanical injury of some kind is thoughtto be necessary for the formation of thislesion. Since the innovation of flexibleendotracheal tubes in the early 20th centuryreports of granuloma formation have beenassociated with their use. Endotrachealtubes are positioned to lie between thecartilaginous larynx and the vocal process.Figure 1: Typical appearance of a vocal processgranuloma.Figure 2a: Intubation granuloma of the right vocalprocess.The resultant pressure is thought to quicklycompromise circulation in the thin mucosacausing erythema and ulceration 7 . Longtermintubation also has the capability ofdisrupting the perichondrium and causingsclerosis of the arytenoid or cricoarytenoidjoint. Damage to the vocal process occursmore frequently after intubation with a largediameter tube, simultaneous nasogastric tubeplacement, and with difficult intubation 8 .Intubation granuloma was shown totypically occur approximately four weekspost-intubation and was more commonin females than males, while granuloma ingeneral was more common in males (Figure2). Other studies claim that intubationassociatedgranulomas tend to have a lowerrecurrence rate, even after surgical excision 6 .Most granuloma formation does not occurin association with intubation. Traumafrom speaking patterns (phonotrauma) orfrom chronic cough is thought to be a morecommon contributor to vocal process lesions.Cough, while some argue as to whether itis the proverbial chicken or egg, leads toplosive apposition of the vocal processes in arepetitive fashion. Regardless of the etiologyof cough (infection, reflux, post-nasal drip,Figure 2b: Resolution of granuloma after voice rest, PPI,and four weeks of inhaled steroids.Figure 3: Vocal cord papilloma with the appearance ofbilateral vocal process granuloma. In diagnostic uncertainty,biopsy is indicated.or the presence of the granuloma itself), itcan cause, maintain, or worsen granuloma.Phonotrauma has been found frequentlyto be associated with these lesions. Thesepatients exhibit monotonous vocal patterns,low fundamental frequency, vocal frye, andlaryngeal hyperfunction (muscle tensiondysphonia and hard vocal stops) 9 . Vocaltherapy techniques that slightly elevatethe fundamental, reduce frye, and reducemonotony in the speaking voice havebeen successful in reducing the size of thegranuloma and the associated symptoms.Visual and sensory feedback techniques thatassist patients in speaking without allowingthe vocal processes to fully AD-duct havealso produced very good results 10 .Since multiple predisposing factors arelikely necessary for granuloma to occur,treatment algorithms must address the twomost significant factors, vocal cord traumaand reflux, or the likelihood for successdecreases substantially. Treatment modalitiesinclude anti-reflux regimens (medical andbehavioral), voice therapy, voice rest, cough7

suppression, steroid therapy, Botulinumtoxin A (“BOTOX”) therapy and, finally,surgical excision.Kaufman and colleagues suggest the use ofdouble dose treatment with PPIs (30 minutesprior to breakfast and dinner) 11 . Behavioralmodifications include reduction of certainfoods, including citrus and tomato basedproducts, as well as caffeine, chocolatesand mint. Cessation of eating at least twoto three hours before lying supine helps todecrease refluxate. Kaufman has also recentlydiscussed the role of smoking in promotingrefluxate and has shown pH evidence of acidin the pharynx after smoking (unpublishedGrand Rounds discussion, New York Eye andEar Infirmary). While some studies notedless than 50% improvement in granulomaafter these modifications, this may be dueto inadequate length of treatment; Kaufmannoted that granuloma often took six to eightmonths to resolve – much longer than mostphysicians and patients are tolerant enoughto wait 12 . Often, even after resolution, antirefluxprecautions need to be continued toprevent recurrence of the lesion.Reduction in vocal cord mechanical traumais also imperative for the management ofgranuloma. Months of voice rest used to betraditional treatment for this ailment and oftenproduced good, albeit short-lived, results.Unfortunately, most patients are unable toadequately self-limit their speaking for morethan a few days and are often unable to stoptalking due to the demands of their professions.The voice therapist is a useful assistant,both in terms of vocal retraining exercises,as well as to monitor (i.e., police) vocal8abuse patterns. As previously discussed,some forms of voice therapy have been documentedto reduce the size and symptoms ofgranulomas, and often the retraining of vocalmonotony, frye, and fundamental frequencycan help to decrease recidivism.Vocal retraining may also assist in breakingthe cycle of cough and throat clearingif these behaviors have become habitual.When cough is due to reflux, allergy, andpostnasal drip, treating the underlying etiologyis extremely important and, in myopinion, is one of our most common areasof failure. Aggressively treating allergy andnasal drainage, as well as prescribing inhaledsteroids and cough syrups can significantlyimpact cough and may be performed forshort periods of time. While not advocatedby all laryngologists, inhalant steroids usedin aspirate voice (in order to AD-duct thevocal cords while inhaling the medication)can deposit the anti-inflammatory agent directlyon the larynx. While oral steroid usehas not shown to impact recurrence rate, onegroup showed resolution in 85% of thosewho had received topical steroid for intubationgranuloma versus only 43% of thosewho had not 13,14 . Patients must rinse theirmouths after the use of steroid, and theyshould be evaluated periodically for fungalovergrowth. Intra-lesional steroid injectionis another option that may assist in decreasinggranulation and fibrin production thusassisting in the resolution of the granuloma.The use of BOTOX for treatment of vocalprocess granulomas may be useful in casesthat have not responded to treatment aftereight to twelve months. The main goal ofBOTOX use is to decrease AD-duction,reducing contact trauma between the vocalprocesses for a prolonged period of time(two to three months), allowing for healingand resolution of the granuloma 15 . This canbe performed unilaterally or bilaterally, andit has been used alone or in conjunctionwith conservative surgical excision.Candidates for BOTOX are patients whowere either unable to adequately utilizetheir vocal retraining or may have otherpoor prognosticators for healing, such as asclerotic arytenoid.Surgical excision is rarely used to treat vocalprocess granuloma because the lesion tendsto recur after excision. Some advocateoperative intervention only in cases of airwayobstruction or when diagnostic dilemmais present. Very rarely, papilloma (Figure3), sarcoma, carcinoma, or sarcoid canimitate granuloma 16 . Others contend thatafter failed “conservative” therapy, surgicalintervention for intubation granulomashows less recurrence than those from otheretiologies 6 . If excision is considered, a smallendotracheal tube or a jet ventilator shouldbe considered to minimize surgical trauma.Also, removing granulation without causingfurther trauma to the perichondrium isnecessary. Some feel that this should onlybe performed using a cold-knife techniquesince CO2 laser excision may cause thermalinjury to the surrounding tissue. In-officetrans-oral removal of pedunculated lesions,repeat partial excision of larger lesions,in-office KTP or PDL laser ablation ofthe granuloma, have also been recentlydescribed 17 . These mechanisms couldpotentially cause involution of the lesion bydestroying angioneogenesis supporting thegranulation tissue. It is also important torecognize that pedunculated lesions, withtime, may autoinfarct and be cleared withcough from the airway, leaving a muchsmaller lesion.So what do we tell our patients? Whilesome causes are more straightforward thanothers, curing the disease is never a certainty.Helping the patient understand all of thepossible factors involved in the etiology of– and also the reasons for persistence of –the granuloma can create an ally during thearduous treatment course. Initially settingthe course of therapy at a minimum of sixmonths gives the patient a realistic time framewithin which to evaluate progress. Stressingthe fact that in these cases, surgery (“can’t

you just take it off?!!”) could possibly worsenthe situation, will help the patient come toterms with the multi-modality treatmentthat is recommended (e.g., voice therapy,medication, behavioral modification).With this treatment regimen, studies haveshown that 88% of patients have partial orcomplete resolution of their symptoms, andonly 12%of patients become truly chronic 18 .With time and patience, the proverbial“pain in the throat” doesn’t have to leave abad taste in your mouth.REFERENCES1. Haggit RC. Histopathology of refluxinducedesophageal and supraesophagealinjuries. Am J Med 2000; 108 (Suppl4a):109S-111S.2. Hoffman HT, et al. Vocal processgranuloma. Head and Neck 2001; 23:1061-1074.3. Ward PH et al. Contact ulcers andgranulomas of the larynx: new insights intotheir etiology as a basis for more rationaltreatment. Otolaryngol Head Neck Surg1980; 88:262-269.4. Ylitalo R and Ramel S. Extraesophagealreflux in patients with contact granuloma:a prospective controlled study. Ann OtolRhinol Laryngol 2002; 111(5 Pt 1):441-46.5. Delahunty JE and Cherry J.Experimentally produced vocal cordgranulomas. Laryngoscope 1968; 78:1941-1947.6. Lemos EM, et al. Vocal process granuloma:clinical characterization, treatment andevolution. Rev Bras Otorrinolaringol 2005;71:494-498.7. Jackson C. Contact ulcer granulomaand other laryngeal complications ofendotracheal anesthesia. Anesthesiology1953; 14:425-436.8. Santos PM, Afrassiabi A, and WeymullerEA Jr. Risk factors associated with prolongedintubation and laryngeal injury. OtolaryngolHead Neck Surg 1994; 111(4):453-459.9. Ylitalo R, and Hammarberg B. Vocecharacteristics, effects of voice therapy, andlong-tern follow-up of contact granulomapatients. J Voice 2000;14(4):557-566.10. Leonard R, and Kendall K. Effects ofvoice therapy of vocal process granuloma:a phonoscopic approach. Am J OtolaryngolHead Neck Surg 2005; 26:101-107.11. Zeitels SM et al. Management ofcommon voice problems: Committeereport. Otolaryngol Head Neck Surg 2002;126(4):333-348.12. Koufman JA. Contact ulcer andgranuloma of the larynx. Curr TherOtolaryngol Head Neck Surg 1994; 5:456-459.13. Jaroma M, Pakareinen L, and NuuteinenJ. Treatment of vocal cord granuloma. ActaOtolaryngol 1989; 107:296-299.14. Roh HJ et al. Topical inhalant steroid(Budesonide, Pulmicort Nasal) therapy inintubation granuloma. J Laryngol Otol1999; 113(5):427-432.15. Nasri S et al. Treatment of vocal foldgranuloma using boulinum toxin type A.Laryngoscope 1995; 105:585-588.16. Devaney KO, Rinaldo A, and FerlitoA. Vocal process granuloma of the larynx—recognition, differential diagnosis andtreatment. Oral Oncology 2005; 41:666-669.17. Clyne SB et al. Pulsed dye laser treatmentof laryngeal granulomas. Ann Otol RhinolLaryngol 2005; 114:198-201.18. Emami AJ et al. Treatment of laryngealcontact ulcers and granulomas: a 12-year retrospective analysis. J Voice 1999;13(4):612-617. •9

Ti n n i t u sR i c h a r d Ro s e n b e r g , M.D., F.A.C.S.Tinnitus is a problem faced by approximately15% of the Americanpopulation, or 50 million individuals.It is more commonly noted in theelderly and hearing loss is the greatest riskfactor. Men seem to perceive it more oftenthan women. The problem can vary greatlyin the severity of the symptom and, at times,can be very challenging to treat. Here is abrief review of the disease, along with suggestionsregarding treatment.Tinnitus is generally divided into twosubtypes: objective and subjective. Objectivetinnitus is composed of sounds that can berecorded or heard by a listener. The soundmay be pulsatile. The differential diagnosisof pulsatile tinnitus includes the following:1) Turbulent blood flow in an artery2) Arterial-venous malformation3) Valvular heart disease, usuallyaortic stenosis4) Vascular tumor in and aroundthe skull5) Severe anemia6) High cardiac output of any causeMuscle contractions can also cause objectivetinnitus. This is observed in palatal myoclonusand with stapedial or tensor tympanimuscle spasm. Theoretically, spontaneousOtoacoustic emissions (OAEs) may causeobjective tinnitus. OAEs are secondary tospontaneous vibrations of the cilia on the outerhair cells of the cochlea (inner ear). Eustachiantube insufficiency can present as a “blowingtinnitus” coinciding with respiration.Treatment of objective tinnitus is directedat the exact causal nature of the problem.Those causes that are more physiologicthan pathologic may be treated by reassuranceto the patient of the benign nature ofthe problem.Subjective tinnitus is much more common.It is characterized by a false perception ofsound in the absence of an environmentalsource. It may be described as a ringing,hissing, buzzing, cricket-like, or hummingsound. The etiology of subjective tinnitusis unknown, but there are many theories.There is little evidence that abnormalities ofthe cochlea (inner ear) are directly involvedin tinnitus generation. Injuries involvingthe auditory nerve are very likely the causeof tinnitus. These injuries may be vascular,metabolic, pharmacologic, traumatic, orhormonal in origin. Tinnitus may be due11

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Daniel Grinberg, M.D., F.A.C.S.Otolaryngology & Head and Neck SurgeryWest NyackJohn Huang, M.D., F.A.C.S.Otolaryngology & Head and Neck SurgeryOradell and West NyackMichael Hugh, M.D.Allergy, Asthma and ImmunologyMount Kisco and CarmelChandra Ivey, M.D.Otolaryngology & Head and Neck SurgeryMount Kisco and Gramercy ParkJeffrey Jablon, M.D., F.A.C.S.Otolaryngology & Head and Neck SurgeryFacial Plastic and Reconstructive SurgeryPurchase and New RochelleMitchell Kolker, M.D.Otolaryngology & Head and Neck SurgeryNewburgh and FishkillDavid Lawrence, M.D., F.A.C.S.Otolaryngology, Head and Neck SurgeryPurchaseJonathan Lesserson, M.D.Otolaryngology & Head and Neck SurgeryHackensack and OradellMarc J. Levine, M.D., F.A.C.S.Otolaryngology & Head and Neck SurgeryWest NyackGuy Lin, M.D.Otolaryngology & Head and Neck SurgeryFacial Plastic and Reconstructive SurgeryEast SideJohn Parrinello, M.D.,F.A.A.A.A.I., F.A.C.A.A.I.Allergy, Asthma and ImmunologyNewburghGeorge Pazos, M.D.Otolaryngology & Head and Neck SurgeryCarmel and Yorktown HeightsPreshant Ponda, M.D.Allergy, Asthma and ImmunologyNewburgh and FishkillTheresa Quilop, M.D.Allergy, Asthma and ImmunologyBronxJayanti Rao, M.D.Allergy, Asthma and ImmunologyTuckahoe and YonkersSteven Sacks, M.D, F.A.C.S.Otolaryngology & Head and Neck SurgeryEast SideJohn Sadowski, M.D.Otolaryngology & Head and Neck SurgeryWest NyackJohn Scheibelhoffer, M.D., F.A.C.S.Otolaryngology & Head and Neck SurgeryFacial Plastic and Reconstructive SurgeryWayneDaniel Scher, M.D.Otolaryngology & Head and Neck SurgeryWayne and CliftonFrank Shechtman, M.D.F.A.C.S.Otolaryngology & Head and Neck SurgeryWhite PlainsDhar Sreepada, M.D.Otolaryngology & Head and Neck SurgeryWayneGerald Suh, M.D.Otolaryngology & Head and Neck SurgeryYonkers and BaysideMichael Tom, M.D., F.A.C.S.Otolaryngology & Head and Neck SurgeryYonkersStanley Yankelowitz, M.D.Otolaryngology & Head and Neck SurgeryBronxHale Yarmohammadi, M.D., MPHAllergy, Asthma and ImmunologyGramercy Park and Wall Street17

O u r Ph y s i c i a n Pr o f i l e s ( c o n t i n u e d )Irene Yu, M.D.Otolaryngology & Head and Neck SurgeryNew Rochelle and PurchaseRichard Yung, M.D., F.A.C.S.Otolaryngology & Head and Neck SurgeryFacial Plastic and Reconstructive SurgeryWhite PlainsJill Zeitlin, M.D.Otolaryngology & Head and Neck SurgerySleepy HollowSeasoned professionals on the leading edge of healthcare...dedicated to clinical excellence, one patient at a time.ENT a n d Al l e r g y We l c o m e s Ne w Ph y s i c i a n sAndrew L. Blank, M.D., F.A.C.S.Otolaryngology & Head and Neck SurgeryBaysideGerald Fenster, M.D.Otolaryngology & Head and Neck SurgerySomervilleJohn Freiler, M.D.Allergy, Asthma and ImmunologyParsippany and SomervilleMichael Gordon, M.D., F.A.C.S.Otolaryngology & Head and Neck SurgeryGarden City and BaysideAmy D. Lazar, M.D.Otolaryngology & Head and Neck Surgery,Facial Plastic and Reconstructive SurgerySomervilleBrian Lebovitz, M.D., F.A.C.S.Otolaryngology & Head and Neck SurgeryParsippanyKenneth Kunzman, M.D.Otolaryngology & Head and Neck SurgerySomervilleRobert Marchlewski, M.D., F.A.A.P.Allergy, Asthma and ImmunologyGarden City and BaysideMichael G. Mendelsohn, M.D.,F.A.C.S., F.A.A.P.Otolaryngology & Head and Neck SurgeryGarden CityHeather C. Nardone, M.D.Otolaryngology & Head and Neck SurgeryParsippanySheldon Palgon, M.D.Otolaryngology & Head and Neck SurgeryWall Street, Bensonhurst and Bay RidgeCharles M. Schultz, M.D.Otolaryngology & Head and Neck SurgeryParsippanyJason Surow, M.D., F.A.C.S.Otolaryngology & Head and Neck SurgeryMahwahJared M. Wasserman, M.D.,Otolaryngology & Head and Neck SurgeryOradell, Englewood and WayneKaren Wirtshafter, M.D.Otolaryngology & Head and Neck SurgeryParsippany18

St i c k s , St o n e s a n dB r o k e n Bo n e sM i c h a e l Sh o h e t , M.D., F.A.C.S.Fall is upon us. With that, we see anincrease in the incidence of pediatrictrauma. Since a high percentage ofthis involves the head and neck area, thismay be a worthy time to review some importantissues regarding facial trauma in theyounger population.Fortunately, craniofacial skeletal trauma isquite rare in children. This is due to therelative composition of cancellous to corticalbone, and to the high cranial to facial ratio.However, as children grow they become moresusceptible to injuries. In early childhood,there are few primary teeth and smallpermanent tooth buds. As a child growsinto the mixed dentition stage, the mandiblebecomes more susceptible to fracture due tomore teeth and developing tooth crypts.The development of paranasal sinuses atapproximately 5 years of age further weakensthe bones. This weakness allows for themidface to be fractured or separated from thebase of the skull with trauma. Increasingly,popular sports activities add to the numberof facial injuries. Children and teenagersnow drive multi-speed bicycles, dirt bikes,and off-road vehicles. This contributes tothe frequency of facial injuries.Reconstruction of pediatric facial fractures,including those involving the orbit, themidface, and the mandible, requires anunderstanding of craniofacial developmentas well as the consequence of injury on futuregrowth. The patterns of facial fracture notonly differ significantly between adults andchildren, but also among children of differentages. Some of the treatment strategies forfacial fractures in adults and children aresimilar. Some algorithms used in adultsadversely affect craniofacial development.There is also controversy regarding thetiming of repair in children. Nevertheless,intraoperative CT scanning, craniofacialexposure, bone grafting, stereotactic imageguidance and the advent of resorbable rigidhave advanced our ability to reconstructeven the most complex 3D disfigurements.These techniques have reducedthe late sequelae of severe facialfractures.Fractures of the nose are relativelycommon in children. Two-thirdsof nasal fractures are minimallydisplaced and do not requiresurgery. Other injuries aroundthe nose are possible and shouldnot be overlooked. A septalhematoma can cause septalnecrosis and perforation. Forthis reason, if a nasal fracture issuspected, a thorough examinationof the internal and external nasalstructures is warranted. In highimpact trauma with persistentrhinorrhea, cerebrospinal fluidfistula deserves consideration.CSF leaks can typically berepaired by minimally invasiveendoscopic techniques if they donot resolve spontaneously. As inadults, displaced nasal bone andseptal fractures are reduced andstabilized with splints, thoughreduction should be performedsooner in children than in adults.In order to treat lacerations, burns, andother soft tissue trauma properly, oneneeds knowledge of basic wound physiology.Many options for wound closure exist,and the option chosen depends on thetype of wound. The ultimate goal is to obtainthe ideal functional and cosmetic resultwithout complications. This can often beaccomplished without transcutaneous suturesthus obviating suture removal. Multilayeredclosure utilizing high retensionresorbable monofilaments with or withoutcyanoacrylate is one option for managing facialwounds of moderate depth. Meticuloushandling of the soft tissues with thoroughwound cleaning is essential.Tetanus prophylaxis must be considered.A wound is considered tetanus-prone if ithas any of the following features: age ofwound greater than 6 hours, stellate woundor avulsion, depth of wound greater than1 cm, missile, crush, burn, or frostbite injuries,presence of infection, devitalized tissue,or contaminants.If there is one message worthy of relaying,it is the importance of timeliness in thediagnosis and management of both softtissue and skeletal facial injuries. As bothwound healing and fracture fixation isaccelerated in youth, the negative impact oflate management is substantially magnified.Pediatricians and family practitioners aretypically the first line of care and should haveaccess to a facial plastic surgeon on a promptbasis. Most otolaryngologists are qualified toassess these injuries and can direct the mostappropriate care for the patient. Expertmanagement of even the most complexsituations is just a phone call away. •19

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“Pe a r l o f t h e In d i a nO c e a n” S r i La n k aNa g a l i n g a m Je y a l i n g a m , M.D.Sri Lanka, the island nation formerlyknown as Ceylon -- “Pearl of the IndianOcean”-- is the home to over20,000,000 people. Its lush tropical forests,white sandy beaches and breathtaking landscapeare a paradise destination for honeymooners,golfers and adventure seekersworld wide. Vacationers at Sri Lanka’s manybeachside resorts are often impressed at howquickly much of the island recovered fromthe devastating tsunami that killed hundredsof thousands of people on December 26,2004. The shoreline had been destroyed.The tsunami was the result of the secondlargest earthquake ever recorded in seismographichistory, measuring 9.3 on the Richterscales. It lasted so long in duration that itsfive-minute life span caused the entire earthto vibrate at least half an inch and triggeredearthquakes as far away as Alaska.Restoration has been a slow tedious process.With the help of private industry, moniescollected by the Red Cross, and othergovernment agencies, the tourist industryis booming. People in the tsunami tornvillages and cities are slowly moving out oftemporary housing facilities and back intohomes. Unfortunately for one group, the SriLankan Tamils, a normal life is just a dream.Since the 1980’s, political unrest compoundedby a Tamil separatist movementled by the Liberation Tigers of Tamil Eelam(LTTE) has caused the Government of SriLanks to discriminate against the Sri LankaTamils, labeling them all “terrorists” or “ter-21

orist affiliated”. In the past 20 years, asmany as forty thousand Sri Lankan Tamilshave been displaced. Some lost their homesas a result of the military activity betweenthe government and the LTTE; others losteverything after the tsunami. They continueto live in prison like conditions in governmentcamps. They are unable to return totheir livelihoods or resume any normal life.They depend on the government for theirfood, water, and medical treatment. Theyhave been denied tsunami aid money.Newburgh, New YorkDr. Nagalingam Jeyalingam, “Dr. Jey” tothose who know him well, leaves his familyhome overlooking the Hudson River andboards a plane--destination Sri Lanka. Heis not packing sunscreen or golf clubs. Hewill not be checking into the local HiltonResort Hotel.By birth, he is a Sri Lankan Tamil, an ethnicgroup whose recorded history goes back morethan two thousand years. Dr. Jey graduatedin 1968 from the Medical College of theUniversity of Colombo, located in the largest22city in Sri Lanka, before coming to the UnitedStates. He is no stranger to this land.This is not Dr. Jey’s first medical missionto Sri Lanka and it will not be his last. Heis a determined man, a well respected EarNose and Throat specialist who has cared forthousands in the Hudson Valley over the lasttwenty-five years. He makes this journeywith a heavy heart, knowing that as muchas he accomplishes in his two-week mission,it will not be enough to relieve the suffering

and despair of the Sri Lankan Tamils livingin the northeastern part of the island.Dr. Jey says that the government has wronglylabeled all the Tamils in that region as terrorists.He believes that it is unconstitutional towithhold aid from people who want nothingmore than to return to work and resume anormal life with their families. Dr. Jey andhis daughter, Brintha, have traveled to thewar zone created between the LTTE and theSri Lankan government, at great risk to themselves.They have witnessed the starvation,lack of healthcare and sparse living conditionsforced upon these people. Dr. Jey oftenworries that their situation will not improve.After what seems an endless flight, Dr.Jey disembarks the plane in the city ofColombo. He hires vehicles to transportthe medical supplies and equipment thegovernment inspectors allow him to carry.On his last visit, he was not allowed to carryhis luggage, which contained medicine hebrought from his own medical practice. Heand other volunteers traveled through sixhoursof rough terrain, hampered by severalcheckpoints, before reaching the hospital.His patients may walk over two hours to seehim. Some days he sees as many as seventypatients. Those who have traveled far formedical care often camp outside the hospitaluntil the next day.Dr. Jey sees children with chronicallydraining ears from untreated ear infections.The cases are so severe that some have leadto deafness. He has seen patients who haveruptured ear drums caused by constantbombing of buildings, even schools thatare filled with innocent children, which arebelieved to be terrorist training camps. Dr.Jey speaks of atrocities against his peoplewith such energy and passion it is clear hecarries their future with him everywhere.He teaches local doctors and nurses howto perform follow up care while he is gone.He trains them on the use of the medicalequipment donated by the Cornwall-StLukes Hospital. However, he knows thatmost of these patients, who risk their livescoming to the hospital in the first place,won’t return for follow-up care. There areno weekly appointments or recheck visitsfor them. No refills of medication to callin to a pharmacy. For many, even aftermedical treatment from Dr. Jey and theother volunteers, their conditions continueto worsen.Dr. Jey envisions that one day the sufferingwill end but he does not know when. Untilthen he will continue to collect medicineand medical equipment for his next trip toSri Lanka, and to make a difference in thelives of Sri Lankan Tamils the best way hecan for now, one patient at a time. •Courtesy of Julia McGuire, “The Sentinel”(revised for republication)23

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“Wh a t ’s in a No s e ?”A h i s t o r i c a l r e v i e w a n d u p d a t e o nT h e u s e o f g r a f t s a n d i m p l a n t s i n rh i n o p l a s t yG u y Li n, M.D.Rhinoplasty is the 6th most commoncosmetic surgical procedure performedin the United States. Sincethe overall number of cosmetic proceduresperformed in this country continues to rise,physicians are faced with a growing numberof dissatisfied patients who present withcosmetic or functional complaints related toprevious rhinoplasty. Revision rhinoplastycan be performed to resolve a patient’s complaint,but only if there is an understandingof what material was used during the originalreconstructive procedure.Historically, the art of improving deformitiesof the nose by means of surgery was onlyunderstood in the context of reconstructionof a mutilated nose. The earliest recordedpublication that refers to rhinoplastyin an aesthetic context was in 1845, byDieffenbach. By the early twentieth century,American surgeons, John Roe and RobertWeir, as well as the German surgeon, JacquesJoseph, were simultaneously pioneering theart of performing cosmetic rhinoplasty.The surgeons developed their techniqueswithout knowledge of the work being doneon opposite continents. A current literaturesearch (at the time of this writing) lists 5343articles with the keyword “rhinoplasty”. Thiswealth of information has helped transformthe art of rhinoplasty into a science.The goal of rhinoplasty is achieving nasalbalance and establishing harmony withthe face while preserving a functionalnasal airway. Historically, rhinoplasty wasmostly reductive surgery. The aestheticideal has shifted to creating a natural lookwith long-term stability. This is achievedthrough a combination of reduction andaugmentation techniques, with an emphasison preservation of the existing frameworkof the nose. Graft and implant materials inrhinoplasty are used primarily to strengthenthe structural framework, to provide contouror camouflage defects, and to restore thenose to an aesthetic ideal.The ideal graft or implant material is biocompatibleand possesses physical propertiesand long-term stability devoid of complications.There are three broad categories ofgraft and implant materials that are currentlyavailable for rhinoplasty: autografts(derived from the patients own tissues);homografts (derived from tissues obtainedfrom a different donor of the same species);and alloplasts (implants that are either semisyntheticor entirely synthetic). Autogenousseptal or auricular cartilage is generally acceptedas the gold standard of nasal graftingmaterials, with the major disadvantage beingan insufficient amount due to prior trauma,surgery, or infection. Costal cartilageprovides the advantages of a large volumeof grafting material with excellent structuralsupport. The disadvantages are warping andpotential morbidity to the donor site. Thereis ample literature to support the use of cartilagegrafts with long-term success, withthe largest series including over 2000 graftsperformed over the course of 17 years withinfrequent complications.Homograft materials are not ideal substitutesfor autogenous grafting material because oftheir long-term unpredictability and thefear of disease transmission. Homologousirradiated costal cartilage has been shownto resorb on long-term follow up and hasthe potential to warp. Alloderm® is anotherhomograft that has been used as a volumefilling material as well as for onlayingover cartilage or other grafting material25

to soften sharp edges under the skin. Themain disadvantage of this substance is theunpredictability in the degree of resorption(up to 80% resorption at 12 months).Significant advancements in biomaterial sciencein the late twentieth century led to theincreased use of synthetic implants in facialplastic surgery. Alloplast materials can beclassified as porous versus solid, and noninjectableversus injectable substances. Thepredominant complications associated withalloplasts in rhinoplasty include infection,extrusion, and overlying skin discoloration.Foreign body reactions occur with fragmentation.Relatively inert materials between20 and 60 μm can be phagocytized, but ingestionleads to macrophage demise, releaseof inflammatory factors, and a foreign bodyreaction characterized by chronic inflammation(i.e. silicone gel and proplast). Alloplastmaterials that are associated with foreignbody reactions continue to be used in partsof the world. A Korean publication in 2006reported upon a series of 47 patients whorequired the removal of liquid paraffin causingforeign body reactions requiring complicatednasal reconstructions. Injectable alloplastsare used for volumetric filling of smalldefects. There are reports in the literaturereporting the use of Restylane, Collagen,Radiesse and Bioplastique (a copolymer thatis not FDA approved and composed of particlesranging from 100-400 μm) in rhinoplasty.The inability to predict and maintainlong-term volumetric correction continuesto be the major limitation of using injectablefiller material in rhinoplasty.Solid silicone provides excellent structuralsupport. It was the first alloplast to achievewidespread use in facial plastic surgery.A major disadvantage of silicone is itsnotorious mobility after implantation andits propensity for exposure or extrusionfollowing trauma. Large retrospectivetrials have shown high complication anddissatisfaction rates (ranges between 9.7-16%). Nevertheless, silicone has been verypopular for nasal augmentation in Asianpatients. Medpor, Gore-Tex, and Mersileneare the more commonly used porous meshalloplasts. Mesh implants are difficult toremove once fibrous ingrowth has takenplace. Large series of patients have beenstudied with the use of mesh implants withrelatively low complication rates (2.5-7%).However, long-term data is lacking.The use of autogenous cartilage in rhinoplastywas limited in the early 20th centuryby a lack of knowledge of the etiologyof warping. An understanding of thebiomechanical properties of mature cartilageand control of warping by incisionaltechniques resulted in the wider clinicalapplication of autologous cartilage. However,a lack of readily accessible autogenousgrafting has resulted in an explosion in theproduction of alloplasts, and hence, in theuse of a much wider range of implants. Itis imperative that the facial plastic surgeonmaintains a strong knowledge of the variousimplants which have been used in the past,as well as those which are used in modernday surgery.It is equally important for all types ofphysicians to recognize potential candidatesfor revision rhinoplasty. The forces ofmaturation and gravity lead to changes inthe appearance and function of the nose overtime. These changes may warrant referralfor a revision procedure. With the growingnumber of patients interested in revisionrhinoplasty, it has become increasinglyimportant for surgeons to know “what’s ina nose”. ■Seamless commercial real estate solutions...worldwide.Operating from over 165 offices on six continents, Newmark Knight Frankis one of the largest independent real estate service firms in the world.With a full range of services including leasing and corporate advisory, propertyand facilities management, investment sales and financial services, consultingand project management services, we provide comprehensive real estatesolutions to prominent corporations as well as medical associations, propertyowners, investors and developers across the globe.Newmark Knight Frank is proud to provide real estate services to ENT & Allergy Associates.Matthew T. LeonSenior Managing Director212.372.2041mleon@newmarkkf.comPeter RossiExecutive Managing Director201.460.5154prossi@newmarkkf.comNorth America • Europe • Asia-Pacific • Latin America • Africa • www.newmarkkf.com26

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Tu r m o i l i n Ha i t iBy I. Da v i d Bo u g h Jr. M.D., F.A.C.S.My journey, which started as a medicalmission organized by a localchurch group, turned into an unexpectedadventure. Most of the volunteersin our group were experienced in providingcare to Haitians on previous missions.During our pre-trip meetings the groupmembers extolled the personal satisfactiongained on each mission. The common sayingwas that they “received much more thanthey gave”. Helping those with such direneeds and receiving the heartfelt gratitudeof the people they served was deeply satisfying.It is the reason they go back year afteryear. I have had the desire to volunteer for amedical mission for a long time. The lack oftime, the demands of private practice, alongwith the demands of a growing family, hadalways kept me away. This year I decidedto block out a week, commit the time, andfulfill that desire to “do some good” for thepoor of another country.I really was not worried about safety issuesuntil a week before the scheduled departure.During our final pre-trip meeting, when wepacked the 15 bins of medical supplies, toys,and children’s clothing, someone mentionedthe updated number of kidnappings in Haiti.The number was actually down from previousyears, but still in the high teens. Noone seemed concerned. They all said that ifwe stayed together in a group, there wouldbe no problems. The larger concern wasgetting our supplies and medicines throughcustoms so that we could have a productiveclinic. Nevertheless, I did start to lose abit of sleep thinking about the kidnappingtopic. Even so, I did not expect what wasactually to follow.Customs in Haiti has become very “strict”over the last two years. They have beenknown to disallow supplies from othermedical missions, thereby forcing thevolunteers to turn around and head backhome. Medications are strictly disallowed.They are supposed to be shipped separately,passing through a different screeningprocess. In our case, most of our medications28were donated from a French charitableorganization. Although the medicationsarrived in Port-au-Prince weeks before ourplanned arrival, they were not released toour Haitian counterparts until the daybefore we arrived. We were ecstatic whenwe heard about the release.As it turned out, passing our 15 binsthrough customs went very smoothly. Ithelped that we had “Bob”, a jovial and wellrespected parliamentary official, meet us atthe airport. He knew the customs officialsworking the counter that day. We were ableto select which bins were to be inspected,and passed without questions.Our clinic was located on the southeastcorner of the country, in the mountainousregion. The bus ride to the area could takeanywhere between four to six hours, dependingon the condition of the roads. Thescenery was a mix of beauty and despair.We passed what has been called the poorestslum in the world, a huge shanty town, withrows of connected shacks made up of sheetmetal, cloth, sticks, and even cardboard. Wethen passed into the countryside, where theview could be stunning, with the mountainsideand crystal clear ocean sitting under abright blue sky. Huge crater-like potholesplagued the main road that cuts through thecountry. We were fortunate because muchof the road was recently repaved, cutting ourjourney to five hours. We would have beenthere more quickly if we had enough dieselfuel for our dilapidated bus. Our transportationhad tape holding together the frontwindshield, rust worn holes on the floor sothat the ground below was visible, and, ofcourse, no functioning gauges to determinethe level of fuel in the vehicle. Nevertheless,out of nowhere, in the sparsely populatedarea where we ran out of fuel, a man miraculouslyappeared with a five-gallon barrelof fuel. Unbeknownst to me, a diesel enginemust have the air bled from the lines to eachpiston in order for the engine to run again.Fortunately, our driver was also a mechanic.Another hurdle passed!Our journey to our destination was interruptedby one other event which could havewarned us about the future of our trip, a stopat a United Nations checkpoint. The machinegun toting uniformed soldiers questioned ourdriver, and made a cursory inspection of ourbus. They claimed that they were on the look-

out for weapons being transported to andfrom Les Cayes…the city located about 45minutes from our destination.What we did not know at the time was thatan uprising was starting in Les Cayes. Wehad left for Kennedy Airport at 5:00 thatmorning, and did not arrive at our destinationuntil 7:00 that evening. The day before wearrived, four Haitians were shot and killedby the UN stabilization force in Les Cayes.This occurred as a group of Haitians weretrying to storm the UN compound justoutside of that city. Since we had no mediaaccess, we relied mainly on word of mouth.We were unaware that we were headingright into the hotbed of turmoil. In fact,we celebrated enthusiastically the eveningthat we arrived, basking in thought that wepassed all our supplies through Customs,and that not even a broken down bus couldstop our timely arrival!Our hotel was located in Aquin, a town about30 minutes from the area in which we wereto run a makeshift clinic. The Hotel Aldy,situated up a dirt road on a mountainside,was the closest dwelling that had roomswith running water (from a cistern underthe building) and a generator for electricity.We had a wonderful view of the ocean in thedistance…a view that I became very familiarwith over the next week. Our hosts at thehotel were extremely gracious. Fortunately,they had obtained much of the suppliesneeded for our stay prior to our arrival.The clinic was to be set up in a hall nextto a local church. The exam “rooms” werecurtained cubicles, a few folding tableswould be used to set up a pharmacy, and thecourtyard was our designated waiting room.The local nuns had given out a set numberof “tickets” to people in the surrounding areafor admission to the clinic, in order to aidin crowd control. Much of the populationin the area receives no medical care at all.Therefore, the types of problems seen inthe clinic could be quite varied. However,fungal and gastrointestinal infections alongwith hypertension were historically the mostcommon problems encountered.The plan was to leave at 8:00 sharp the nextmorning in order to set up the clinic sowe could open by noon. As it turns out,we were fortunate that we started towardsthe clinic site later than planned. After wedrove down the dirt road from our hotel, weimmediately came upon a small group ofyoung men blocking the main thoroughfare.Our translator obtained permission for us topass through because we were there to setup a free medical clinic. About a mile ortwo down the road, we encountered a largergroup of men. This time there were tiresburning on the side of the road. We decidednot to negotiate with them and to turn backto the hotel. Unfortunately, by the time wegot back to the first roadblock, the crowd ofprotestors, mostly young men, had tripled.They had constructed a formidable barrier,made up of tree branches, large rocks, andempty barrels. They had started burningtires on the side of the road and had becomemore agitated and boisterous. Although Icould not understand their language, it wasobvious that they were not pleased that wereturned. An ill-advised photo flash riledup the crowd. They started banging theirfists on the side of the bus. Sam, one of ourtranslators, was spectacular in his abilityto negotiate with the leader of the rioters,handing over the camera memory stick,and convincing them to take down theirbarricade so we could return to the hotel.Later, I learned that Sam was a Marine forsix years and had experience in controllinghostile crowd situations. Had we left thehotel earlier, as planned, we may havetravelled further down the road beforehitting a roadblock. We probably wouldnot have been able to return to the hotel.Three hours later, while sitting around atable in the back of the hotel, we heard a“pop”, followed by multiple bursts of “rat,tat, tat”, the sound of machine gunfire.The sounds from the street below echoedup the mountain, and sounded as if theywere coming right from the other side ofour hotel. Like in an action movie, we allscrambled around looking for cover. Ourfear was that the protestors were looking forus. As it turns out, they were not marchingup the dirt road. Instead, the UN forceswere plowing through the main street withtheir armored vehicle, dispersing the crowdwith gunfire. This could be seen from therooftop of our hotel, where some of us ranto for cover.It became obvious that our plan to run amedical clinic that week was in serious jeopardy.Our medical mission to help others inneed soon turned into a mission to help ourselvesfind a way to get back home. The roadblockshad quickly spread from Les Cayes toour area. Then the roadblocks spread alongthe main road to Port-Au-Prince. In a matterof two days, the entire capital, along withall the major cities were shut down secondaryto riots and looting. Absolutely no carsor trucks were able to travel the roads. Peoplemoved only on foot, bicycles, or motorbikes. The protest was successful in shuttingdown the entire country. The underlyingreason for the unrest was the rising cost andshortage of food.One system that continued to work verywell in Haiti was the cell phone system. Inoticed that the only roadside billboardswere advertisements for Voila! the cell phoneservice provider in the country. Verizon’scell phones even worked in the area!We kept in constant contact with the USEmbassy. Our concerns heightened whenwe learned that the US Embassy was forcedto close due to the unrest in Port-au-Prince.With protests and violence in the capital rising,and no apparent progress seen in thegovernment’s ability to appease the population,we started to reach out to connectionsat home to pressure the US Governmentand the UN to help us. With the help ofmany friends here in the United States, wewere able to attract the attention of both theUN Command Center and the US Embassy.Plans were made twice to escort us outof the area with armored vehicles. However,due to the constant changing conditions in29

the state of affairs on the ground, both convoyswere cancelled. We were instructed to“sit tight” and wait until the condition becamemore favorable for an extraction.Many thoughts run through your mindwhen you are forced to pace the same pathhour after hour, day by day. There was concernthat the riots could shut the countrydown for weeks. There was fear that oursupplies would run out. There was concernabout the condition of those who were worryingabout us at home. Most of us worriedto ourselves, showing the fearless facade soas not to upset one another. As expected,when you confine 15 people together in astressful situation, some tempers flared, likean episode of “Survivor”. But overall, weremained a cohesive group. The topic thatcaused the most tension was whether or notto seek assistance from the UN. The UNstabilization forces are despised as ineffectiveoccupiers, and generally disliked by the Haitians.Many in our group did not want tobecome targets by associating with the UN.On the sixth day of our stay, there wasmovement in the streets. We began to seevehicles travelling on the main road. Wequickly decided to “make a run” for it. Weborrowed vehicles from the local priest,and took off for Les Cayes to catch a planeto Port-au-Prince. We knew that we weretravelling to the area where the tensionbegan, but a five-hour drive to Port-au-Prince was not an option. Les Cayes wasless than an hour away, and the US Embassyassured us that we would be able to charter aplane from there to the capital.The road to Les Cayes was riddled withroadblocks…about 25 of them along theway. There was enough room for onlyone vehicle at a time to pass through thepartially cleared barriers. Our road tripbecame unforgettable after we ran into anoncoming UN military convoy in the midstof capturing, with machine gun fire, tworioters trying to reestablish a barrier. TheUN soldiers captured the two rioters, boundtheir hands together, and placed them in thebed of our pick-up truck, along with tworifle toting National Policemen. Despite ourvigorous objections, the UN commanderdid not give us any option but to carry thesemen to the next town, 20 minutes down theroad. As I peered out of the back windshieldof the cab, I stared into the face of thecaptured prisoner plastered against the glass.After trying to escape Aquin without thehelp of the UN, we ended up helping theUN transport Haitian rebels to prison. The20 minutes seemed endless.One flat tire repair later, we made it to LesCayes, and subsequently, to Port-au-Princeand then, finally, Miami. We arrived back inNewark exhausted, elated, yet disappointed.We had started our journey as a medicalmission, but we did not get to practice anymedicine. However, as it turns out, our storywas made into headlines in the New York/New Jersey press. The publicity definitelyraised awareness of the underlying problemin poor countries, like Haiti. I noticedarticles in the paper about the crises in Haitifor a few weeks after we returned. Haitians,as well as people from other poverty strickennations, are struggling under the burden ofrising food prices, shortage of staple foodproducts, and lack of medical care. Maybe,our medical mission misadventure fulfilled ahidden mission to open the eyes of people inthis area about the plight of our neighborsin the Caribbean who have no electricity,running water, medical care, and barelyenough food to survive. Hopefully, somegood will come of that. ■30

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