Temporal Arteritis

Temporal Arteritis is also known as Giant Cell, Cranial, or Granulomatous Arteritis.  It is the most common Vasculititis in the head and neck.  In 50% of cases it is comorbid with Polymyalgia Rheumatica (PMR).  It will often present with anemia, depression, morning stiffness and low grade fever for more than a month.  It is more common in Women and more prevalent over 60.  The vasculitis leads to small vessel ischemia and most notably visual loss.  Patients will often have intense pulsatile cephalagia, hyperalgesia or the scalp, jaws and tongue.  Masticatory claudication is very prevalent.   Odynophagia, odynophonia, anorexia, fever, and streaking erythema over the temporal artery are very common.  The ESR is usually over 40, and often over 100.  Patients will often have high immunoglobulin counts and low albumin.  A third of patients will have othamologic involvement.  Early steroids are indicated and a six centimeter segment for biopsy is taken as there are skip lesions in up to 30% of patients.  If the biopsy is negative and your clinical suspicion is high, might perform a biopsy on the contralateral side.  If the diagnosis is made, you may have to treat with steroids up to 2 years.  You never want to misdiagnose as migraines or treat with ergotomines, as the risk of blindness exists.

Endoscopic DCR

Endoscopic DCR is a relatively straightforward procedure that opens the lacrimal sac into the anterior middle meatus. I typically stent it for anywhere from 2-6 months.  Afterwards, I place the patient on tobramycin drops tid for 10 days.  Success should be greater than 90% and the cpt code is 31239.

Intradermal Vaccines

There has been good data on the efficacy of vaccines given intradermally vs subcutaneously or intramuscularly. It actually seems to function superiorly in children and the elderly. I personally take my flu shot this way as I feel it also limits my systemic side effects.   0.1 ml of both the influenza vaccine (Fluogen) and the Herpes Zoster Vaccine (Varivax) in opposite arms seems to lessen the frequency and severity of recurrent upper respiratory tract illnesses.


I very experienced allergist and friend surprised me when he treated what I thought was just a heat rash with Permethrin.  Scabies (Sarcoptes scabiei) is an itch mite that is highly contagious.  It can be sexually transmitted for sure, but it is not always so.  It does however require close contact to spread and seems limited to humans (it is not compatible with pets).  Itching is severe and it forms papules that often blister.  Microscopy scrapings can be difficult and there is even a PCR test available.

Middle Ear Treatments

There was an interesting study on the middle ear volume, and it ended up being about 1.4 ml in non diseased individuals.  In reality, you rarely get a full ml of fluid into the middle ear when you inject it.  There is a number of reasons we put medications directly into the middle ear, such as Meneir’s Disease, sudden sensorineural hearing loss, etc…  We are typically using an anti inflammatory such as dexamethasone or an ablative medication such as Gentamycin.  Sometimes we combine the agents.  When I use the Dexamethasone, I do no dilute, and I put in as much as the middle ear will handle.  I typically anesthetize the ear with phenol or EMLA and have patient stay laying in the injection position without swallowing for 20  minutes if possible.





Challenging scalp lesions

Exposed calvarium represents an interesting challenge in reconstructing scalp defects.  In order to lay on a skin graft, tissue such as a temporalis flap needs to be mobilized to give a base for the graft to survive on.  Otherwise, large “pinwheel” type flaps can be constructed to close this primarily with good success.

This defect was closed with a double layer temporalis muscle flap underlying an occipitally based scalp advancement flap.


Tongue Tie

I am reposting this because of a social media interest in what is termed “posterior tongue tie”.  It is described as a fibrous banding deep in the floor of mouth that causes feeding difficulties.  It seems to be a problem mostly manufactured by those wanting to exploit others. Most of us think of being tongue-tied as a situation where we find ourselves too excited or nervous to speak. Actually, tongue tie is a term for a relatively common physical condition that limits the use of the tongue, medically called “ankyloglossia”.

tounge_tie_mediumBefore we are born, a strong cord of tissue (the frenulum) that guides development of mouth structures is positioned in the center of the mouth. After birth, the frenulum continues to guide the position of incoming teeth. As we grow, it recedes and thins.

This frenulum is visible and easily felt if you look in the mirror under your tongue. In some children, the frenulum is especially tight or fails to recede and may cause tongue mobility problems.

The tongue is one of the most important muscles for speech and swallowing. For this reason, having tongue tie can lead to eating or speech problems, which may be serious in some individuals.  Posterior tongue tie is a nebulous term that lacks a clear definition or treatment.

Lip “Tie”

Labial Frenulectomy

Frenum_composite 1106CFP_PC_Frenum_AB-1A labial frenectomy is a form of frenectomy performed on the lip.

The labial frenulum often attaches to the center of the upper lip and between the upper two front teeth. This can cause a large gap and gum recession by pulling the gums off the bone. A labial frenectomy removes the labial frenulum. Orthodontic patients often have this procedure done to assist with closing a front tooth gap. When a denture patient’s lips move, the frenulum pulls and loosens the denture which can be uncomfortable. This surgery is often done to help dentures fit better.

The removal of the frenulum does not cause any adverse effects to the lip and mouth.  The real question is if it has any beneficial effects.

“Potential” benefits include better feeding, diminished decay of the front incisors, and avoiding a central diastema (gap in the front teeth).  I remain a bit skeptical that the benefits exist.

Challenging scalp lesions

Exposed calvarium represents an interesting challenge in reconstructing scalp defects.  In order to lay on a skin graft, tissue such as a temporalis flap needs to be mobilized to give a base for the graft to survive on.  Otherwise, large “pinwheel” type flaps can be constructed to close this primarily with good success.IMG_1689IMG_1863

Merkel-cell Carcinoma


IMG_1692Is caused by the Merkel cell polyomavirus (MCV) 80% of the time, discovered at the University of Pittsburgh in 2008.  It is also known as a cutaneous APUDoma, primary neuroendocrine carcinoma of the skin, primary small cell carcinoma of the skin, and trabecular carcinoma of the skin.  It is a tumor of the tactile merkel cell in the stratum basale of the epidermis.  Histologically it looks like small cell lung cancer with dense cohesive sheets of highly mitotic cells with scant cytoplasm.  They are s-100 positive and are undifferentiated cells of neural crest origin.

It is a rare and aggressive neoplasm that behaves and even looks like an aggressive amelanotic melanoma.  55% present in the head and neck, 20% in the periorbital region, and  primarily in the 6th decade of life.  They are flesh colored and more than 50% overall have regional metastasis.  Surgically we treat them like a melanoma.  However, surgery alone is rarely the treatment plan as they seem to be radiosensitive.  As up to 20% may have distant metastasis at presentation, PET scanning seems appropriate.

In the past we used to say 3 cm margins with lymphoscintigraphy alone for stage 1, 40 GY radiation for stage 2, and induction chemo for stage 3.  Probably palliative chemo for stage 4.