Levels of nitrite and pyridine alkaloid-derived total tobacco-specific nitrosamines (TSNA) were significantly higher in tobacco leaf (normal or late harvest) air-cured at 32 degrees C/83% relative humidity (RH) than in more moderate environments, i.e., 15 degrees C/50% RH and 24 degrees C/70% RH. These constituents increased appreciably from day 10 to day 21 of the cure. The near-concurrent appearances of maximal total contents of TSNA [sum of N'-nitrosonornicotine (NNN), N'-nitrosoanatabine (NAT), N'-nitrosoanabasine (NAB) and 4-(N-nitrosomethylamino)-1-(3-pyridyl)-1-butanone)(NNK)] and nitrite supports the concept that nitrite is a limiting and proximal precursor of total TSNA during the curing of tobacco. During a long curing period (50 days) at 32 degrees C/83% RH, nicotine and anatabine contents decreased, but TSNA contents increased in leaves of all harvest dates and stalk positions. These results support the view that nicotine and anatabine are precursors of TSNA. Measurement of nitrite and individual alkaloids during post-harvest processing of tobacco leaf may provide an index of the potential accumulation of alkaloid-derived nitrosamines.

Knowing when to change a tracheostomy tube is important for optimal management of all patients with tracheostomy tubes. The first tracheostomy tube change, performed 1-2 weeks after placement, carries some risk and should be performed by a skilled operator in a safe environment. The risk associated with changing the tracheostomy tube then usually diminishes over time as the tracheo-cutaneous tract matures. A malpositioned tube can be a source of patient distress and patient-ventilator asynchrony, and is important to recognize and correct. Airway endoscopy can be helpful to ensure optimal positioning of a replacement tracheostomy tube. Some of the specialized tracheostomy tubes available on the market are discussed. There are few data available to guide the timing of routine tracheostomy tube changes. Some guidelines are suggested.

BACKGROUND:: Monoaxial and polyaxial screw insertion are used in angular stable plating of displaced proximal humeral fractures. Aim of the study was to compare both fixation techniques by radiographic evaluation. METHODS:: Prospective randomized treatment with monoaxial or polyaxial screw insertion in angular stable anatomic preshaped plates of displaced proximal humeral fractures. Analysis of standardized true anterior-posterior (true a.p.) and outlet-view radiographs at 1 day, 6 weeks, 3 months, and 6 months after surgery by two radiologists with respect to radiographic evidence of secondary varus displacement, cut out of screws, osteonecrosis, and hardware failure. Secondary varus displacement was defined as a varus decrease of the humeral head-shaft angle of >10 degree in true a.p. radiographs. RESULTS:: Sixty-six consecutive patients (48 women,[72.7%]; 18 men,[27.3%]; mean age 67.7 years [95% CI, 63.9-71.6]) with displaced proximal humeral fractures were evaluated in this study. Nineteen patients (29%) showed secondary varus displacement of >10-degree angle. In 6 cases (9%), intra-articular cut out of screws was found. Furthermore, 1 case (2%) of nonunion was observed. No relationship between monoaxial and polyaxial screw insertion was found regarding occurrence of secondary varus displacement (monoaxial, 11/polyaxial, 8; p = 0.91) or screw cut out (monoaxial, 4/polyaxial, 2; p = 0.64). Prevalence of secondary varus displacement and hardware cut out was related to patients age (p = 0.02) and fracture pattern, according to Neer- and AO/OTA-classification (p < 0.001). The average immediate postoperative head-shaft angle was 135.2 degrees (CI, 132.3-138.1) in the group without radiographic complication, compared with 126.7-degree angle (CI, 123.6-129.7) among those with secondary varus displacement of >10-degree angle and screw cut out (p < 0.001). Furthermore, in cases of an immediate postoperative head-shaft angle of <130 degrees, there was a 48% incidence of secondary varus dislocation (n = 13) versus 15% in cases with a head-shaft angle >130 degrees (n = 6, p = 0.004). CONCLUSION:: Monoaxial and polyaxial screw insertion allow for mechanical stabilization in angular stable plating of unstable proximal humerus fractures. Radiographic evidence of secondary varus displacement of >10-degree angle and screw cut out was seen similarly often in both fixation techniques. To avoid secondary varus displacement and screw cut out, restoration of a humeral head-shaft angle of >130 degrees seems to be important in monoaxial and polyaxial fixation of proximal humeral fractures.

Patients with severe infections of the potential spaces of the head and neck are commonly managed in the ICU. These infections may present with devastating complications such as airway obstruction, jugular septic thrombophlebitis, lung abscess, upper airway abscess rupture with asphyxiation, mediastinitis, pericarditis, and septic shock. A thorough understanding of the anatomy and microbiology of these infections is essential for proper management of these patients. Retropharyngeal, danger, prevertebral, lateral pharyngeal, and submandibular space infections and their site-specific clinical manifestations, complications, and therapeutic interventions are discussed.

BACKGROUND A quasi-experimental retrospective study was undertaken to evaluate a new concept of free tissue volume restoration combined with bridging reconstruction plate (compartment approach) to reduce plate-related complication rates. METHODS We evaluated 40 patients with large lateral mandible defects and associated complex soft tissue defects reconstructed with a revascularized soft tissue flap and titanium hollow screw reconstruction plates. A case-control comparison was performed based on reconstruction type: restoration of soft tissue defect (conventional approach-group 1) versus over-reconstruction of soft tissue defect (compartment approach-group 2). RESULTS Plate exposure rate was 6 of 16 (38%) in group 1 versus 2 of 24 (8%) in group 2, and the difference was statistically significant (p =.04). The mean time to exposure was 10 months. Plate fracture rate was 6 of 23 (26.1%) in dentulous patients versus 1 of 17 (5.9%) in edentulous patients. Gastrostomy tube dependence was 6 of 16 (38%) in group 1 versus 6 of 24 (25%) in group 2. CONCLUSION The "compartment approach" reduces plate exposure rate and gastrostomy tube dependence. Revascularized osseocutaneous reconstruction is still required in dentulous patients.

Although airway obstruction secondary to cricoarytenoid arthritis is an infrequent perioperative complication of rheumatoid arthritis, it must be promptly recognized and appropriately managed to avoid fatal consequences. We report a case of cricoarytenoid dysfunction leading to acute respiratory insufficiency requiring tracheostomy in the immediate postoperative period after total knee arthroplasty in a patient with severe rheumatoid arthritis.

OBJECTIVE The purpose of this study was to evaluate the incidence, causes, management, and complications of the different head and neck space infections in a Melanesian population. STUDY DESIGN AND SETTING We conducted a retrospective study in a tertiary referral and teaching hospital. RESULTS Of the total 103 patients with deep neck space infections (DNSI), odontogenic causes and suppurative lymphadenitis were responsible in 62 (60%) patients. A wide range of DNSI was encountered in our series. Ludwig's angina was the most commonly encountered infection seen in 38 (37%) patients, whereas prevertebral abscess was only seen in 1 (1%) patient. A combination of surgical drainage and medical treatment was the main mode of treatment. Nine (8.7%) patients with DNSI with upper airway obstruction underwent tracheostomy; 9 (8.7%) patients with DNSI succumbed to their infection. CONCLUSION DNSI needs early detection and aggressive management in order to evade dreaded complications.

Trauma to oral soft tissues in comatose patients may be more widespread than reported, as no extensive study of this problem has been conducted. Various appliances for the prevention of self-inflicted injuries to oral tissues particularly in children and the physically and mentally challenged have been documented, but there is little information on their use in adult comatose patients. Because comatose patients lack cerebral control of the masticatory cycle, they can easily injure themselves. Although it is not uncommon for patients with a decreased level of consciousness and in need of intensive care to be restrained to prevent injury due to involuntary movement of the limbs, head and neck restraint is often difficult and may be dangerous to the patient. This case report presents a simple solution to the problem of self-inflicted trauma to oral tissues.

Respiratory disturbance occurs sometimes after anterior cervical fusion. This is often a result of upper airway obstruction due to prevertebral soft tissue swelling. Therefore we used cricothyrotomy tubes (Mini-Trach) in two patients with postoperative upper airway obstruction and performed assist-ventilation via the tubes. After starting to ventilate through Mini-Trach II, respiratory disturbance disappeared soon and respiration improved markedly. Mini-Trach II is an effective device to use in patients with post-operative respiratory disturbance due to prevertebral soft tissue swelling.

Warthin's tumor is one of the benign tumors of major salivary glands. It was mostly found in parotid glands of male patients in their sixties. Warthin's tumor with extraparotid location is rare. We here report a 65-year-old male patient with a movable mass about 25 x 20 x 15 mm over his leftjugular-digastric area. The fibroscopic examination found no malignancy over the head and neck region. Computed tomographic scan showed a soft tissue mass about 18 mm in diameter in the left upper neck. The mass was not in connection with the parotid gland or the submandibular gland and was excised completely through a transverse neck incision. Histopathologic examination revealed Warthin's tumor. We present an original report of a case of Warthin's tumor with its unusual extraparotid location.

Extramedullary plasmacytomas are hematologic malignancies that occur primarily in the head and neck region. They usually involve the submucosal lymphoid tissue of the nasopharynx or paranasal sinuses and present as soft tissue masses, but have not been previously reported to cause airway obstruction. In general, detection of plasmacytoma antedates the eventual development of the systemic hematologic malignancy, multiple myeloma, by months or years. We describe a unique case of acute upper respiratory tract obstruction secondary to compression by an extramedullary plasmacytoma occurring in the neck of a patient with history of long-standing multiple myeloma. Upper airway obstruction may be a manifestation of untreated plasmacytoma. It is imperative for otolaryngologists and head and neck surgeons to be familiar with this entity because total excision, as well as radiation therapy, for plasmacytomas can be curative in patients without underlying overt plasma cell dyscrasias.