Chyle fistula is a potentially devastating phenomenon that results from violation of the thoracic duct or right lymphatic duct in the neck, most commonly during radical neck dissection. It may impair nutrition, compromise and delay wound healing, and prolong hospitalization. In view of the morbidity produced by chyle leak discovered postoperatively and the lack of success of its management by aggressive surgical techniques, we have employed a different protocol for the past six years. It is based on careful intraoperative inspection of the neck for possibly chyle fistula, minimal but specific surgical handling of the damaged duct, and a postoperative nutritional program designed to reduce chyle formation and facilitate spontaneous closure. The nutritional element involves the use of medium chain triglycerides (MCT) that are easily ingested, rapidly absorbed, and readily metabolized directly into the portal venous system, bypassing the thoracic duct lymphatic system. During a four-year period, 1976 to 1980, 574 radical neck dissections were performed with only six chyle fistulas being detected postoperatively. All have been successfully treated by the protocol with no patients requiring reexploration. There have been no deaths owing to chyle fistula and no complications or side effects from the use of medium chain triglycerides.

Objective: To evaluate the use of autogenous maxillary bone for the repair of orbital floor defects secondary to blunt facial trauma.Design: Retrospective case series of 41 patients with a mean follow-up of 1.7 years.Setting: Major metropolitan teaching hospital.Patients: Forty-one consecutive patients who underwent repair of orbital floor fractures with maxillary antral wall bone grafts.Main Outcome Measures: Presence of diplopia, orbital dystopia, implant extrusion, enophthalmos, infection, and donor site complications.Results: On follow-up clinical examinations, none of the 41 patients presented with any evidence of orbital dystopia or complications relative to the implant or donor site. Two patients had persistent enophthalmos, and 4 had persistent infraorbital nerve paresthesia. Postoperative computed tomographic scans in 12 patients revealed an adequate maintenance of orbital volume without any evidence of resorption of the graft. Conclusion:The use of maxillary antral wall bone for the repair of orbital floor fractures is a highly reliable technique that carries minimal morbidity.

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Four patients with spastic dysphonia refractory to speech and phychiatric therapy were treated by crushing the recurrent laryngeal nerve. Vocal cord paralysis was produced in all patients. Vocal spasticity subsided in all patients. Vocal cord motion returned in four to six months. Three of four patients remained free of spasticity for a minimum of 24 months.