The Endoscopic Buccal Fat Pad Flap for Closure of Skull Base Defects: A Report of 5 Cases.

OBJECTIVE: To demonstrate the clinical utility of the buccal fat pad flap (BFPF) for closing a variety of skull base defects. METHODS: A retrospective chart review of 5 consecutive patients who underwent endoscopic cranial base surgery with endoscopic harvest of BFPF pedicled along the internal maxillary artery for reconstruction of the skull base between October 2013 and November 2014. RESULTS: All 5 patients had complete take of the BFPFs with mucosalization on postoperative follow-up with no reported complications or cerebrospinal fluid leak. CONCLUSIONS: This is the first report on the application of endoscopic BFPF. Our experience suggests that this recently described flap is viable and a useful addition to the armamentarium of the skull base surgeon.

The endoscopic transoral approach to the craniovertebral junction: an anatomical study with a clinical example.

OBJECTIVE The microscopic transoral, endoscopic transnasal, and endoscopic transoral approaches are used alone and in combination for a variety of craniovertebral junction (CVJ) pathologies. The endoscopic transoral approach provides a more direct exposure that is not restricted by the nasal cavity, pterygoid plates, and palate while sparing the potential morbidities associated with extensive soft-tissue dissection, palatal splitting, or mandibulotomy. Concerns regarding the extent of visualization afforded by the endoscopic transoral approach may be limiting its widespread adoption. METHODS A dissection of 10 cadaver heads was undertaken. CT-based imaging guidance was used to measure the working corridor of the endoscopic transoral approach. Measurements were made relative to the palatal line. The built-in linear measurement tool was used to measure the superior and inferior extents of view. The superolateral extent was measured relative to the midline, as defined by the nasal process of the maxilla. The height of the clivus, odontoid tip, and superior aspect of the C-1 arch were also measured relative to the palatal line. A correlated clinical case is presented with video. RESULTS The CVJ was accessible in all cases. The superior extent of the approach was a mean 19.08 mm above the palatal line (range 11.1-27.7 mm). The superolateral extent relative to the midline was 15.45 mm on the right side (range 9.6-23.7 mm) and 16.70 mm on the left side (range 8.1-26.7 mm). The inferior extent was a mean 34.58 mm below the palatal line (range 22.2-41.6 mm). The mean distances were as follows: palatal line relative to the odontoid tip, 0.97 mm (range -4.9 to 3.7 mm); palatal line relative to the height of the clivus, 4.88 mm (range -1.5 to 7.3 mm); and palatal line relative to the C-1 arch, -2.75 mm (range -5.8 to 0 mm). CONCLUSIONS The endoscopic transoral approach can reliably access the CVJ. This approach avoids the dissections and morbidities associated with a palate-splitting technique (velopharyngeal insufficiency) and the expanded endonasal approach (mucus crusting, sinusitis, and potential lacerum or cavernous-paraclival internal carotid artery injury). For appropriately selected lesions near the palatal line, the endoscopic transoral approach appears to be the preferred approach.

Metastatic breast carcinoma of the jugular foramen: a rare case of Villaret syndrome.

BACKGROUND: The differential diagnosis of skull base masses is diverse and includes benign and malignant neoplasms, vascular anomalies, congenital lesions, as well as infectious and inflammatory processes. Metastatic masses of the skull base are a rare manifestation of systemic malignancies. Breast cancer is the most common cause of skull base metastases. Villaret syndrome refers to cranial nerves IX, X, XI, and XII and sympathetic chain neuropathies. It is a clinical subtype of jugular foramen syndromes. METHODS AND RESULTS: A 62-year-old woman with a history of breast carcinoma presented with hoarseness dating to shortly after her mastectomy years earlier. CT angiography showed enhancing tissue just outside the right jugular foramen, and biopsy confirmed metastatic adenocarcinoma consistent with breast cancer. CONCLUSION: Villaret syndrome caused by breast cancer metastases has not been previously described. We present a case of Villaret syndrome caused by metastasis of invasive breast adenocarcinoma and a review of the literature of metastases of breast cancer to the skull base.

A Case of Trigeminocardiac Reflex During Infrastructure Maxillectomy.

IMPORTANCE: The trigeminocardiac reflex refers to the sudden development of bradycardia or even asystole with arterial hypotension from manipulation of any sensory branches of the trigeminal nerve. Although it has only rarely been associated with morbidity and tends to be self-limited with removal of the stimulus, it is an important phenomenon for head and neck surgeons to recognize and respond to. OBSERVATIONS: We present the case of a woman in her late 60s with maxillary alveolar ridge squamous cell carcinoma who developed episodes of asystole and bradycardia during posterior maxillary manipulation for an infrastructure maxillectomy at a tertiary academic medical center. Administration of atropine and removal of the inciting stimulus sufficed to extinguish the episodes and allow procedure completion. CONCLUSIONS AND RELEVANCE: The trigeminocardiac reflex can be provoked by a number of head and neck and skull base procedures including parotidectomy and posterior maxillectomy. Surgeons and anesthesiologists should be wary of inciting the reflex during manipulation of trigeminal branches. Careful dissection for prevention and early intervention with stimulus removal and anticholinergic use as needed are paramount to ensure good outcomes.

An unusual and rare cause of acute airway obstruction in the elderly: Forestier's disease.

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease, is an ossifying disease of unknown etiology affecting mainly elderly men. It is characterized by hypertrophic anterior vertebral osteophytes with ossification of the spinal anterior longitudinal ligament. Hypertrophic osteophytes can encroach on the aerodigestive tract, leading to significant swallowing and respiratory symptoms. OBJECTIVE: Acute stridor and respiratory compromise requiring a surgical airway have rarely been reported in patients with DISH. This entity, although rare, should be in the differential diagnosis of acute airway obstruction, particularly in the elderly. CASE REPORT: We describe a case of a 91-year-old patient who was transferred to the Emergency Department at Tufts Medical Center with acute stridor. A computed tomography scan of the neck prior to transfer revealed a large anterior cervical osteophyte causing significant airway narrowing. Fiberoptic evaluation confirmed the radiologic finding of near-complete airway obstruction. The patient's respiratory status rapidly deteriorated and he subsequently underwent an emergent awake tracheostomy to secure his airway. CONCLUSION: Given the rarity of DISH and the increase in life expectancy, clinicians should be aware of this disease entity and its potential for acute life-threatening respiratory presentation.

Nasopharyngeal branchial cysts-diagnosis and management: a case series.

Nasopharyngeal branchial cysts (NBCs) have been discussed in the literature in only a limited number of publications. Differing from Tornwaldt cysts, NBCs present laterally and arise from the fossa of Rosenmuller and may track superiorly within the bony confines of the Eustachian tube. Initially patients are asymptomatic but may present with aural fullness, unilateral conductive hearing loss, and serous otitis media as the cyst mass grows. Two of our three patients had the lesion incidentally identified at the time of assessment for another diagnosis. In this case series, imaging characteristics and response to treatment are reviewed. A literature search was performed to summarize the management options for this entity.