Delayed Esophageal Perforation Diagnosed 12 Years After Anterior Cervical Diskectomy and Fusion: A Case Report and Review of Current Literature.

Esophageal perforation associated with anterior cervical diskectomy and fusion (ACDF) is a rare but serious complication. ACDF-related esophageal perforations can be acute or delayed. Delayed perforations more than 10 years after ACDF are exceedingly rare. Here, a delayed esophageal perforation discovered 12 years after a three-level ACDF is presented. This case highlights two main points. First, all diverticula after an ACDF warrant close clinical monitoring. Second, routine follow-up should be performed for patients with screw pullout to assist in early diagnosis of delayed esophageal perforation.

Treatment of VPI with Customized Pharyngeal Flaps: One Size Does Not Fit All.

Failure of complete closure of the velopharyngeal sphincter results in velopharyngeal insufficiency (VPI), which may severely interfere with speech. The pharyngeal flap remains a common procedure for correcting VPI. We aimed to study whether customization of pharyngeal flaps using a dynamic preprocedural assessment can result in successful outcomes in the surgical treatment of VPI, despite variations in surgical technique. Methods: This is a retrospective review of patients between the ages 4 and 18 years old with VPI who underwent surgical correction by one of four surgeons at our institution. All four surgeons used a superiorly based pharyngeal flap (SBPF) with slight variations in operative technique. All patients also received an evaluation by the speech and language pathologist that included nasometry, multiplanar videofluoroscopy, and flexible videonasopharyngoscopy. Individualized preoperative planning was performed based on the findings. Results: In total, 158 patients (92%) demonstrated overall successful correction of VPI, defined by a normal post-operative mean nasalance. Thirteen patients (8%) presented with resonance improvement but persistent abnormal mean nasalance. The most common causes of failed VPI correction were inferior migration and/or shrinking of the pharyngeal flap. There was a nonsignificant association between surgical technique and unsuccessful corrections. Conclusions: The optimal surgical approach for performing pharyngeal flaps to correct VPI is individualized, customizing the procedure based on preoperative imaging. This study demonstrates that despite variations in surgical techniques for performing SBPF, high rates of success can be achieved when adequate surgical planning is based on imaging findings.

Primary Parotid Tumor Thrombosis: Immunohistologic Features and Awareness of Metastatic Potential.

Tumor thrombosis is a poor prognostic feature and an exceptionally rare occurrence in salivary gland malignancies. We present a case of primary parotid myoepithelial carcinoma (MC) with tumor thrombosis in the external jugular vein (EJV). An 82-year-old man presented with a right-sided facial mass. MRI with and without gadolinium demonstrated a mass of the right parotid gland with a filling defect of the right EJV. The patient underwent right parotidectomy and selective neck dissection. Tumor thrombosis was found intraoperatively within the EJV. Final pathology demonstrated a poorly differentiated MC. Adjuvant radiation therapy without concurrent systemic therapy was administered. Three months later, restaging positron emission tomography (PET) with CT revealed numerous bilateral pulmonary nodules with biopsy, demonstrating poorly differentiated MC without locoregional relapse. Given that primary parotid tumor thrombosis is associated with a poor prognosis, the use of early systemic therapy should be investigated.

Occult subtotal cleft of the secondary palate with VPI associated to 8q22.2 deletion.

BACKGROUND: Submucous cleft palate is a cleft of the secondary palate with low phenotypic gene expression. It can occur as an isolated malformation or associated with a syndrome that includes certain facial features and other vocal tract malformations. Velopharyngeal insufficiency (VPI) is rare in cases of non - syndromic occult clefts of the secondary palate (OSCSP). In contrast, syndromic OCSP has a high prevalence of VPI. VPI requires surgical treatment in the vast majority of cases. OBJECTIVE: To present a case of OSCSP with VPI after partial tonsillectomy and adenoidectomy (T & A) associated with facial features and other vocal tract malformations. A chromosomal abnormality (8q22.2 deletion) was demonstrated by cytogenetic testing. CASE PRESENTATION: Eight year old female with VPI following partial T & A. OSCSP was diagnosed. Complete T & A was performed in preparation for a pharyngeal flap. Pharyngeal flap surgery was customized according to findings of videonasopharyngoscopy (VNP) and multiplanar videofluoroscopy (MPVF). VPI was corrected without intraoperative or postoperative complications. CONCLUSION: The presence of multiple vocal tract malformations should be a red flag for suspecting a syndromic OSCSP. Surgical treatment of VPI in cases of OSCSP should be performed after complete T & A, Imaging procedures for assessing neck blood vessels and it should be customized according to imaging (VNP and MPVF) findings.

Comparison of three different surgical techniques for designing pharyngeal flaps according to findings of videonasopharyngoscopy and multiplanar videofluoroscopy.

BACKGROUND: Velopharyngeal insufficiency (VPI) occurs when the velopharyngeal sphincter (VPS) is unable to completely seal anatomical closure between the nasal and oral cavities during speech. Palatal repair can restore VPS function but the prevalence of VPI after repair has been reported ranging from 20% to 40%. The combination of flexible videonasopharyngoscopy (FVNP) and multiplanar videofluoroscopy (MPVF) has been reported as the best approach for assessing the VPS mechanism and planning effective surgical procedures aimed to correct VPI. OBJECTIVE: To study the outcome of three different techniques for performing pharyngeal flaps with the common denominator of individually designing the flap according to findings of VFNP and MPVF. MATERIAL AND METHODS: A total of 140 cases of pharyngeal flap surgery were reviewed. Three surgeons performed 3 different surgical techniques. All cases underwent nasometry, VNP and MPVF preoperatively. All surgical procedures were carefully planned and designed according to findings of VNP and MPVF. RESULTS: Nasal emission was completely eliminated in all cases. One-hundred-thirty-four patients (95%) demonstrated mean nasalance within normal limits after the surgical procedure whereas 6 patients persisted with mean nasalance scores above reference values postoperatively. There were no intraoperative or postoperative complications in any of the cases. No clinical data of sleep disordered breathing was detected in any of the cases after 2 months of postoperative follow-up. However, one case presented with clinical data of sleep disordered breathing 8 months postoperatively. CONCLUSIONS: The results of this study suggest that as long as pharyngeal flaps are being designed according to the findings of imaging procedures, different surgical techniques can provide similar successful outcomes with minimal complications.

Velopharyngeal videofluoroscopy: Providing useful clinical information in the era of reduced dose radiation and safety.

BACKGROUND: The state of the art for correcting velopharyngeal insufficiency (VPI) is a surgical procedure which is customized according to findings on imaging procedures: multiplanar videofluoroscopy (MPVF) and flexible videonasopharyngoscopy (FVNP). Recently, the use of MPVF has been challenged because of the potential risk of using ionizing radiation, especially in children. OBJECTIVE: To study whether using a protocol for performing MPVF can effectively decrease radiation dose in patients with VPI while providing useful information for planning surgical correction of VPI in combination with FVNP. The methodology used for performing the imaging procedures is described as well as the effectiveness of the surgical procedure. MATERIAL AND METHODS: Eighty - nine patients (Age range = 3-17 years; median = 5.5 years) with VPI resulting from multiple etiologies were studied. All patients underwent MPVF and FVNP for planning surgical correction of VPI. Radiation dosage data in each case was recorded. Forty of the 89 patients also completed a postoperative evaluation. Eleven out of the remaining 49 patients have not completed a postoperative evaluation and 38 patients are still pending surgical correction. RESULTS: Radiation dosage ranged from 1.00 to 8.75 miliSieverts (mSv); Mean = 2.88 mSv; SD = 1.575 mSv. Preoperative nasometry demonstrated mean nasalance ranging from 41%-95%; Mean = 72.30; SD = 4.54. Postoperatively mean nasalance was within normal limits in 36 (90%) out of 40 cases, ranging from 21% to 35%; Mean = 28.10; SD = 5.40. Nasal emission was eliminated postoperatively in all cases. CONCLUSION: MPVF provides useful information for planning the surgical procedure aimed at correcting VPI. The combination of MPVF and FVNP is a reliable procedure for assessing velopharyngeal closure and to surgically correcting VPI with a highly successful outcome.

Spatiotemporal patterns of neuronal programmed cell death during postnatal development of the gerbil cochlea.

During early postnatal development, afferent neurons of the cochlear (spiral) ganglion progressively refine their projections to auditory hair cells so that, by hearing onset, most cochlear nerve fibers innervate a single hearing receptor. One mechanism that might contribute to these changes in cochlear innervation is the programmed cell death (apoptosis) of developing neurons within the spiral ganglion. In the present study, we used the TUNEL method and morphological criteria to identify apoptotic cells within the spiral ganglion of the Mongolian gerbil during the first week of postnatal life when afferent projections to the cochlea are actively refined in this species. The locations of individual apoptotic spiral ganglion cells were mapped onto three-dimensional reconstructions of the entire ganglion for an age-graded series of gerbils to produce the first high-resolution, spatiotemporal maps of apoptotic ganglion cell death for the postnatal cochlea. We observed a significant increase in apoptosis in the spiral ganglion from postnatal day (P) 4 through P6. During this time, the most intense apoptotic activity occurred in regions of the spiral ganglion providing innervation to the lower middle and apical turns of the cochlea. The time course and regional variation of programmed cell death within the developing gerbil spiral ganglion are discussed in terms of the postnatal refinement of cochlear innervation and its possible functional significance for hearing in gerbils.

Current Controversies in Diagnosis and Management of Cleft Palate and Velopharyngeal Insufficiency.

BACKGROUND: One of the most controversial topics concerning cleft palate is the diagnosis and treatment of velopharyngeal insufficiency (VPI). OBJECTIVE: This paper reviews current genetic aspects of cleft palate, imaging diagnosis of VPI, the planning of operations for restoring velopharyngeal function during speech, and strategies for speech pathology treatment of articulation disorders in patients with cleft palate. MATERIALS AND METHODS: An updated review of the scientific literature concerning genetic aspects of cleft palate was carried out. Current strategies for assessing and treating articulation disorders associated with cleft palate were analyzed. Imaging procedures for assessing velopharyngeal closure during speech were reviewed, including a recent method for performing intraoperative videonasopharyngoscopy. RESULTS: Conclusions from the analysis of genetic aspects of syndromic and nonsyndromic cleft palate and their use in its diagnosis and management are presented. Strategies for classifying and treating articulation disorders in patients with cleft palate are presented. Preliminary results of the use of multiplanar videofluoroscopy as an outpatient procedure and intraoperative endoscopy for the planning of operations which aimed to correct VPI are presented. CONCLUSION: This paper presents current aspects of the diagnosis and management of patients with cleft palate and VPI including 3 main aspects: genetics and genomics, speech pathology and imaging diagnosis, and surgical management.

State of the art in craniomaxillofacial trauma: frontal sinus.

PURPOSE OF REVIEW: Many of the successes and controversies in endoscopic management of craniofacial trauma are exemplified in the management of frontal sinus trauma. RECENT FINDINGS: The effort to reduce surgical morbidity and to optimize reconstruction of craniomaxillofacial injuries has resulted in the development of less invasive surgical approaches and in the use of computer image guidance in surgical planning and execution. Minimally invasive management of frontal sinus inflammatory disease has gained wide acceptance. The technology and techniques applied to surgery of the floor of the frontal sinus is now being applied to the management of frontal sinus trauma. A paradigm shift in the treatment of frontal sinus trauma may be underway. SUMMARY: An increasing scope of less severe injuries is being managed expectantly with endoscopic frontal sinus surgery available for salvage. There may be an overall decrease in the most severe frontal sinus injuries owing to enforcement of seatbelt and airbag usage. And the most severe injuries are often best managed through cranialization with anterior skull base reconstruction. Thus, the role for frontal sinus obliteration purely to obviate fractures of the frontal sinus outflow tract may be vanishing.

Impact of age on clinical care pathway length of stay after complex head and neck resection.

OBJECTIVE: This article investigates the effect of patient age on postoperative pathway length of stay (LOS) for head and neck surgery. Aggregate clinical results for 43 patients, enrolled in the CCP from June 1996-July 1997, are described. Patient age, comorbid status, and postoperative complications are analyzed with respect to impact on LOS. SETTING: Tertiary level academic medical center with an operative otorhinolaryngology volume of approximately 1200 cases per year. PATIENTS: Forty-three patients undergoing head and neck resection with primary closure, local flap, or free flap closure were enrolled on CCP from June 1996-July 1997. Length of stay, frequency of selected aggregated comorbidities, and frequencies of complications are analyzed with nonparametric statistics. A pre-pathway group of 87 consecutive patients is used for comparison. MAIN OUTCOME MEASURES: Length of stay and age. RESULTS: Median actual LOS post-pathway for the patients enrolled in the first year of the pathway was 8 days. This met the CCP target and improved on pre-pathway LOS by 5 days (p <.001). The average LOS increased 25% from 8 days to 10 days for patients older than 65 years of age (p =.036, Mann-Whitney U test). Presence of a comorbidity and a complication concomitantly was statistically associated with increased LOS though not with advancing age (p =.003). CONCLUSIONS: The CCP-reported performance improvement achieved by this pathway suggests improved resource use, and improved patient outcomes are achieved for postoperative care of head and neck surgery patients. Our experience suggests that advancing age creates a clinically significant increase in resource use represented by our finding of increasing LOS. This finding warrants further investigation.