Diagnosis and Prognostic Implications of Primary Intraosseous Carcinoma: A Case Report and Literature Review.

Primary Intraosseous Carcinoma (PIOC) is a rare and aggressive squamous cell carcinoma (SCC) derived from remnants of odontogenic epithelium with no initial connection to oral mucosa. Due to the rarity of the disease, etiology and epidemiology are not clearly defined. The most affected site is the posterior mandible, and clinical features include swelling of the jaw, jaw pain, and sensory disturbances. Given the similarities of PIOC to other odontogenic carcinomas, diagnosis is often difficult, resulting in delays in intervention. Treatment of PIOC of the mandible includes surgery alone, surgery with adjuvant radiotherapy or chemotherapy, and free flap reconstruction. PIOC prognosis is poor, with the lymph nodal status acting as an important indicator. We present a case of a 60-year-old female who presented with a left submandibular mass initially thought to be SCC of unknown primary origin. Further investigation led to a final diagnosis of PIOC of the mandible. Clinical, radiological, and histological features of PIOC will be discussed.

Incidental Finding of Double Posterior Belly of Digastric Muscle in Head and Neck Cancer Patient.

OBJECTIVES: The digastric muscles have important roles in swallowing, chewing, speech, and landmark identification during neck dissection. The posterior belly of the digastric muscle (PBDM) is often useful for defining boundaries in surgical neck dissection as it contributes to the carotid, submandibular, and submental triangles. The cadaveric prevalence rate of anatomic variations in the digastrics has been reported to be 31.4% of the population with most occurring in relation to the anterior belly of the digastric muscle (ABDM). Few reports describe variations in the PBDM. While anatomic variants of the digastric muscles do not present with clinical manifestations, they can be mistaken as neck masses and contribute to intraoperative complications. METHODS: We present a case report of a 73-year-old male with a past medical history significant for Parkinson's Disease, who was incidentally found to have a duplicate PBDM intraoperatively while receiving surgical management of a left buccal squamous cell cancer. RESULTS: Nine months prior to surgery, the patient began experiencing trismus and some mild dysphagia that were eventually worked up to reveal left buccal squamous cell carcinoma (SCC). Prior to this, the patient did not have clinical symptoms demonstrating dysfunction that could be related to or indicative of this anatomical abnormality preceding symptoms related to left buccal SCC growth. The procedure included a wide local excision, left modified radical neck dissection and left submental artery island flap with suprahyoid neck dissection. The superior duplicate PBDM was found to be overlying the stylohyoid muscle. CONCLUSIONS: It is important for surgeons operating in the head and neck to be aware of the possibility of this rare variation, and to be conscientious when it is identified so that it does not prohibit or limit a thorough dissection of the neck structures where oncologic clearance is paramount.

Two Rare Cases of Metastatic Occult Thyroid Carcinoma Without Primary Cancer in the Thyroid Gland.

Papillary thyroid cancer (PTC) contributes to the majority of all thyroid malignancies. In this case report, we detail two cases of occult thyroid carcinoma (OTC), which presents with thyroid metastasis to locoregional lymph nodes without having an initial primary tumor detected in the thyroid gland. OTC may be found incidentally on biopsy, surgery, or imaging. Advancements in diagnostic technology have allowed physicians to identify and treat OTC at an earlier stage. We present two patients who were found to have metastases to cervical lymph nodes without a primary identification in the thyroid gland. The first patient was a 67-year-old female who noticed an enlarging mass in her right neck at levels III and IV. Fine needle aspiration (FNA) revealed the presence of PTC. The patient underwent a total thyroidectomy, central nodal dissection, and right-modified radical neck dissection. Final pathology confirmed the presence of PTC metastasis to cervical lymph nodes, but no primary tumor was identified within the thyroid gland. The second patient was a 79-year-old male who presented with a painless mass of the left parotid gland. The FNA of the patient revealed PTC metastasis to his left parotid gland. The patient underwent a total thyroidectomy, ipsilateral central nodal dissection, ipsilateral modified radical neck dissection, and inferior superficial and deep lobe parotidectomy. No malignancy was detected within the thyroid gland or central or lateral neck lymph nodes on final pathology. Carcinoma was confined to an intra-parotid node in the deep lobe of the parotid gland. OTC is a rare phenomenon in PTC. One proposed theory for OTC includes spontaneous regression of the primary tumor and genetic mutations to the BRAF gene. Due to the fact that it is easy for this rare condition to be misdiagnosed, more studies should be conducted to standardize diagnostic and treatment plans for OTC.

Granulomatosis With Polyangiitis as an Etiology of Silent Sinus Syndrome: A Case Report.

Silent sinus syndrome (SSS) is a rare condition characterized by the collapse of the maxillary sinus and the sinking of the eye socket (enophthalmos). Only around 100 cases of SSS have been reported so far. The underlying cause of this condition is the chronic obstruction of the osteomeatal complex, which leads to sinus contraction. In this case, we present a novel finding linking SSS with granulomatosis with polyangiitis (GPA). The patient described is a 39-year-old male who was diagnosed with SSS after a prolonged period of sinus pressure, headaches, epistaxis, and generalized congestion. Additionally, the patient reported a significant autoimmune history, including a previous occurrence of ANCA-mediated glomerulonephritis. Surgical intervention revealed the presence of significant granulation tissue, while histopathological examination identified areas of necrosis, vasculitis, and multinucleated giant cells consistent with GPA. This finding was further supported by the detection of positive blood c-ANCA. This case is particularly noteworthy as it is the first reported instance of GPA causing SSS. It serves as an excellent example to illustrate the underlying pathophysiology of SSS.

Treatment of Warthin's Tumors of the Parotid Gland With Radiofrequency Ablation: A Systematic Review of the Current Literature.

Objective: Warthin's tumors of the parotid gland can be safely observed. Definitive treatment usually requires parotidectomy under general anesthesia. The decision to operate on Warthin's tumors of the parotid gland can be complicated in patients who wish to avoid risks of surgery and general anesthesia. This systematic review explores the potential of radiofrequency ablation (RFA) as a minimally invasive alternative. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model was used to collect 3 relevant studies that focused on RFA treatment for Warthin's tumors. The cumulative averages for tumor size and cosmetic scores were then quantified for patients with Warthin's tumors who underwent RFA therapy. The PRISMA systematic review method was employed to the PubMed and EMBASE databases. The comprehensive search term "Warthin Tumor Treatment" yielded 1299 articles from the years 1955 to 2023, 3 of which met inclusion criteria and were then selected. Results: The 3 quantitative studies collectively assessed 37 patients with Warthin's tumors treated with RFA. Patients experienced an average tumor size reduction of 85.03% at 12 months post-RFA. There were minimal complications associated with RFA in these patients. Conclusion: This study suggests that RFA is an alternative to parotidectomy for the symptomatic treatment of Warthin's tumors. RFA procedures demonstrated substantial tumor size reduction with few complications. However, further meta-analysis and comparison with alternative treatments is warranted to establish RFA's role in treatment of Warthin's tumors. The study is limited by its reliance on only 2 databases and a lack of comprehensive examination of different RFA settings.

Indocyanine Green Angiography as the Principal Design and Perfusion Assessment Tool for the Supraclavicular Artery Island Flap in Head and Neck Reconstruction.

A consecutive case series of supraclavicular artery island flaps was designed using indocyanine green angiography (IcG-A) in head and neck reconstruction to demonstrate its utilization in supraclavicular artery island flap (SCAIF) head and neck reconstruction. IcG-A was used consecutively between April 2014 and July 2015 to evaluate its use in flap design, inset, and intraoperative decision-making in five patients undergoing head and neck reconstruction. Six SCAIFs were harvested in five patients where IcG-A was used as the primary tool for flap design by visually mapping the supraclavicular artery under fluorescence. Each flap was harvested around the mapped course of the artery. Confirmatory Doppler was present in each flap raised with this technique. In all five patients, IcG-A was used to assess flap perfusion after inset. This case series demonstrates IcG-A as another tool for SCAIF design in head and neck reconstruction. The technology provides direct visualization of the pedicle before harvest. It can also be used as an intraoperative tool to visualize the blood supply once the flap is rotated to assess flap perfusion and detect areas that may be compromised, thereby improving flap survival.

Transoral robotic submandibular gland transposition to reconstruct radical tonsillar resection defects.

Significant dysphagia, pain, and risk of bleeding occur after transoral robotic surgery (TORS) radical tonsillectomy. We present a novel surgical technique utilizing robotically assisted submandibular gland transposition (SMGT) to reconstruct the radical tonsillar defect. A 48-year-old male with p16+ tonsillar squamous cell carcinoma underwent deep TORS radical tonsillectomy, contralateral tonsillectomy, ipsilateral neck dissection, and TORS-assisted reconstruction of the radical defect with ipsilateral SMGT. Postoperatively, the patient experienced minimal pain and was discharged on postoperative day (POD) 3 tolerating a soft diet. There were no episodes of postoperative bleeding. This procedure was performed in five other cases as well. Transoral robotic SMGT can be used successfully to repair deep TORS radical tonsillectomy defects and may theoretically reduce dysphagia, pain, and the risk of hemorrhage.

Incidence of pedicle ossification in osseous free flap reconstruction in the head and neck.

BACKGROUND: There are several reports of ossification occurring along the pedicle of fibular free flaps in head and neck microvascular reconstruction, but the incidence of pedicle ossification of other osseous flaps in head and neck surgery has never been investigated. METHODS: A retrospective chart review was conducted for all patients undergoing free flap reconstruction in the head and neck between 2005 and 2016. Patients were included if they had reconstruction with an osseous free flap and if they had computed tomography (CT) scans at least 1 month post-operatively. Available CT images were reviewed for each patient. RESULTS: Three-hundred thirty four osteocutaneous free flaps were performed. The average age was 64 years (range 8-89). There was slight male predominance with 63.5% of the cohort being male (n = 212). One hundred fifty-five patients had fibular flaps (45%), 108 had radial forearm flaps (34%) and 71 had scapular flaps (21%). One hundred fibulas had available imaging, 73 forearms had available imaging, and 44 scapulas had imaging post-operatively. Of the images reviewed, pedicle ossification was identified in 21 fibular flaps (21%). None of the radial forearm or scapular flaps developed pedicle ossification. DISCUSSION: Pedicle ossification is relatively common in osteocutaneous free flap reconstruction and is uniquely associated with fibular. The presence of pedicle ossification is benign and does not compromise the flap, though it can create concern in cancer surveillance as the lesion is often identified as a new neck mass. As such, head and neck surgeons should be aware of this relatively frequent finding.

Papillary-Type Carcinoma of the Thyroglossal Duct Cyst: The Case for Conservative Management.

OBJECTIVES: Thyroglossal duct cyst (TGDC) is the most common congenital neck mass, presenting in up to 7% of the population. TGDC carcinoma is much less common, occurring in roughly 1% of patients diagnosed with TGDC. The vast majority of these tumors are papillary-type thyroid cancer. Given its rarity, there is wide variation in management recommendations for this disease. Extent of surgical management and need for adjuvant therapy including radioactive iodine ablation (RAI) are particularly debated, with some authors arguing aggressive therapy including RAI for any patients who undergo concurrent thyroidectomy with the Sistrunk procedure for TGDC carcinoma. We present a series of patients treated for TGDC carcinoma at our institutions and discuss our management algorithm. METHODS: This is a retrospective chart review of patients with TGDC treated at 2 separate institutions. Factors reviewed included patient age, sex, preoperative diagnosis, preoperative work-up, extent of therapy, and use of adjuvant therapy. RESULTS: Six patients who were treated for TGDC carcinoma at our institutions were identified. One patient was excluded because the patient had been treated at an outside facility prior to referral. All patients had papillary-type thyroid cancer. One patient underwent the Sistrunk procedure alone, and the remaining 4 underwent the Sistrunk procedure plus total thyroidectomy. Two of 4 patients were noted to have malignancy in the thyroid. Two of 4 patients who underwent thyroidectomy additionally received adjuvant RAI. CONCLUSION: Thyroglossal duct cyst carcinoma is uncommon and management is controversial. In low-risk patients (single tumor focus, negative margins, normal preoperative neck/thyroid imaging, no extension of TGDC carcinoma beyond the cyst wall), the Sistrunk procedure alone with observation of the thyroid may be sufficient. In this patient population, RAI is unlikely to be of any substantial benefit.

Flexible microsensor technology for real-time navigation tracking in balloon sinus ostial dilation.

BACKGROUND: Microsensor navigation has the potential to aid balloon sinus ostial dilation by providing real-time tracking of balloon devices within the complex anatomy of the sinonasal cavities. OBJECTIVE: This feasibility study evaluated the incorporation of a new microsensor technology into a flexible guidewire for use with current instruments in balloon sinus ostial dilation. METHODS: A retrospective study was conducted to include seven men and one woman (age range, 33-68 years), who underwent balloon sinus ostial dilation with flexible microsensor navigation in the operating room setting. All the procedures were performed at target sinuses with the patient under general anesthesia, in conjunction with subsequent endoscopic sinus surgery. RESULTS: Balloon dilation was attempted at the maxillary (n = 3), frontal (n = 14), and sphenoid (n = 1) sinuses. In all the cases, the surgical navigation system displayed the flexible wire tip as it was advanced to the target sinus ostia; this visual feedback for wire position guided the balloon placement. Successful balloon dilation with assistance of flexible microsensor navigation was performed on most sinuses, except a single frontal sinus with adjacent type 2 frontal cells. CONCLUSION: Flexible navigation technology may be combined with balloon sinus technology to facilitate localization of instruments in the sinus anatomy. Additional optimization of both the device and software technology is warranted.

Hemostasis in Pediatric Surgery.

Hemostasis is an important concept in pediatric otolaryngologic surgery. This article details the considerations the otolaryngologist should take when it comes to clinical evaluation and surgical technique. It begins with the preoperative evaluation, and evolves into the use of different mechanical and chemical methods of operative hemostasis. We detail use of different hemostatic techniques in common pediatric procedures, and finally, we discuss indications for intraoperative and postoperative blood transfusion in pediatric patients if the surgeon encounters significant intraoperative hemorrhage. This paper gives a comprehensive look into the hemostatic considerations for the pediatric patient through the preoperative to postoperative period.

Augmented reality for endoscopic sinus surgery with surgical navigation: a cadaver study.

BACKGROUND: Augmented reality (AR) fuses computer-generated images of preoperative imaging data with real-time views of the surgical field. Scopis Hybrid Navigation (Scopis GmbH, Berlin, Germany) is a surgical navigation system with AR capabilities for endoscopic sinus surgery (ESS). METHODS: Predissection planning was performed with Scopis Hybrid Navigation software followed by ESS dissection on 2 human specimens using conventional ESS instruments. RESULTS: Predissection planning included creating models of relevant frontal recess structures and the frontal sinus outflow pathway on orthogonal computed tomography (CT) images. Positions of the optic nerve and internal carotid artery were marked on the CT images. Models and annotations were displayed as an overlay on the endoscopic images during the dissection, which was performed with electromagnetic surgical navigation. The accuracy of the AR images relative to underlying anatomy was better than 1.5 mm. The software's trajectory targeting tool was used to guide instrument placement along the frontal sinus outflow pathway. AR imaging of the optic nerve and internal carotid artery served to mark the positions of these structures during the dissection. CONCLUSION: Surgical navigation with AR was easily deployed in this cadaveric model of ESS. This technology builds upon the positive impact of surgical navigation during ESS, particularly during frontal recess surgery. Instrument tracking with this technology facilitates identifying and cannulation of the frontal sinus outflow pathway without dissection of the frontal recess anatomy. AR can also highlight "anti-targets" (ie, structures to be avoided), such as the optic nerve and internal carotid artery, and thus reduce surgical complications and morbidity.

Galectin-3 is a new MerTK-specific eat-me signal.

Phagocytosis of apoptotic cells and cellular debris is a critical process of maintaining tissue and immune homeostasis. Defects in the phagocytosis process cause autoimmunity and degenerative diseases. Phagocytosis ligands or "eat-me" signals control the initiation of the process by linking apoptotic cells to receptors on phagocyte surface and triggering signaling cascades for cargo engulfment. Eat-me signals are traditionally identified on a case-by-case basis with challenges, and the identification of their cognate receptors is equally daunting. Here, we identified galectin-3 (Gal-3) as a new MerTK ligand by an advanced dual functional cloning strategy, in which phagocytosis-based functional cloning is combined with receptor-based affinity cloning to directly identify receptor-specific eat-me signal. Gal-3 interaction with MerTK was independently verified by co-immunoprecipitation. Functional analyses showed that Gal-3 stimulated the phagocytosis of apoptotic cells and cellular debris by macrophages and retinal pigment epithelial cells with MerTK activation and autophosphorylation. The Gal-3-mediated phagocytosis was blocked by excessive soluble MerTK extracellular domain and lactose. These results suggest that Gal-3 is a legitimate MerTK-specific eat-me signal. The strategy of dual functional cloning with applicability to other phagocytic receptors will facilitate unbiased identification of their unknown ligands and improve our capacity for therapeutic modulation of phagocytic activity and innate immune response.

Phospholipid scramblase 1 binds to the promoter region of the inositol 1,4,5-triphosphate receptor type 1 gene to enhance its expression.

Phospholipid scramblase 1 (PLSCR1) is a multiply palmitoylated, endofacial membrane protein originally identified based on its capacity to promote accelerated transbilayer phospholipid movement in response to Ca(2+). Recent evidence suggests that this protein also participates in cell response to various growth factors and cytokines, influencing myeloid differentiation, tumor growth, and the antiviral activity of interferon. Whereas plasma membrane PLSCR1 was shown to be required for normal recruitment and activation of Src kinase by stimulated cell surface growth factor receptors, PLSCR1 was also found to traffic into the nucleus and to tightly bind to genomic DNA, suggesting a possible additional nuclear function. We now report evidence that PLSCR1 directly binds to the 5'-promoter region of the inositol 1,4,5-triphosphate receptor type 1 gene (IP3R1) to enhance expression of the receptor. Probing a CpG island genomic library with PLSCR1 as bait identified four clones with avidity for PLSCR1, including a 191-bp fragment of the IP3R1 promoter. Using electrophoretic mobility shift and transcription reporter assays, the PLSCR1-binding site in IP3R1 was mapped to residues (-101)GTAACCATGTGGA(-89), and the segment spanning Met(86)-Glu(118) in PLSCR1 was identified to mediate its transcriptional activity. The significance of this interaction between PLSCR1 and IP3R1 in situ was confirmed by comparing levels of IP3R1 mRNA and protein in matched cells that either expressed or were deficient in PLSCR1. These data suggest that in addition to its role at the plasma membrane, effects of PLSCR1 on cell proliferative and maturational responses may also relate to alterations in expression of cellular IP3 receptors.