Systematic review of submental artery island flap versus free flap in head and neck reconstruction.

PURPOSE: The aim of this systematic review is to compare the perioperative characteristics and outcomes of submental artery island flap (SAIF) to free tissue transfer (FTT) in head and neck reconstruction. MATERIALS AND METHODS: Screening and data extraction were done with Pubmed, Embase, and Web of Science databases by two independent authors to identify randomized and observational studies that compared patient outcomes for SAIF vs. FTT for reconstruction head and neck cancer ablative surgery. Data were pooled with random-effects meta-analysis to determine pooled difference in means (DM), absolute risk differences, and 95% confidence intervals (CI). Heterogeneity was assessed with the I-squared statistic. RESULTS: Initial query yielded 997 results, of which 7 studies met inclusion criteria. The pooled sample sizes for the SAIF and FTT cohorts were 155 and 198, respectively. SAIF reduced mean operative time by 193 min (95% CI -160 to -227), reduced hospital stay by 2.1 days (95% CI -0.9 to -3.4), and had a smaller flap area of 22.5cm2 (95% CI 6.5 to 38.4). SAIF had a 5% higher incidence of partial flap necrosis than FTT (95% CI, 1 to 10), but all other perioperative complications, including recurrence rate in malignant cases, were statistically comparable. CONCLUSIONS: The SAIF requires less operative time, hospital stay, and has comparable perioperative outcomes to FTT, but the area of flap harvest is significantly smaller. The findings of this study add to the growing body of evidence demonstrating the safety and reliability of SAIF in head and neck reconstruction.

Fetal cervical teratoma: What is the role of fetal MRI in predicting pulmonary hypoplasia?

OBJECTIVE: To determine whether total fetal lung volumes estimated by MRI could predict lethal pulmonary hypoplasia in a cohort of fetuses with cervical teratomas. METHODS: We performed a retrospective cohort study of fetal cervical teratomas from January 1, 2005, through April 1, 2012. The primary outcome was the ability of total lung volumes measured by MRI to predict neonatal mortality specifically due to pulmonary hypoplasia. Measured lung volumes were compared to previously reported normal values. The percent of observed-to-expected lung volume and the percent predicted lung volume were calculated. The positive and negative predictive values were calculated for each variable. RESULTS: Fetal MRI-derived total lung volumes 1 standard deviation below the median for gestational age had a positive predictive value of 100% in predicting lethal pulmonary hypoplasia. Conversely, total lung volumes above this level were uniformly associated with pulmonary survival (100% negative predictive value). Additionally, percent predicted lung volume ≤75.7 and observed-to-expected lung volume ≤68.3 were associated with lethal pulmonary hypoplasia. CONCLUSION: In this small cohort, MRI-estimated lung volumes were helpful in predicting the presence of pulmonary hypoplasia complicating fetal cervical teratoma.

Ex utero intrapartum treatment to extracorporeal membrane oxygenation: lifesaving management of a giant cervical teratoma.

BACKGROUND: Ex utero intrapartum treatment ('EXIT' procedure) is a well described method for maintaining maternal-fetal circulation in the setting of airway obstruction from compressive neck masses. When ex utero intrapartum treatment to airway is not feasible, ex utero intrapartum treatment to extracorporeal membrane oxygenation ('ECMO') has been described in fetal cardiopulmonary abnormalities. OBJECTIVE: This paper presents the case of a massively compressive midline neck teratoma managed with ex utero intrapartum treatment to extracorporeal membrane oxygenation, allowing for neonatal survival, with controlled airway management and subsequent resection. CASE REPORT: A 34-year-old-female presented with a fetal magnetic resonance imaging scan demonstrating a 15 cm compressive midline neck teratoma. Concern for failure of ex utero intrapartum treatment to airway was high. The addition of the ex utero intrapartum treatment to extracorporeal membrane oxygenation procedure provided time for the planned subsequent resection of the mass and tracheostomy. CONCLUSION: Ex utero intrapartum treatment procedures allow for securement of the difficult neonatal airway, while maintaining a supply of oxygenated blood to the newborn. Ex utero intrapartum treatment circulation lasts on average less than 30 minutes. The arrival of extracorporeal membrane oxygenation has enabled the survival of neonates with disease processes previously incompatible with life.

Prenatal diagnosis of cervical masses by magnetic resonance imaging and 3D virtual models: perinatal and long-term follow-up outcomes.

Objective: To assess perinatal and long-term follow-up outcomes of fetal cervical masses diagnosed by three-dimensional (3D) magnetic resonance imaging (MRI) and 3D virtual models.Methods: This retrospective cohort study evaluated 15 pregnant women (age, 21-38 years) at 29-40 weeks of singleton gestation, whose fetuses exhibited congenital oral and cervical masses. These women were referred to our facility because of suspected fetal malformations on routine obstetric ultrasound, and the cases were confirmed, excluded, or complemented by MRI. Demographic data and perinatal and long-term follow-up outcomes were assessed.Results: Cervical masses were predominant in females (3:2), and the most frequent diagnosis was lymphatic-venous malformation (71%). The masses were cystic in 53.3% of the cases and solid in 46.7%. The esophagus and trachea were displaced in 46.6% of the cases. Associated malformations were diagnosed in 13.3% of the cases. There was complete agreement between prenatal MRI and postnatal diagnoses. Among the newborns, 40% had complications and 46.6% were admitted to the neonatal intensive care unit. Two infants died from complications due to epignathus. Surgical resection was performed in 33.3% of the cases, including complete resection in 26.6%. Sclerotherapy was administered to 53.3% of the cases, with complete remission achieved in 50% of these cases.Conclusion: Cervical masses diagnosed in the prenatal period had good postnatal outcomes except for cases of epignathus, which were associated with high mortality. MRI demonstrated the relationship between cervical masses and adjacent organs and allowed 3D virtual reconstruction of the airways. There was complete agreement between the prenatal diagnosis of cervical masses on MRI and postnatal diagnosis. Surgical treatment was effective in most cases, and sclerotherapy was satisfactory in cases with intrathoracic components.

[Therapy for prenatally diagnosed lymphangioma--multimodal procedure and interdisciplinary challenge]. / Die Therapie von pränatal diagnostizierten Lymphangiomen--Multimodales Vorgehen und eine interdisziplinäre Herausforderung.

INTRODUCTION: Ultrasound diagnostics enable the prenatal diagnosis of extensive lymphatic malformations. The diagnosis is made prenatally or directly after birth in 50-60% of the cases, in about 80% of the afflicted in the first year of life and up to 90% of the cases in the second year of life. PRENATAL DIAGNOSTICS AND POSSIBILITIES OF PRE- AND PERINATAL INTERVENTIONS: The so called hygroma colli is a primary symptom, which is detected during the routine ultrasound examination. Lymphatic malformations, which are diagnosed antenatally are often associated with chromosome abnormalities. The EXIT procedure allows invasive therapeutic or diagnostic interventions. Hereby the airway safety of Newborns with extended cervical or zerviko-facial lymphangiomas can be warranted. The survival chance and the prognosis may be significantly improved. MANIFESTATION AND ENT-CLINICS: 72 patients (mean age 12.3 yrs) with lymphatic malformations of the Head and Neck presented for the first time during a 5-years period until 31.12.2008 at the Department of Otolaryngology of the University of Marburg. Therapeutic interventions consisted in conventional surgery, laser assisted therapy, sclerosing therapy or a combined therapeutic approach. CONCLUSION: Extensive lymphatic malformations of the Head and Neck challenge treating physicians and affected families. Advancements of prenatal diagnostics and opportunities of peri- and postnatal interventions contribute to an improved survival chance and prognosis. Intensive interdisciplinary cooperation in specialised centers is of outstanding importance for an optimal care of these patients.

[Head and neck paragangliomas. Embryological origin and anatomical characteristics: topographic distribution and vascularization pattern]. / Paragangliomas cervicocefálicos. Origen embriológico y características anatómicas: distribución topográfica y patrón de vascularización.

Paragangliomas are tumors that arise in the extraadrenal paraganglia and result from migration of neural crest cells during embryonic development. Based on their anatomical distribution, innervation and microscopic structure, these tumors can be classified into interrelated families: branchiomeric paraganglia (related to the branchial clefts and arches), intravagal, aortic-sympathetic and visceral-autonomic. Head and neck paragangliomas belong mainly to the first two of these families. The present article is divided into two parts. The first part reviews the embryological origin of these tumors. Special emphasis is placed on the process of neurulation or neural tube formation, neurosegmentation (with a summary of the mechanisms involved in the initial segmentation of the neural tube and of the hindbrain and spinal medulla), and the development of the sensory placodes and secondary inductions in the cranial region. Subsequently, the neural crest is analyzed, with special attention paid to the cranial neural crest. The embryonogenesis of paragangliomas is also described. The second part describes the topographical distribution of head and neck paragangliomas according to their localization: jugulotympanic, orbit, intercarotid, subclavian and laryngeal. The embryonogenesis and most important anatomical characteristics are described for each type.

Three-step management of a newborn with a giant, highly vascularized, cervical teratoma: a case report.

BACKGROUND: A giant congenital cervical teratoma is often highly vascularized; thus, in addition to a life-threatening airway occlusion at birth it comprises a high risk for significant and lethal blood loss during resection. In the case presented, an endovascular embolization of the carotid artery that supplied a giant congenital cervical teratoma was done as part of a three-stage treatment soon after birth and contributed to an overall good outcome. Embolization in cases of cervical teratomas was not described previously. CASE PRESENTATION: We present a case of a preterm newborn from a Sephardic jewish origin with a giant, highly vascularized, congenital cervical teratoma that was managed successfully in three stages: (1) delivery by an ex utero intrapartum treatment procedure after extensive preoperative planning and followed by tracheostomy, (2) endovascular embolization of the carotid artery that supplied the tumor in order to decrease blood loss during resection, and (3) complete surgical resection. The parents were involved in all the ethical and medical decisions, starting just after the cervical mass was diagnosed prenatally. CONCLUSION: The management of giant congenital cervical teratoma is often challenging from both a medical and ethical prospective. Meticulous perinatal planning and parents' involvement is crucial. Endovascular embolization of the tumor feeding vessels can significantly improve the resection outcome and overall prognosis.

Parapharyngeal cyst: considerations on embryology, clinical evaluation, and surgical management.

Branchial cleft anomalies represent a common cause of cervical mass in adults. Describing a case report, we reviewed embryology, clinical elements, and treatment options for parapharyngeal congenital cysts. A case of a parapharyngeal cyst mimicking a tonsillar abscess is presented. A second branchial cleft cyst was hypothesized on a clinical and radiologic basis and then confirmed by histologic data. Magnetic resonance imaging provided fundamental information for the study of the parapharyngeal mass and its relationship with surrounding structures. In literature, surgical excision is the recommended therapy. We removed the cyst through a transcervical approach, with no complications or recurrence after 3 years. In our opinion, cervicotomy should be considered the gold standard approach, even for lesions not palpable in the cervical area. When dealing with a parapharyngeal cyst, second branchial cleft anomalies should be considered. Our experience confirms that cervicotomy is a safe approach to parapharyngeal congenital lesions.

Congenital cervical immature teratoma arising in the left lobe of the thyroid gland.

We report on a fetal autopsy case in which a congenital cervical immature teratoma was diagnosed. A 24-year-old Japanese woman had carried a male fetus that was aborted because of a cervical tumor at 20 weeks 5 days of gestation. The cervical tumor weighed 93 g and measured 7.5x5.5x5 cm. The soft tumor was encapsulated by a fibrous layer, was solid with small cysts on the cut surface, and showed a brain-like appearance. The tumor was composed of neoplastic cells derived from the three germ cell layers: ectoderm, mesoderm, and endoderm. The cells showed both immature and mature features. Small areas of thyroid tissue were detected in the cervical tumor. The left lobe of the thyroid gland was not observed, but the right lobe of the thyroid gland was present laterally between the trachea and the esophagus. Therefore, we concluded that the cervical tumor had arisen in the left lobe of the thyroid gland rather than from the soft tissue of the neck.

Gastroschisis with fetal chromosomal abnormality: a case report.

Gastroschisis is a rare anomaly and it is usually not associated with other syndromic or nonsyndromic anomalies. The first case of gastroschisis with aneuploidy (Turner syndrome) is presented. A fetal huge cystic hygroma was diagnosed by prenatal sonography at 12 weeks of pregnancy and chorionic villi sampling (CVS) was performed. Cytogenetic analysis revealed 45, X0. The pregnancy was terminated by induction of labor at 16 weeks of pregnancy. The female fetus had a big membrane of cystic hygroma surrounding the fetal neck. Additionally, a full abdominal thickness defect with multiple loops of bowel outside the abdomen, which could not be diagnosed on prenatal ultrasound scan, was detected on postnatal examination.

Use of the GlideScope video laryngoscope for intubation during ex utero intrapartum treatment in a fetus with a giant cyst of the 4th branchial cleft: A case report.

INTRODUCTION: In fetuses who are predicted to be at risk of catastrophic airway obstruction at delivery, the ex utero intrapartum treatment (EXIT) procedure is useful for securing the fetal airway while maintaining fetal oxygenation via placental circulation. Factors, including poor posture of the fetus and physician, narrow visual field, and issues of contamination in the aseptic surgical field, make fetal intubation during the EXIT procedure difficult. Herein, we report our experience of the usefulness of the GlideScope video laryngoscope (GVL) for intubation during the EXIT procedure. SYMPTOMS AND CLINICAL FINDINGS: A 28-year-old woman presented with a fetus having a cystic neck mass diagnosed on prenatal ultrasound at 25 weeks of gestation. We planned the EXIT procedure in conjunction with cesarean delivery at 38 weeks of gestation, as the mass enlarged to 4.9 cm × 3.2 cm, protruded externally at the neck, and subsequently resulted in polyhydramnios. THERAPEUTIC INTERVENTION AND OUTCOMES: After induction of anesthesia using intravenous thiopental (300 mg), adequate uterine relaxation was achieved with sevoflurane (2.0-3.0 vol%) combined with continuous intravenous infusion of nitroglycerin (0.5-1.0 µg/kg/min) for maintaining uteroplacental circulation. After hysterotomy, the head and right upper limb of the fetus were partially delivered, and fetal heart tones were monitored with a sterile Doppler probe. After oropharyngeal suctioning to improve the visual field, the fetus was intubated successfully using a sterile GVL by an anesthesiologist, and the passage of the endotracheal tube beyond the vocal cords was confirmed on the screen of the GVL system. Immediately after the fetal airway was definitely secured, the fetus was fully delivered with umbilical cord clamping. After delivery, nitroglycerine administration was ceased and sevoflurane administration was reduced to 0.5 minimum alveolar concentration. Additionally, oxytocin (10 units) and carbetocin (100 µg) were administered for recovery of uterine contraction. Cesarean delivery was successfully performed without any problems, and the neonate successfully underwent surgery for removal of the neck mass under general anesthesia on the 7th day after delivery. The neonate is developing normally. CONCLUSION: The GVL approach may be a useful noninvasive approach for establishing a clear fetal airway during the EXIT procedure.

MR imaging and ultrasound of fetal cervical cystic lymphangioma: utility in antepartum treatment planning.

We present a case of fetal cystic lymphangioma that was initially diagnosed by ultrasonography and further evaluated by prenatal MR imaging. MR imaging findings aided in improved delineation of the neck mass. T2-weighted MR images revealed partial compression of the airway by the neck mass. This information was useful in the decision to use ex utero intrapartum treatment (EXIT) and helped surgeons in planning their approach to establish airway control during delivery.

Ectopic hamartomatous thymoma. A distinctive benign lesion of lower neck.

Five cases of a distinctive tumor located in the soft tissues of the lower neck in adults are described. The lesion is characterized microscopically by the presence of four components: cellular areas made up of spindle elements; epithelial islands composed of solid nests, trabeculae and cysts; mature adipose tissue; and lymphocytes, sometimes arranged in a Hassall's corpuscle-like fashion. Electron microscopy and immunostaining for keratin showed that the spindle cell component was of epithelial nature. These tumors were supraclavicular or suprasternal in location, and no local recurrence has developed in any case following local resection. We interpret these lesions as benign tumors arising on the basis of a developmental defect. We think that they are derived from the third branchial arch and that they are composed of abnormal thymic tissue.

Mixed teratoid tumors of the liver and neck in trisomy 13.

A fetus with trisomy 13 syndrome and teratomas of liver and neck is described. The relationship of aneuploidy and chromosomal instability to neoplasia is discussed. Teratomas of the liver are reviewed.

Ectopic vestigial lesions of the neck and shoulders.

A series of five vestigial lesions of the shoulder and back is reported. Their derivation is discussed and in four cases a branchial rather than a bronchial origin is favoured. The fifth case is held to represent skin involvement by thyroglossal duct elements.

Management of fetal airway obstruction.

Fetal airway obstruction can make it difficult if not impossible to secure the airway at birth, before hypoxia, brain injury, or death results. Fetal airway obstruction can result from an intrinsic defect in the airway, such as the congenital high airway obstruction syndrome or extrinsic compression of the airway caused by a cervical mass, most commonly a cervical teratoma or lymphangioma. As fetuses with fetal airway obstruction reach viability, they should be monitored closely for the development or progression of hydrops in intrinsic obstruction cases or polyhydramnios in extrinsic obstruction cases. The fetus should be delivered by using the ex utero intrapartum treatment procedure, with maintenance of uteroplacental circulation and gas exchange. This approach provides time to perform procedures such as direct laryngoscopy, bronchoscopy, or tracheostomy to secure the fetal airway, thereby converting an emergent airway crisis into a controlled situation.

Common congenital anomalies of the neck. Embryology and surgical anatomy.

A good knowledge of embryology and surgical anatomy allows for the anticipation of intraoperative findings, and, hence, for safer and more efficient care of patients with congenital anomalies of the neck. Presumptive thyroglossal anomalies that are at or above the level of the hyoid mandate extra vigilance: the patient may not have sufficient thyroid tissue in the usual thyroid location. The discontinuous character of thyroglossal tracts, related to ontogenesis, ordains dissection to the lingual mucosa. First branchial cleft cysts and fistulas require knowledge of facial nerve anatomy; in some of these cases, the facial nerve is best identified in the temporal bone. Branchial cysts, sinuses, and fistulas only can be assigned to a specific pouch-cleft by their anatomic relations to cervical structures.

Cervical hibernoma.

The hibernoma is a rare neoplasm derived from vestigal remnants of brown fat left from early embryologic development. Review of the world literature reveals only 40 cases to which we are adding a report of a tumor arising in the posterior cervical triangle of a 20-year-old man. The distribution, histology and cytochemistry of brown fat and the hibernoma are discussed, and evidence supporting its histogensis is presented.

Fourth pharyngeal pouch sinus.

This is the first description and documentation of an extremely rare developmental anomaly of the pharyngeal apparatus in a 15-year-old female. The clinical, radiological, histological, and anatomical findings indicated that the anomaly originated in the pharyngeal fourth pouch. It presented as a recurrent lateral neck abscess which was due to a paratracheal sinus. This sinus penetrated the larynx and after a translaryngeal course ended in the pyriform sinus. It was caudad to the superior laryngeal nerve and external to the recurrent laryngeal nerve. Its penetration into the larynx at the cricothyroid joint region could serve as a useful surgical landmark.