Novel Endoscopic Transnasal Technique for Anterolateral Thigh Flap Inset Post Nasopharyngeal Carcinoma Resection.

Post-nasopharyngectomy reconstruction for recurrent nasopharyngeal carcinomas has been used for defect coverage and protection of vital structures. With the increasing use of endoscopic transnasal nasopharyngeal extirpation to offset complications faced with open techniques, there is a need for corresponding reconstructive support through a similar approach. We describe a novel endoscopic transnasal anterolateral thigh flap inset technique, combined with a transverse neck incision, in two patients who underwent transnasal nasopharyngectomy. We also include a video presentation of our operative technique. A vastus lateralis fascia free flap was used for one patient, and a vastus lateralis muscle free flap for the other. Both patients were aged 51 years. Mean nasopharyngeal defect size was 20 cm2 (range 12-28 cm2). Average surgical stay was 13.5 days (11-16 days) and flap mucosalization was complete for both patients. No recipient site complications were observed in either patient, although donor site seroma formation was seen in one patient. Average time to speech recovery was 1.5 months (range 1-2 months) for both patients. Time to diet recovery was 2 months for one patient, whereas the other was on long-term percutaneous endoscopic gastrostomy feeding. There were no flap failures or peri-operative mortalities. Endoscopic transnasal anterolateral thigh flap inset to reconstruct the nasopharyngeal space is an effective technique that confers reduced morbidity and potentially better outcomes compared with open techniques.

Grisel's Syndrome in an Adult After Endoscopic Nasopharyngectomy.

BACKGROUND: Grisel's syndrome is rare in adults, and is characterized by nontraumatic atlanto-axial subluxation secondary to infection. Here, we report a case of Grisel's syndrome occurring after endoscopic nasopharyngectomy. METHODS: A 67-year-old man complained of fever and neck pain with reduced lateral rotation after an endoscopic nasopharyngectomy for recurrent nasopharyngeal carcinoma. Flexion and extension X-rays of the cervical spine demonstrated atlanto-axial subluxation, and magnetic resonance imaging showed infective changes with cervical osteomyelitis. A diagnosis of Grisel's syndrome with cervical spine osteomyelitis was made. A later computed tomography (CT) scan demonstrated subluxation of C1 on C2, as well as the occipital-C1 joint. RESULTS: The patient was treated with intravenous antibiotics and offered surgery for spinal stabilization, but declined. He remained well 15 months post-op on a cervical collar with minimal pain and no neurologic deficits. CONCLUSION: A high index of suspicion for Grisel's syndrome is suggested in patients who have neck pain with reduced range of motion postnasopharyngectomy, and imaging is useful in clinching the diagnosis. LEVEL OF EVIDENCE: 4.

Decreased gastrostomy tube incidence and weight loss after transoral robotic surgery for low- to intermediate-risk oropharyngeal squamous cell carcinoma.

BACKGROUND: Functional outcomes after treatment for oropharyngeal squamous cell carcinoma (SCC) are increasingly prioritized. The purpose of this study was to investigate the incidence of gastrostomy tube placement and weight loss in patients with oropharyngeal SCC who may be eligible for either transoral robotic surgery (TORS) or nonsurgical management. METHODS: We conducted a retrospective review of previously untreated T1 to T2 and N0 to N2b oropharyngeal SCC to determine the rates of gastrostomy tube placement and weight loss according to Common Terminology Criteria for Adverse Events (CTCAE) criteria. Multivariate regression models were fit to compare these end points between groups. RESULTS: Two hundred twenty-three patients were included, comprised of 66 patients who underwent TORS and 157 patients who underwent (chemo)radiation. Thirty-two (48.5%) of the TORS patients received adjuvant radiation. On multivariate analysis, patients treated nonsurgically were 10.6 times and 8.1 times more likely to receive a gastrostomy tube and experience greater than CTCAE grade 1 weight loss, respectively. CONCLUSION: In selected patients with oropharyngeal SCC, TORS may help avoid critical weight loss and gastrostomy tube placement in the acute treatment period.

A case series of complicated infective otitis media requiring surgery in adults.

INTRODUCTION: With the advent of antibiotics, complications of otitis media have become less common. It is crucial for physicians to recognise otitis media and treat its complications early. Herein, we present our institution's experience with patients who required emergency surgical intervention for complications of otitis media. METHODS: Data on patients who underwent emergency surgery for complications of otitis media from 2004 to 2011 was retrieved from the archives of the Department of Otolaryngology, Changi General Hospital, Singapore. RESULTS: A total of 12 patients (10 male, two female) underwent emergency surgery for complications of otitis media. The median age of the patients was 25 years. Otalgia, otorrhoea, headache and fever were the main presenting symptoms. Extracranial complications were observed in 11 patients, and six patients had associated intracranial complications. The primary otologic disease was acute otitis media in six patients, chronic otitis media without cholesteatoma in three patients and chronic otitis media with cholesteatoma in three patients. Mastoidectomy and drainage of abscess through the mastoid, with insertion of grommet tube, was the main surgical approach. Two patients required craniotomy. The mean length of hospital stay was 16.2 days and the mean follow-up period was 16.3 months. Five patients had residual conductive hearing loss; two patients with facial palsy had full recovery. CONCLUSION: Otitis media can still result in serious complications in the post-antibiotic era. Patients with otitis media should be monitored, and prompt surgical intervention should be performed when necessary to attain good outcomes.