The Relationship Between the Retromandibular Vein and the Extratemporal Segment of the Facial Nerve: A Prospective Cadaveric Study of 24 Hemifaces.

INTRODUCTION: Anatomical preservation and functional integrity of the facial nerve (FN) are the main concerns of parotid surgery. Even though a variety of anatomical landmarks have been proposed and widely utilized, temporal or permanent postoperative FN palsy is still a significant comorbidity of parotid surgery. Therefore, the literature must fully elucidate the consistency of the anatomical relationship between the FN and the retromandibular vein (RMV). METHODS: We conducted a cadaveric study of 24 hemifaces to map the relationship between the FN and the RMV. Three distinct patterns were identified. Fourteen of the hemifaces were males, and 10 were females. Thirteen cadaveric dissections were performed on the right side and 11 on the left side. RESULTS: Our study found three distinct patterns and proposed a classification system. Type I (66.7%) is when the nerve lies exclusively lateral to the RMV. Type II (29.2%) is when the FN lies superficial to the RMV, but its mandibular branch lies deep to the anterior branch of the RMV, and type III (4.1%) is when the FN lies exclusively medial to the RMV. CONCLUSION: The FN and RMV relationship is not constant, and surgeons should be aware of every anatomical variation. Especially in cases where the FN is estimated to lie more in-depth to the level of the RMV, a retrograde approach may be required to avoid a FN injury.

A Novel and Simple Technique to Reduce the Rate of Pharyngocutaneous Fistula Formation Following a Total Laryngectomy - our Initial Results.

Objective: Pharyngocutaneous fistula (PCF) is a common and often devastating complication of total laryngectomy. Patients undergoing a total laryngectomy need enhancement of the neopharynx to reduce the risk of PCF formation. Our study aimed to evaluate the formation of a PCF following a total laryngectomy in patients that underwent a modified closure technique of their neopharynx. This technique included the recruitment of a flap of the muscular division of the pretracheal fascia that invests the strap muscles as a protective blanket. We called this surgical technique the 'curtain call'. Methods: We conducted a retrospective study for patients who underwent a total laryngectomy in our department between May 2022 and May 2023. Results: Twelve patients were identified. Our results demonstrated that the recruitment of this modified closure technique to cover the neopharynx resulted in a very low rate of postoperative PCF formation (8.3%). Conclusion: The 'curtain call' technique is an excellent method to support the neopharynx with extremely low rates of postoperative chronic dysphagia and with no evidence of impairing the development of esophageal speech. It could sometimes substitute much more time-consuming techniques like major pectoralis flap and supraclavicular flap. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-04343-7.

The Discovery of an S-shaped Kidney in a Patient With Prostate Cancer: A Rare Finding.

Crossed fused renal ectopia (CFRE) constitutes a rare congenital anomaly of the urinary tract, typically characterized by its predominantly asymptomatic nature and frequent incidental discovery. This case report delineates the clinical profile of a 56-year-old male admitted to our Prostate Cancer Outpatient Clinic due to elevated prostate-specific antigen (PSA) levels, ultimately leading to the diagnosis of prostate cancer. The patient was asymptomatic, with no family or surgical background. Notably, a fused ectopic kidney was incidentally identified during the staging process involving abdominal computed tomography (ACT) scanning. Remarkably, no additional abnormalities of the urinary tract or renal dysfunction manifested in this specific case. The significance of this report lies in the underscored emphasis on the importance of employing precise imaging techniques and tailored management strategies for patients harboring such anatomical variations.

Paraneoplastic Neurological Syndromes as Initial Presentation of Tumors: An Eight-Year Single-Center Experience.

BACKGROUND: Paraneoplastic Neurological Syndromes (PNS) comprise a diverse group of disorders propagated by immune-mediated effects of malignant tumors on neural tissue. METHODS: A single-center longitudinal study was performed including consecutive adult patients treated at a tertiary academic hospital between 2015 and 2023 and diagnosed with PNS. PNS were ascertained using the 2004 and the revised 2021 PNS-Care diagnostic criteria. RESULTS: Thirteen patients who fulfilled the 2004 definite PNS criteria were included. PNS comprise diverse neurological syndromes, with neuromuscular junction disorders (54%) and limbic encephalitis (31%) being predominant. PNS-related antibodies were detected in 85% of cases, including anti-AChR (n = 4), anti-P/Q-VGCC (n = 3), anti-Hu (n = 3), anti-Yo (n = 1), anti-Ma (n = 1), anti-titin (n = 1), anti-IgLON5 (n = 1), and anti-GAD65 (n = 1). Thymoma (31%), small-cell lung cancer (23%), and papillary thyroid carcinoma (18%) were the most frequent tumors. Imaging abnormalities were evident in 33% of cases. Early immunotherapy within 4-weeks from symptom onset was associated with favorable outcomes. At a mean follow-up of 2 ± 1 years, two patients with anti-Hu and anti-Yo antibodies died (18%). Four and three patients fulfilled the 2021 PNS-Care diagnostic criteria for definite and probable PNS, respectively. CONCLUSIONS: This study highlights the clinical heterogeneity of PNS, emphasizing the need for early suspicion and prompt treatment initiation for optimal outcomes.

Clinical Behavior of the Mucoepidermoid Carcinoma of the Larynx-A Scoping Review.

OBJECTIVE: Mucoepidermoid carcinomas (MEC) of the larynx account for less than 1% of all laryngeal tumors. The unique features and clinical behavior of these rare entities remain unknown. To fill this knowledge gap, we performed a scoping review of every reported case of laryngeal MEC to study the clinical behavior and the treatment modalities in this rare entity. REVIEW METHODS: We followed the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) statement. DATA SOURCES: MedLine, Google Scholar, and Science Direct databases were searched to identify eligible studies. RESULTS: We concluded with 25 studies and overall 66 cases. Our study revealed that the average age of cases was 55.7 years, and the range was from 12 to 81 years, with younger onset in females. Supraglottic (60%) is the most common subsite of laryngeal MEC s followed by glottis (27.3%). Supraglottic carcinomas frequently present with metastatic neck disease at the time of the initial diagnosis and require more extensive surgical approaches. Surgery with negative surgical margins seems to be the cornerstone in the treatment of MEC. Radiation therapy has not been tested widely as monotherapy but is considered a useful adjuvant modality. CONCLUSION: This study suggests that negative surgical margins seem to be associated to higher disease control rate and that high-grade supraglottic cases likely benefit from addressing neck disease simultaneously. LEVEL OF EVIDENCE: NA Laryngoscope, 2023.

The Presence of a Zygomatic Nerve Plexus in a Cadaveric Specimen Without a Zygomatic Branch of the Facial Nerve.

The extratemporal course of the facial nerve distributes in facial mimic muscles in a complex pattern. The traditional depictions of five main branches without anastomoses are not common. Davis classification remains the gold standard in the classification of facial nerve branching patterns. During a routine dissection of an 74-year-old male cadaveric specimen, we detected a very rare anatomical variation. The zygomatic branch of the facial nerve was totally absent. The temporofacial division of the main trunk was bifurcated to a temporal and a buccal branch. The anterior temporal and posterior buccal branches formed a plexus to supply the orbicularis oculi muscle. This unique variability highlights the complexity of the extratemporal facial nerve course. Retrograde facial nerve dissection requires deep knowledge of every anatomical variation of the facial nerve course to avoid an iatrogenic injury. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03601-y.

External Jugular Vein Perforation by the Transverse Cutaneous Nerve of The Neck: A Case Report and Review of The Literature.

A very rare anatomical variation of external jugular vein's penetration by the transverse cutaneous nerve of the neck is displayed in the current study. The phenomenon of veins' fenestration or penetration by other structures, such as nerves along with its likely embryologic development are discussed. Moreover, the potential clinical significance of that variation's awareness on behalf the physician is discussed in detail.

Early Trifurcation of the Mandibular Branch of the Facial Nerve in a Cadaveric Specimen.

Rare facial nerve branching patterns, pose dangers due to their unexpected course. Cases with multiple branches may reduce the intraoperative risk, due to the compensation of adjacent branches. We present a case of a cadaveric specimen where an early trifurcation of the mandibular branch of the facial nerve was noted. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03352-2.

Bilateral Thyroid Foramina in a Completely Ossified Laryngeal Framework: A Case Report.

The presence of a thyroid foramen in the thyroid cartilage of the larynx is not uncommon. It may be occluded by a fibrous layer, or it may be an abnormal path for the neurovascular bundle of the larynx. The superior laryngeal nerve and the superior laryngeal vessels are the most common contents of the thyroid foramen. During the observation of the skeleton of a 32-year-old female, we found a completely ossified laryngeal framework with bilateral double thyroid foramina. Three of the foramina were circular, and one was oval in shape. This is a very rare anatomical variation. Deep knowledge of the thyroid cartilage anatomy is mandatory during laryngeal and thyroid surgery. The meticulous dissection of laryngeal vessels and nerves is of paramount importance to control bleeding and avoid postoperative neurological sequelae due to nerve injury. The surgeon should be aware that in the whole length of the oblique line of the thyroid cartilage, a thyroid foramen may be detected.

Is the origin of the superior thyroid artery consistent? A systematic review of 5488 specimens.

PURPOSE: The superior thyroid artery (STA) point of origin is strongly debated with controversial results among studies. External carotid artery (ECA), carotid bulb, and common carotid artery (CCA) have been presented as points of origin with variable percentages among authors. We conducted a systematic review of all existing studies that included cadaveric, surgical, and angiographic specimens and recorded the origin of STA according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. MATERIALS AND METHODS: Fifty-two studies, with an overall of 5488 specimens were included. RESULTS: Our results indicated ECA as the most common site of origin (55.0 %) followed by carotid bifurcation at 27.5 % and CCA at 15.0 %. Absent STA or branching from the internal carotid artery (ICA) was an extremely rare finding. We proposed a new simple classification system based on our results. CONCLUSIONS: The huge variability in the branching pattern of STA makes head and neck surgery and radiographic interventions challenging and poses the integrity of STA at risk. Therefore, we strongly recommend preoperative angiographic studies for STA identification to prevent an intraoperative iatrogenic injury.

Safety of COVID-19 vaccines in multiple sclerosis: A systematic review and meta-analysis.

BACKGROUND: Data are sparse regarding the safety of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines in patients with multiple sclerosis (MS). OBJECTIVE: To estimate (1) the pooled proportion of MS patients experiencing relapse among vaccine recipients; (2) the rate of transient neurological worsening, adverse events, and serious adverse events; (3) the previous outcomes of interest for different SARS-CoV-2 vaccine types. METHODS: Systematic review and meta-analysis of pharmacovigilance registries and observational studies. RESULTS: Nineteen observational studies comprising 14,755 MS patients who received 23,088 doses of COVID-19 vaccines were included. Mean age was 43.3 years (95% confidence interval (CI): 40-46.6); relapsing-remitting, secondary-progressive, primary-progressive MS and clinically isolated syndrome were diagnosed in 82.6% (95% CI: 73.9-89.8), 12.6% (95% CI: 6.3-20.8), 6.7% (95% CI: 4.2-9.9), and 2.9% (95% CI: 1-5.9) of cases, respectively. The pooled proportion of MS patients experiencing relapse at a mean time interval of 20 days (95% CI: 12-28.2) from vaccination was 1.9% (95% CI: 1.3%-2.6%; I2 = 78%), with the relapse risk being independent of the type of administered SARS-CoV-2-vaccine (p for subgroup differences = 0.7 for messenger RNA (mRNA), inactivated virus, and adenovector-based vaccines). After vaccination, transient neurological worsening was observed in 4.8% (95% CI: 2.3%-8.1%) of patients. Adverse events and serious adverse events were reported in 52.8% (95% CI: 46.7%-58.8%) and 0.1% (95% CI: 0%-0.2%) of vaccinations, respectively. CONCLUSION: COVID-19 vaccination does not appear to increase the risk of relapse and serious adverse events in MS. Weighted against the risks of SARS-CoV-2-related complications and MS exacerbations, these safety data provide compelling pro-vaccination arguments for MS patients.

Is the course of the cervicofacial division of the facial nerve consistent with the adjacent vessels?

Individual facial nerve branching patterns can be difficult to predict. The superficial course of its terminal branches poses them at risk of injury during head and neck surgeries. We report the rare course of a branch of the facial nerve deep into the posterior facial vein.

Clinical, Neuroimaging, and Genetic Markers in Cerebral Amyloid Angiopathy-Related Inflammation: A Systematic Review and Meta-Analysis.

BACKGROUND: There are limited data regarding the prevalence of distinct clinical, neuroimaging and genetic markers among patients diagnosed with cerebral amyloid angiopathy-related inflammation (CAA-ri). We sought to determine the prevalence of clinical, radiological, genetic and cerebrospinal fluid biomarker findings in patients with CAA-ri. METHODS: A systematic review and meta-analysis of published studies including patients with CAA-ri was conducted to determine the prevalence of clinical, neuroimaging, genetic and cerebrospinal fluid biomarker findings. Subgroup analyses were performed based on (1) prospective or retrospective study design and (2) CAA-ri diagnosis with or without available biopsy. We pooled the prevalence rates using random-effects models and assessed the heterogeneity using Cochran-Q and I2-statistics. RESULTS: We identified 4 prospective and 17 retrospective cohort studies comprising 378 patients with CAA-ri (mean age, 71.5 years; women, 52%). The pooled prevalence rates were as follows: cognitive decline at presentation 70% ([95% CI, 54%-84%]; I2=82%), focal neurological deficits 55% ([95% CI, 40%-70%]; I2=82%), encephalopathy 54% ([95% CI, 39%-68%]; I2=43%), seizures 37% ([95% CI, 27%-49%]; I2=65%), headache 31% ([95% CI, 22%-42%]; I2=58%), T2/fluid-attenuated inversion recovery-hyperintense white matter lesions 98% ([95% CI, 93%-100%]; I2=44%), lobar cerebral microbleeds 96% ([95% CI, 92%-99%]; I2=25%), gadolinium enhancing lesions 54% ([95% CI, 42%-66%]; I2=62%), cortical superficial siderosis 51% ([95% CI, 34%-68%]; I2=77%) and lobar macrohemorrhage 40% ([95% CI, 11%-73%]; I2=88%). The prevalence rate of the ApoE (Apolipoprotein E) ε4/ε4 genotype was 34% ([95% CI, 17%-53%]; I2=76%). Subgroup analyses demonstrated no differences in these prevalence rates based on study design and diagnostic strategy. CONCLUSIONS: Cognitive decline was the most common clinical feature. Hyperintense T2/fluid-attenuated inversion recovery white matter lesions and lobar cerebral microbleeds were by far the most prevalent neuroimaging findings. Thirty-four percent of patients with CAA-ri have homozygous ApoE ε4/ε4 genotype and scarce data exist regarding the cerebrospinal fluid biomarkers and its significance in these patients.

A Rare Case of a Fenestrated Retromandibular Vein Lying Lateral to the Facial Nerve Bifurcation.

Facial nerve integrity is the cornerstone of parotid surgery. Although a variety of anatomical landmarks have been employed, facial nerve injury still happens causing devastating functional and cosmetic sequelae. The retromandibular vein is considered one of the most consistent structures lying just deep into the facial nerve. In our cadaveric study, we found a fenestrated retromandibular vein lying superficial to the bifurcation of the facial nerve. This rare anatomical variation would have been a challenge for a hypothetic parotidectomy. Surgeons should be aware of both anterograde and retrograde dissection of the facial nerve and choose the most proper approach to preserve the integrity of the facial nerve.

Neuronal and Neuroaxonal Damage Cerebrospinal Fluid Biomarkers in Autoimmune Encephalitis Associated or Not with the Presence of Tumor.

The aim of this study was to evaluate the association of neuronal damage biomarkers (neurofilament light chain (NFL) and total tau protein (T-tau)) in the CSF of patients with autoimmune encephalitis (AE) with the presence of an underlying malignancy and to determine correlations with patient characteristics. The study comprised 21 patients with encephalitis associated with antibodies against intracellular (n = 11) and surface/synaptic antigens (extracellular, n = 10) and non-inflammatory disease controls (n = 10). Patients with AE associated with intracellular antigens had increased CSF-NFL (p = 0.003) but not T-tau levels compared to controls. When adjusted for age, CSF-NFL but not CSF-T-tau was higher in patients with encephalitis associated with intracellular antigens as compared to those with encephalitis associated with extracellular antigens (p = 0.032). Total tau and NFL levels were not significantly altered in patients with encephalitis associated with extracellular antigens compared to controls. NFL in the total cohort correlated with neurological signs of cerebellar dysfunction, peripheral neuropathy, presence of CV2 positivity, presence of an underlying tumor and a more detrimental clinical outcome. AE patients with abnormal MRI findings displayed higher NFL levels compared to those without, albeit with no statistical significance (p = 0.07). Using receiver operating characteristic curve analysis, CSF-NFL levels with a cut-off value of 969 pg/mL had a sensitivity and specificity of 100% and 76.19%, respectively, regarding the detection of underlying malignancies. Our findings suggest that neuronal integrity is preserved in autoimmune encephalitis associated with extracellular antigens and without the presence of tumor. However, highly increased NFL is observed in AE associated with intracellular antigens and presence of an underlying tumor. CSF-NFL could potentially be used as a diagnostic biomarker of underlying malignancies in the clinical setting of AE.

Surgical administration of multiple glomus tumors in uncommon anatomic regions in a 17-year-old female. A rare case report.

Glomus tumor (GT) constitutes a rare, benign, soft-tissue tumor emerging from neuro-myo-arterial glomus bodies. Due to its rarity, and absence of typical symptoms, GT is usually misdiagnosed, with a potential risk of rupture and infection, or even malignant transformation. The present manuscript reports a rare case of a 17-year-old young woman with multiple GTs in her lower back, breach and left thigh that was surgically treated. The manuscript aims to highlight the importance of prompt diagnosis and surgical treatment of this peculiar tumor in young patients and raise surgeons' awareness.

Role of the endoscope in cochlear implantation: A systematic review.

OBJECTIVE: To review the role of the endoscope in cochlear implantation (CI). METHODS: MEDLINE, ScienceDirect, Google Scholar and the Cochrane Library databases, as well as other sources, were searched by two independent reviewers. Studies including patients undergoing either exclusively endoscopic or endoscopically assisted CI were eligible for inclusion. Endoscopic CI approaches and postoperative complications were the primary outcomes. Secondary endpoints included the degree of round window (RW) microscopic visualisation according to St Thomas' Hospital classification and type of cochleostomy for electrode insertion in the scala tympani (ST). RESULTS: Fourteen studies met the inclusion criteria comprising 191 endoscopic or endoscopically assisted CI cases. The endoscope was used for better visualisation of the RW across all included studies, facilitated the insertion of the electrode in the ST and spared a mastoidectomy in a number of cases. No facial nerve palsy was reported in any of the studies. The most common complication was external auditory canal/tympanic membrane tear followed by chorda tympani injury. CONCLUSION: The microscopic CI approach is still the gold standard. The endoscope facilitates the recognition of the RW area and leads to successful and safe implantation, particularly in difficult anatomical scenarios, ear malformations and advanced otosclerosis. Endoscopically assisted CI procedures offer the opportunity to avoid a posterior tympanotomy and reduce the risk of facial nerve injury. To date, the lack of long-term data does not permit the widespread adoption of completely endoscopic CI procedures without a mastoidectomy.

Basivertebral foramina of true vertebrae: morphometry, topography and clinical considerations.

PURPOSE: Basivertebral foramina (BVF) are openings of the posterior wall of vertebral body (VB) that lead to basivertebral canals (BVC), where homonymous neurovascular bundle courses. BVF and BVC are implicated with spinal fractures, vertebral augmentation and basivertebral nerve radiofrequency ablation. Despite their essential clinical impact, knowledge of BVF precise anatomy is scarce. The current study describes in detail the BVF typical morphological and topographical anatomy, morphometry and variants. METHODS: In total, 1561 dried true vertebrae of 70 Greek spines of known gender and age were examined. BVF number, location, shape and size (in foramina > 1 mm), BVF distance from VB rims and pedicles, as well as VB morphometry (diameters, heights and distance between pedicles) were studied. Ten spines were re-examined by computed tomography and BVC depth and shape were recorded. Correlations and differences were statistically analyzed. RESULTS: C1 lack BVF (3.4%). One BVF was found in 45.1%, two in 36.9%, three in 3.8% and four BVF in 0.6%. Multiple small (< 1 mm) foramina were observed in 10.1%. Asymmetry was detected in 12.3%. C2 and T10-L1 presented typical pattern, whereas C3 and T2 had the greatest variability. BVF were significantly closer to the upper rim in C2 and T10-L4 and to the lower rim in C7-T4, T6-T8 and L5. The mean BVC depth was 12-21.8% of the VB anteroposterior diameter. CONCLUSION: BVF number, shape, size and topography are described, in detail, per vertebral level. The provided morphological classification and the created cumulative BVF topographic graphs should assist in clinical practice and surgery.

Diffuse glioma manifesting as normal pressure hydrocephalus: A potential pitfall in diagnosis-a case report.

•Hydrocephalus is rarely reported in patients with diffuse glioma.•We describe a patient with a low-grade glioma presenting a complex phenotype initially masquerading as hydrocephalus of unknown etiology.•The exact pathophysiological mechanism underlying hydrocephalus in the setting of diffuse glioma remains to be elucidated.•Caution is advised regarding hydrocephalus of unknown etiology, reevaluation is necessary.