Progressive functional improvement in hemiglossectomy defects reconstructed with radial forearm free flap at 6-months.

OBJECTIVE: The purposes of the study was to evaluate for the functional improvement of outcomes of patients undergoing surgical management for tongue cancer at varying periods after surgery. DESIGN: Case series with intervention. PARTICIPANTS: Thirty consecutive patients, from 2011 to 2015, with carcinoma of the tongue undergoing surgical resection and reconstruction with a radial forearm free flap. MAIN MEASURES: The Speech Intelligibility Test (SIT) is used for objective evaluation of speech function. The 7-point ordinal scale Functional Oral Intake Score (FOIS) was used to estimate the swallowing function. RESULTS: The patients included were 25 men and 5 women with a mean age of 50.4 years (range - 27-65). All tumors were squamous cell carcinomas and all patients underwent a hemiglossectomy. There were two complete flap failures, with a resultant flap success rate of 93.3%. The initial mean speech intelligibility scores at 1-month increased from 72.3 ±â€¯0.2 to 77.7 ±â€¯8.9 at 6-months after surgery (p = 0.05). Similarly, the mean score of swallowing function improved from 6.1 at 1-month to 6.8 at 6-months after surgery (p = 0.05). CONCLUSION: Reconstruction of hemiglossectomy defects with a radial forearm free flap offers functional benefits in speech and deglutition that demonstrate progressive improvement when 1- and 6-month post-surgical assessments are compared.

Squamous cell carcinoma presenting with trigeminal anesthesia: An uncommon presentation of head & neck cancer with unknown primary.

BACKGROUND: The differential diagnosis of facial anesthesia is vast. This may be secondary to trauma, neoplasm, both intracranial and extracranial, infection, and neurologic disease. When evaluating a patient with isolated facial anesthesia, the head and neck surgeon often thinks of adenoid cystic carcinoma, which has a propensity for perineural invasion and spread. When one thinks of head and neck squamous cell carcinoma with or without unknown primary, the typical presentation involves dysphagia, odynophagia, weight loss, hoarseness, or more commonly, a neck mass. Squamous cell carcinoma presenting as facial anesthesia and perineural spread, with no primary site is quite rare. METHODS: Case presentations and review of the literature. CONCLUSIONS: Trigeminal anesthesia is an uncommon presentation of head and neck squamous cell carcinoma with unknown primary. We present two interesting cases of invasive squamous cell carcinoma of the trigeminal nerve, with no primary site identified. We will also review the literature of head and neck malignancies with perineural spread and the management techniques for the two different cases presented.

Diagnosing Fish Bone and Chicken Bone Impactions in the Emergency Department Setting: Measuring the System Utility of the Plain Film Screen.

OBJECTIVES: In the emergency department, fish and chicken bone impactions are typically evaluated with screening x-rays. We sought to determine whether this modality ultimately improves system outcomes, including length of stay (LOS), cost, and radiation dosage. METHODS: We reviewed patients ≥ 18 years old presenting to an urban academic emergency department over a 4-year period who received a screening soft-tissue x-ray to determine the presence of a retained fish or chicken bone. We calculated the diagnostic accuracy of x-ray and computed tomography (CT) evaluations, respectively, in addition to system outcomes. RESULTS: Twenty-seven of the 78 patients included for analysis were ultimately positive for bone impaction. Initial x-ray interpretations demonstrated a sensitivity of 24.0% (95% CI, 9.4%-45.1%) and a specificity of 90.0% (95% CI, 78.2%-96.7%). However, initial CT interpretation (ie, a preliminary read from on-call residents) demonstrated a sensitivity of 75% (95% CI, 19.4%-99.4%) and a specificity of 100% (95% CI, 59.0%-100%). LOS, cost, and radiation dosage were not significantly different between patients who ultimately had true bone impactions and those who did not (P > .05). CONCLUSIONS: X-rays are poor screening tools in determining fish or chicken bone impactions with poor diagnostic and system utility. Further studies should be performed to evaluate the role of a low-radiation CT screen.

Primary fibrosarcoma of the trachea presenting with acute airway loss.

Primary sarcomas of the trachea are rare occurrences that present with nonspecific symptoms, making timely diagnosis difficult. We report a case of primary fibrosarcoma of the trachea that presented with acute airway loss secondary to tracheal discontinuity due to tumor destruction. This unusual clinical presentation highlights the difficulties posed in the diagnosis and management of tracheal sarcomas. A discussion of the relevant literature is presented.

Benign proliferative myositis of the sternohyoid muscle: review and case report.

We report a case of a 51-year-old woman who presented with a rapidly enlarging, painful, midline neck mass that developed over a three day period. A CT scan of the neck showed a solid circumscribed mass in the sternohyoid muscle. The initial differential diagnosis included inflammation of thyroglossal duct remnant, an abnormal lymph node, and thyroid carcinoma. The patient underwent operative excision with final pathology revealing proliferative myositis. Proliferative myositis is an uncommon benign proliferation of skeletal muscle and has only been reported a limited number of times in the head and neck region.

Intramuscular myxoma of the cervical paraspinal musculature: case report and review of the literature.

CASE: A 57year old female patient presented with a painful right-sided neck mass that on MRI was shown to be adherent to the posterior aspect of the sternocleidomastoid muscle. The mass was surgically resected en bloc without complications. Histopathologic analysis revealed the mass to be a myxoma. REVIEW: To date, there have been several case reports of myxomas, although very few involving the head or neck. The majority of the literature available concurs that myxomas are benign neoplasms that exhibit characteristic qualities on MRI imaging. The definitive treatment by consensus is surgical excision. CONCLUSIONS: Although the incidence of head and neck myxomas is low, it is important to include in the differential of a neck mass with certain radiographic findings.

An unusual and rare cause of acute airway obstruction in the elderly: Forestier's disease.

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease, is an ossifying disease of unknown etiology affecting mainly elderly men. It is characterized by hypertrophic anterior vertebral osteophytes with ossification of the spinal anterior longitudinal ligament. Hypertrophic osteophytes can encroach on the aerodigestive tract, leading to significant swallowing and respiratory symptoms. OBJECTIVE: Acute stridor and respiratory compromise requiring a surgical airway have rarely been reported in patients with DISH. This entity, although rare, should be in the differential diagnosis of acute airway obstruction, particularly in the elderly. CASE REPORT: We describe a case of a 91-year-old patient who was transferred to the Emergency Department at Tufts Medical Center with acute stridor. A computed tomography scan of the neck prior to transfer revealed a large anterior cervical osteophyte causing significant airway narrowing. Fiberoptic evaluation confirmed the radiologic finding of near-complete airway obstruction. The patient's respiratory status rapidly deteriorated and he subsequently underwent an emergent awake tracheostomy to secure his airway. CONCLUSION: Given the rarity of DISH and the increase in life expectancy, clinicians should be aware of this disease entity and its potential for acute life-threatening respiratory presentation.

Management of a postradiation esophageal web in the setting of a coexisting Zenker's diverticulum.

We present a case of postradiation obstructive esophageal web, seen in the setting of a coexisting Zenker's diverticulum, that was treated with combined anterograde and retrograde esophagoscopy puncture and dilation. We also review the relevant literature. Obstructing esophageal webs and stenoses are well-documented complications seen in patients with head and neck cancer treated with radiation therapy. For thin webs, combined anterograde and retrograde esophagoscopy along with puncture and dilation can be a relatively safe treatment option for selected patients. The presence of a coexisting Zenker's diverticulum may predispose the patient to the development of postradiation esophageal complications and make subsequent assessment more difficult to perform.

A unique presentation of Epstein-Barr virus-associated Castleman's disease.

Castleman's disease (CD) is a rare, benign lymphoproliferative disorder. The association of human herpes virus 8 (HHV8) and human immunodeficiency virus infections with CD is well established however the role of Epstein-Barr Virus in CD is less well understood. We present a unique case of Castleman's disease in a patient with concomitant EBV infection, which mimicked the clinical presentation of nasopharyngeal carcinoma (NPC) versus lymphoma. After a delayed diagnosis, the patient underwent a left superficial parotidectomy and neck dissection and has had no recurrence of disease.

Hibernoma presenting as an asymptomatic neck mass.

BACKGROUND: Hibernomas are rare benign tumors of brown fat tissue origin. These tumors are generally found in locations where fetal fat persists (back, axilla, thorax and retroperitoneum). METHODS AND RESULTS: We report a case of a patient with an asymptomatic neck mass that initially presented for evaluation of hoarseness. Imaging and complete surgical excision of the mass were performed and revealed hibernoma. Review of the literature for the presentation of hibernoma in the neck is performed. CONCLUSION: Hibernomas are rare benign tumors that infrequently present in the neck. Complete surgical removal is curative. To date no malignant transformation or metastasis has been described.

Oral squamous cell carcinoma in post-transplant patients.

OBJECTIVE: Patients on immunosuppressant therapy after transplantation have an increased risk of developing cutaneous squamous cell carcinomas. The risk of developing solid tumors of the upper aerodigestive tract in this population has been less defined. We present five patients that subsequently developed oral squamous cell carcinoma after transplantation. STUDY DESIGN: Retrospective chart review and literature review. RESULTS: Three bone marrow and two heart transplant patients were subsequently diagnosed with oral (oral cavity or oropharynx) carcinoma. The timing of diagnosis of oral cancer after transplant ranged from 18 months to 17 years post-transplantation. CONCLUSIONS: Patients with a history of transplantation should be routinely assessed for the potential development of oral neoplastic lesions. Oral squamous cell carcinoma in transplant patients can be more aggressive and clinically mistaken for chronic graft versus host disease. It is therefore reasonable to consider early biopsy in these patients to guide the need for intervention.

A rare presentation of a large extra-abdominal desmoid tumor of the posterior neck and back.

OBJECTIVE: To describe a difficult case of a large extra-abdominal desmoid fibroma of the posterior neck and back; to discuss the pathologic findings and treatment options of this case and to review the current literature for a rare presentation of this disease. METHOD: A case report and review of the current relevant English literature, carried out using PubMed Medline, are presented. RESULTS: We present a challenging case in which a locally invasive desmoid of the posterior neck and back had grown to such an extent that complete surgical excision in one procedure was not possible. CONCLUSION: Extra-abdominal desmoid fibromas are rare tumors with multiple treatment options. The literature supports incomplete surgical resection when necessary to reduce postoperative morbidity. Further options described for residual or recurrent disease include repeat surgical excision, radiation therapy, and possible chemotherapy. For particularly large tumors, close observation and a planned second stage procedure are an appropriate choice.

Thyroid hemiagenesis: a case series and review of the literature.

PURPOSE: The purpose of this study is to present a case series and review recommendations within the literature concerning thyroid hemiagenesis. MATERIALS AND METHODS: This is a (1) retrospective case series review of 5 patients and (2) literature review (using Medline) on thyroid hemiagenesis. RESULTS: Most reported cases are female with the left thyroid lobe absent. Compensatory hypertrophy occurs in most thyroid remnants. Associated diagnoses in the remaining lobe include hyperthyroidism, hypothyroidism, simple and multinodular goiter, and carcinoma. There is no increased risk for the subsequent development of cancer in the remaining lobe, and empiric thyroidectomy is not justified. CONCLUSIONS: Thyroid hemiagenesis is an uncommon presentation that is frequently asymptomatic and detected incidentally when imaging for another condition. Awareness of its existence can help prevent unnecessary interventions associated with incorrect assumptions in patient care.

Use of the double-paddle anterolateral thigh flap for locally advanced tongue carcinoma requiring second site reconstruction.

BACKGROUND: Advanced oral tongue carcinoma can present with extension beyond the oral cavity. Operative defects after resection may involve multiple anatomical sites and significantly impact speech and swallowing. Dependence on long-term enteral feeding is not uncommon for these patients. The anterolateral thigh (ALT) flap is one of the most reliable and flexible flaps used in the reconstruction of total and subtotal tongue defects. The double-paddle flap modification may be a more suitable option for complex oral tongue defects after advanced tumor ablation. METHODS: Case series of 31 patients with oral tongue squamous cell carcinoma that were classified as stage IV. The age of patients ranged from 32 to 63 years. We designed the double-paddle ALT flaps to reconstruct the two-site surgical defects (tongue defect and pharynx or neck skin defect). Postoperative viability of the flap was checked by clinical observation. The last examination was performed at 3-months after the completion of adjuvant chemoradiotherapy. The functional capacity of our patients was evaluated by three physicians (Head and Neck Surgeon, Radiation Oncologist, and Physiatrist) using a Speech Intelligibility Score and the Functional Oral Intake Scale. RESULTS: A total of 31 patients with surgical defects after total or subtotal tongue resection for cancer underwent double-paddle ALT flaps for reconstruction from March 2018 to December 2019. The dimension of flaps from 8 × 12 cm to 10 × 18 cm were divided into double-paddle from 8 × 5 cm to 10 × 10 cm. There was one case of pedicle thrombosis, one case of postoperative bleeding, three cases of neck infection, and six cases of salivary fistula. Our patients were seen in follow up from 6 to 36 months, with median follow-up of 23.5 months. The survival rate of ALT flap was 100%. All of our patients achieved an oral diet by 9 months after surgery. The mean score speech intelligibility was 2.74 ± 0.68 (4-point ordinal scale). The 2-year disease-free survival rate was 61.3%. CONCLUSIONS: The double-paddle ALT flap is a reliable flap suitable for oral defects involving multiple subsites after ablative procedures. The majority of patients demonstrated acceptable functional rehabilitation. CLINICAL QUESTION/ LEVEL OF EVIDENCE: Therapeutic, IV.

Vein preservation strategies to improve the survival rate of the infrahyoid musculocutaneous flap.

The infrahyoid musculocutaneous flap (IHMCF) is a good alternative in the reconstruction of moderate-sized oral cavity surgical defects. Insufficient venous drainage can significantly affect the survival rate of this flap. OBJECTIVES: Identify the survival rates of the IHMCF and evaluate the functional capacity of reconstructed patients. DESIGN: We report a case series. SETTING: This study took place at the Department of Head and Neck Surgery of Oncology Hospital Ho Chi Minh City, the largest oncology center in South Vietnam. PARTICIPANTS: One hundred and twelve patients with surgical defects after oral cavity resection for cancer underwent IHMCF reconstruction from November 2013 to November 2018. During the harvest of the flap, our modification of the surgical technique specifically attempted to preserve more secondary veins for IHMCF. MAIN OUTCOME MEASURES: Postoperative viability of the flap was checked by clinical observation. The last examination was performed at 3-months after reconstructive operation or after the completion of adjuvant radiotherapy. The functional capacity of our patients was evaluated by three physicians (Head and Neck Surgeon, Radiation Oncologist, and Physiatrist) with understandability of speech scale and the functional oral intake score items assessed. RESULTS: Two cases of partial skin necrosis (1.8%) were experienced. The majority of patients demonstrated favorable functional rehabilitation at long-term follow up. CONCLUSIONS: The IHMCF is a reliable flap suitable for moderate-sized defects of the oral cavity. Altering the surgical approach to specifically preserve more venous outflow can improve the survival rate of the flap. LEVEL OF EVIDENCE: 4.

Papillary thyroid carcinoma and familial adenomatous polyposis of the colon.

OBJECTIVE: Case report and limited review of the literature on the topic of papillary thyroid carcinoma and familial adenomatous polyposis and its genetic associations. METHODS: A patient with multiple prior surgeries for colonic polyps, abdominal perineal resection for colorectal cancer, and wedge resection for metastatic adenocarcinoma (consistent with rectal primary) presented with a thyroid mass. Fine-needle aspiration demonstrated papillary thyroid carcinoma. RESULTS: The patient underwent total thyroidectomy. Pathologic examination revealed the cribriform-morular variant of papillary carcinoma that has been reported in patients with familial adenomatous polyposis. CONCLUSIONS: Cribriform-morular variant of papillary thyroid carcinoma is an uncommon diagnosis known to be associated with familial adenomatous polyposis. Although the incidence is rare, this diagnosis should raise the clinician's suspicions to recommend both colorectal screening and genetic counseling for family members.

Metastatic insular thyroid carcinoma in the pediatric patient.

OBJECTIVES: The clinical history of a pediatric patient with metastatic insular thyroid carcinoma will be reviewed. Previously reported cases will be examined to allow for comparison of prognosis. METHODS: A 4-year-old female with the complaint of chronic cough, progressive shortness of breath, and weight loss for 2 months underwent cervical lymph node biopsy. The biopsy revealed metastatic thyroid carcinoma. Preoperative imaging was suspicious for miliary metastatic spread to the lungs. RESULTS: Surgical intervention included total thyroidectomy with bilateral paratracheal and modified radical neck dissections. The right internal jugular vein and recurrent laryngeal nerve were removed at the time of surgery because of gross tumor invasion. Final pathologic finding revealed papillary thyroid carcinoma with insular variant features and bilateral regional metastasis. Postoperatively, the patient underwent radioactive iodine I 131 treatment. CONCLUSION: Pediatric metastatic insular thyroid carcinoma is an uncommon form of thyroid malignancy requiring aggressive surgical treatment and adjuvant radioactive iodine.

Parathyroid surgery: what the radiologists need to know.

Hyperparathyroidism represents by a varied spectrum of presentations, from those individuals who have overt symptoms directly attributable to hypercalcemia to those who are asymptomatic at diagnosis. Indications for surgical intervention in the asymptomatic population have changed as the long-term experience with these patients has grown. Use of additional imaging techniques to aid localization and a detailed understanding of the anatomy can be critical to a successful operative outcome. This article discusses the pertinent issues that surround the current surgical management of parathyroid disease with a focus on epidemiology, surgical anatomy, and operative strategies.

Postoperative carotid spasm in the setting of head and neck surgery.

Delayed arterial spasm is a clinical and angiographic condition frequently observed after subarachnoid hemorrhage. It has long been associated with a local myogenic reaction to prolonged arterial contact with fresh blood. Carotid spasm from direct manipulation of the petrous carotid during skull base procedures is also a rare but known response to longitudinal arterial traction. Uncomplicated cervical cases, although subject to similar conditions of arterial manipulation, have less commonly been associated with arterial spasm. Two cases of severe internal carotid spasm leading to stroke in patients undergoing removal of glomus tumors are presented to emphasize carotid spasm as a potential complication in head and neck surgery. The perioperative guidelines to prevent, recognize, and treat this complication are also reviewed as outlined in the literature.

Synchronous reconstruction of the floor of mouth and chin with a single skin island fibular free flap.

OBJECTIVES: The goal this presentation is to: 1) Review the reconstructive options for anterior mandible through-and-through composite defects and 2) Instruct the audience in the application of the double-skin paddle fibular flap in selected patients. METHODS: Case presentation with review of the literature. RESULTS: A 70-year old male with an anterior floor of mouth squamous cell carcinoma underwent composite resection that included resection of a 5-cm ovoid component of overlying chin skin. The defect was reconstructed with a fibular osteocutaneous flap with a double skin paddle technique. CONCLUSIONS: Several reconstructive options have been described in the literature for extended oral cavity defects including the use of multiple free flaps, combinations of regional and distant flaps, and sequential reconstruction. This case report reviews the use of a single flap reconstruction of these defects for selected patients.