Reconstruction of mandibular defects using the scapular tip free flap.

PURPOSE: Purpose of the article is to present the use of the scapular tip free flap (STFF) for the reconstruction of oromandibular defects. PATIENTS: Eleven patients who underwent oromandibular reconstruction with STFF were retrospectively evaluated with regards to form and function assessing mouth opening, dietary intake, and cosmetic outcome. Donor site morbidity was evaluated using the Constant-Murley test for the shoulder unit. RESULTS: Follow-up ranged from 6 to 35 months (mean 20.6 months). Good or excellent results in mouth opening and cosmesis were achieved in eight patients, speech was assessed as intelligible or normal in all but one patient and mean ambulation time after surgery was 2.5 days. Results of Constant score ranged from 45 to 70 (mean 60.6), and the main limitation encountered was elevation of the arm above the head, which was seen in all but one patient confirming the low impact of the technique on the shoulder system. CONCLUSION: Low morbidity, early ambulation time, possibility of simultaneous harvesting with the tumor resection, large musculocutaneous paddles in the chimeric version of the flap are advantages of the STFF and makes it a good choice in elderly patients, when other bone containing free flaps are not indicated because of the related morbidity, when other flaps are not available or when wide composite defects are approached.

Ancillary procedures in facial animation surgery.

PURPOSE: Facial animation surgery with neuromuscular transplants has become a standard procedure for the treatment of facial palsies. However, the forehead, periocular complex, nasal base area, and inferior lip are secondary sites that also need to be considered in the complete rehabilitation of a flaccid facial palsy. MATERIALS AND METHODS: A total of 136 ancillary procedures were performed in 49 patients between 2003 and 2013 and consisted of eyebrow suspensions (11), upper eyelid loading with a platinum chain (39), inferior palpebral suspension with fascia lata (22), nasal base suspension with fascia lata (26), and botulinum toxin injection (38). RESULTS: Cosmetic results were good and excellent in 30.7% and 63.2% of the procedures, respectively. Functionally, periocular complex rehabilitation and nasal base suspension led to excellent improvements in function in 87.2% and 73.1% of the patients, respectively. CONCLUSIONS: The use of ancillary procedures can improve the functional and esthetic results of facial animation surgery.

Mandibular resection and reconstruction in the management of extensive ameloblastoma.

PURPOSE: To present our experience with the management of 31 extensive mandibular ameloblastomas treated with segmental mandibulectomy, reconstruction with free fibula or iliac crest flap, and rehabilitation with immediate or delayed endosteal dental implants. PATIENTS AND METHODS: The study sample comprised 31 patients with histologically confirmed mandibular ameloblastomas. Primary ameloblastomas were treated in 23 patients, and recurrent ameloblastomas affected 8 patients. Mandibular defect sizes ranged from 3.5 to 12.5 cm (mean, 5.6 cm). A free fibula osseous or osteocutaneous flap was used 17 times for reconstruction; in the remaining 14, a free iliac crest osseous or osteomuscular flap was chosen. Dental implants were positioned in 25 patients; implant procedures were performed simultaneously with reconstruction in 21 cases. RESULTS: All flaps were transplanted successfully, and no major complication occurred postoperatively. Final histologic examinations showed 27 multicystic and 4 unicystic ameloblastomas. Free margins were achieved in all patients. The duration of follow-up was 18 to 120 months (mean, 53.6 months). No patient showed clinical or radiologic signs of recurrence. The dental implant success rate was 100%. CONCLUSIONS: Segmental mandibular resection followed by immediate defect reconstruction with bone-containing free flaps with immediate dental implant placement should be considered as the treatment of choice for extensive mandibular ameloblastomas.

Pyogenic spondylodiscitis and osteoradionecrosis of the cervico-thoracic spine: a rare complication after surgery and radiation for hypopharyngeal cancer.

OBJECTIVE: To describe a rare case of osteoradionecrosis and pyogenic spondylodiscitis of the cervico-thoracic spine after surgery and radiotherapy for hypopharyngeal cancer. METHODOLOGY: Diagnostic clues are presented and critically discussed with particular regard to computed tomography, magnetic resonance and positron emission tomography features advising the association between and osteoradionecrosis and spondylodiscitis. RESULTS AND CONCLUSIONS: Pathogen isolation via CT-guided biopsy provided the definite diagnosis and indicated the targeted therapy. Successful recovery was obtained with conservative treatment.

The free anterolateral thigh musculocutaneous flap for head and neck reconstruction: one surgeon's experience in 92 cases.

BACKGROUND: Applications of the free anterolateral thigh (ALT) musculocutaneous flap have been largely underestimated compared with indications for fasciocutaneous or perforator flaps. In this article, the authors critically review the experience of a single surgeon with the free ALT musculocutaneous flap for head and neck reconstruction, focusing on its applications in different cephalic areas and on advantages and disadvantages of this technique. PATIENTS AND METHODS: Ninety-two patients were treated using a free ALT musculocutaneous flap. Reconstructed areas included tongue, oropharynx, mandible, maxilla, hypopharynx, cheek, and skull base. RESULTS: Flap survival rate was 97.8%. Donor site morbidity consisted in two cases of partial necrosis of the skin graft used its closure with a final donor site complication rate of 2.2%. Overall results showed an 89% of patients returned to a normal or a soft diet. Speech was good or intelligible in 88% and cosmesis resulted good or acceptable in 89% of cases. CONCLUSION: The free ALT musculocutaneous flap offers unique advantages in head and neck reconstructions including adequate bulk when needed, obliteration of dead space, support for the soft tissues of the face, low donor-site morbidity, and harvesting without needing for perforators dissection, allowing for optimal patient outcome. Excessive bulky and thickness of subcutaneous tissue, especially in occidental population, have to be considered as the main disadvantages of this technique, finally the high incidence of hairy skin in thigh area in male patients and donor site scars associated with the use of skin grafts have to be considered as supplementary minor drawbacks.

Prophylactic central neck dissection for papillary thyroid carcinoma: the terms of the debate.

An increasing interest in the management of central neck lymph nodes in the surgical treatment of papillary thyroid cancer is observed. While is widely accepted that patients with clinically apparent lymph nodes metastases should undergo compartment-oriented neck dissection, controversy exists about the need for prophylactic central neck dissection. The main issues that have been raised are the following ones: the definition of the anatomic boundaries and terminology of central neck dissection, the value of the recommendations expressed by the most authoritative association, the arguments in favour and against the appropriateness of prophylactic neck dissection, the laterality of central neck dissection. This article aims at reviewing the literature on prophylactic central neck dissection for papillary thyroid cancer in order to clarify some issues and to offer the reader a clear and concise overview of this complex debate.

Isolated fronto-ethmoidal allergic fungal rhinosinusitis: case report and review of the literature.

BACKGROUND AND AIM OF THE WORK: Fungal rhinosinusitis (FRS) is a clinical entity characterized by the presence of fungi within sino-nasal cavities that may occur in patients with normal or defective immunity. Allergic fungal rhinosinusitis (AFRS) is a form of non-invasive FRS that affects patients with an abnormal immuno-mediated response to fungal antigens. This article describes a case of isolated fronto-ethmoidal AFRS. METHODS: A 20-year old male patient presented with a history of a left nasal respiratory obstruction and allergic oculorhinitis. CT scans showed a polypoid mass in the left nasal cavity and opacification of the left ethmoid sinus, frontal recess and frontal sinus with hyperdense component. The patient underwent functional endonasal sinus surgery (FESS) with removal of nasal polyps from the left nasal cavity and of cheesy-like material and dense mucus from the left ethmoid and frontal sinus. Histological examination showed presence of fungal hyphae within the allergic mucus; a diagnosis of AFRS was made. RESULTS: Follow up at 14 months showed no signs of recurrence. CONCLUSIONS: The AFRS case reported herein is characterized by isolated unilateral fronto-ethmoid involvement, a rare presentation. Endoscopic nasal treatment was effective with complete patient recovery. (www.actabiomedica.it).

Primary Epithelioid Angiosarcoma of the Thyroid in a Patient Occupationally Exposed to Radiations.

Background: Angiosarcoma (AS) of the thyroid is a rare and aggressive tumor. Its incidence is higher in iodine-deficient areas but cases unrelated to endemic goiter have been reported. Case Presentation: We describe a case of a 63-year-old Italian man living in a non-iodine-deficient area, with no previous diagnosis of thyroid disease with a history of radiation exposure. The patient-an interventional cardiologist who had worked for 15 years in an angiographic room- came to the clinical observation because of the rapid onset of dyspnea and dysphonia. Computed tomography (CT) showed a 13-cm inhomogeneous neck mass, originating from the left thyroid lobe which caused displacement and stenosis of the trachea. The patient underwent diagnostic fine-needle aspiration that was followed by total thyroidectomy and lymphadenectomy of central and left lateral cervical nodes. The final pathological diagnosis was epithelioid angiosarcoma (EAS), high grade. The preoperative staging by CT of the head, neck, abdomen, chest and pelvis was negative. At pathological staging, the tumor was angionvasive but it was limited to the thyroid; no lymphnode metastases were detected. Chemotherapy with Epirubicin and Ifosfamide was administered for 4 cycles and, then, it was discontinued due to significant bone marrow toxicity. Conclusion: One year after diagnosis, the CT of neck, abdomen, chest, and pelvis were negative. At 2 years after diagnosis, the FDG-PET was negative with no evidence of the disease at CT Due to the known association between the occurrence of angiosarcoma after radiation therapy it is tempting to speculate that in this patient the presence of thyroid EAS may be linked to radiation exposure.The patient is still alive at 62 months after diagnosis. He is on a follow-up program by a 6-month /1-year neck, chest, abdomen, and pelvis CT evaluation with no signs of metastases.

Oncocytic carcinoma of parotid gland: a case report with clinical, immunohistochemical and ultrastructural features.

BACKGROUND: Oncocytic carcinoma is an extremely rare neoplasm of the salivary glands. We report a case of oncocytic carcinoma arising in a parotid gland in a 66-year-old female. METHOD: An excisional biopsy of the parotid tumor was performed. The specimen was submitted for histology and after fixation in formalin solution and inclusion in paraffin, 3-5 microm sections were stained with hematoxylin and eosin for conventional evaluation and Periodic acid Schiff stain. Immunohistochemical studies were performed using antibodies against mitochondrial antigen, keratin, S-100, alpha-actin, vimentin, alpha-1-antichymotrypsin as well as an ultrastructural analysis was performed. RESULTS: Frozen sections revealed an infiltrative growth pattern and the diagnosis of a malignant epithelial lesion was made. Permanent sections stained with haematoxylin and eosin revealed a neoplasm that had replaced a wide area of the parotid gland and had invaded subcutaneous adipose tissue. Perineural invasion was evident, but vascular invasion was not found. Neoplastic elements were large, round or polyhedral cells and were arranged in solid sheets, islands and cords. The cytoplasm was abundant, eosinophilic and finely granular. The nuclei were large and located centrally or peripherally. The nucleoli were distinct and large. Periodic acid Schiff stain demonstrated a granular cytoplasm. Immunohistochemistry demonstrated mitochondrial antigen, keratin, and chymotrypsin immunoreactivity in the neoplastic cells. Ultrastructural analysis revealed numerous mitochondria packed into the cytoplasm of the neoplastic cells. Thus, the final diagnosis was that of oncocytic carcinoma of parotid gland. CONCLUSION: This neoplasm shows clinical, microscopical, histological and ultrastructural features of oncocytic carcinoma and this must be considered in the differential diagnosis of other proliferations in the parotid gland with abundant granular cytoplasm and metastatic oncocytic carcinomas.

Ear, nose and throat manifestations of Churg-Strauss syndrome.

CONCLUSION: Ear, nose and throat (ENT) involvement is common in Churg-Strauss syndrome (CSS), usually manifesting as allergic rhinitis and chronic rhinosinusitis with or without polyps. Otolaryngologists may play a pivotal role in making an early diagnosis of this disease. OBJECTIVES: CSS is a systemic vasculitic disorder that affects small to medium-sized blood vessels. Although the cause of CSS remains unknown, tissue damage seems more likely to be mediated by activated eosinophils. Patients affected by CSS frequently have ENT manifestations, which are often present at the time of disease onset and may represent relevant clues for the diagnosis. Thus, our objective was to present the ENT manifestations at the onset, at the diagnosis and at some point during the course of the disease in a series of patients with CSS collected at a single center. MATERIALS AND METHODS: Twenty-eight patients with CSS, as defined according to the 1990 American College of Rheumatology classification criteria, were identified. Twenty-one (75%) of these patients had ENT involvement. We evaluated the clinical course, laboratory data, histologic findings, treatment and outcomes. RESULTS: Of the 21 patients, 13 (61.9%) had ENT involvement at asthma onset and 8 (38%) at diagnosis or during follow-up. The most common ENT manifestations were allergic rhinitis in 9 (42.8%) patients and nasal polyposis in 16 (76.1%). Three (14.2%) patients developed chronic rhinosinusitis without polyps, three (14.2%) had nasal crusting, one (4.7%) serous otitis media, one (4.7%) purulent otitis media, two (9.5%) progressive sensorineural hearing loss, and one (4.7%) unilateral facial palsy. Corticosteroid therapy associated with immunosuppressive drugs usually yielded improvement or stabilization.

Prognostic factors in stage IV oropharyngeal squamous cell carcinoma: the "punto" experience.

PURPOSE: Squamous Cell Carcinoma (SCC) of Oropharynx is often diagnosed in advanced stages. Treatment options have improved during recent years, however the choice of most appropriate treatment is still controversial. Prognostic factors can help to optimize the care. This study investigate the role of 9 potential prognostic factors, including HPV status, in Oropharyngeal SCC. MATERIALS AND METHODS: Nine prognostic factors were investigated in a retrospective chart of 98 patients treated for stage IV SCC of Oropharynx from january 2006 to january 2012, including  age (<60 or >60), gender, tumor subsite , histological grading, T stage, N stage, AJCC stage, BMI pre-treatment and HPV status. Moreover treatment modalities were compared  and the data regarding the treatment factors, like radiotherapy technique and kind of chemotherapy  were collected and compared.Primary endpoint was the impact of the prognostic factors on OS, DFS and DSS.Seconrdary endopoint were the impact of these factors on QOL and Toxicity. RESULTS: On univariate analisys significant improved OS was associated with age < 60 (p= 0,004), grading G3 (p=0.003), BMI > 25 (p= 0.03), radiotherapy with IMRT/SIB IMRT  technique (p=0,01) and AJCC stage IVa (p=0,01).No prognostic factor was associated to DFS improvement.Instead a significant improved DSS was associated with age <60 (p=0,01) , Grading G3 (p=0,04), T stage (p=0,02), AJCC stage IVa (p=0,03) and tonsil subsite (p=0.04). in the analysis of hazards ratios for OS age (HR 2.22; 95% CI 1.00-4.93; p=0.019), grading (HR 0.17; 95% CI 0.047-0.64 ; p= 0.008), AJCC stage (HR 4.81; 95% CI 1.34-17.2; p=0.016) and radiotherapy technique (HR 0.2; 95% CI 0.08-0.87; p=0.02) maintained significance, whereas BMI (HR 0.45; 95% CI 0.09- 2.2; p=0.3) did not. In the analysis for DSS only age (HR 2.22; 95% CI 1.22-7.81; p= 0.017) and grading (HR 0.11; 95% CI  0.02- 0.59; p=0.009) maintained significance. CONCLUSION: improved outcomes were significantly associated with lower age and tumor stage, grading G3, tonsil subsite, radiotherapy performed with IMRT technique, and BMI > 25.

Occult nasolacrimal duct ectasia in a child with acute sinusitis: clinicopathological considerations and literature review.

BACKGROUND: Enlargement of the nasolacrimal duct (NLD) in the absence of neoplasm is rare. As there are few reports on this condition in the literature, its pathologic significance and proper management remain unclear. We report a case of asymptomatic NLD enlargement incidentally discovered on high resolution computed tomography scan performed for a complicated acute sinusitis. METHODOLOGY: Case report and literature review. RESULTS AND CONCLUSIONS: NLD enlargement, defined as a truly isolated asymptomatic dilatation of the NLD, is rarely encountered. Etiology and clinical significance are unclear although the absence of nasolacrimal pathway or sinonasal disease and radiological findings of bone remodelling suggest that it may be congenital. In such cases, diagnosis may be incidental and based on imaging studies, and the term NLD ectasia seems to be more appropriate to describe this distinct entity. NLD enlargement may favour osteomeatal complex obstruction, thus leading to severe acute sinusitis.

FDG-PET/CT appearance of injected silicone particles (VOX Implants®) in head and neck tissues.

OBJETIVES: In head and neck surgery, Positron Emission Tomography/Computed Tomography imaging (FDG-PET/CT) is often used to identify primary tumor site in patients with unknown primary carcinoma, to predict response after chemoradiotherapy and in some cases, to detect recurrence. To rehabilitate swallowing after surgery in patients with persistent dysphagia, an injectable suspension of silicone (VOX® Implants) can be used to reduce the gaps in the neoglottis. The purpose of this report is to document the PET appearance of PDMS in a series of 3 patients who underwent partial laryngectomy with subsequent VOX® Implants injection. MATERIAL AND METHODS: a retrospective chart and imaging review was performed at our institution. Three patients were identified and included in the study. Appearance of PDMS at PET was described and discussed. RESULTS: An increased uptake of 2-fluoro-2-deoxy-d-glucose (FDG) was noticed at PET in all patients. CONCLUSIONS: the increased uptake was possibly due to active inflammatory reactions that are necessary for tissue integration of textured silicone particles.

Reflux esophagitis as a possible risk factor in the development of pharyngolaryngeal squamous cell carcinoma.

AIMS AND BACKGROUND: To determine the role of reflux esophagitis in the development of pharyngolaryngeal squamous cell carcinoma in non-smoking and non-drinking patients. METHODS: The study population consisted of 92 consecutive non-smoking and non-drinking patients with histologically confirmed squamous cell carcinoma of the pharynx and the larynx. As a control, a group of 125 lifetime non-smoking and non-drinking cancer-free subjects was selected. RESULTS: Patients with pharyngolaryngeal cancer had a higher prevalence of reflux esophagitis than the control subjects (P <0.0001). CONCLUSIONS: Our results confirm that reflux esophagitis in itself is associated with an increased risk of upper aerodigestive tract cancer.

Compliance and outcomes in locally advanced head and neck cancer patients treated with alternating chemo-radiotherapy in clinical practice.

BACKGROUND AND AIMS: To evaluate the feasibility in clinical practice of alternating chemo-radiotherapy in locally advanced head and neck cancer patients. PATIENTS AND METHODS: From August 1993 to April 1998 at the Division of Medical Oncology of Parma, 48 consecutive patients were observed, and 38 (79%) started the Merlano chemo-radiotherapy. The characteristics of the patients were: males (32, 84%); median age, 57 years; PS <2 (32, 84%). The primary sites were the oropharynx (18, 47%), oral cavity (8, 21%), hypopharynx (7, 19%), larynx (5, 13%); stage IV disease was present in 29 (76%) patients. Twenty-five (66%) patients were married, and 24 (63%) resided outside of the city. RESULTS: The compliance was very low: 21 patients (55%) performed all the programmed cycles of chemotherapy, whereas only 5 patients (13%) performed the chemo-radiotherapy at full doses without any delay. The objective responses were 3 (8%) complete and 21 (55%) complete plus partial responses. Failures were 2 (5%) stable disease and 2 (5%) progressive disease, and the response was not assessable in 10 (26%). The median duration of the response was 8 months. The median overall survival and the time to progression were 18 and 13 months, respectively; the 5-year overall and relapse-free survival were 36% and 26%, respectively. Nine (24%) patients were still alive as of August 30, 2001, 8 (21%) of them without progression. Twenty-six patients (68%) died with a local-regional relapse. One patient (3%) died for a second cancer. Grade 3-4 hematologic toxicity was leukopenia (n = 25, 66%) and thrombocytopenia (n = 9, 24%); grade 3-4 non-hematologic toxicity was diarrhea (n = 3, 8%) and mucositis (n = 2, 5%). Two patients (5%) died for intestinal infarction and perforation possibly related to treatment. CONCLUSIONS: Compliance to the chemo-radiotherapy was very poor. The response rate was lower than that reported in clinical trials, whereas overall survival was comparable. The alternating chemo-radiotherapy is a very complex treatment that cannot be easily applied in clinical practice; a careful selection of patients is mandatory not only considering oncologic and medical criteria, but also the level of awareness of the patient and his family.

Cross-facial nerve graft and masseteric nerve cooptation for one-stage facial reanimation: principles, indications, and surgical procedure.

BACKGROUND: The use of facial cross-grafting in acquired recent unilateral facial palsy provides spontaneity and emotional activation. Masseteric nerve for facial animation has mainly been described for reinnervation of neuromuscular transplants, babysitter procedures, or direct facial nerve cooptation. The simultaneous use in a single procedure of cross-facial nerve grafting and masseteric cooptation has not been described. METHODS: Eight patients underwent facial animation using single stage cross-facial nerve grafting and masseteric nerve cooptation. The mean duration of facial palsy was 10.2 months (range, 1-23 months). RESULTS: Voluntary contraction in response to masseteric nerve activation was observed after 2 to 4 months. All patients underwent postoperative rehabilitation and spontaneous contraction was achieved in 7 to 13 months postoperatively. Cosmetic outcomes were evaluated as moderate in 1 patient, good in 5 patients, and excellent in the remaining 2 patients. CONCLUSION: This new technique could provide good results with fast, reliable, and powerful reinnervation, spontaneity, and low morbidity.