Innovative Use of dHACM in Conjunction With Hyperbaric Oxygen Therapy to Treat a Nonhealing Nasal Wound Subsequent to Squamous Cell Carcinoma Resection and Radiation: A Case Study.

INTRODUCTION: Hyperbaric oxygen therapy is known to improve wound healing in the setting of chronic, nonhealing wounds of irradiated skin; however, failure of wound healing may still occur. Dehydrated human amnion/chorion membrane (dHACM) grafting is a technology that has been proven to promote wound healing of wounds related to venous stasis. Little has been published to date regarding use of dHACM in the setting of nonhealing wounds of irradiated skin. CASE REPORT: A 75-year-old man with a history of squamous cell carcinoma of the nose presented to the wound clinic with a chronic, nonhealing nasal wound following tumor resection, radiation therapy, and full-thickness skin graft and auricular cartilage allograft failure. The patient was found to have a nasal cutaneous fistula associated with rhinorrhea, adjacent skin irritation, and discomfort related to the passage of air through the fistulous tract. Following 30 days of standard wound care in the wound clinic (including weekly debridement), the patient continued to have an open, nonhealing wound. As he preferred not to proceed with a surgical flap reconstruction, the patient elected to continue with more conservative management. Hyperbaric oxygen therapy was initiated with some success but with continued presence of a nonhealing fistula tract. A dHACM graft then was applied with successful resolution of the patient's symptoms and decrease in defect size of 45% after 4 applications. CONCLUSIONS: This treatment approach ultimately resulted in complete reepithelization of the wound, and a decrease in defect area. The patient's symptoms of nasal drainage and physical discomfort due to air passage through the fistula also had resolved completely. Although the fistula was still present at the conclusion of treatment, the tract was well-epithelialized and overall size of the defect diminished greatly.

Sinonasal hemangiopericytoma caused hypophosphatemic osteomalacia: A case report.

RATIONALE: Tumor-induced osteomalacia (TIO) is a rare, paraneoplastic syndrome featured with fibroblast growth factor 23 (FGF23) secretion primarily by benign mesenchymal tumors and sometimes by malignancies. TIO diagnosis and treatment is often delayed because TIO usually has nonspecific generalized bone pain and weakness, and location of TIO tumor is quite challenging. Very few TIO caused by sinonasal hemangiopericytoma have been reported in the literature. PATIENT CONCERNS: A 40-year-old Chinese woman presented with diffuse bone pain for more than 1 year. Laboratory examination showed hypophosphatemia, hyperphosphaturia, hypocalcemia, an elevated serum alkaline phosphatase (ALP) level and bone-specific ALP level. Imaging studies revealed low bone mineral density (BMD) and multiple pseudofractures at the ribs. F-18 fluorodeoxyglucose positron emission tomography was negative in searching for tumors. Because no tumor was located, the patient was treated with oral phosphate, calcium, and alfacalcidol, and achieved great relief in her symptoms and improvement in BMD. Six years later, the patient had breast cancer surgery and received chemotherapy, and still had hypophosphatemia. During this time, nasopharyngo-fiberscope showed nasal mass in her left nasal cavity. Then she had her nasal polyps removed and surprisingly the serum phosphate became normal. DIAGNOSES AND INTERVENTIONS: The patient had the nasal mass resected, and pathological diagnosis of the nasal mass was sinonasal hemangiopericytoma. Immunohistochemical analysis was positive for FGF23. Thus the final diagnosis was osteomalacia induced by sinonasal hemangiopericytoma. Phosphate supplementation and alfacalcidol were discontinued. OUTCOMES: The patient had normal serum phosphate after 6-month follow-up. LESSONS: By presenting this case, we hope to remind clinicians that in patients with osteomalacia with undetermined reason and intranasal polypoid mass, sinonasal hemangiopericytoma should be suspected.

Epithetic nasal reconstruction for nasal carcinoma: retrospective analysis on 22 patients.

Advanced nasal cancers usually demand partial or total rhinectomy followed by radiotherapy. Reconstruction of the resulting defects can be achieved by means of reconstructive plastic surgery and/or epithetic surgery. The data of 22 patients who had been treated after nasal ablation by means of custom-made silicone nasal epithesis fixed by bone-anchored magnets between 2003 and 2014 were evaluated retrospectively. There were 15 male (68.2 %) and 7 (31.8 %) female patients. The most common etiology that led to epithetic rehabilitation was a squamous cell carcinoma in 16 patients. An operative revision was necessary in two patients due to screw loss. Twenty patients were still alive with no evidence of disease after minimum follow-up of 2 years (90.9 %). Epithetic rehabilitation after nasal ablation to treat nasal malignancies is an interesting alternative to plastic and reconstructive surgery. Bone-anchored fixation using magnets can achieve a stable epithetic fixation after nasal ablation necessitating, in numerous cases, additional adjuvant therapy like radiation.

Tumor mesenquimatoso fosfatúrico de fosa nasal con compromiso intracraneano: reporte de un caso y revisión de la literatura / Nasal fossa phosphaturic mesenchymal tumor with intracraneal compromise: case report and review of the literature

El tumor mesenquimatoso fosfatúrico (TMF) es una enfermedad extremadamente rara. Según evidencia reciente es causado por la sobreexpresión del factor de crecimiento fibroblástico 23 (FGF23), el cual genera hipofosfemia y osteomalacia. A continuación presentamos el caso de un paciente de 42 años con un tumor mesenquimatoso fosfatúrico de fosa nasal izquierda con extenso compromiso intracraneano. Cabe destacar que hasta la fecha hay 142 casos reportados de TMF en la literatura de los cuales solo 11 se ubican en fosa nasaly cavidades sinusales, y sólo dos de ellos ubicados en fosa nasal¹. El paciente tuvo una exitosa resolución quirúrgica con la consecuente normalización de parámetros analíticos (incluido el FGF23), mejoría sintomática y ausenia de recidiva hasta la fecha.

The phosphaturic mesenchymal tumor (PMT) is an extremely rare disease. According to recent evidence is caused by overexpression of fibroblast growth factor 23 (FGF23) which generates hypophosphatemia and osteomalacia. We report the case of a 42 year old patient with a left nasal fossa phosphaturic mesenchymal tumor with intracranial involvement. Should be noted that to date there are 142 reported cases of PMT in the literature of which only 11 are located in nasal fossa and sinus cavities, two of them located in nasal fossa¹. The patient had a successful surgical resolution with consequent normalization of analytical parameters (including FGF23), absence of symptoms and no recurrence to date.

[Endoscopic surgery for advanced malignant nasal and sinus tumors].

OBJECTIVE: To evaluate the effect of endoscopic surgery for advanced malignant tumors in the nasal cavity and paranasal sinuses. METHODS: A retrospective data analysis was performed on 49 patients with advanced sinonasal tumors undergoing either an exclusive endoscopic approach or with a complemental approach from January 2004 to October 2010. Forty-nine patients were considered eligible for the present analysis, among them, T3:T4a:T4b were 12:13:24 (T stage was assessed with the sixth editions of the UICC staging systems). The histotypes encountered were squamous cell carcinoma 20 cases, adenocarcinoma 12 cases, mucosal melanoma 8 cases, olfactory neuroblastoma 6 cases, others 3 cases. These patients were operated on either by an exclusive endoscopic endonasal approach or with a complementary external approach; 36 patients received adjuvant radiotherapy or/and chemotherapy. The data were analyzed by Kaplan-Meier method and Log-rank test. RESULTS: The hemorrhage varied from 200 to 5000 ml during the operation, with an average of 600 ml. The post-operative complications were rare, 1 patient lost her sight after operation, and no patient got infected at the site of operation (nor intracranial infection). After full amount of radiotherapy, no cerebrospinal fluid rhinorrhea was found. Four patients (8.2%) lost to follow-up. Sixteen patients died during the follow-up period, only three of them were without craniocerebral or orbital invasion. Four in 9 patients in the other pathological group (with the pathology of olfactory neuroblastoma or glioma etc), which had a poor prognosis, died during the follow-up period, of them, 3 had definitive evidence of intracranial metastasis, and none of the nine patients had been followed-up beyond 25 months. The 2 and 3 year disease-free rates were 34.2% and 21.4%, and overall survival rates were 62.5% and 58.4% respectively. The T stage, margin status, and whether accepted post operative adjuvant therapy were significant factors in predicting disease recurrence (χ² were 7.7, 4.9, 6.8 respectively and P < 0.05). CONCLUSIONS: Now the endoscopic techniques with or without complementary approaches is an effective way for complete tumor removal. With postoperative complementary therapy, it provides a satisfactory survival rate with few side effects and better quality of life.

Retalho em ilha de tubarão: uma técnica cirúrgica reconstrutiva de defeitos localizados na área nasal alar/perialar. Um procedimento simples / Shark island pedicle flap for repairing of basal cell carcinoma localized in nasal ala-perialar region: a simple procedure

O Carcinoma Basocelular é a neoplasia cutânea mais frequente. Os autores descrevem uma técnica realizada unicamente num tempo operatório para correção de defeitos na asa do nariz após excisão tumoral. Esta técnica simples permite a correção cirúrgica de defeitos nesta localização possibilitando a reconstrução da anatomia local e a preservação das unidades cosméticas, sem a necessidade de enxerto.

Basal Cell Carcinoma is the most common skin cancer. We describe a single-staged technique for correction of nasal ala defect after the excision of a basal cell carcinoma. This technique allows correction of surgical defects of the ala rebuilding the original anatomy, maintaining cosmetic units, without need for a graft.

Implant-retained nasal prosthesis for reconstruction of large rhinectomy defects: the Salisbury experience.

The authors report their experience with 34 patients who had large full thickness nasal defects reconstructed with an implant-retained prosthesis. Their technique of modifying post-rhinectomy defects is described and factors influencing implant success are evaluated. 111 implants were placed to retain a nasal prosthesis. Age, sex and tumour histology did not affect the outcome. Smoking, extent of rhinectomy, use of radiotherapy (pre- and post-implant), hyperbaric oxygen, length and location of the implant and type of retention (bar/magnets) influenced implant success. The overall success rate was 89% (99/111); 94% in patients who did not receive radiotherapy and 86% in those who did. The prosthesis was in place in all patients (100%) at the time of last follow up. Post-rhinectomy defect modification enables adequate access for safe placement of long implants with good primary stability and helps the maintenance of good hygiene (further enhanced by the use of skin grafts). The authors think implant-retained prosthesis is a reliable option for reconstructing large full thickness rhinectomy defects. They suggest their technique of modifying the defect, use of long implants and magnets for retention is responsible for the high success rate of implants used to retain a nasal prosthesis.

Metronomic chemotherapy against cancer: from paradigm to clinical practice?

We describe two paradigmatic cases where metronomic antitumor chemotherapy was successfully employed in patients not suitable for standard treatments. The first patient was affected by advanced soft tissue sarcoma but she also had ischemic cardiopathy. She received oral cyclophosphamide 50 mg once daily and methotrexate 2.5 mg bid twice weekly, obtaining a significant clinical response with a progression-free survival of 7 months. The second patient was over 70 years of age and suffered from metastatic gastric cancer. Because of his poor performance status he was given capecitabine 1500 mg daily, achieving a complete remission with a current disease-free survival of 13 months. In both cases no significant toxicities were observed.

Surgery for head and neck skin tumors in the elderly.

BACKGROUND: Our aim was to determine the surgical characteristics of an elderly cohort of patients undergoing resection of head and neck skin neoplasms. METHODS.: All cases of patients with head and neck skin neoplasms (excluding malignant melanoma) who underwent surgical resection in a regional referral center over a 10-year period were retrospectively reviewed. The study group comprised 152 patients (208 cases) aged >or=80 years. They were compared with 311 patients (430 cases) aged <80 years. RESULTS: Elderly patients had higher Charlson comorbidity index, American Society of Anesthesiologists' physical status scores, dementia, and aspirin intake (all p < .05). They also had a higher incidence of scalp involvement and lower incidence of nasal involvement (both p < .05). Elderly patients had a larger lesion size at presentation and required sacrifice of a greater area of skin (both p < .05). However, they also underwent more local anesthetic procedures, although the need for local flap or skin graft repair was not increased. Two elderly patients had intraoperative tachyarrythmias induced by local anesthesia. However, no patient died within 30 days of surgery, and wound complication rate and disease-free survival were comparable to younger patients. CONCLUSION: With careful attention to comorbid illness and perioperative monitoring, surgical resection of head and neck skin neoplasms is safe in the elderly. Lesions are more advanced at presentation and hence require sacrifice of a larger area of skin to obtain macroscopic clearance. Yet for the majority of lesions, local anesthesia is adequate and surgical resection and simple skin closure can be accomplished without the need for complex flap or skin graft reconstructions.

Histological comparison of nasal polyposis in black African, Chinese and Caucasian patients.

We have compared the histological aspects of nasal mucosa biopsies (n = 130) obtained during bilateral polypectomy and ethmoidectomy performed in black African (n = 50), Chinese (n = 30) and Caucasian patients (n = 50) suffering from bilateral nasal polyposis (NP). The three groups of patients were matched for age and sex. The African and Chinese patients did not receive any medical treatment before endoscopic nasal surgery (ENS). All Caucasian patients were treated with corticosteroid nasal spray (400 mg/day) for 6 months. In the absence of subjective and objective clinical improvement, ENS was performed after antibiotic treatment for 10 days and prednisolone 1 mg/kg/day for 5 days. Clinical staging of the NP was graded from I to III (I = polyps limited to the middle meatus, II = polyps extending beyond the middle meatus, and III = polyps occupying the entire nasal cavity). Stage I NP was present in 22% of the Caucasians and 30% of the Chinese. Stage II was found in 58% of the Caucasians, 56% of the Chinese and 8% of the Africans. Stage III was found in 92% of the Africans, while only 20% of the Caucasians and 14% of the Chinese patients had stage III. The extent of submucosal oedema and number of mast cells were similar for the three groups of patients. A significantly greater number of eosinophils were observed in African polyps. Lymphocytes as well as plasmocytes were rare in African but abundant in polyps from both Chinese and Caucasian. Ulceration of the overlying epithelium of the polyps was observed in 20% of the African and 10% of both Chinese and Caucasians patients. We did not find any significant thickening of the basal membrane. We cannot exclude the possibility that the histological difference observed between African and Chinese polyps is related to the very common use among the Chinese population of topical intranasal treatment according to their traditional medicine practices. Since no major histological difference was found in the nasal mucosa and polyps obtained from the three groups of patients, NP in African, Chinese and Caucasian patients is very probably a similar inflammatory disease in all three ethnic groups.

Mature teratoma of the nasal vestibule: a case report.

Teratomas are rare congenital neoplasms that arise from pluripotent cells. They consist of tissue from all three embryonic germ layers. According to most studies, teratomas of the head and neck account for only 2 to 9% of all cases. In this article, we report the first case of a teratoma of the nasal vestibule in a newborn. We also discuss methods of diagnosis and treatment of upper airway teratomas, and we include a brief review of the literature.

Expansores tisulares: conceptos generales / Tissue expansion: general concepts

In this article, we present a review of general concepts regarding tissue expansion, history, operative technique, clinical application, principal complications as well as advantages and disadvatages presented with the use of this alternative in reconstructive surgery

[Indications for the Schmid-Meyer frontal-temporal flap for nasal reconstruction. Four clinical cases]. / Les indications du lambeau frontotemporal de Schmid-Meyer dans la reconstruction nasale. A propos de quatre cas cliniques.

The fronto-temporal flap described by Schmid and modified by Meyer is a tubular flap with an internal supraciliary pedicle which allows the transposition of the temporal skin with the addition of ear cartilage on the tip of the nose or the ala nasi. This meticulous reconstruction requires four stages which are workable under local anesthesia. Four clinical cases allow to specify the advantages and the drawbacks of this technique. They place this technique in the therapeutic possibilities between the composite grafts and various local and distant flaps.

[Angiosarcoma of the nasal septum]. / Angiosarkom des Nasenseptums.

This is a report on a female patient, 37 years old, with a polypous, sessile tumor on the nasal septum covered by smooth mucous membrane. She was treated with local excision. The histological diagnosis was an angiosarcoma, confirmed by immunohistological stain with factor VIII-like antigen, thrombomodulin, and UEA. She currently remains free of the disease 12 months after diagnosis. Angiosarcoma in the head and neck area and especially the localization in the nasal septum are extremely rare. Prognosis, differential diagnosis, metastasis formation, and therapy of this tumor are presented.