Effectiveness and Safety of Sclerotherapy for Treatment of Low-Flow Vascular Malformations of the Oropharyngeal Region.

PURPOSE: To evaluate the efficacy and safety of sclerotherapy with sodium tetradecyl sulfate (STS) and bleomycin for treatment of venous malformations (VMs) of the oropharyngeal region. MATERIALS AND METHODS: A retrospective study of 33 patients with 46 VMs of the buccal and pharyngolaryngeal cavity associated with impairment of eating, respiration, or elocution was performed. Individual lesions were divided based on their anterior or posterior location, using the base of the tongue as an anatomic landmark. Lesion size was estimated with the use of orthogonal measurements on magnetic resonance or ultrasound images before and after treatment to assess radiologic response. Sclerotherapy sessions were performed under ultrasound, fluoroscopic, and, if needed, endoscopic guidance. Clinical response was assessed with the use of the Manchester Orofacial Pain Disability Scale. Methods for airway management were also compiled. RESULTS: Following sclerotherapy, average VM diameter was reduced by 31.4% (P < .0001) on a per-patient basis and by 30.8% (P < .0001) on a per-lesion basis. The Manchester score improved by an average of 37.0% (P = .013). Four patients reported a worsening of symptoms, and 11 patients experienced symptomatic recurrence. Complications include pneumonia (5 patients) and urgent placement of a post-procedure tracheostomy (4 patients). Patients with posterior malformations experienced more complications (emergency tracheostomies in 4 and pneumonias in 4). CONCLUSIONS: Sclerotherapy using STS is an efficient treatment for venous malformations of the buccal and pharyngolaryngeal cavity but can lead to significant complication for posterior lesions. Careful assessment of the airway is needed before treatment, and prophylactic tracheotomy should be considered in patients with posterior lesions.

Blunt Intraoral Trauma Resulting in Internal Carotid Artery Dissection and Infarction in a Child.

A 16-month-old child fell forward onto her toothbrush sustaining minor oropharyngeal injury. The following day, she became acutely lethargic with localizing neurologic signs of a cerebrovascular infarct. CTA and MR imaging demonstrated occlusion of the right internal carotid artery with a large right middle cerebral artery territory infarction. She was treated with decompressive craniectomy and anticoagulation but remained weak on the left side. Pediatric oropharyngeal injuries can rarely be complicated by internal carotid artery injury with dissection, thrombosis, or embolization to the cerebral circulation. For the best outcome, carotid dissection treatment requires prompt diagnosis at the initial onset of neurologic symptoms. However, further research is needed to determine the best management and advanced imaging work-up for neurologically intact children.

Applications of medial sural perforator free flap for head and neck reconstructions.

Oropharyngeal defects left after tumor resection are usually reconstructed with radial forearm or anterolateral thigh (ALT) perforator free flaps, but these flaps can be too thin or too thick. In this study, medial sural perforator free flaps with intermediate volumes were used for oropharyngeal reconstruction. Of the 243 patients with oropharyngeal cancer who underwent head and neck reconstruction between October 2006 and October 2011, the medial sural perforator free flap was used 20 times. The number and locations of the main sizable perforators, the dimensions and thickness of the flap, and the length of the pedicle were recorded. Satisfactory results were achieved in 18 patients. The flaps in the two remaining cases failed. The vertical locations of the main sizable medial sural perforators were 6 to 15 cm away from the popliteal crease. The medial sural perforator free flaps ranged from 4 to 10 mm in thickness. Medial sural perforator free flaps may be an alternative for medium-sized defects that cannot be properly reconstructed with radial forearm or ALT perforator free flaps because of their inappropriate flap volume.

Aberrant internal carotid artery in the mouth mimicking peritonsillar abscess.

The calculated incidence of aberrant internal carotid artery in the oropharynx is approximately 5% in the general population. An experienced otolaryngologist is not always available in general hospital; therefore, some invasive procedures in the oropharynx, such as aspiration, incision/drainage, and biopsy, which were performed for general infectious diseases or tissue diagnosis, may have resulted in fatal complication in these patients with misdiagnosis. We report a case to reveal that the awareness of such an anatomical variation before performing oropharyngeal procedures remains crucial.

Confocal endomicroscopy: a novel application for imaging of oral and oropharyngeal mucosa in human.

Confocal endomicroscopy is an emerging technique for intravital visualization of neoplastic lesions, but its use has so far been limited to the gastrointestinal (GI) tract. This study was designed to assess the feasibility of in vivo confocal endomicroscopy of different regions of the oropharyngeal mucosa and to evaluate different contrast agents. We examined five different regions of the human oropharynx in vivo, and images were collected in real time by using a confocal laser endoscope as formerly described for the GI tract. Additionally ex vivo specimens were examined using a topical contrast agent. Confocal scanning was performed at 488-nm illumination for excitation of exogenously applied fluorophores (topical acriflavine and intravenous fluorescein). Confocal endomicroscopy allowed for visualization of cellular and subcellular structures of the anterior human oropharyngeal region. Fluorescein staining yielded architectural details of the surface epithelium and also subepithelial layers. Images taken at increasing depth beneath the epithelium showed the mucosal capillary network. Acriflavine strongly contrasted the cell nuclei of the surface epithelium. The findings correlated well with the histology of biopsy specimens. This is the first report showing that the use of fluorescence confocal endomicroscopy represents a promising method to examine cellular details in vivo in different oropharyngeal regions in human.

Augmented reality for image guidance in transoral robotic surgery.

With the advent of precision surgery, there have been attempts to integrate imaging with robotic systems to guide sound oncologic surgical resections while preserving critical structures. In the confined space of transoral robotic surgery (TORS), this offers great potential given the proximity of structures. In this cadaveric experiment, we describe the use of a 3D virtual model displayed in the surgeon's console with the surgical field in view, to facilitate image-guided surgery at the oropharynx where there is significant soft tissue deformation. We also utilized the 3D model that was registered to the maxillary dentition, allowing for real-time image overlay of the internal carotid artery system. This allowed for real-time visualization of the internal carotid artery system that was qualitatively accurate on cadaveric dissection. Overall, this shows that virtual models and image overlays can be useful in image-guided surgery while approaching different sites in head and neck surgery with TORS.

Airway management in a bleeding adult following tonsillectomy: a case report.

A 37-year-old morbidly obese man with a history of obstructive sleep apnea underwent elective tonsillectomy. The patient was successfully intubated with an 8.0-mm regular cuffed endotracheal tube. A large video laryngoscope (GlideScope, Verathon Inc, Bothell, Washington) was used for intubation, as airway assessment indicated a potentially difficult airway. The surgery was uneventful, but active bleeding was noticed in the oropharynx after extubation. The patient was reintubated, again with the use of a GlideScope. The bleeding site was cauterized, and the patient was extubated after meeting the criteria for an awake extubation. He was discharged home the following day. Eight days postoperatively, the patient returned to the emergency center with spontaneous bleeding from the oropharynx. He was taken to the operating room and, based on the previous GlideScope use, an attempt was made to intubate the patient with a GlideScope. The attempt failed, as the GlideScope screen was blurred by the presence of blood in the oropharynx, even though the oropharynx was suctioned. Resuctioning and reinsertion of the GlideScope probe did not provide an adequate visual field. After 2 failed attempts, the use of the GlideScope was abandoned. Subsequently, the patient's trachea was successfully intubated with a size 4 Macintosh blade.

Postoperative bleeding in transoral laser microsurgery for upper aerodigestive tract tumors.

OBJECTIVES: To report the incidence, cause, and outcome of bleeding after transoral laser microsurgery. STUDY DESIGN: A two-center prospective case series analysis. SUBJECTS AND METHODS: Seven hundred one patients underwent transoral laser microsurgery for tumors of the oral cavity, pharynx, and larynx from June 1996 through September 2006. RESULTS: Ten patients (1.4%) experienced postoperative bleeding between 0 and 17 days after surgery. Five patients had previously untreated tumors, and five patients had salvage surgery. Two patients (0.3%) had minor bleeding and required observation only. Five patients (0.7%) experienced major bleeding requiring exploration under general anesthesia. Three patients (0.4%) had catastrophic life-threatening bleeds, two of whom died. The bleeding vessel was identified as the lingual artery in four patients, the superior laryngeal artery in two, the facial artery in two, and unknown in two. CONCLUSIONS: Bleeding after transoral laser microsurgery is rare but potentially life-threatening.

[Effect of foam sclerotherapy for the treatment of oropharyngeal venous malformation].

Objective: To evaluate the safety and efficacy of foam sclerotherapy with polidocanol for the treatment of venous malformation in the oropharynx. Methods: The clinical data of 21 children with venous malformation in the oropharynx treated by foam sclerotherapy were retrospectively analyzed. There were 10 males and 11 females, ranging in age from 1 month to 13 years, with a median age of 2.3 years. MRI was performed in all children, and the diagnosis was further confirmed by radiography. After general anesthesia, the oropharynx was exposed by opening device. Scalp acupuncture was used to pucture lesions and polidocanol foam was injected after the nidus was confirmed by digital subtraction angiography(DSA). The follow-up time ranged from 2-29 months, with a mean time of 15 months. The clinical symptoms, imaging data, therapeutic effects and postoperative complications were evaluated. Results: Total numbers of treatment were 52 times, 1-6 times/case; 13 cases were cured, 7 cases was relieved and no response in one case. Postoperative swelling in 13 cases, fever in 3 cases, local mucosal ulcer in 2 cases, difficult extubation in 2 cases. No nerve injury, swallowing function damage and cardiopulmonary accidents were found in all patients. Conclusion: Foam sclerotherapy with polidocanol in the treatment of venous malformation in the oropharynx is a safe and effective method.

[Treatment analyses of 143 patients with maxillofacial and cervical venous malformations involved in isthmus faucium area].

Objective: To analyze the clinical data and summarize therapeutic experiences of cervicofacial venous malformations involving isthmus faucium area. Methods: Clinical records from 143 patients with venous malformations involving isthmus faucium area treated at our hospital between January 2012 and January 2016 were reviewed. There were 70 males and 73 females. Age ranged from 1 to 52 years old, with a median age of 14.5 years. There were 19 cases with lesions involving in only 1 subanatomic area above and 124 cases with lesions involving in more than 1 subanatomic areas, including 63 cases with lesions involving in more than 2 areas. There were 50 patients presenting with additional maxillofacial and cervical lesions. Clinical symptoms included snoring (n=98), indistinct phonation (n=49), and tonsil hypertrophy more than degree Ⅱ (n=19). Tracheotomy was performed in 3 patients prior to hospitalization, contigency tracheotomy during hospitalization in 10 patients, and oral trachea cannula in other patients. All therapeutic procedures, including single chemical ablation with ethanol injection (n=94), single lesion resection (n=9) and both of them (n=40), were performed under general anesthesia. Treatment remedies included mesh suture, macroglossia reduction and excision of maxillofacial and cervical lesions for patients presenting with extensive malformations extending to maxillofacial and cervical area. Tonsil resection were done in patients having tonsil venous malformations or tonsil hypertrophy more than degree II. Achauer's 4-grade criterion was applied to evaluate the treatment outcomes. SPSS 18.0 software was used to analyze the data. Results: Trachea cannula were not extubated untill 24 to 48 hours after treatment. Emergency tracheotomy was done in 2 cases after extubations because of dyspnea, and successful extubations were obtained in other cases. There were no advents of pulmonary vascular spasm or pulmonary embolism. There was significant difference between before and after operation (snore: χ(2)=105.431, ambiguous pronunciation: χ(2)=59.698, tonsil hypertrophy more than degree Ⅱ: χ(2)=33.530, all P<0.01). The patients were followed-up for 1-4 years, and there were 123 cases at grade Ⅳ (complete disappear of lesions in 62 cases without recurrence), 17 at grade Ⅲ , 3 at grade Ⅱ, and no case at gradeⅠ. Conclusions: Chemical ablation with ethanol injection for venous malformations involving isthmus faucium area is recommended, wheras combined remedies including injection, mesh suture, macroglossia reduction, and excision of cervicofacial lesions are suggested in treatment of extensive lesions extending to maxillofacial and cervical area. Tonsil resection should be done in patients having tonsil venous malformations or tonsil hypertrophy more than degree Ⅱ, which is safe and highly effective, with good reservation of function, in the treatment of maxillofacial and cervical venous malformations involving isthmus faucium area.

Microvascular invasion in cancer of the oral cavity and oropharynx.

The presence of squamous cell carcinoma within capillaries and/or venules in the immediate vicinity of primary lesions of the oral cavity and oropharynx may be related to regional lymph node metastasis. To evaluate this possibility, we have reviewed the clinical and histopathologic features of 43 consecutive cases of previously untreated T2 or greater squamous cell carcinoma of these sites managed with simultaneous surgical treatment of the primary neoplasm and the neck. The incidence of histologically proved cervical metastasis for all lesions with vascular invasion compared with those without vascular involvement was highly significant. No statistical correlation was found for the clinical stage of neck disease or for the other pathologic features of the primary tumor, ie, size, appearance, differentiation, depth of invasion, periphery of lesion, inflammatory infiltrate, and perineural invasion, when compared with the histopathologic status of regional lymph nodes.

[Tortuosity of the internal carotid artery and its implications for the oropharyngeal and skull base surgery]. / Tortuosidad de la arteria carótida interna y sus implicaciones en la cirugía de la base de cráneo y de la cirugía orofaríngea.

Conventional textbooks on anatomy emphasize the consistency in the pathway of the cervical internal carotid artery (ICA) from the carotid bifurcation to the skull base. Deviations in its route as result of developmental and acquired conditions have received little attention in the literature. A case of a tortuous cervical ICA presenting as pharyngeal pulsatile swelling is presented. The differential diagnosis includes an enlarged ascending pharyngeal artery, aneurysm of the cervical ICA, and displacement of the cervical ICA by a tumour. Its presence warrants radiological assessment to establish a diagnosis and modify any planned surgery. Inadvertent injury or ligation of a tortuous cervical ICA can result in serious if not fatal complications. Clinical, radiological and cadaver studies on the tortuosity of the cervical ICA are reviewed.

[Cold and warm thermoregulation by oropharynx area and esophagus]. / Termoregulación al frío y al calor por la región Buco-Faringea y el Esófago.

UNLABELLED: After being ingested, food and liquids suffer a thermal regulation process, which adapts them immediately to the body temperature by means of the mucosa diffusion. We have not found bibliographical information about this matter yet. OBJECTIVES: 1) To describe the reaction of the oropharynx area and the esophagus by heat and coldness. 2) To compare both areas reaction. STUDY POPULATIONS: Six patients (three men, three women, Age: mean 42 years old, SD 11.8), healthy individuals without both gastrointestinal and systemic disease that could after microcirculation. MATERIALS & METHODS: Temperature measurement of liquid at mouth entrance and at 24 cm and 38 cm from dentary superior arcade using two thermocouples. Deglution of 40 ml of hot water (X 60 degrees C at entrance) or cold water (X 4 degrees C) in two draughts. Temperature measurement at both thermocouples at the end of deglution (time = 0 (zero)) and every 10 seconds. Random sequences every 30 minutes. RESULTS: Using water at 60 degrees C, the temperature descended to 42 degrees C in the distal end. The oropharynx region dissipated 45% of the initial temperature while the esophagus completed the other 55%. The esophagus itself dissipated 65.6% of the 12.2 degrees C in time = 0 (zero). After 40 seconds the temperature reached the normal body temperature. In the case of the iced water (4 degrees C), the total work consisted on increasing temperature 33.6 degrees C to the normal corporal temperature. The 68.45% of the difference between the initial and the final temperature was obtained by the oropharynx region and the rest by the esophagus. In time = 0 (zero) the temperature increased up to 30 degrees C and the esophagus only contributed with 28.3% of the total work. The normal corporal temperature was reached after 40 seconds. It was observed a significant difference in the heating capacity between the oropharynx region and esophagus (p > 0.001). There was also a significant difference in the oesophagus itself between heat and coldness in time = 0 (zero) ¿65.6% (heat) Vs. 28.3% (coldness), 0.02 > p > 0.01¿ and values between time = 0 (zero) and 10-40 seconds (p > 0.001). CONCLUSION: 1) The ability of cooling was similar in both regions. 2) In the oropharynx region the capacity of heating was higher (voluntary time of deglution) than in the esophagus region. 3) The esophagus initial response before coldness was slower than oropharynx region's one. The buccal retention was greater. 4) Before both stimulus, normal corporal temperature was reached after 40 seconds. COMMENTARY: The isothermation of coldness and heat would work through the same mechanism: the mucosa vasodilatation and the increase of blood flow. This hypothesis would be valid for all the mucosa of the digestive tract. This mechanism could be altered in inflammatory diseases. Iced water washings on bleeding wounds be counter-productive. The persistence of extreme temperatures in the environment modifies the structure of the esophagus mienteric plexus (Auerbach's plexus). Frequent ingestion of fluids above 60 degrees C would be a predisponent factor for esophagus cancer.

The fish in the turtle: on the functionality of the oropharynx in the common musk turtle Sternotherus odoratus (Chelonia, Kinosternidae) concerning feeding and underwater respiration.

In tetrapods, the oropharyngeal cavity and its anatomical structures are mainly, but not exclusively, responsible for the uptake and intraoral transport of food. In this study, we provide structural evidence for a second function of the oropharynx in the North American common musk turtle, Sternotherus odoratus, Kinosternidae: aquatic gas exchange. Using high-speed video, we demonstrate that S. odoratus can grasp food on land by its jaws, but is afterward incapable of lingual based intraoral transport; food is always lost during such an attempt. Scanning electron microscopy and light microscopy reveal that the reason for this is a poorly developed tongue. Although small, the tongue bears a variety of lobe-like papillae, which might be misinterpreted as an adaptation for terrestrial food uptake. Similar papillae also cover most of the oropharynx. They are highly vascularized as shown by light microscopy and may play an important role in aquatic gas exchange. The vascularization of the oropharyngeal papillae in S. odoratus is then compared with that in Emys orbicularis, an aquatic emydid with similar ecology but lacking the ability of underwater respiration. Oropharyngeal papillae responsible for aquatic respiration are also found in soft-shelled turtles (Trionychidae), the putative sister group of the kinosternids. This trait could therefore represent a shared, ancestral character of both groups involving advantages in the aquatic environment they inhabit.

Acute upper airway obstruction secondary to late presentation of a massive oropharyngeal arteriovenous malformation.

The case of a 65 year-old man with a massive oropharyngeal arteriovenous malformation, with acute deterioration and airway compromise, is presented. Optimal airway management was deemed to be fiberoptic intubation without sedative drugs.

Massive blood loss during tonsillectomy in a child with congenital venous malformation.

Tonsillectomy and adenoidectomy have become frequently performed outpatient procedures and are generally considered to have a low morbidity profile. Postoperative haemorrhage remains a rare but important complication, while intraoperative uncontrollable bleeding is extremely uncommon. A child with congenital vascular malformation of the lip and oropharynx undergoing tonsillectomy experienced massive blood loss, subsequent resuscitation and significant perioperative morbidity including a prolonged intensive care unit stay. Preoperative/preanaesthetic nasopharyngoscopic exam and magnetic resonance imaging did not reveal vascular prominence of the tonsils. Preoperative consideration of angiography or magnetic resonance angiography may be prudent to avoid this potentially fatal complication.

Does using a mouthwash instead of water improve the oropharyngeal removal of inhaled flovent (fluticasone propionate)?

Rinsing the mouth with water is recommended to remove inhaled corticosteroid (ICS) deposited on the oropharyngeal mucosa. Given the lipophilicity of fluticasone propionate (FP), an ethanol-based mouthwash was hypothesized to be superior to water. This study's purpose was to compare the effectiveness of water versus Listerine (Warner Lambert, Lititz, PA) in removing FP from the oropharyngeal mucosa. Asthma patients were randomly assigned water or a Listerine-rinsing vehicle. A 440-microgram dose of FP was inhaled. After the second puff, patients rinsed for 30 seconds with 20 mL of the assigned agent and then repeated the process, spitting each "wash" into the same cup. At visit 2, patients used the alternate vehicle and repeated the procedure. Samples were frozen until analyzed using liquid chromatography/mass spectrophotometry (lower limit of detection 0.067 microgram/mL). Thirty-six patients (mean age, 44 years; 66% female) participated. Mean inhaler technique score was 11.3 (scale of 1-12). Eighty-three percent used the closed-mouth technique. The mean concentration of FP removed by Listerine was not statistically different than that removed by water, 1.67 micrograms/mL (range, 0.067-4.195 micrograms/mL) and 1.42 micrograms/mL (range, 0.067-5.107 micrograms/mL), respectively, and the total milliliter returned was assumed to be 40 mL. Regression analysis using sex, age, and inhaler technique showed no statistical relationship with the amount of FP removed. Therefore, Listerine was not more effective than water in removing FP from the oropharyngeal mucosa (p = 0.53). Thus, water is an adequate rinsing vehicle for removal of ICS deposited on the oropharyngeal mucosa. Other factors besides the rinsing vehicle are strong factors in determining the amount of drug removed.