Vascularized Clavicular Bone With Supraclavicular Artery Island Flap for Oromandibular Reconstruction.

OBJECTIVE: To explore the feasibility of an original surgical technique for head and neck oncologic reconstruction utilizing a pedicled osteocutaneous supraclavicular artery island flap (SCAIF) in a cadaver model. METHOD: Cadaver dissection, Review of literature. DESCRIPTION: Two fresh frozen cadavers, 1 male and 1 female, were used for the dissection. Prior to dissection, measurements were taken on length of clavicle and distance between clavicular articulations and mandibular landmarks with the head in a neutral position. The SCAIF flap was raised in a subfascial plane and a 4.0 cm partial thickness clavicular bone graft was harvested attached to the flap. The pedicle was identified and the length of the supraclavicular artery was noted. The skin paddle was tunneled into the floor of mouth and the bone was placed into a pre-cut 4.0 cm mandibular body defect and fixated with a 1.7 mm Stryker mandibular reconstruction plate. RESULTS: The male cadaver clavicle measured 16.4 cm in length. The distance from the sternoclavicular joint (SC) to the angle and symphysis of the mandible was 15.3 cm and 15.0 cm, respectively. In this cadaver, the bony graft and the vascular pedicle was not of sufficient length to reach the mandibular defect after tracing the vascular pedicle to the thyrocervical trunk (TCT), which was 13.3 cm from the mandibular angle (MA). The female cadaver had an average clavicular length of 15.0 cm, SC to angle 10.5 cm and SC to symphysis 8.1 cm. The bony graft and the vascular pedicled effortlessly reached without tension, with TCT only 7.8 cm from the MA and allowed sufficient bone graft mobility for plating. CONCLUSION: In this cadaveric model, a novel approach utilizing an osteocutaneous SCAIF was shown as a feasible reconstruction option for oromandibular defects in selected patients. This technique is limited by the anatomical relationship between the neck and vascular pedicle length. Viability could be determined by pre-operative measurements, where the clavicular length should be significantly greater than the distance from SC to MA.

4D-CT facilitates focused parathyroidectomy in patients with primary hyperparathyroidism by maintaining a high negative-predictive value for uninvolved quadrants.

INTRODUCTION: Improved preoperative localization facilitates minimally invasive parathyroidectomy for removal of parathyroid lesions therefore preventing an invasive bilateral neck exploration. As 4D-CT has emerged, its high specificity has helped with preoperative parathyroid lesion localization. A high negative predictive value (NPV) would serve to further confirm parathyroid lesion localization and limit unnecessary surgical exploration. This study's objective was to determine the NPV of preoperative 4D-CT and its facilitation of minimally invasive parathyroidectomy. METHODS: A retrospective review was compiled for patients undergoing parathyroidectomy for primary hyperparathyroidism with a preoperative 4D-CT. Included patients were sorted into various groups for comparison: those with 4D-CT localizing to a single lesion, localizing to multiple lesions, and those with nonlocalizing findings; multiple hypercellular parathyroid gland versus single gland findings; extent of surgical exploration; lesion location; and patients with concomitant thyroid nodules. Negative predictive value was calculated and used to quantify the ability for 4D-CT to rule out biochemically significant parathyroid lesions. RESULTS: In our review of 68 patients: sensitivity was 81.3%, specificity was 95.5%, positive predictive value was 87.1%, and negative predictive value was 93.3%. 86% had a single localizing 4D-CT, 7% had a non-localizing 4D-CT, and 7% had a multiple quadrant localizing 4D-CT. NPV for single and multi-localizing 4D-CT were 96.8% and 88.9%, respectively. CONCLUSION: Preoperative 4D-CT has a high negative predictive value (93.3%), suggesting in the majority of cases, a quadrant with no 4D-CT radiographic findings suspicious for parathyroid is unlikely to harbor biochemically significant parathyroid lesions.

Comparing success rates of anesthesia providers versus trauma surgeons in their use of palpation to identify the cricothyroid membrane in female subjects: a prospective observational study.

PURPOSE: The primary aim of this study was to compare the success rates of anesthesia providers vs trauma surgeons in their use of palpation to identify the cricothyroid membrane (CTM). The secondary aim was to explore whether prior training and experience performing surgical airways affected the success rates for identifying the CTM. METHODS: Four female adults participated in this prospective observational study. The participants had varying measurements of neck anatomy that were known or theorized to affect the accuracy of identifying the CTM location. For test purposes, the subjects were positioned with optimal neck extension via placement of a shoulder roll. Anesthesia providers (n = 57) and surgeons (n = 14) of various training levels and clinical experience marked the presumed CTM location on each subject. These palpation markings were then referenced against the ultrasound-confirmed CTM location, and the success rates for identifying the CTM were compared between groups. RESULTS: The overall success rate using palpation to identify the CTM was ≤ 50%, and there were no differences in success rates between the anesthesia providers and trauma surgeons (16% vs 26%, respectively; absolute difference, -10%; 95% confidence interval, -23 to 3; P = 0.15). Furthermore, there were no significant differences in the success rates for identifying the CTM based on either clinical experience or emergency surgical airway experience. CONCLUSION: The success rates for identifying the CTM using palpation were low and not significantly different for anesthesia providers and surgeons, collectively, as well as for the various levels of training. Anesthesiologists' ability to mark the CTM location correctly did not improve with years of experience.

Case Report: The effect of automated manual lymphatic drainage therapy on lymphatic contractility in 4 distinct cases.

Introduction: Automated manual lymphatic drainage therapy (AMLDT) is available for home use in the form of a pneumatic mat of 16 pressurized air channels that inflate and deflate to mimic the stretch and release action of manual lymphatic drainage therapy. Four cases (a patient with complex regional pain syndrome and lymphedema, a healthy patient, a breast cancer survivor with chronic pain, and a patient with a history of abdominal surgery) underwent near-infrared fluorescence lymphatic imaging (NIRFLI) with AMLDT to evaluate the effect of AMLDT on lymphatic pumping and pain. Methods: Each patient received 32-36 injections of 25 µg indocyanine green (ICG) on the anterior and posterior sides of their body and underwent 1 h of NIRFLI to assess the drainage of ICG laden lymph toward regional nodal basins at baseline. Each patient lay supine on the mat for 1 h of AMLDT with NIRFLI to assess lymphatic flow during treatment. A final NIFRFLI assessment was done 30-60 min posttreatment with the patient in the supine and prone position. Patients reported baseline and posttreatment pain using the Visual Analogue Scale. An imager analyzed NIRFLI images using ImageJ (US National Institutes of Health). Using time stamps of the first and last images to determine time lapsed and the number of pulses observed in a timeframe, pulsing frequency (pulses/min) was obtained to assess lymphatic function. Results: All 4 cases completed the NIRFLI and AMLDT without complications; all 3 patients with baseline pain reported reduced pain posttreatment. AMLDT appeared to alter lymphatic contractility, with both increased and decreased pulsing frequencies observed, including in nonaffected limbs. Pulsing frequencies were very heterogeneous among patients and varied within anatomic regions of the same patient. Discussion: This proof-of-concept study suggests that AMLDT may impact lymphatic contractility. Further research on its effect on lymphatic function is warranted.

Synchronous Presentation of Right Parotid Branchial Cleft Cyst and Left Neck HPV-Associated Cystic Metastatic Squamous Cell Carcinoma: A Diagnostic Quandary.

Branchial cleft cyst arising within the parotid space is considered an extremely rare phenomenon. In contrast, cystic squamous cell carcinoma in the lateral neck is not an uncommon presentation of HPV-related head and neck cancer. Although they have singly been narrated in literature, simultaneous expression of these anomalies has yet to be reported. We describe a case of synchronous presentation of branchial cleft cyst of the right parotid gland and cystic metastatic squamous cell carcinoma of the left neck. These findings are discussed in light of the challenges in fine needle aspiration biopsy of cystic masses, and the risk of two distinct pathologic entities presenting as cysts in the head and neck.

Infected Ruptured Parathyroid Cyst Presenting with Hypercalcemia and Airway Obstruction: A Case Report.

Parathyroid cysts (PC) are infrequently encountered and characterize less than 1% of all head and neck masses. When present, PCs may present as a palpable neck mass and lead to hypercalcemia and rarely respiratory depression. Furthermore, the diagnostics of PCs is difficult as they can masquerade as a thyroid or mediastinal mass given their proximity. PCs are theorized to be a progression of parathyroid adenomas and often routine surgical excision is sufficient for cure. To our knowledge, there is no documented report of a patient with an infected parathyroid cyst that led to severe dyspnea. This case describes our experience of a patient with an infected parathyroid cyst presenting as hypercalcemia and airway obstruction.

Oligometastatic Parathyroid Carcinoma Presenting as Neck Pain: A Case Report.

BACKGROUND: Parathyroid carcinoma (PC) is an exceedingly rare, slow-growing but progressive endocrine malignancy that represents a diagnostic and therapeutic challenge. Vertebral metastasis of PC is remarkable, with only 3 prior cases of spinal metastasis reported in the literature. CASE DESCRIPTION: A 62-year-old woman presented with 1 week of neck pain radiating down her right arm. Cervical x-ray revealed a lytic lesion of the C4 vertebral body. Lab work revealed hypercalcemia with an elevated parathyroid hormone level. Computed tomography and magnetic resonance imaging revealed frank destruction of the C4 vertebral body and pedicles by PC. She was treated with corpectomy, mass excision, anterior cervical discectomy and fusion, postoperative radiotherapy, and nonspecific inhibitors of active tumor pathways. Her symptoms resolved postoperatively, and she has remained negative for reoccurrence at 15-month follow-up. CONCLUSIONS: To the authors' knowledge, we report the first described cervical spine metastasis of PC. Additionally, we review the treatment of this rare neoplasm in an extremely rare location in the age of tumor sequencing and morphoproteomic analysis.

Aerosol Production with Surgical Instrumentation: Implications for Head and Neck Surgery in the COVID-19 Era.

Evaluating the aerosolization of droplets from surgical instruments to assess the implications of surgery in SARS-CoV-2 transmission for both patients and providers. Cadaver study. Outpatient surgery center. Aerosolized particles between 0.3 and 25 microns were measured. Instruments tested included monopolar cautery with and without suction, bipolar cautery, a bipolar vessel sealing device, and tissue scissors. Each trial was compared to a background reading. Monopolar cautery without suction, Ligasure used continuously and Bipolar cautery produced the most aerosols. Monopolar cautery with simultaneous suction produced no detectable aerosols. Ligasure used for a single cycle produced notably fewer aerosols than during continuous use. Most aerosols produced were < 5 microns. These data support n95 use during surgical management of the upper aerodigestive tract, as well as the use of suction in the surgical field.

NUT Carcinoma of the Submandibular Gland: A Case at This Uncommon Site with Review of the Literature.

Nuclear protein in testis (NUT) carcinoma is a rare, highly aggressive, undifferentiated carcinoma that harbors a characteristic rearrangement of the NUTM1 gene. The majority arise in adolescents and young adults especially from the midline structures of the thorax, head, and neck. Until the present, there have only been three reported cases of NUT carcinoma of the submandibular gland, two of which were reported in children and another one in an adult from Korea. Here, we report the first case of NUT carcinoma arising in the submandibular gland of an adult female in the United States, representing the fourth case worldwide. A fine needle aspiration and biopsy was performed, and the diagnosis was confirmed by NUT immunohistochemical staining and fusion of the BRD4 (19p13.12) and NUTM1 (15q14) gene loci by fluorescence in-situ hybridization on the resection specimen. Salivary gland is an unusual site for NUT carcinoma and is rarely described in submandibular gland. We reviewed the clinicopathologic features of this entity at this site along with role of NUTM1 gene rearrangements in NUT tumorigenesis.

Spindle Cell Squamous Cell Carcinoma of the Larynx with Malignant Osteoid Differentiation: A Case Report and Review of Literature.

Spindle cell squamous cell carcinoma of the larynx is a rare, aggressive variant of squamous cell carcinoma. It comprises 0.6-1.5% of all laryngeal cancers. Heterologous mesenchymal differentiation as bone, cartilage, and muscle is uncommon, especially malignant osteoid differentiation, as a handful of cases reported in the literature. We present the case of a 66-year-old male active smoker who presented with dysphonia and acute stridor. On examination, a 2.0 cm pedunculated, broad-base, glottic mass involving the left true vocal cord and ventricle was noted, with extension to the anterior commissure causing a narrowing of the airway. The patient underwent localized left vocal cordectomy. The histopathologic and immunohistochemical findings were consistent with spindle cell carcinoma with malignant osteoid differentiation. The patient is alive, status-post adjuvant five cycles of cisplatin therapy, with no recurrence at 18 months of follow-up. We discuss a literature review of this rare entity with either malignant osteoid or osteocartilaginous differentiation.

Lymphatic Dissemination and Axillary Web Syndrome in Primary Cutaneous Tuberculosis Secondary to Needlestick Injury.

Cutaneous tuberculosis secondary to skin inoculation of Mycobacterium tuberculosis is uncommon but it can occur in the health care settings. Herein, we report an unusual case of primary cutaneous tuberculosis of the thumb following a needlestick injury. The infection progressed with a necrotic granuloma, lymphatic dysfunction as visualized by near-infrared fluorescence lymphatic imaging, and the development of an axillary web syndrome.

Desmoplastic Small Round Cell Tumor of Parotid Gland: A Rare Entity With Diagnostic Challenge.

Desmoplastic small round cell tumor (DSRCT) is a rare malignant mesenchymal neoplasm that typically affects young patients and presents as large intraabdominal masses. We report a rare case of parotid gland DSRCT in a 38-year-old man. The tumor cells were large sized and form irregular nests embedded in abundant desmoplastic stroma. Immunohistochemically, the tumor cells were positive for cytokeratin, GATA3, p40, and p63. Working differential diagnosis included squamous cell carcinoma, myoepithelial carcinoma, hyalinizing clear cell carcinoma, NUT (nuclear protein of the testis) carcinoma, and adamantinoma-like Ewing sarcoma. The characteristic morphologic features and presence of EWSR1-WT1 gene fusion are diagnostic of DSRCT. Salivary gland DSRCT is an exceedingly rare entity, with only 6 cases reported in the literature.

Longitudinal effects of a novel advanced pneumatic compression device on patient-reported outcomes in the management of cancer-related head and neck lymphedema: A preliminary report.

BACKGROUND: Head and neck cancer (HNC) survivors experience head and neck lymphedema (HNL), which requires treatment to prevent morbidity. We explore the self-reported outcomes and satisfaction of patients with HNC receiving treatment for HNL with an advanced pneumatic compression device (APCD). METHODS: HNC survivors (n = 205) prescribed with an at-home Flexitouch head and neck APCD completed pretreatment and posttreatment self-reported assessments addressing efficacy, function, and symptoms. Participant average age was 60 years with 74% male. Pre-post responses for ≥25 days of use were assessed via the non-parametric Wilcoxon Signed Rank test. RESULTS: Analysis revealed statistically significant improvement in all symptoms and all function items (P < 0.00001). Compliance with prescribed therapy (at least 30 minutes daily) was high with 71% of participants reporting daily use and 87% reporting overall satisfaction. CONCLUSIONS: The reported improvements in function and symptoms, and high compliance rate, provide a rationale for a subsequent randomized controlled trial.

Povidone-iodine solution as SARS-CoV-2 prophylaxis for procedures of the upper aerodigestive tract a theoretical framework.

BACKGROUND: The COVID-19 pandemic has raised concerns of inadvertent SARS-CoV-2 transmission to healthcare workers during routine procedures of the aerodigestive tract in asymptomatic COVID-19 patients. Current efforts to mitigate this risk focus on Personal Protective Equipment, including high-efficiency filtration as well as other measures. Because the reservoir for SARS-CoV-2 shedding is in the nasopharynx and nasal and oral cavities, the application of viricidal agents to these surfaces may reduce virus burden. Numerous studies have confirmed that povidone-iodine inactivates many common respiratory viruses, including SARS-CoV-1. Povidone-iodine also has good profile for mucosal tolerance. Thus, we propose a prophylactic treatment protocol for the application of topical povidone-iodine to the upper aerodigestive tract. CONCLUSION: Such an approach represents a low-cost, low-morbidity measure that may reduce the risks associated with aerosol-generating procedures performed commonly in otorhinolaryngology operating rooms.

Assessing lymphatic route of CSF outflow and peripheral lymphatic contractile activity during head-down tilt using near-infrared fluorescence imaging.

Evidence overwhelmingly suggests that the lymphatics play a critical role in the clearance of cerebrospinal fluid (CSF) from the cranial space. Impairment of CSF outflow into the lymphatics is associated with a number of pathological conditions including spaceflight-associated neuro-ocular syndrome (SANS), a problem that limits long-duration spaceflight. We used near-infrared fluorescence lymphatic imaging (NIRFLI) to dynamically visualize the deep lymphatic drainage pathways shared by CSF outflow and disrupted during head-down tilt (HDT), a method used to mimic the cephalad fluid shift that occurs in microgravity. After validating CSF clearance into the lymph nodes of the neck in swine, a pilot study was conducted in human volunteers to evaluate the effect of gravity on the flow of lymph through these deep cervical lymphatics. Injected into the palatine tonsils, ICG was imaged draining into deep jugular lymphatic vessels and subsequent cervical lymph nodes. NIRFLI was performed under HDT, sitting, and supine positions. NIRFLI shows that lymphatic drainage through pathways shared by CSF outflow are dependent upon gravity and are impaired under short-term HDT. In addition, lymphatic contractile rates were evaluated from NIRFLI following intradermal ICG injections of the lower extremities. Lymphatic contractile activity in the legs was slowed in the gravity neutral, supine position, but increased under the influence of gravity regardless of whether its force direction opposed (sitting) or favored (HDT) lymphatic flow toward the heart. These studies evidence the role of a lymphatic contribution in SANS.

A practical guide for understanding confidence intervals and P values.

The 95 percent confidence interval about the mean demarcates the range of values in which the mean would fall if many samples from the universal parent population were taken. In other words, if the same observation, experiment, or trial were done over and over with a different sample of subjects, but with the same characteristics as the original sample, 95 percent of the means from those repeated measures would fall within this range. This gives a measure of how confident we are in the original mean. It tells us not only whether the results are statistically significant because the CI falls totally on one side or the other of the no difference marker (0 if continuous variables; 1 if proportions), but also the actual values so that we might determine if the data seem clinically important. In contrast, the P value tells us only whether the results are statistically significant, without translating that information into values relative to the variable that was measured. Consequently, the CI is a better choice to describe the results of observations, experiments, or trials.

Practical guide to efficient analysis and diagramming articles.

OBJECTIVE: In a busy practice, time is a commodity in rare supply, and keeping abreast of the relevant medical literature is a daunting task. Even after reading an article carefully, important information may be lost because of undue attention to the methodological minutia. METHOD: Fundamental to reducing a complex article into a well-organized and consistent format is the technique of quantitatively diagramming the principal components in the design and findings of the study. This approach allows a coherent brief summary statement of the article, and a platform for a focused scientific discussion and analysis of the clinical applicability of the findings. CONCLUSIONS: The technique of diagramming an article is a tool that the senior author has used for years and has found it valuable in capturing the scientific fundamentals of a manuscript. Once prepared, the diagram has proven to be useful in clarifying presentations during journal club, preparing the background and significance sections of grant applications, reviewing articles as a journal editor and as a journal reviewer, and easily retrieving documents to support evidence-based practice efforts.

Head and Neck Lymphedema: Treatment Response to Single and Multiple Sessions of Advanced Pneumatic Compression Therapy.

Ten head and neck cancer survivors diagnosed with head and neck lymphedema (HNL) were imaged using near-infrared fluorescence lymphatic imaging (NIRFLI) prior to and immediately after an initial advance pneumatic compression device treatment and again after 2 weeks of daily at-home use. Images assessed the impact of pneumatic compression therapy on lymphatic drainage. Facial composite measurement scores assessed reduction/increase in external swelling, and survey results were obtained. After a single pneumatic compression treatment, NIRFLI showed enhanced lymphatic uptake and drainage in all subjects. After 2 weeks of daily treatment, areas of dermal backflow disappeared or were reduced in 6 of 8 subjects presenting with backflow. In general, reductions in facial composite measurement scores tracked with reductions in backflow and subject-reported improvements; however, studies are needed to determine whether longer treatment durations can be impactful and whether advanced pneumatic compression can be used to ameliorate backflow characteristic of HNL.

Practical guide to understanding the value of case reports.

Case reports have been vital to the advancement of medicine, providing a mechanism for scholarly education and for sharing new discovery and rare observations. However, journals are increasingly reluctant to publish this type of manuscript. Additionally, case reports and limited case series are infrequently cited, potentially interfering with the impact factor of a journal. The increasing emphasis on evidence-based medicine may have artificially decreased the value of case reports. This article describes the value of case reports to medicine, citing 3 examples that have significantly improved the practice of medicine. We also provide criteria for effective reporting, which include the elements of both surprise and closure. In summary, we offer support for the contention that case reports are fundamental to the scholarly practice of medicine and enhance the intent of a quality medical journal.