Transoral Robotic Surgery for Eagle Syndrome: A Systematic Review.

Objectives: Transoral robotic surgery (TORS) is gaining popularity and has been introduced for the treatment of Eagle syndrome. This review aims to evaluate the safety and efficacy of TORS for the treatment of Eagle syndrome. Methods: A systematic review of the English language literature using multiple databases was completed for studies describing TORS for Eagle syndrome. The quality of studies and risk of bias were evaluated using the MINORS scoring system. Results: Out of 1495 articles screened, 4 studies met criteria for inclusion in the final analysis. Across all studies, there was a 100% surgical success rate. In total, every patient had some level of symptom improvement with 84% of patients having complete symptom improvement and 16% having partial improvement. Reported estimated blood loss averaged 12.5 mL. A total of 94.7% of patients had no surgical complications and no cases were complicated by postoperative bleeding. Operative time averaged 65 minutes. The average length of stay was 2.1 days. A total of 92% of patients resumed their diet on postoperative day 1, with the remainder resuming on postoperative day 2. MINORS criteria scoring suggested moderate risk of bias in all studies. Conclusion: Based on limited quality evidence, this review suggests that TORS is a safe and effective surgical approach in the treatment of Eagle syndrome with low complication rates. Further large-scale prospective studies are warranted.

Systematic review of the free thoracodorsal artery perforator flap for head and neck reconstruction.

BACKGROUND: The thoracodorsal artery perforator (TDAP) flap has gained interest as a option for reconstruction of head and neck defects while minimizing donor site morbidity as compared to traditional workhorse flaps. The primary aim of this systematic review is to assess the postoperative outcomes and efficacy of this flap. METHODS: Several databases were screened for relevant citations. The quality of studies and risk of bias were evaluated using the MINORS scoring system. RESULTS: Twenty articles containing 168 patients undergoing at least one TDAP flap reconstruction met the inclusion criteria. There were no incidences of total flap failure and only 10 incidences of partial flap failure (5.95 %). Flap complications and donor site morbidity was low. The average MINORS score of the studies suggested a moderately high amount of bias. CONCLUSIONS: Based on limited quality evidence, this review suggests that TDAP flap is a safe and feasible option for head and neck reconstruction with comparable success rates as other commonly used flaps, with low complication rate and donor site morbidity. Further large-scale studies are warranted.

Acquired Stenosis of the External Ear Canal.

Acquired stenosis of the external ear canal (ASEEC) is a relatively uncommon condition. Stenosis or narrowing of the external ear canal (EEC) occurs lateral to the tympanic membrane resulting in a skin lined blind canal. Recurrent otorrhea, and conductive hearing loss are typical clinical features. Although ASEEC can be due to different etiologies, a common pathogenesis, namely an inflammatory cascade, has been implicated. Clinical evaluation, audiogram, and Computed tomography (CT scan) form the mainstay of diagnosis. Surgery is the primary modality for treatment. Restenosis is the most common postsurgical complication.

Current management of xerostomia in head and neck cancer patients.

Radiotherapy (RT) continues to play a key role in the management of head and neck cancer (HNC). Xerostomia remains a principal detriment to the quality of life (QoL) for 80 % of surviving patients receiving head and neck radiation. Radiation-induced injury to the salivary glands is dose-dependent, and thus efforts have been focused on decreasing radiation to the salivary glands. Decreased saliva production reduces both short-term and long-term quality of life in head and neck survivors by impacting on taste and contributing to dysphagia. Several radioprotective agents to the salivary gland have been investigated. Although not widely practiced, surgical transfer of the submandibular gland prior to RT is the mainstay of surgical options in preventing xerostomia. This review focuses on the strategies to improve xerostomia following radiation therapy in head and neck cancers.

A systematic review and meta-analysis on the outcomes of type I thyroplasty in the irradiated neck.

BACKGROUND: Type I thyroplasty has been well-documented as a safe and effective treatment modality for vocal fold motion impairment, as well as other select cases of persistent glottic insufficiency. However, history of prior radiation to the neck has traditionally been viewed as a relative, if not formal contra-indication to this procedure. The objective of this systematic review was to analyze all available data in the literature on type I thyroplasty in previously irradiated patients and perform a meta-analysis assessing whether complications and revision rates are significantly different between radiated and non-irradiated patients. Secondary outcomes were to compare voice outcomes between these cohorts. METHODS: Several databases were screened for relevant citations using the PICO process. The quality of studies and risk of bias were evaluated using the MINORS scoring system. Main endpoints for analysis in this study were complication rate and revision rate. Secondary endpoint was reported voice outcome. RESULTS: Three articles were included in the analysis. Zero major complications were reported, including no instances of implant extrusion or explantation. There was an 11.8 % rate of minor complications. There were similar rates of revision between radiation and control groups. There was no significant difference in voice outcomes between groups. The average MINORS score of the studies suggested a high risk of bias. CONCLUSIONS: Based on limited quality evidence, this review suggests that type I thyroplasty is safe and feasible in carefully selected irradiated patients, with comparable complication and success rates as their non-irradiated cohorts. Further large-scale studies are warranted.

Targets for improving disparate head and neck cancer outcomes in the low-income population.

Low-income patients have worse head and neck cancer outcomes than those with high-income. Yet, few targets have been identified to specifically improve outcomes in the low-income population. Here, we conduct a review on the current literature on head and neck cancer outcomes in the low-income population and identify targets for intervention. The degree of disparity is in the range of 20%-90% worse overall survival in the low-income population. Eliminating smoking would have the greatest effect on head and neck cancer mortality rates in the low-income population. Additionally, access to oral cancer exams, assistance with transportation, and continued expansion of telemedicine would facilitate early diagnosis and timely treatment in patients who develop head and neck cancer.

Infrahyoid myocutaneous flap: A systematic review.

INTRODUCTION: The infrahyoid myocutaneous flap (IHMCF) is an often-overlooked flap of the anterior neck used for reconstruction of oral cavity and laryngopharyngeal defects. The primary goal of this systematic review is to evaluate the postoperative outcomes and efficacy of this flap. METHODS: A comprehensive search of PubMed, Biological Abstracts, CINAHL Plus, and Web of Science was conducted. Two researchers independently scrutinized the studies to determine inclusions based on relevance, sample size, and English language publications. RESULTS: Twenty-eight studies containing 1027 IHMCF cases met the inclusion criteria. Primary outcomes included flap necrosis and postoperative functional outcomes. The rate of flap survival was 99%. Total skin necrosis and partial skin necrosis were minor complications that occurred in 2.5% and 5.8% of cases respectively. Poor speech and swallowing outcomes were reported in 6.4% and 6.5% of cases respectively. The included studies were predominantly retrospective. An average MINORS score of 9.6 suggests moderate bias among the studies. CONCLUSIONS: The IHMCF is both safe and effective for repairing medium sized mucosal lesions of the head and neck region in carefully selected patients. IHMCF use in oral cavity reconstruction is particularly appealing although functional outcomes remain difficult to statistically assess. Complications of IHMCFs are rare and often minor. To ensure the best outcome, pre-surgical planning needs to be conducted and all contraindications should be respected. Further large prospective multi-centered trials are needed for more accurate analysis.

Neurosurgical management of vascular compression presenting as visual symptoms secondary to elongated styloid processes (Eagle syndrome).

BACKGROUND: Eagle syndrome (ES) was first described in 1937, to characterize elongation of the styloid process. It is rarely encountered by neurosurgeons but does present the potential for vascular sequelae and neurological complications. DEMONSTRATIVE CASES: We discuss three patients with uncommon presentations of neurovascular compromise with uncommon symptomatology, secondary to ES. Their management ranged from retrospective diagnoses following self-limited events, antiplatelet therapy, and endovascular and surgical interventions. DISCUSSION: While traumatic fractures, chiropractic manipulation, and history of prior neck surgery have been implicated as the etiologies for ES, congenital cases are common. The styloid process intimately interplays with adjacent neurovascular and nervous structures; its elongation can cause symptoms in 10% of patients. CONCLUSION: Awareness of this potentially dangerous but rare disease - more commonly seen by our otolaryngology colleagues - may help reduce diagnostic delays when an elongated styloid process is the cause, as surgery may be required.

Transoral endoscopic parathyroidectomy vestibular approach: A systematic review.

BACKGROUND: Transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) is a novel surgical approach that has gained increasing traction as a remote access approach for parathyroid surgery. The primary aim of this systematic review is to assess the feasibility and safety of this approach. METHODS: Several databases were screened for relevant citations. The quality of studies and risk of bias were evaluated using the MINORS scoring system. RESULTS: Nine articles containing 78 cases of TOEPVA met the inclusion criteria. Overall, there was a 96% success rate. There were three cases (3.8%) that had complications, including one case of transient recurrent laryngeal nerve palsy. The average MINORS score of the studies suggested a moderate amount of bias. CONCLUSIONS: Based on limited quality evidence, this review suggests that TOEPVA is safe and feasible, with reasonable success rates and low complication rates in a very carefully selected patient population. Further large-scale studies are warranted.

Cervical ganglioneuroma mimicking a carotid body tumour.

A 30-year-old woman was referred to the ear, nose and throat clinic by her primary care physician for a 10-year history of an asymptomatic, large, right-sided neck mass. On examination, the patient had a palpable, non-tender, five-by-four centimetre, mobile, right-sided level II neck mass. CT scan with intravenous contrast showed an enhancing mass with multiple fluid cavities, splaying the external carotid and internal carotid arteries, concerning for a carotid body tumour. Patient was then referred to interventional radiology for angiography and embolisation prior to definitive surgical excision. However, when the mass was then excised surgically, final pathology identified the mass as a ganglioneuroma. Patient recovered well postoperatively with some ptosis of the right eye and symptoms consistent with first bite syndrome, treated with conservative measures.

Systematic review of microvascular coupling devices for arterial anastomoses in free tissue transfer.

BACKGROUND: Coupling devices have become commonplace in performing venous anastomoses during microvascular free tissue transfer (FTT). However, arterial anastomoses are still most commonly performed using traditional microvascular suture techniques. OBJECTIVE: To describe the safety and feasibility of using microvascular coupling devices for free flap arterial anastomosis. METHODS: A systematic review of English language literature was performed for studies that investigated the use of an arterial coupler for microvascular FTT in human patients. A comprehensive search of MEDLINE (January 1948 to August 2018), EMBASE (January 1974 to August 2018), and Web of Science was performed. RESULTS: Fifteen studies were included. All studies were retrospective case series. A combined total of 395 arterial anastomoses were attempted with a coupling device. All studies except for one used the 3M Unilink/Synovis coupling device. One study used a novel absorbable coupling device. The coupling device was aborted and converted to a suture technique in 8.4% of attempted anastomoses. Rupture of the anastomotic device was reported in only 1 patient (0.3%). Thrombosis was also infrequent at 1.9%. The quality assessment showed a high risk of bias in all studies. CONCLUSION: In selected patients, coupling devices for arterial anastomoses have a good success rate with low rates of thrombosis based on limited quality evidence.

Bone marrow macrophages support prostate cancer growth in bone.

Resident macrophages in bone play important roles in bone remodeling, repair, and hematopoietic stem cell maintenance, yet their role in skeletal metastasis remains under investigated. The purpose of this study was to determine the role of macrophages in prostate cancer skeletal metastasis, using two in vivo mouse models of conditional macrophage depletion. RM-1 syngeneic tumor growth was analyzed in an inducible macrophage (CSF-1 receptor positive cells) ablation model (MAFIA mice). There was a significant reduction in tumor growth in the tibiae of macrophage-ablated mice, compared with control non-ablated mice. Similar results were observed when macrophage ablation was performed using liposome-encapsulated clodronate and human PC-3 prostate cancer cells where tumor-bearing long bones had increased numbers of tumor associated-macrophages. Although tumors were consistently smaller in macrophage-depleted mice, paradoxical results of macrophage depletion on bone were observed. Histomorphometric and micro-CT analyses demonstrated that clodronate-treated mice had increased bone volume, while MAFIA mice had reduced bone volume. These results suggest that the effect of macrophage depletion on tumor growth was independent of its effect on bone responses and that macrophages in bone may be more important to tumor growth than the bone itself. In conclusion, resident macrophages play a pivotal role in prostate cancer growth in bone.

Osteal macrophages support physiologic skeletal remodeling and anabolic actions of parathyroid hormone in bone.

Cellular subpopulations in the bone marrow play distinct and unexplored functions in skeletal homeostasis. This study delineated a unique role of osteal macrophages in bone and parathyroid hormone (PTH)-dependent bone anabolism using murine models of targeted myeloid-lineage cell ablation. Depletion of c-fms(+) myeloid lineage cells [via administration of AP20187 in the macrophage Fas-induced apoptosis (MAFIA) mouse model] reduced cortical and trabecular bone mass and attenuated PTH-induced trabecular bone anabolism, supporting the positive function of macrophages in bone homeostasis. Interestingly, using a clodronate liposome model with targeted depletion of mature phagocytic macrophages an opposite effect was found with increased trabecular bone mass and increased PTH-induced anabolism. Apoptotic cells were more numerous in MAFIA versus clodronate-treated mice and flow cytometric analyses of myeloid lineage cells in the bone marrow showed that MAFIA mice had reduced CD68(+) cells, whereas clodronate liposome-treated mice had increased CD68(+) and CD163(+) cells. Clodronate liposomes increased efferocytosis (clearance of apoptotic cells) and gene expression associated with alternatively activated M2 macrophages as well as expression of genes associated with bone formation including Wnt3a, Wnt10b, and Tgfb1. Taken together, depletion of early lineage macrophages resulted in osteopenia with blunted effects of PTH anabolic actions, whereas depletion of differentiated macrophages promoted apoptotic cell clearance and transformed the bone marrow to an osteogenic environment with enhanced PTH anabolism. These data highlight a unique function for osteal macrophages in skeletal homeostasis.

Impact of proteoglycan-4 and parathyroid hormone on articular cartilage.

Proteoglycan-4 (Prg4) protects synovial joints from arthropathic changes by mechanisms that are incompletely understood. Parathyroid hormone (PTH), known for its anabolic actions in bone, increases Prg4 expression and has been reported to inhibit articular cartilage degeneration in arthropathic joints. To investigate the effect of Prg4 and PTH on articular cartilage, 16-week-old Prg4 mutant and wild-type mice were treated with intermittent PTH (1-34) or vehicle control daily for six weeks. Analyses included histology of the knee joint, micro-CT of the distal femur, and serum biochemical analysis of type II collagen fragments (CTX-II). Compared to wild-type littermates, Prg4 mutant mice had an acellular layer of material lining the surfaces of the articular cartilage and menisci, increased articular cartilage degradation, increased serum CTX-II concentrations, decreased articular chondrocyte apoptosis, increased synovium SDF-1 expression, and irregularly contoured subchondral bone. PTH-treated Prg4 mutant mice developed a secondary deposit overlaying the acellular layer of material lining the joint surfaces, but PTH-treatment did not alter signs of articular cartilage degeneration in Prg4 mutant mice. The increased joint SDF-1 levels and irregular subchondral bone found in Prg4 mutant mice introduce novel candidate mechanisms by which Prg4 protects articular cartilage.

Proteoglycan 4: a dynamic regulator of skeletogenesis and parathyroid hormone skeletal anabolism.

Proteoglycan 4 (Prg4), known for its lubricating and protective actions in joints, is a strong candidate regulator of skeletal homeostasis and parathyroid hormone (PTH) anabolism. Prg4 is a PTH-responsive gene in bone and liver. Prg4 null mutant mice were used to investigate the impact of proteoglycan 4 on skeletal development, remodeling, and PTH anabolic actions. Young Prg4 mutant and wild-type mice were administered intermittent PTH(1-34) or vehicle daily from 4 to 21 days. Young Prg4 mutant mice had decreased growth plate hypertrophic zones, trabecular bone, and serum bone formation markers versus wild-type mice, but responded with a similar anabolic response to PTH. Adult Prg4 mutant and wild-type mice were administered intermittent PTH(1-34) or vehicle daily from 16 to 22 weeks. Adult Prg4 mutant mice had decreased trabecular and cortical bone, and blunted PTH-mediated increases in bone mass. Joint range of motion and animal mobility were lower in adult Prg4 mutant versus wild-type mice. Adult Prg4 mutant mice had decreased marrow and liver fibroblast growth factor 2 (FGF-2) mRNA and reduced serum FGF-2, which were normalized by PTH. A single dose of PTH decreased the PTH/PTHrP receptor (PPR), and increased Prg4 and FGF-2 to a similar extent in liver and bone. Proteoglycan 4 supports endochondral bone formation and the attainment of peak trabecular bone mass, and appears to support skeletal homeostasis indirectly by protecting joint function. Bone- and liver-derived FGF-2 likely regulate proteoglycan 4 actions supporting trabeculae formation. Blunted PTH anabolic responses in adult Prg4 mutant mice are associated with altered biomechanical impact secondary to joint failure.

Demographics and efficacy of head and neck cancer screening.

OBJECTIVE: This study was designed to 1) describe the demographics and 2) determine the efficacy of a head and neck cancer screening program to optimize future programs. STUDY DESIGN: Database analysis plus chart review. SETTING: Tertiary care academic medical center. SUBJECTS AND METHODS: After Institutional Review Board approval, we reviewed our 14-year experience (1996-2009) conducting a free annual head and neck cancer screening clinic. Available demographic and clinical data, as well as clinical outcomes, were analyzed for all participants (n = 761). The primary outcome was the presence of a finding suspicious for head and neck cancer on screening evaluation. RESULTS: Five percent of participants had findings suspicious for head and neck cancer on screening evaluation, and malignant or premalignant lesions were confirmed in one percent of participants. Lack of insurance (P = 0.05), tobacco use (P < 0.001), male gender (P = 0.03), separated marital status (P = 0.03), and younger age (P = 0.04) were the significant demographic predictors of a lesion suspicious for malignancy. Patients complaining of a neck mass (P < 0.001) or oral pain (P < 0.001) were significantly more likely to have findings suspicious of malignancy. A high percentage (40%) was diagnosed with benign otolaryngologic pathologies on screening evaluation. CONCLUSION: A minority of patients presenting to a head and neck cancer screening clinic will have a suspicious lesion identified. Given these findings, to achieve maximal potential benefit, future head and neck cancer screening clinics should target patients with identifiable risk factors and take full advantage of opportunities for education and prevention.