Vascular Malformations of the Head and Neck in Children.

BACKGROUND/AIM: Vascular malformations are congenital abnormalities that result from disturbances in the embryologic development of the vascular system. A retrospective study at a single institution was performed to determine the localization and treatment patterns for vascular malformations in children. PATIENTS AND METHODS: A total of 198 pediatric patients were identified. Age at diagnosis and presentation, sex, localization, diagnostics, and therapy were described. RESULTS: The most common diagnosis was lymphatic malformation (LM, 58.6%), followed by venous (VM, 31.8%) and arteriovenous malformation (AVM, 4.5%). The mean age at diagnosis was 2.2 years, while the mean age at presentation at our hospital was 7.2 years. The sex ratio showed a female predominance (1.44:1), which was most evident in children with AVM. The neck, cheek/parotid gland and oral cavity were the most predominant locations. Half of the patients required at least one intervention at our hospital. Especially, CM and LM were managed by watch-and wait, whereas lymphovenous malformation (LVM) and AVM were most often treated. Treatment differed between the various malformation types, the most common used treatment was conventional surgery followed by laser therapy. In case of treatment, the average number of procedures in our hospital was 1.58 for VM, 1.53 for LM, 1.33 for AVM, and 1.0 for LVM. CONCLUSION: In children with vascular malformations interventional treatment is often necessary, in many cases more than one treatment step is needed. Correct identification of the malformation type is important for optimal treatment and appropriate care of patients with vascular malformations.

Indications of cone beam CT in head and neck imaging.

CONCLUSION: Cone Beam Computed Tomography (CBCT) can be widely used in imaging of bony structures of the anterior and lateral skull base. Significant differences of applied dosages result from the different protocols of the various indications. OBJECTIVES: CBCT is increasingly being used in head and neck imaging. Until now, no precise knowledge about its dedicated usage existed. METHODS: All CBCT of 2012 and 2013 were analysed with regard to the technical parameters, the performance, and the indication for imaging. RESULTS: In total, 1862 patients were examined in 2012 and 2013. The top eight indications of the anterior skull were (1) chronic rhinosinusitis with disturbed nasal breathing (30.3%); (2) chronic rhinosinusitis (17.6%); (3) midfacial traumatology (13.7%); (4) disturbed nasal breathing (12.8%); (5) acute rhinosinusitis (7.9%); (6) polyposis nasi (6.3%); (7) search for focus (3.9%); and (8) persistent rhinorrhea (1.2%). For the lateral skull base, the top eight were (1) control after cochlear implantation (28.4%); (2) cholesteatoma (19.7%); (3) visualization of ear anatomy (8.7%); (4) chronic otitis media mesotympanalis (6.3%); (5) conductive hearing loss (5.1%); (6) suspected mastoiditis (4.8%); (7) pathology of external auditory canal (4.8%); and (8) otosclerosis (3.3%). Applied dosage for the anterior skull base was significantly lower than for the lateral skull base (2.90 mGy vs 5.92 mGy, p < 0.05); 2.4% and 3.6% of patients' images, respectively, had to be repeated.

Visualisation of the Bonebridge by means of CT and CBCT.

BACKGROUND: With the Bonebridge, a new bone-anchored hearing aid has been available since March 2012. The objective of the study was to analyse the visualisation of the implant itself as well as its impact on the representation of the bony structures of the petrosal bone in CT, MRI and cone beam CT (CBCT). METHODS: The Bonebridge was implanted unilaterally in two completely prepared human heads. The radiological imaging by means of CBCT, 64-slice CT, 1.5-T and 3.0-T MRI was conducted both preoperatively and postoperatively. The images were subsequently evaluated from both the ENT medical and nd radiological perspectives. RESULTS: As anticipated, no visualisation of the implant or of the petrosal bones could be realised on MRI because of the interactive technology and the magnet artefact. In contrast, an excellent evaluability of the implant itself as well as of the surrounding neurovascular structures (sinus sigmoideus, skull base, middle ear, inner ear, inner auditory canal) was exhibited in both the CT and in the CBCT. CONCLUSION: The Bonebridge can be excellently imaged with the radiological imaging technologies of CT and CBCT. In the process, CBCT shows discrete advantages in comparison with CT. No relevant restrictions in image quality in the evaluation of the bony structures of the petrosal bones could be seen.

Delayed lymph node metastases after elective neck dissection in patients with oral and oropharyngeal cancer and pN0 neck.

PURPOSE: Patients with surgically treated head and neck cancer and clinical N0 neck with high risk of occult lymph node metastasis undergo elective neck dissection (ND). Late lymph node metastasis may appear in those patients with pN0 neck. The aim of the present study was to analyze the incidence and clinical relevance of late lymph node metastasis in patients with head and neck cancer. MATERIALS AND METHODS: The clinical data of 61 patients with head and neck cancer who had undergone elective ND with pN0 neck were retrospectively analyzed. Only patients without local failure, second primary, or radiochemotherapy were included in the study. RESULTS: Late lymph node metastasis could be observed in 4 (6.5%) cases at the margin or outside the initially dissected lymph node levels. In those patients, the primary tumor was localized in the oral cavity (n = 3) or oropharynx (n = 1) and was classified in all cases as T1 or T2. Lymph node metastasis could be found in levels I (n = 2), II (n = 1), and IV (n = 1), respectively. CONCLUSION: Even in the case of pN0 neck after an elective ND, the appearance of late lymph node metastases must be expected. The low proportion of patients with late lymph node metastases after a selective ND in clinical and histologic N0 does not justify an extended form of neck surgery.

EXIT (Ex utero Intrapartum Treatment) in lymphatic malformations of the head and neck: discussion of three cases and proposal of an EXIT-TTP (Team Time Procedure) list.

OBJECTIVES: Ex utero Intrapartum Treatment (EXIT) is a technique to secure the fetal airway while oxygenation is maintained through utero-placental circulation. The aim of the study is to present three cases of fetal lymphatic malformation of the head and neck that required EXIT and to summarize EXIT details. METHODS: The cases were studied before the delivery and EXIT was planned with a multidisciplinary team. The key factors of EXIT are considered and the type, stage and clinical score of the three lymphatic malformations are defined. RESULTS: In the three cases of EXIT the time working on placental support to secure the airway was 9, 7, and 9 min, respectively (from the hysterotomy to clamping the umbilical cord). Procedures performed on the airway were laryngo-tracheo-bronchoscopy in the first case, laryngoscopy and intubation in the second one, laryngoscopy, drainage of the lymphatic macro-cyst, and intubation in the third case. A sketching to detail the EXIT steps are presented: EXIT-Team Time Procedure list (EXIT-TTP list). Lymphatic malformations were classified as mixed (micro/macro-cystic) in two cases, and macro-cystic in one. de Serres Stage was IV, V and II. Therapy varied in the three neonates (surgery alone, surgery+Picibanil+Nd-YAG, or Picibanil alone). CONCLUSIONS: In case of prenatal suspicion of airway obstruction, EXIT should be planned with a multidisciplinary team. The EXIT-Team Time Procedure list (EXIT-TTP list), reviews the most critical phases of the procedure when different teams are working together. The type of lymphatic malformation, the anatomic location and the clinical score predict the outcome.

Postoperative morbidity after different types of selective neck dissection.

OBJECTIVES/HYPOTHESIS: Although selective neck dissection (SND) is an oncologically efficient procedure for the N0 neck, its functional results are discussed controversially. The aim of the present study was to analyze the frequency of morbidity related to SND. STUDY DESIGN: Retrospective single-institution series. METHODS: The clinical data of 98 patients who had undergone unilateral SND of different dimensions and neck levels were analyzed. Radiotherapy was carried out in 37 (37.8%) patients. Functional and aesthetic results were evaluated in the context of aftercare consultation in 52 patients. The contralateral side of each patient served as the control. The mean follow-up period was 2.6 (0.5-9.1) years. RESULTS: SND-related complications arose in two out of 50 patients (4%) with dissection of level IV in terms of an injury of the thoracic duct. Ten (19.2%) patients showed persistent slight lymph edema, and 34 (65.4%) patients noticed cervical incision sensibility disturbances after at least 6 months. Concerning head, neck, and shoulder function, no significant side differences were noticed by 31 (82%) patients for arm abduction, 32 (84%) for head rotation, and 30 (79%) for lateral head inclination. Subjectively, 50 (96.2%) patients had no restriction in head, neck, and shoulder movement after SND. Concerning the aesthetic results, only one (2%) patient was subjectively not satisfied. CONCLUSIONS: SND of different dimensions and neck levels shows low incidence of surgical complications and acceptable functional and aesthetic results.

Bilateral vocal cord paralysis associated with laryngeal myxedema.

For managing dyspnea caused by bilateral vocal cord paralysis as a complication of thyroidectomy in the acute postoperative period, reversible vocal cord lateralisation is performed at the authors' departments. However, in the later postoperative period of thyroidectomy when there is no chance for recovery of the recurrent laryngeal nerves, they perform irreversible procedure. Applying these operative techniques satisfactory breathing can be achieved in about 95% of cases avoiding tracheostomy. In 5% of cases there are other comorbidities in the background of unsuccessful operative results which can cause potential dyspnea as well. From these complications the authors emphasize the role of laryngeal obstruction and myxedema as a consequence of hypothyroidism developed after thyroidectomy. Management of severe dyspnea caused by association of these two complications of thyroidectomy means a great therapeutic challenge. Between 01 Jan 1989 and 30 Nov 2008 the authors performed 161 reversible and 135 irreversible vocal cord lateralisations to manage dyspnea caused by bilateral vocal cord paralysis as a complication of thyroidectomy. From these cases four patients had further obstruction due to laryngeal myxedema. By performing endoscopic laryngeal surgeries and applying levothyroxine replacement therapy sufficiently wide glottic chink has been achieved in all the cases. According to the experience of the authors dyspnea caused by bilateral vocal cord paralysis after thyroidectomy needs complex, interdisciplinary therapeutic approach beside glottis widening operations.

Botulinum toxin prevents radiotherapy-induced salivary gland damage.

Radiotherapy of head and neck malignancies results in severe damage to salivary glands. Irradiation-induced sialadenitis with xerostomia leads to a significant deterioration of the quality of life which lasts life-long. Here we show in a preliminary study that intraglandular application of botulinum toxin performed prior to radiation reduces significantly the radiation induced toxicity of the glandular tissue in rats.

Digital volume tomography (DVT) as a diagnostic modality of the anterior skull base.

CONCLUSION: Because of high resolution and the relatively lower costs in comparison with modern helical CT scanners, digital volume tomography (DVT) can be recommended in the diagnosis of the nasal cavity and paranasal sinuses. OBJECTIVES: DVT is an advancement of panoramic tomography and is based on the principles of rotational tomography. It enables high resolution visualization of osseous structures. The slices can be displayed in three orthogonal planes that can be changed in angle arbitrarily. Data volumes of up to 12×17 cm can be examined with a new generation of the DVT. The aim of this study was to point out the potential of DVT in the anterior skull base. SUBJECTS AND METHODS: DVT scans with a cylindrical size of 10 cm in diameter and 10 cm in height were performed in 23 patients. The identification of surgical key landmarks (uncinate process, middle turbinate, ethmoidal bulla, agger nasi cells, Haller cells, frontal recess, anterior ethmoidal artery in its relationship to the skull base, the cribiform plate of the sphenoidal sinus in relation to the optic nerve, and the internal carotid artery) was evaluated. RESULTS: Display of the essential surgical key landmarks was possible in all patients.

[Screening for systemic manifestations of vascular malformations in patients with hereditary haemorrhagic telangiectasia (Osler disease)]. / Exploración multiorgánica de los pacientes con telangiectasia hemorrágica hereditaria (enfermedad de Osler).

Hereditary haemorrhagic telangiectasia (Rendu-Osler- Weber syndrome) is a disease characterized by systemic vascular malformations. Typical clinical manifestations are recurrent epistaxis and telangiectases of the skin and the mucous membranes. The syndrome is furthermore characterized by its hereditary aspect. The disease seems to be much more complicated than previously thought, mainly because of the accompanying vascular malformations in vital organs, like the liver, the kidney, the lung, the brain, and the eyes. The diagnosis and treatment of systemic vascular malformations requires interdisciplinary management.

Surgery of adult bilateral vocal fold paralysis in adduction: history and trends.

Bilateral vocal fold paralysis (BVFP) in adduction is characterised by inspiratory dyspnea, due to the paramedian position of the vocal folds with narrowing of the airway at the glottic level. The condition is often life threatening and therefore requires surgical intervention to prevent acute asphyxiation or pulmonary consequences of chronic airway obstruction. Aside from corticosteroid administration and intubation, which are only temporary measures, the standard approach for improving respiration is to perform a tracheotomy. Over the past century, a vast majority of surgical interventions have been developed and applied to restore the patency of the airway and achieve decannulation. Surgeons can generally choose for every individual patient from various well-established treatment options, which have a predictable outcome. An overview of the surgical techniques for laryngeal airway enlargement in BVFP is presented. Included are operative techniques, which have found application in clinical practice, and only to a small extent in purely anatomic or animal studies. The focus is on two major groups of interventions--for temporary and for definitive glottic enlargement. The major types of interventions include the following: (1) resection of anatomical structures; (2) retailoring and displacing the existing structures, with minimal tissue removal; (3) displacing existing structures, without tissue resection; (4) restoration or substitution of the missing innervation of the laryngeal musculature. The single interventions of these four major types have always followed the development of the medical equipment and anaesthesia. At the beginning of the twentieth century, when medicine was unable to counteract surgical infection, endoscopic or extramucosal surgical techniques were dominant. In the 1950s, the microscopic endoscopic laryngeal surgery boomed. At the end of the twentieth century many of the classical endoscopic operations were performed either with the help of surgical lasers alone, or in combination with other interventions.

Evaluation of head and neck squamous cell carcinoma invasiveness by the electrical resistance breakdown assay.

Invasion of tumor cells into the surrounding tissue is a hallmark of cancer. Squamous cell carcinomas of the head and neck region (HNSCC) are characterized by their early primarily lymphatic metastatic spread. The aim of the present study was to evaluate the use of the electrical resistance breakdown assay for determining HNSCC tumor cell invasiveness. The assay utilizes the high transepithelial electrical resistance (TEER) of an epithelial MDCK-C7 monolayer as a sensitive indicator of monolayer integrity and permeability. MDCK-C7 cells were grown to confluence in microfilter membrane cups. 3 x 10(6) cancer cells of cell lines UM-SCC-3, UM-SCC-27, UMB-SCC-745, UMB-SCC-864, UMB-SCC-969 and UT-SCC-26A derived from HNSCC tumors, were seeded on top of this epithelial test barrier. A7-melanoma cells served as a positive control whereas MDCK-C7 cells were used as a negative control and were applied in the same number as the tested tumor cells. TEER was measured over the following days and compared to control values. A significant reduction in TEER was observed in the UMB-SCC-745, UMB-SCC-969 and UT-SCC-26A cell lines within the first 72 h, whereas no significant reduction in TEER was seen in the UM-SCC-3, UM-SCC-27 and UMB-SCC-864 cell lines. HNSCC cell lines in general are found to be less invasive in the resistance breakdown assay compared to other tumor cells such as A7-melanoma cells, however, the electrical resistance breakdown assay appears capable of demonstrating differences in invasiveness between different HNSCC cell lines and therefore potentially could serve as a versatile tool in distinguishing high and low invasive tumors with a potential application as a diagnostic and prognostic marker in clinical investigations.

Extracellular matrix molecules in chronic obstructive sialadenitis: an immunocytochemical and Western blot investigation.

The exact pathomechanism of inflammation progress and fibrosis in chronic sialadenitis is unknown. Connective tissue growth factor (CTGF), matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) have been implicated in the pathogenesis of various fibrotic conditions. These factors are thought to be essential in the regulation of extracellular matrix turnover and the development of tissue fibrosis. In the present study, the expression of CTGF, MMP-2, -3, -9, -13 and TIMP-3 was examined in chronic obstructive sialadenitis. Tissue samples of 13 patients with chronic sialadenitis of the submandibular gland associated with sialolithiasis and 4 normal tissue samples of the submandibular gland were analyzed immunohistochemically and by Western blot analysis. An intense CTGF immunoreactivity was observed in the ductal system of inflamed salivary glands, whereas in normal glands no reactivity or a very low CTGF immunoreactivity was present. Immunohistochemical studies revealed a low to strong reactivity of MMP-2, -3, -9, -13, and TIMP-3 in the ductal system, in acinar cells and in lymphomonocytic infiltrates in normal and inflamed tissues. The expression of MMP-2, -3, -9, -13, and TIMP-3 was confirmed by Western blotting in all cases. Over-expression of CTGF in chronic obstructive sialadenitis suggests that this factor may play a role in glandular fibrosis. However, the physiological role of MMP-2, -3, -9, -13, and TIMP-3 in normal glands, as well as their possible role in inflammation progress and fibrosis in chronic obstructive sialadenitis, remains to be elucidated.

Nasal snuff: historical review and health related aspects.

With cigarette smoking declining in the modern world, the tobacco industry has to look for other products that can keep the old customers and attract new ones. Different forms of smokeless tobacco are currently massively promoted and are gaining in importance. Dry nasal snuff--the oldest known form of tobacco in Europe--is one of them. The health risks associated with it are different to those attributed to smoking and oral wet snuff. The nicotine contained leads to dependency. Its resorption rate is similar to that of smoking, so it could be seen as an adequate substitutional therapy. The risk for cardiovascular diseases is lower, compared to that for smokers. Chronic abuse leads to morphological and functional changes in the nasal mucosa. Although it contains substances that are potentially carcinogenic, at present, there is no firm evidence, relating the use of nasal snuff to a higher incidence of head and neck or other malignancies.

Is there evidence of a sphincter system in Wharton's duct? Etiological factors related to sialolith formation.

The exact cause of the formation of sialoliths is unknown. Detailed knowledge of the pathogenesis of sialolithiasis is necessary to define new therapeutic procedures. The possible presence of a sphincter system in Wharton's duct has been described frequently in the context of diagnostic sialendoscopy. Serial histological examination of the entire Wharton's duct in four samples revealed no anatomical correlation for the presence of a sphincter. Secretory disturbances and viscous secretions as well as microlith formation and ductal obstruction cannot fully explain the genesis of sialoliths. The coaction of those factors with participation of bacteria leads to the development of sialoliths.