A Novel Method of Fibula Flap In Situ Distraction Osteogenesis Prior to Flap Transfer.

BACKGROUND: The fibula flap is the workhorse for mandibular reconstruction, but fibula bone width is not ideal to match mandibular height. In this study, in situ widening of the fibula with distraction osteogenesis before transfer is evaluated as a solution. The authors present a proof of concept of this technique with a patient series, including one patient who has undergone subsequent orthognathic surgery of the reconstructed mandible. METHODS: A retrospective review of patients undergoing the authors' technique was performed. A longitudinal fibula osteotomy was made in situ and distraction was performed in the leg to widen the fibula. After distraction and consolidation periods, flaps were osteotomized and transferred to the mandible. RESULTS: This technique was applied to three patients (ages 9, 11, and 13 years) with Pruzansky III mandibular hypoplasia at the authors' institution over 15 years. In all cases, bony union was achieved. Mean surgical follow-up was 5 years. No significant morbidity occurred at the donor sites. Partial flap resorption was observed a number of years postoperatively in one patient. Temporomandibular joint ankylosis developed in one patient after closed treatment of an unrelated mandible fracture. A sinus tract developed in one patient, requiring débridement of a partial flap necrosis. One patient had orthognathic surgery, including osteotomy of the fibula. CONCLUSIONS: In situ fibula distraction osteogenesis is a novel technique to prelaminate a fibula flap before transfer to the mandible. This method allows for the reconstruction of challenging mandibular defects without compromising bone height, pedicle length, or the ability to perform orthognathic surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Deep Lobe Parotid Tumors: A Systematic Review and Meta-analysis.

OBJECTIVE: We performed a systematic review and meta-analysis of deep lobe parotid tumors to evaluate their unique characteristics. DATA SOURCES: PubMed/Medline, Embase, Web of Sciences, and Cochrane Library databases were queried for relevant literature. REVIEW METHODS: Studies were individually assessed by 2 independent reviewers. Risk of bias was assessed with the Cochrane bias tool, GRADE criteria, and MINORS criteria. Results were reported according to the PRISMA guidelines. Statistical analysis was performed by comparing rates of malignancy between deep and superficial lobe tumors. RESULTS: In total, 8 studies including 379 deep lobe parotid tumors met inclusion criteria. Mean age at diagnosis was 44.9 years. Computed tomography scan was the most common imaging modality. Preoperative diagnostic fine-needle aspiration was utilized in 39.4% of patients and demonstrated high sensitivity for malignant disease. The most common approach was subtotal parotidectomy with facial nerve preservation (58.9%). The rate of malignancy was 26.6%, which was significantly higher than that of the superficial lobe tumors in this study (risk ratio, 1.25; 95% CI, 1.01-1.56). The rate of temporary postoperative facial nerve weakness between deep and superficial lobe tumors was 32.5% and 11.7%, respectively. CONCLUSION: Deep lobe parotid tumors had a 26.6% rate of malignancy. On meta-analysis, deep lobe tumors appeared to have higher rates of malignancy than superficial lobe tumors. Surgical excision of deep lobe tumors showed increased rates of temporary facial nerve paresis as compared with superficial lobe tumors. Computed tomography scan was the most common imaging modality. There were limited data regarding the utility of fine-needle aspiration.

Anaplastic Hemangiopericytoma of the Jugular Foramen: Case Report and Systematic Review.

BACKGROUND: Hemangiopericytomas (HPCs) and solitary fibrous tumors (SFTs) are rare tumors of mesenchymal origin. Here, the authors present a rare case of anaplastic HPC in the jugular foramen (JF). The authors also conduct a systematic review of the literature to examine the current fund of knowledge on JF HPC/SFTs. METHODS: A systematic MEDLINE search was conducted using key words "hemangiopericytoma" OR "solitary fibrous tumor" AND "jugular foramen" OR "extracranial" OR "skull base." Clinicopathologic characteristics and outcomes of the present case were reviewed and compared with those in the literature. RESULTS: A 41-year-old male, who had undergone stereotactic radiation therapy 6 years ago for a presumed glomus jugulare tumor, presented to our institution with worsening dysphagia, hoarseness, persistent tongue weakness, and radiographic evidence of tumor progression. The patient underwent uncomplicated gross total resection with sacrifice of the infiltrated hypoglossal nerve. Histopathologic evaluation revealed anaplastic HPC/SFT (World Health Organization grade III). Review of the literature yielded 9 additional cases of JF HPC/SFT in 5 males (56%) and 4 females (44%), with a mean age of 49.6 years old. Patients commonly presented with pain (37.5%) and lower cranial nerve deficits (100%). Preoperative diagnoses included glomus jugulare (n = 2) or JF schwannomas (n = 3). All patients underwent microsurgical resection of the lesion, except for 1 who refused all treatment after diagnostic biopsy. CONCLUSION: The authors present the only reported case of anaplastic HPC of the JF. The illustrative case and those found on systematic review of the literature highlight the importance of tissue diagnosis and appropriate management.

Percutaneous Revascularization for COVID-19 Induced Spontaneous Arterial Thrombosis.

The optimal management strategy of acute limb ischemia in non-ventilated patients with COVID-19 is uncertain. We propose that non-ventilated patients who develop COVID-19 related spontaneous arterial thrombosis with associated limb threat may be best suited with percutnaeous revascularization to achieve limb salvage. Herein we describe 5 cases of patients who had severely threatened limbs with complete thrombosis of all 3 tibial arteries who were treated with percutaneous revascularization. All 5 patients were felt to be facing inevitable amputation without revascularization should they survive their COVID hospitalization. We were able to achieve limb salvage in all 5 patients selected for therapy, although 2 ultimately succumbed to respiratory failure.

A Novel Technique for the Diagnosis and Management of Middle Ear Myoclonus.

A novel technique for the diagnosis and management of middle ear myoclonus is described. A patient with middle ear myoclonus underwent a trans-canal microscopic middle ear exploration with injection of botulinum toxin into the stapedius and tensor tympani muscles. Postoperatively, the patient noted complete resolution of symptoms. This is the first report of the use of botulinum toxin directly applied to the middle ear musculature via a trans-canal approach for the management of middle ear myoclonus. This approach is both a useful diagnostic and therapeutic tool that allows for temporary muscle paralysis prior to offering definitive surgical management. Laryngoscope, 131:E248-E249, 2021.

Facial-Stapedial Synkinesis Following Acute Idiopathic Facial Palsy.

INTRODUCTION: While most patients note a complete resolution of facial paralysis in Bell's Palsy, up to 30% will have persistent facial weakness and develop synkinesis. All branches of the facial nerve are at risk for developing synkinesis, but stapedial synkinesis has rarely been reported in the literature. CASE PRESENTATION: A 45-year-old man presented with sudden onset, complete right facial paralysis. One-and-a-half years later, he had persistent facial weakness and synkinesis. He noted persistent right aural fullness and hearing loss. Audiometry demonstrated facial-stapedial synkinesis. DISCUSSION: The patient was diagnosed with stapedial synkinesis based on audiometric findings by comparing his hearing at rest and with sustained facial mimetic movement. A literature review revealed 21 reported cases of this disorder. CONCLUSIONS: Facial-stapedial synkinesis is an underdiagnosed phenomenon for patients recovering from idiopathic facial palsy. Patients who develop facial synkinesis also may have a component of stapedial synkinesis and should be referred to an otolaryngologist if they complain of any otologic symptoms, such as unilateral hearing loss or tinnitus. Definitive management involves surgical transection of the stapedial tendon.