Migration of Broken Dental Needle Through the Internal Jugular Vein in the Parapharyngeal Space.

Accidental broken dental needles during dental blocks have become a rare occurrence but still occur. Although the treatment for such occurrence is controversial, an increasing body of literature demonstrates that migration of such needles is possible. In this case, we report on a 48-year-old male with migration of a broken dental needle from an inferior alveolar block. Over the course of 2 years, we demonstrated radiological documentation of the course of migration with penetration of the internal jugular vein at the jugular foramen which was subsequently successfully retrieved through a transcervical approach without neurovascular injury. This case is unique given the location of migration to the skull base as well as radiologically documented time course. Furthermore, it highlights the need for prompt retrieval of broken dental needles given the high potential of migration and injury to neurovascular structures.

Detection of Head and Neck Cancer Based on Longitudinal Changes in Serum Protein Abundance.

BACKGROUND: Approximately 85% of the U.S. military active duty population is male and less than 50 years of age, with elevated levels of known risk factors for oropharyngeal squamous cell carcinoma (OPSCC), including smoking, excessive use of alcohol, and greater numbers of sexual partners, and elevated prevalence of human papilloma virus (HPV). Given the recent rise in incidence of OPSCC related to the HPV, the Department of Defense Serum Repository provides an unparalleled resource for longitudinal studies of OPSCC in the military for the identification of early detection biomarkers. METHODS: We identified 175 patients diagnosed with OPSCC with 175 matched healthy controls and retrieved a total of 978 serum samples drawn at the time of diagnosis, 2 and 4 years prior to diagnosis, and 2 years after diagnosis. Following immunoaffinity depletion, serum samples were analyzed by targeted proteomics assays for multiplexed quantification of a panel of 146 candidate protein biomarkers from the curated literature. RESULTS: Using a Random Forest machine learning approach, we derived a 13-protein signature that distinguishes cases versus controls based on longitudinal changes in serum protein concentration. The abundances of each of the 13 proteins remain constant over time in control subjects. The AUC for the derived Random Forest classifier was 0.90. CONCLUSIONS: This 13-protein classifier is highly promising for detection of OPSCC prior to overt symptoms. IMPACT: Use of longitudinal samples has significant potential to identify biomarkers for detection and risk stratification.

Total Auricular Rehabilitation: Combined Cosmetic and Functional Lateral Temporal Bone Reconstruction.

OBJECTIVE: The aim of the study was to describe 3 cases of total auricular rehabilitation, including the novel use of iliac crest bone grafts to support bone-anchored auricular prostheses. STUDY DESIGN: This study is a retrospective case series from a single institution. RESULTS: Three cases with large lateral temporal bone and soft tissue defects were successfully treated with total auricular rehabilitation. Rehabilitation included the following: soft tissue coverage with an anterolateral thigh microvascular free flap, iliac crest-free bone graft with staged placement of a bone-anchored auricular prosthesis into the bone graft, and audiologic rehabilitation with a bone-anchored hearing aid (BAHA). All of the cases with grafts and flaps survived and were without significant donor site morbidity. Bone-anchored hearing aid abutment skin overgrowth was seen in 2 cases and was revised under local anesthesia. All of the patients had expected functional recovery on postoperative audiologic testing. Each patient continues to consistently wear his/her auricular prosthesis and BAHA during 3 years of follow-up. CONCLUSIONS: Total auricular rehabilitation is a complex task involving reconstruction of extensive soft tissue defects, bony defects, and the hearing apparatus. Acceptable cosmetic and functional outcomes and high patient satisfaction is possible in committed patients.

Voice outcomes after total thyroidectomy, partial thyroidectomy, or non-neck surgery using a prospective multifactorial assessment.

BACKGROUND: Voice alteration remains a significant complication of thyroid surgery. We present a comparison of voice outcomes between total thyroidectomy (TT), partial thyroidectomy (PT), and non-neck (NN) surgery using a multifactorial voice-outcomes classification tool. STUDY DESIGN: Patients with normal voice (n = 112) were enrolled between July 2004 and March 2009. The patients underwent TT (n = 54), PT (n = 35), or NN (n = 23) surgery under general endotracheal anesthesia as part of a prospective observational study involving serial multimodality voice evaluation preoperatively, and at 2 weeks, 3 months, and 6 months postoperatively. Patients with adverse voice outcomes were grouped into the negative voice outcomes (NegVO) category, including patients with objective (abnormality on videolaryngostroboscopy and substantial voice dysfunction) and subjective (normal videolaryngostroboscopy but with notable voice impairment) NegVO. Voice outcomes were compared among study groups. RESULTS: Negative voice outcomes occurred in 46% (95% CI, 34-59%) and 14% (95% CI, 6-30%) of TT and PT groups, respectively. No NegVOs were observed after NN surgery. Early NegVOs were more common in the TT group than in the NN or PT groups (p < 0.001). Most voice disturbances resolved by 6 months (TT 84%; PT 92%) with no difference in NegVO among all groups (p = 0.23). Black race and significant changes in certain voice outcomes measures at the 2-week follow-up visit were identified as predictors of late (3 to 6 months) NegVO. CONCLUSIONS: This comprehensive voice outcomes study revealed that the extent of thyroidectomy impacts voice outcomes in the early postoperative period, and identified risk factors for late NegVO in post-thyroidectomy patients who should be considered for early voice rehabilitation referral.

Microvascular reconstructive surgery in Operations Iraqi and Enduring Freedom: the US military experience performing free flaps in a combat zone.

BACKGROUND: Local nationals with complex wounds resulting from traumatic combat injuries during Operations Iraqi Freedom and Enduring Freedom usually must undergo reconstructive surgery in the combat zone. While the use of microvascular free-tissue transfer (free flaps) for traumatic reconstruction is well documented in the literature, various complicating factors exist when these intricate surgical procedures are performed in a theater of war. METHODS: The microvascular experiences of six military surgeons deployed during a 30-month period between 2006 and 2011 in Iraq and Afghanistan were retrospectively reviewed. RESULTS: Twenty-nine patients presented with complex traumatic wounds. Thirty-one free flaps were performed for the 29 patients. Location of tissue defects included the lower extremity (15), face/neck (8), upper extremity (6). Limb salvage was successful in all but one patient. Six of eight patients with head and neck wounds were tolerating oral intake at the time of discharge. There were three flap losses in 3 patients; two patients who experienced flap loss underwent a successful second free or regional flap. Minor complications occurred in six patients. CONCLUSION: Microvascular free tissue transfer for complex tissue defects in a combat zone is a critically important task and can improve quality of life for host-nation patients. Major US combat hospitals deployed to a war zone should include personnel who are trained and capable of performing these complex reconstructive procedures and who understand the many nuances of optimizing outcomes in this challenging environment.

Utility of the voice handicap index as an indicator of postthyroidectomy voice dysfunction.

OBJECTIVES/HYPOTHESES: The Voice Handicap Index (VHI) is a simple, reliable, self-administered questionnaire that has been used to identify negative voice outcomes after thyroidectomy. This study provides an updated report of a multiyear study examining the predictive ability of the VHI to classify normal versus negative voice outcomes (VOs). STUDY DESIGN: Prospective observational, longitudinal study of the patient reported impact of voice changes after thyroidectomy using the VHI. Since the preliminary report, the sample size doubled and methods for classifying voice outcomes (VOs) were refined. METHODS: Ninety-one adults provided voice assessment data preoperatively (baseline) and at approximately 2 weeks postthyroidectomy. VO was defined according to endoscopic laryngeal examination, acoustic, auditory perceptual, and patient report parameters. The VHI was tested for its sensitivity and specificity for identifying VO. RESULTS: Twenty-two participants (24.2%) qualified as having adverse VOs during the early postoperative period. A change from baseline in VHI of 13-16 points had a diagnostic accuracy of 86% sensitivity and 88% specificity for classifying early VO and had 70% and 95% positive and negative predictive values, respectively. The Functional and Physical subscales of the VHI had higher predictive value than the Emotional subscale. Adjunctive analyses of a two-subscale version of the VHI and of the 10 items that comprises the VHI-10 also revealed high predictive value for differentiating groups by VO. CONCLUSIONS: Balanced sensitivity and specificity are achieved at a change in the total VHI score of 13-16. These results are generally consistent with several other studies examining voice problems over time. The VHI, as well as its alternate versions, appear to be useful and should be incorporated into the diagnostic process for identifying patients with voice problems after thyroidectomy.

Primary squamous cell carcinoma of the thyroid gland: a case report and review.

BACKGROUND: Primary squamous cell carcinoma (SCC) of the thyroid gland is a rare malignancy that presents with advanced disease and poor prognosis. METHODS: A 75-year-old woman with a history of Hashimoto thyroiditis presented with 6 months of dysphagia and stridor. Imaging revealed a thyroid mass invading the larynx. Primary SCC of the thyroid was diagnosed by histopathologic and immunohistochemical evaluation. Total thyroidectomy, total laryngectomy, bilateral modified neck dissection, and adjuvant radiotherapy (RT) were performed. Radiologic follow-up at 21 months demonstrated no disease and total length of survival was 31 months. RESULTS: Despite an aggressive T4aN0M0 tumor, survival in this case was more than double the median survival rate previously reported. Concomitant Hashimoto thyroiditis is rare and histopathologic and immunohistochemical evaluation is imperative for an accurate diagnosis. CONCLUSION: The case and literature reported here support that a thorough diagnostic workup of primary SCC of the thyroid with aggressive locoregional surgery and adjuvant RT may improve the length of survival.

The role of listener experience on Consensus Auditory-perceptual Evaluation of Voice (CAPE-V) ratings of postthyroidectomy voice.

PURPOSE: To determine whether experienced and inexperienced listeners rate postthyroidectomy voice samples similarly using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). METHOD: Prospective observational study of voice quality ratings of randomized and blinded voice samples was performed. Twenty-one postthyroidectomy patients' voices, representing a wide range of severities, were rated using a custom-automated version of the CAPE-V. Ten male and 11 female voices were rated by 10 experienced and 10 inexperienced listeners. Experienced listeners consisted of 5 otolaryngologists (ENTs) and 5 speech-language pathologists (SLPs); inexperienced listeners were medical professionals with no formal training or experience in voice disorders. RESULTS: Inexperienced listeners rated voices as more severely impaired than experienced listeners for all CAPE-V parameters (p < or = .003). Those without experience in voice disorders had lower intra- and interrater reliability (e.g., r = .838 and .528, respectively, for overall severity) than those with experience in voice disorders (e.g., r = .911 and .722, respectively, for overall severity) for all parameters. Among experienced listeners, ENTs and SLPs rated voices similarly for most parameters. CONCLUSIONS: Experienced and inexperienced listeners judged voice quality differently given minimal training with the use of the CAPE-V. SLPs and ENTs rated postthyroidectomy voice quality similarly. These findings indicate that the CAPE-V can be used reliably and similarly by professionals who specialize in voice disorders.

Functional voice outcomes after thyroidectomy: an assessment of the Dsyphonia Severity Index (DSI) after thyroidectomy.

BACKGROUND: The Dysphonia Severity Index (DSI) is an objective multiparametric acoustic calculation of vocal function; however, its changes after thyroidectomy have not yet been described. METHODS: Patient-reported symptoms, as well as auditory perceptual, acoustic, and videolaryngostroboscopic (VLS) data, were collected prospectively before and after thyroidectomy. Voice outcomes (normal versus negative voice outcome [NVO]) at 6 months after thyroidectomy were based on a combination of voice symptoms and objective findings. The DSI was assessed over the peri-operative course, and differences were determined with Wilcoxon signed rank tests. The DSI was compared between study groups (normal versus NVO) using t tests, analyses of variance (ANOVAs), or rank sum tests as appropriate. The predictive value of DSI for long-term voice dysfunction was assessed by an area under the receiver operating characteristics curve analysis. Correlations between DSI and Consensus Auditory Perceptual Ratings of Voice (CAPE-V) and the patient reported Voice Handicap Index (VHI) were determined with Pearson's correlation coefficients. RESULTS: In all, 62 patients were evaluated before, 1-4 weeks after, and 6 months after thyroidectomy. Eight (13%) patients were diagnosed with NVO at 6 months. The DSI was different postoperatively between NVO and normal voice (P=.005, repeated measures [RM]-ANOVA), with the NVO group demonstrating a lesser DSI value and greater change from pre-operative assessment at the first postoperative visit when compared with the normal group (P<.006 each). The DSI differed significantly for pre-operative and 6-month assessments according to sex, smoking status, and age. Short-term postoperative DSI (area under the curve [AUC]=0.795) and DSI change from baseline to 1-4 weeks (AUC=0.835) were highly predictive of 6-month NVO. DSI measurements over the post-thyroidectomy course were correlated poorly to moderately (maximum r = -0.62) with CAPE-V and VHI assessments for the same time points. CONCLUSION: The DSI is decreased in the early post-thyroidectomy period, mostly in persons who were ultimately found to have a long-term NVO. Early postoperative DSI and change of DSI from baseline at 1--4 weeks postoperation predict long-term post-thyroidectomy voice dysfunction. The modest correlations between the DSI and other vocal assessments point to the utility of DSI as an independent predictor of voice dysfunction after thyroidectomy, which can select patients who may benefit from voice therapy.

Prospective trial of voice outcomes after thyroidectomy: evaluation of patient-reported and clinician-determined voice assessments in identifying postthyroidectomy dysphonia.

BACKGROUND: Reliable voice grading systems to identify postoperative voice dysfunction by surgeons are needed. PURPOSE: To examine the utility of patient-reported and clinician-determined voice assessment in identifying postthyroidectomy voice dysfunction. PATIENTS AND METHODS: Fifty patients enrolled in a prospective observational trial evaluating voice function perioperatively by patient-reported symptoms (Voice Case History [VCHx]) and perceived voice handicap (Voice Handicap Index [VHI]), clinician-determined judgment of voice quality (Consensus Auditory-Perceptual Evaluation--Voice [CAPE-V]), and laryngeal examination via video laryngoscopy (VLS). Voice dysfunction at first postoperative visit in symptomatic patients was defined by objective laryngeal abnormalities on VLS. Postoperative changes from baseline in voice parameters were compared between patients with and without voice dysfunction using the Wilcoxon rank sum test. Receiver operating characteristics were evaluated to determine area under the curve (AUC) for tested parameters. RESULTS: Eight (16%) had early transient and 1 (2%) had permanent postoperative voice dysfunction. VCHx symptoms had negative (NPV) and positive (PPV) predictive values of 96%-100% and 39%-53%, respectively for voice dysfunction. The rating of overall severity from the CAPE-V was highly predictive (AUC = 0.96), and a change in severity from preoperative baseline >or=20% at 1-2 weeks had a PPV of 86% and NPV of 95% for postoperative dysphonia. Patient-reported total VHI score was most predictive (AUC = 0.97) and a change in VHI from preoperative baseline >or=25 early postoperatively had a PPV of 88% and NPV of 97% for postoperative dysphonia. CONCLUSION: Patient self-assessment of voice handicap using the VHI reliably identifies voice dysfunction after thyroidectomy. Patients with a change in VHI >or=25 from preoperative baseline warrant early referral to speech pathology and laryngology.

The functional impact on voice of sternothyroid muscle division during thyroidectomy.

BACKGROUND: Post-thyroidectomy voice dysfunction may occur in the absence of laryngeal nerve injury. Strap muscle division has been hypothesized as one potential contributor to dysphonia. METHODS: Vocal-function data, prospectively recorded before and after thyroidectomy from two high-volume referral institutions, were utilized. Patient-reported symptoms, laryngoscopic, acoustic, and aerodynamic parameters were recorded at 2 weeks and 3 months postoperatively. Patients with and without sternothyroid muscle division during surgery were compared for voice changes. Patients with laryngeal nerve injury, sternohyoid muscle division, arytenoid subluxation or no early postoperative follow-up evaluation were excluded. Differences between study groups and outcomes were compared using t-tests and rank-sum tests as appropriate. RESULTS: Of 84 patients included, 45 had sternothyroid division. Distribution of age, gender, extent of thyroidectomy, specimen size, and laryngeal nerve identification rates did not differ significantly between groups. There was a significant predilection for or against sternothyroid muscle division according to medical center. No significant difference in reported voice symptoms was observed between groups 2 weeks or 3 months after thyroidectomy. Likewise, acoustic and aerodynamic parameters did not differ significantly between groups at these postoperative study time points. CONCLUSION: Sternothyroid muscle division is occasionally employed during thyroidectomy to gain superior pedicle exposure. Division of this muscle does not appear to be associated with adverse functional voice outcome, and should be utilized at surgeon discretion during thyroidectomy.

Revision lateral skull base surgery.

OBJECTIVE: To describe functional and reconstructive results after revision lateral skull base surgery with comparison of benign and malignant lesions. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: All patients undergoing revision surgery for benign and malignant lateral skull base tumors. INTERVENTIONS: Surgical resection of recurrent lateral skull base tumors and reconstruction of resulting defects. MAIN OUTCOME MEASURES: Cranial nerve function postoperative complications. RESULTS: Forty operations for recurrent lateral skull base tumors occurred between January 1, 1987, and December 31, 2003, with follow-up of at least 1 year. Thirty-three operations were for benign lesions, 27 of which were glomus tumors. Seven operations were for malignant tumors. Fifty-eight percent of patients had preoperative cranial nerve deficits (66% of benign tumors and 14% of malignancies). The most common preoperative deficit occurred in the Xth cranial nerve. Postoperative cranial nerve deficits were seen in 95% of patients and multiple nerve deficits were seen in 75%. The most common postoperative deficits were observed in the IXth and Xth cranial nerves. Thirty-one patients had one previous procedure, six had two previous procedures, and three had three previous procedures. Abdominal fat and temporoparietal fascia were the most common reconstruction materials. There was one case of meningitis, two cerebrospinal fluid leaks, and one pseudomeningocele. There was one recurrent adenoid cystic tumor resulting in death and two partially resected glomus tumors. Subsequent procedures are discussed. CONCLUSION: Postoperative cranial deficits are more common after revision skull base surgery than after primary surgery. Complete resection without recurrence can be expected for revision skull base surgery. Modern reconstruction techniques reduce major postoperative complications and morbidity from cranial nerve deficits.

Squamous cell carcinoma of the oropharynx and hypopharynx.

Oropharyngeal and hypopharyngeal squamous cell carcinomas require an interdisciplinary approach to manage patients appropriately. Tumor stage and histology, functional outcome, and patient comorbidities are important factors to consider. Various surgical approaches as well as chemotherapy and radiation therapy alone or in combination remain the mainstay of therapy.

Tumors of the accessory lobe of the parotid gland: a 10-year experience.

OBJECTIVES/HYPOTHESIS: The differential diagnosis of midcheek masses include pathology arising from normal anatomic structures or from variations of normal accessory parotid gland tissue. Accessory parotid gland tissue has been described as salivary tissue adjacent to Stenson's duct that is separate from the main body of the parotid gland. We report our 10-year experience with the diagnosis and treatment of eight accessory parotid gland neoplasms that have been followed by the senior authors. STUDY DESIGN: This is a retrospective review of our experience with eight accessory parotid gland neoplasms. METHODS: A literature review and retrospective chart review of our experience with accessory parotid gland tumors over the past 10 years. The presentation, evaluation, management, treatment, and outcome were recorded. RESULTS: Eight cases of accessory lobe parotid tumors were identified, which have been followed since the date of initial treatment. All of the patients presented with a slowly growing cheek mass. There was one case of carcinoma expleomorphic adenoma, one case of undifferentiated carcinoma (small cell carcinoma), one case of basal cell adenocarcinoma, one case of benign salivary cyst, two cases of pleomorphic adenoma, and two cases of monomorphic adenoma. A standard facelift approach or modified Blair incision was used to excise these tumors. CONCLUSIONS: Neoplasms of the accessory parotid gland are rare. Management of these tumors include a high index of suspicion, good understanding of the anatomy, and meticulous surgical approach.

Glomus jugulare tumors with intracranial extension.

Glomus tumors provide unique surgical challenges for both tumor resection and defect reconstruction. Tumors with intracranial extension compound these challenges. Surgical techniques have evolved, and now, with a multidisciplinary team, single-stage surgeries are the standard. In this paper the authors will report the results of the Otology Group protocol for surgical management of glomus tumors with intracranial extension. Particular attention will be paid to prevention of cerebrospinal fluid leaks with the use of vascularized tissue for defect reconstruction.

Current concepts in lip reconstruction.

PURPOSE OF REVIEW: Approximately 25% of all oral cavity carcinomas involve the lips, and the primary management of these lesions is complete surgical resection. The management of the resulting lip defect remains a significant reconstructive challenge, requiring meticulous preoperative planning and surgical technique to optimize the functional and cosmetic outcome. Reviewed here are the accepted techniques of lip reconstruction, as well newer techniques that have been reported. RECENT FINDINGS: There have been no major advances in lip reconstruction; rather, continued improvement on accepted techniques. The main goals of reconstruction remain the restoration of oral competence, maintenance of oral opening, and the restoration of normal anatomic relations such that both the active (smile) and passive (form) cosmetic outcome is acceptable. The reconstruction should be tailored to the individual needs of the patient and should take into account the patient's condition, local tissue characteristics, previous treatment(s), and functional needs (eg, denture use), in addition to the size and location of the defect. SUMMARY: The lips play a key role in facial expression, speech, and eating. This requires meticulous attention to preoperative planning and surgical technique to maximize the functional and cosmetic outcome. It is important to assess local tissue characteristics (skin laxity) and previous treatment (surgery and/or irradiation) before the surgical plan is made final. Local tissue should be used whenever possible to provide the least donor site morbidity and the best overall tissue color and texture match. Whenever possible, dynamic reconstruction should be attempted. Careful preoperative assessment and planning will allow the surgeon to reach an acceptable balance between form and function with the reconstruction.

Use of the anterolateral thigh flap for reconstruction of the head and neck.

PURPOSE OF REVIEW: The anterolateral thigh free flap has achieved recent popularity in North America for the reconstruction of head and neck defects after ablative surgery. The flap is most often based on either the septocutaneous or musculocutaneous perforators of the descending branch of the lateral circumflex femoral artery. Its versatility allows for a subcutaneous, fasciocutaneous, myocutaneous, or adipofascial flap to be obtained. RECENT FINDINGS: Recent publications have described the utility of the anterolateral thigh flap for reconstruction of head and neck defects. It has been used successfully in the reconstruction of the laryngopharynx, oral cavity, oropharynx, external skin, and maxilla. Furthermore, when a thinner flap is needed, a suprafascial anterolateral thigh flap may be raised or the flap may be thinned after it is obtained. SUMMARY: The anterolateral thigh flap is a highly versatile and reliable flap for use in the reconstruction of various soft tissue defects of the head and neck. This flap has gained great popularity in mainland China, Taiwan, and Japan given its versatility, ability for a two-team approach, and minimal donor site morbidity. However, it has not met the same enthusiasm in Europe and North America because of the relative difficulty in perforator dissection, reported variations of the vascular anatomy, and the presumed increased thickness of the anterolateral thigh tissue in the Western population in comparison with the patient population of the Far East. These obstacles may be overcome by increased surgical experience and by the ability to create a thinner suprafascial flap or thinning the flap after it has been obtained.

Gaze-evoked amaurosis: a report of five cases.

OBJECTIVE: To highlight the various causes of gaze-evoked amaurosis. DESIGN: Retrospective noncomparative interventional case series. PARTICIPANTS: Five patients treated at our facility over the past 6 years. METHODS: Clinical presentation, radiologic studies, surgical management, and postsurgical results are presented. MAIN OUTCOME MEASURES: Visual acuity, clinical findings of gaze-evoked amaurosis. RESULTS: Only two patients had classic intraorbital etiologies, one with an intraconal cavernous hemangioma and one with an intraconal foreign body. Three patients had extraorbital processes, two with orbital fractures and one with a sinus tumor. Only two of our patients initially were aware of the gaze-evoked amaurosis at presentation. Appropriate surgery was curative in all cases. CONCLUSIONS: Gaze-evoked amaurosis is a rare condition, classically implicating intraconal orbital pathology. In one of the largest case series published to date, we found extraorbital etiologies are also capable of producing gaze-evoked vision loss. Gaze-evoked amaurosis should be suspected and tested for in any orbital condition.