Institutional experience with total pharyngectomy reconstruction: Exploring the role of the salivary bypass tube.

BACKGROUND: There is a lack of consensus regarding the effectiveness of salivary bypass tubes during total pharyngectomy reconstruction to prevent pharyngocutaneous fistula or pharyngoesophageal stricture. METHODS: Our study examined tubed free flap reconstruction outcomes for total pharyngectomy defects over 11 years at a single tertiary referral center. We compared postoperative fistula and stricture rates between two groups: those with salivary bypass tubes inserted during reconstruction and those without. RESULTS: Among 36 patients, 26 had radial forearm, and 10 had anterolateral thigh free flap reconstruction. 53% received salivary bypass tubes. However, the tubes did not significantly reduce the relative risks of fistula or stricture. Notably, neck dissection during total pharyngectomy was associated with increased fistula incidence. Minor salivary bypass tube-related complications affected 21% of subjects. CONCLUSION: The role of salivary bypass tubes in total pharyngectomy reconstruction remains uncertain.

IgG4-RD in a Unilateral Parotid Mass: A Rare Manifestation and Review of the Literature.

IgG4 related disease (IgG4-RD) is a rare, immune-mediated inflammatory disease that varies widely in its presentation because it can affect nearly any organ. We present a case of a 73-year-old male who presented with an ill-defined mass of the parotid gland, found to be IgG4-RD, after several months of work up and tissue sampling. Most cases of salivary gland involvement in IgG4-RD present as bilateral swelling of the submandibular glands. We present this case as a unique manifestation of salivary gland disease in IgG4-RD as a persistent, non-discrete unilateral mass in the parotid gland. It is critical that clinicians who regularly treat salivary gland pathologies are familiar with this rare disease and its potential manifestations in the oral cavity.

An institutional review of recurrent pleomorphic adenoma of the parotid gland.

OBJECTIVE: Surgical resection is standard treatment for pleomorphic adenoma (PA) of the parotid gland. A small number (2-5%) of these tumors recur. Recurrence usually necessitates reoperation, which is technically challenging and puts the facial nerve (FN) at risk. The aim of this study is to characterize the recurrent parotid PA population and compare outcomes after surgery for singly recurrent and multiply recurrent tumors. METHODS: This study was a retrospective chart review of patients at a single tertiary care academic medical center who underwent operations for recurrent PA of the parotid gland between 2007 and 2020. Demographic data, details of surgical interventions, pre- and postoperative FN function, and recurrence rates were studied. These factors were compared between patients with singly and multiply recurrent tumors. RESULTS: Thirty-eight patients met criteria: 4 patients presented for primary PA and subsequently recurred, 26 with a first recurrence, 7 with a second recurrence, and 1 with a fourth recurrence. Multiply recurrent PAs were more likely to require at least partial nerve sacrifice at the time of reoperation (P = 0.0092). Significantly worse long-term FN outcomes were seen following surgery for multiply recurrent PA (P = 0.008). There was no significant difference between the rate of re-recurrence following first revision surgery vs second-fourth revision surgery. Time to reoperation was significantly shorter between the first and second revision surgery than between the primary surgery and first revision (P = 0.0017). CONCLUSION: Surgery for recurrent PA incurs high risk to the FN, and this risk appears to increase in the setting of multiple recurrences.

Glomus Vagale Tumor Resection: 2-Dimensional Operative Video.

A 37-yr-old female with prior transient left facial paralysis presented with hearing loss, headaches, and resolved transient right facial paralysis. The neurological examination demonstrated normal facial movement, left hearing loss, and left vocal cord weakness. Magnetic resonance imaging demonstrated a >3 cm left paraganglioma traversing the jugular foramen. After obtaining informed consent from the patient, the tumor was embolized and then resected via a combined left postauricular infratemporal fossa and transcervical approach with cranial nerve monitoring. The ossicles were removed and the vertical segment of the facial nerve was skeletonized. The jugular bulb was identified in the hypotympanum and the petrous carotid artery was exposed. The digastric muscle was reflected inferiorly and the extratemporal facial nerve was identified. The stylomandibular ligament was transected to unlock the exposure to the infratemporal fossa. The external carotid branches were ligated. The vagus nerve and cervical sympathetic chain were infiltrated with tumor, requiring resection. The presigmoid dura and occluded jugular bulb were opened to complete the tumor resection, while preserving the medial wall. Despite anatomic preservation, the glossopharyngeal, accessory, and hypoglossal nerves were postoperatively weak and a facial paralysis recovered after 1 wk. Magnetic resonance imaging at 1 yr demonstrated a clean jugular foramen, although a thin rim of tumor remained around the petrous carotid.

Establishing a targeted plan for prophylactic dental extractions in patients with laryngeal cancer receiving adjuvant radiotherapy.

OBJECTIVE: The purpose of this study was to determine dose delivered to individual mandibular tooth-bearing regions during adjuvant intensity-modulated radiotherapy for laryngeal cancers. STUDY DESIGN: Twenty patients with laryngeal cancer treated with intensity-modulated radiotherapy were included. Individual mandibular tooth-borne areas were manually contoured. Average doses were calculated for individual teeth. RESULTS: Doses to individual teeth increased with more posterior location. Highest dose was observed for third molar (M3) (43.1 Gy; P < .001). Doses to molars and premolars correlated with T- and N-stage (P = .007; P < .001, respectively). For ipsilateral nodal disease, there was no difference between the doses to ipsilateral teeth and contralateral teeth. Only in N2 c tumors, dose was above our threshold for extraction for M3 only (51.5 Gy). CONCLUSIONS: T- and N-stage drive dose to individual mandibular tooth-borne areas. With the exception of the posterior molars, particularly in node-positive patients, radiation exposure falls below the threshold reported for pre-RT tooth extractions (50 Gy). We concluded that a more conservative approach to prophylactic tooth extraction with a greater emphasis on dental management may be warranted for the prevention of osteoradionecrosis in patients with laryngeal cancer receiving adjuvant RT.

Spinal epidural abscess following glossectomy and neck dissection: A case report.

INTRODUCTION: Spinal epidural abscess is an uncommon but potentially life threatening entity that rarely occurs after otolaryngology procedures. PRESENTATION OF CASE: We report a case of a diabetic patient who presented with a lumbar spinal epidural abscess eight days after head and neck oncologic surgery. Magnetic resonance imaging revealed an L4 spinal epidural abscess. Cultures from the spinal epidural abscess, blood, urine, and the previous neck incision grew Klebsiella pneumoniae. The patient recovered neurologic function after surgical decompression and drainage, long-term intravenous antibiotics, and physical therapy. DISCUSSION: The development of postoperative spinal epidural abscess is rare after otolaryngology procedures but has been reported in the cervical epidural space. To our knowledge, lumbar spinal epidural abscess has not yet been reported after head and neck oncologic surgery. Even more unique is the presence of the pathogen K. pneumoniae. CONCLUSION: A high index of suspicion of this potential outcome is paramount as early recognition and intervention are keys to recovery of neurologic function.

Subglottic Basal Cell Adenocarcinoma.

OBJECTIVES: To discuss the presentation and management of a rare neoplasm in a previously unreported laryngeal subsite. METHODS: Case report and literature review. RESULTS: An 89-year-old woman presented with a subglottic mass, biopsy of which was consistent with basal cell adenocarcinoma. She was successfully treated with surgical intervention and remains disease free 29 months postoperatively. CONCLUSIONS: Basal cell adenocarcinoma is a rare salivary gland tumor, the laryngeal variant of which is even scarcer. Herein we describe the presentation and successful surgical management of the first reported case of subglottic basal cell adenocarcinoma. We additionally provide a histologic review followed by approaches to treatment.

Combination Trimodality Therapy Using Vismodegib for Basal Cell Carcinoma of the Face.

Background. For large basal cell carcinomas (BCCs) of the head and neck, definitive surgery often requires extensive resection and reconstruction that may result in prolonged recovery and limited cosmesis. Vismodegib, a small-molecule inhibitor of the hedgehog pathway, is approved for advanced and metastatic BCCs. We present a case of advanced BCC treated with combination of vismodegib, radiotherapy, and local excision resulting in excellent response and cosmesis. Case Presentation. A 64-year-old gentleman presented with a 5-year history of a 7 cm enlarging right cheek mass, with extensive vascularization, central ulceration, and skin, soft tissue, and buccal mucosa involvement. Biopsy revealed BCC, nodular type. Up-front surgical option involved a large resection and reconstruction. After multidisciplinary discussion, we recommended and he opted for combined modality of vismodegib, radiotherapy, and local excision. The patient tolerated vismodegib well and his right cheek lesion decreased significantly in size. He was then treated with radiotherapy followed by local excision that revealed only focal residual BCC. Currently, he is without evidence of disease and has excellent cosmesis. Conclusions. We report a case of locally advanced BCC treated with trimodality therapy with vismodegib, radiotherapy, and local excision, resulting in excellent outcome and facial cosmesis, without requiring extensive resection or reconstructive surgery.

Preauricular infratemporal fossa approach for advanced malignant parotid tumors.

OBJECTIVES/HYPOTHESIS: The aims of this study were to demonstrate the surgical technique involved in the preauricular infratemporal fossa (ITF) approach, outline the clinical indications for use of this technique, and present the results in using this approach in 159 patients with malignant parotid tumors. At the conclusion of this article, the reader should be able to understand the utility of the preauricular infratemporal fossa approach in the management of patients with advanced malignant parotid tumors. STUDY DESIGN: This was a retrospective chart review of 159 patients treated at a tertiary care academic medical center following institutional review board approval. METHODS: A comprehensive medical records review was performed for all patients with malignant parotid tumors who underwent a preauricular ITF approach between July 1988 and July 2010. RESULTS: The most common presenting symptoms were pain and trismus, whereas the presence of a parotid mass and facial paralysis were the most common clinical signs. Mucoepidermoid and adenoid cystic carcinoma accounted for 63% of the tumors, and perineural invasion was found in nearly 71% of the patients. Despite negative surgical margins in 92% of the patients, local or regional tumor recurrence was found in 17% of the cases. The mean follow-up time was 12.8 years. CONCLUSIONS: The preauricular ITF approach should be used in the surgical extirpation of advanced malignant parotid neoplasms. This technique provides proximal facial nerve identification, internal carotid artery protection, and negative tumor margins at the skull base.

Postlaryngectomy dysphagia masking as velopharyngeal insufficiency: a simple solution for an anterior neopharyngeal diverticulum.

Postlaryngectomy dysphagia is a common occurrence and can be a source of emotional distress that results in a decrease in quality of life among a patient population that is already exposed to considerable morbidity. One etiologic source that is less commonly reported as a source for postlaryngectomy dysphagia, and perhaps overlooked, is an anterior neopharyngeal diverticulum. Herein, we describe a postlaryngectomy dysphagia caused by a neopharyngeal diverticulum masking as velopharyngeal insufficiency of liquids. The liquid dysphagia was immediately relieved via transoral endoscopic approach using the Harmonic scalpel to resect and simultaneously coagulate the posterior wall.

Late complication of thoracic endovascular stent-grafting.

Thoracic endovascular aortic repair (TEVAR) has become increasingly popular for the treatment of descending thoracic aortic aneurysms. Despite their proven efficacy and safety, several complications can occur with TEVAR. We report a case of a 76-year-old woman with a late-term complication after TEVAR related to recurrent thyroid cancer and carotid-subclavian revascularization.

Osteonecrosis of the mandible or maxilla associated with the use of new generation bisphosphonates.

OBJECTIVE: The use of bisphosphonates is well established for the treatment of patients with metastatic bone disease, osteoporosis, and Paget's disease. Osteonecrosis of the mandible or maxilla associated with the use of bisphosphonates is a newly described entity never before discussed in the otolaryngology literature. In this paper, we review a series of patients diagnosed with osteonecrosis, all treated with new generation bisphosphonates. Our objective is to inform and educate others, particularly otolaryngologists/head and neck surgeons, about this drug induced entity, a condition that should be recognized early to avoid potential devastating consequences. STUDY DESIGN: Retrospective chart review of a series of patients from a tertiary referral center. METHODS: Pathology reports of specimens submitted from either the mandible or maxilla were reviewed from the previous 12 months. Any patient diagnosed with osteonecrosis without evidence of metastatic disease at that site was included; those with a previous history of radiation therapy were excluded. Each patient's medical history and profile were reviewed. RESULTS: Twenty-three patients were identified with osteonecrosis of the mandible or maxilla. All of these were associated with the use of new generation bisphosphonates: zolendronate (Zometa, Novartis), pamidronate (Aredia, Novartis), and alendronate (Fosamax, Merck). Eighteen patients with known bone metastases had been treated with the intravenous form, whereas five patients with either osteoporosis or Paget's disease were using oral therapy. Patients typically presented with a nonhealing lesion, often times the result of previous dental intervention. Although the majority of these patients were treated with conservative surgical debridement, we present a case requiring a near total maxillectomy. CONCLUSIONS: Drug induced osteonecrosis of the mandible or maxilla has been recently recognized as a sequelae of treatment with the new generation of bisphosphonates. Most patients can be treated with conservative surgical debridement and cessation of bisphosphonate therapy, whereas a few may require radical surgical intervention. Other recommendations include regimented prophylactic care with an assessment of dental status before the administration of bisphosphonates, avoidance of dental procedures, and close monitoring of oral hygiene.

Management of neck metastasis with carotid artery involvement.

OBJECTIVES: To demonstrate aggressive management of neck metastasis adherent to the internal or common carotid artery using sound oncologic principles while minimizing the significant risk of complications. STUDY DESIGN: Our 13 year experience of treating patients with recurrent or residual neck metastasis adherent to the internal or common carotid artery was retrospectively reviewed. METHODS: Angiography was used in patients who demonstrated fixation of the carotid artery on examination or imaging, followed by balloon test occlusion and single photon emission computer tomography (SPECT) scanning. The majority of carotid resections were reconstructed with a vein graft, especially if there was insufficient collateral cerebral circulation. Radical resection of the soft tissue including the carotid artery was performed followed by 15 to 20 Gray of electron beam delivered directly to the deep tissue. More recently, the carotid has been permanently occluded preoperatively, if possible. The assessment of the cerebral circulation and management of the carotid artery were analyzed as was survival, site of recurrence, and complications. RESULTS: Fifty-eight charts were reviewed. The majority of patients (41) had their carotid artery reconstructed at time of resection, and the remaining had either the artery ligated or permanently occluded preoperatively. Strokes occurred in 11 patients. The median disease-specific survival was 12 months, with 24% of patients dying from distant metastasis. CONCLUSIONS: The high risk of complications, loss of life's quality, and mortality must be balanced against the natural history of the disease if left untreated. The decision is a heavy burden for the patient, family, and head and neck surgeon.