Prudent management of the mid-cheek mass: revisiting the accessory parotid gland tumor.

OBJECTIVES/HYPOTHESIS: The head and neck surgeon's fascination with parotid surgery arises from the gland's spectrum of histopathological presentations, as well as the diversity of its morphological features. A mass arising in the mid-cheek region may often be overlooked as a rare accessory lobe parotid neoplasm. This report serves to revisit the topic of accessory parotid gland neoplasms to emphasize proper management, particularly the surgical aspects, so that consequences of salivary fistula, facial nerve paralysis, and recurrence are avoided. STUDY DESIGN: This is a retrospective review of our experience with four accessory parotid gland neoplasms and five other masses mimicking this lesion. METHODS: A literature review and retrospective chart review. RESULTS: Over a 6-year period, we have encountered four true accessory lobe tumors, all pleomorphic adenomas. These presented very similarly to four other more commonly encountered masses not of salivary origin and one normal but hyperplastic accessory parotid gland. All were removed through a wide parotidectomy-style approach modified by extending incisions anterosuperiorly and inferoanteriorly. The only complication was a minor salivary fistula in one patient. There were no permanent facial paralyses. CONCLUSIONS: Accessory parotid gland neoplasms are rare and may present as innocuous extraparotid mid-cheek masses. A high index of suspicion, prudent diagnostic skills (including fine-needle aspiration [FNA] biopsy followed by computed tomography [CT] imaging), and meticulous surgical approach (extended parotidectomy-style incision and limited peripheral nerve dissection when possible) are the keys to successful management of these lesions.

Transverse lag screw fixation in midline mandibulotomy. A case series.

Vertical midline mandibulotomy has provided a relatively simple and efficient means of obtaining access to intraoral tumors that are too large or too posterior to be removed transorally. Midline mandibulotomy has had the advantage of nerve and muscle preservation and places the osteotomy outside the typical field of radiotherapy, in contrast to lateral and paramedian osteotomies. Plate and screw fixation has been the usual means of osteosynthesis for these mandibulotomies; however, plate contouring over the symphyseal surface has been a time-consuming process. Unless the plate was contoured exactly, mandibular malalignment and malocclusion in dentulous patients has occurred. Use of parallel transverse lag screws has become a popular method of osteosynthesis for parasymphyseal fractures, and we have extended their use for mandibulotomy fixation. This paper reports our clinical experience with transverse lag screw fixation of midline mandibulotomies in 9 patients from 1994 to 1997. There were 7 men and 2 women with a mean age of 56 (range 35 to 71 years). The pathological diagnosis in all patients was squamous cell carcinoma; 8 cases were primary, and 1 patient presented with recurrent tumor. No tumors involved the mandibular periosteum. One patient had had previous radiotherapy, and 3 patients underwent postoperative radiotherapy. The mean follow-up has been 17 months (range 9 to 27). There was 1 minor complication and 1 major complication related to our technique. The major complication was a delayed nonunion of the mandibulotomy. This occurred because the 2 parallel screws were placed too close to one another, and this placement resulted in a delayed sagittal fracture of the anterior cortex and subsequent nonunion. Transverse lag screw fixation has not affected occlusion in our dentulous patients. Speech and diet were normal in the majority of our patients. Transverse lag screw fixation of the midline mandibulotomy has been a relatively safe, rapid, and reliable method for tumor access and postextirpation mandibular stabilization and has significant advantages over other current methods of mandibulotomy and fixation.

Schwann cell-onion bulb tumor of the trigeminal nerve: hyperplasia, dysplasia or neoplasia?

Onion bulbs are concentric lamellar structures formed by Schwann or perineurial cells, which may be seen in several generalized or localized diseases of the peripheral nerve. There is debate regarding the pathogenesis of localized tumefactions displaying these microscopic structures. We report the fifth case, to our knowledge, of a Schwann cell-onion bulb tumor, which arose in the trigeminal nerve of a child with an unclassifiable, probably distinct, neurocutaneous syndrome; we also provide evidence for a neoplastic or hamartomatous origin. Molecular studies failed to establish an abnormality in the NF1, NF2, PMP22, or Connexin 32 genes. Similar and previously reported cases are discussed, as well as other onion bulb-forming entities.

Simultaneous transfer of free fibula and radial forearm flaps for complex oromandibular reconstruction.

Several composite free flaps have been described for use in oromandibular reconstruction. Particularly in extensive defects, there may be no single flap which combines sufficient bone stock with thin, pliable, soft tissue. By combining two free flaps, the best osseous and soft-tissue elements may be independently selected, to yield a result superior to that achievable with one free flap alone. Thirteen patients underwent reconstruction of extensive oromandibular defects using the free fibula for mandibular reconstruction and the free radial forearm flap for oral lining and soft-tissue reconstruction. Mandibular defects were usually extensive, involving over half of the mandibular contour. Soft-tissue defects were all complex and involved multiple surfaces of the oral, oropharyngeal, and nasopharyngeal mucosa. All patients were operated on in the supine position by two surgical teams (extirpative and reconstructive) working simultaneously. Each free flap was supplied by its own set of recipient vessels. The mean total operating time was 12 hr. Postoperative courses were without mortality or significant morbidity. There were no flap failures. Soft-tissue and osseous reconstructions healed completely. Aesthetic contour was judged good to excellent in 11 patients. Soft and solid diets were achieved in five patients, with six patients on a purée or liquid diet. Oral competence was present in 11 patients. Speech was excellent to good in six patients and fair in four patients. The mean follow-up has averaged 18 months. Three patients have died of recurrent disease, and two of unrelated causes. The remaining eight patients are currently free of disease. In combining the free flaps, the best tissue for bone and soft-tissue reconstruction was selected independently. The two-team approach avoided excessive operating time and operating team fatigue. The added degree of freedom provided by the two free flaps with their independent pedicles made insetting easier, compared to working within the limitations of a single composite flap. For extensive oromandibular defects, the simultaneous free fibula and radial forearm free flaps provided ideal osseous and soft-tissue reconstruction, with acceptable operating times and reasonable functional results.

Pseudoaneurysm of the petrous internal carotid artery after skull base infection and prevertebral abscess drainage.

A 37-year-old woman with a skull base infection sustained massive oropharyngeal bleeding after incisional nasopharyngeal biopsy and drainage of a prevertebral abscess. A pseudoaneurysm originating at the petrous portion of the internal carotid artery was initially misinterpreted on MR images as typical postoperative change within a resolving abscess cavity. Follow-up MR imaging and conventional angiography ultimately disclosed the pseudoaneurysm.

Surgical management of the substernal thyroid gland.

From 1992 to 1996, 19 patients had surgical resection of a substernal thyroid gland at the University of Rochester Medical Center, Rochester, New York. Based on a retrospective review of the 21 procedures performed, an algorithm for evaluation and surgical intervention is proposed. A limited medical workup is indicated and consists of a chest x-ray, thyroid function tests, computed tomography scan, and, possibly, fine-needle aspiration. Given a modestly high malignancy rate (16%) and a 37% reoperative rate, total thyroidectomy should be performed. When extensive mediastinal disease is encountered, a median sternotomy affords excellent access to the substernal thyroid gland.

Solitary subglottic neurofibroma: MR findings.

We present a case of subglottic neurofibroma, which is of interest because laryngeal neurofibroma rarely occurs in the subglottic space. Nonspecific MR findings did not allow us to exclude the preoperative diagnosis of hemangioma.

Subglottic nerve sheath tumor in a pediatric patient: case report and literature review.

BACKGROUND: Although nerve sheath tumors (neurilemmoma and neurofibroma) can occur on any nerve with Schwann cells, laryngeal involvement is very uncommon. The vast majority of reported laryngeal nerve sheath tumors have been located in the supraglottic area. Our case report involves the diagnosis and management of a subglottic nerve sheath tumor in a pediatric patient. Only two previous reports of such a lesion appear in the world literature. METHODS: A 12-year-old girl was initially seen by her allergist for evaluation of a 2-month history of wheezing and nocturnal dyspnea. Therapy with bronchodilators and steroids had limited success. Flow-volume loop studies suggested a fixed upper airway obstruction, and an office laryngoscopy identified a cherry red, submucosal subglottic lesion. Magnetic resonance imaging (MRI) scan verified the presence of a smooth, homogeneous subglottic mass. RESULTS: An endoscopic CO2 laser excision of the lesion was performed using jet ventilation technique. Histopathology determined the lesion to be a nerve sheath tumor (neurilemmoma versus neurofibroma). Postoperatively, the patient has been asymptomatic without evidence of recurrence. CONCLUSIONS: A subglottic nerve sheath tumor in a pediatric patient is very rare. Although endoscopic and open approaches have been advocated, CO2 laser with jet ventilation provided an excellent modality for resecting this lesion.

Total lower lip reconstruction with a sensate composite radial forearm-palmaris longus free flap and a tongue flap.

The technique of total lower lip reconstruction with a composite radial forearm-palmaris longus free flap was further refined in this report. A ventral tongue flap enhanced the lip aesthetics by recreating the vermilion. Lip suspension was enhanced by securing the palmaris tendon to the malar eminences as well as to the cut ends of the orbicularis oris muscle. The patient achieved oral continence as well as dynamic movement of the lip during speaking and swallowing.

Transverse lag screw fixation of the midline mandibulotomy.

Transverse lag screw osteosynthesis of the midline mandibulotomy is a rapidly performed technique that results in reestablishment of mandibular integrity and avoids placement of hardware directly beneath a suture line. We have performed transverse lag screw osteosynthesis in four patients over the past 14 months. All patients received postoperative radiotherapy. Soft-tissue and bone healing have been uneventful.

Thyroid cancers. I. Papillary, follicular, and Hürthle cell.

The well differentiated thyroid carcinomas, papillary, follicular, and Hürthle cell, comprise the majority of malignant thyroid diseases. This article presents guidelines for the evaluation and treatment of these malignancies. Prognostic factors, surgical treatment of the thyroid and regional lymph nodes, postoperative detection of recurrence, and treatment of distant metastases are discussed.

The acute care nurse practitioner in collaborative practice.

Successful collaborative practice between an acute care nurse practitioner and a physician impacts positively on patient care. Collaboration among disciplines can provide the patient with superior care that is organized, efficient, and prompt. Collaboration also gives each partner in the relationship a great deal of professional satisfaction. The acute care setting in Head and Neck Surgical Oncology provides an excellent environment for collaboration. The patient with head and neck cancer has many complicated medical and nursing problems that challenge the efficiency of this integrative practice model. In this article, the authors demonstrate the effectiveness of this practice model in the management of this patient population.

Complications of skull base surgery.

As skull base resections have increased in complexity and magnitude, so have the complications associated with the procedures. In this paper, we have reviewed the major complications of skull base surgery, including CSF leak, bleeding, stroke, meningitis, cranial nerve deficits and recurrent disease. This report summarizes the factors that lead to these complications, as well as measures to prevent them. We have also discussed our approach to the management of these complications, with particular emphasis on CSF leak and vagal nerve paralysis.

Augmented fixation of mandibular fractures with a threaded Kirschner wire.

The maxillofacial surgeon uses a variety of techniques when treating mandibular fractures. The aim of treatment is to restore structure and function while minimizing morbidity. This requires adequate anatomic reduction and immobilization. The surgeon's choice of techniques should be safe, simple, economic, and effective. In this article, we discuss a previously described, yet little known, technique that fulfilled these criteria. The technique of augmented fixation of mandibular fractures using a threaded basal Kirschner wire was successfully used in seven patients. It offered the distinct advantage of rigid basal fixation that augmented interosseous and maxillomandibular fixation techniques. It was especially effective in stabilizing and promoting bone healing in unfavorable comminuted parasymphyseal fractures. Its ease and rapidity of application from readily available materials made it an effective alternate to elaborate techniques such as compression-plating systems.

Anatomic findings and management of choanal atresia and the CHARGE association.

The CHARGE association is a collection of multisystem congenital anomalies including choanal atresia. A review of the literature failed to identify any specific findings that suggested the need to alter the management of choanal atresia in these patients. Our review of 24 patients with choanal atresia managed between 1974 and 1986 identified nine patients with the CHARGE criteria. These nine patients demonstrated a higher prevalence of surgical failures than the patients without the CHARGE association. The reasons are discussed, and computed tomographic scans demonstrate the anatomic findings of a more contracted nasopharynx and narrowed posterior choanal region. Thus, successful repairs require a more radical resection of the posterior nasal septum and lateral bony walls that can be achieved only with a transpalatal approach. The preoperative airways of CHARGE association patients are also at increased risk of obstruction and may require intubation or tracheotomy during the early life of the patient.