Pediatric free flap reconstruction for head and neck defects.

PURPOSE OF REVIEW: The aim of this study was to review recent literature on the use of pediatric free flap reconstruction for head and neck defects with focus on skull base, congenital deformities, mandibular reconstruction and operative considerations. RECENT FINDINGS: Reconstruction of the skull base depends on the defect size, location, bony involvement, and pedicle length with a variety of flaps to choose from. Free flaps may be used to correct congenital anomalies due to facial clefts and syndromic causes requiring bony and tissue bulk. Preservation of the condyle together with free flap mandibular reconstruction has better growth potential. Delayed repair of mandibular defects may be an option especially for patients with malignancy. Chemotherapy and radiation therapy may inhibit the growth potential of the mandible. The use of running or coupled arterial anastomosis is associated with an increased immediate complication. SUMMARY: Pediatric free flap reconstruction is a reasonable option for various head and neck defects such as skull base, congenital, and mandibular defects.

Diagnostic-to-treatment interval and disease progression among head and neck cancer patients undergoing surgery

OBJECTIVE: To determine whether the interval from pathological diagnosis to treatment is significantly delayed, and the presence or absence of disease progression occurring in those with, and without treatment delay, among head and neck cancer patients in our institution.METHODS:Design: Retrospective Chart ReviewSetting: Tertiary Government HospitalParticipants: Medical records of 70 patients with newly diagnosed head and neck cancer who underwent primary surgery from January 2011 to December 2015 were retrieved and available data were extracted.RESULTS: A total of 28 patients were included in this study. Majority of the cancers were in the larynx (42.9%) and oral cavity (42.9%). The mean diagnostic-to-treatment interval (DTI) was 54 days but 5 (17.8%) out of the 28 had a DTI of more than 60 days. Four (80%) with a DTI more than 60 days had an upstage during surgery while 4 (17.4%) patients with DTI less than or equal to 60 days also had an upstage. 2 (60%) patients with treatment delay had tumor progression compared to 5 (21.7%) of those without treatment delay. Only 1 (20%) out of the 5 patients with treatment delay had increased nodal metastasis in contrast to 8 (34.8%) of those who did not have treatment delay.CONCLUSION: A number of patients undergoing surgery in our institution experienced delay to initiate treatment of more than 60 days and majority of these patients were noted to have disease progression. However, even patients with treatment prior to 60 days had increases in tumor stage, which may suggest that the interval aimed for should be shorter than 60 days.

Fibular dimensions for mandibular reconstruction among Filipinos

OBJECTIVE: To determine if the anatomic dimensions (length, cross-sectional width, cortical thickness) of the Filipino fibula are ideal for mandibular reconstruction.METHODS:Design: Cross-Sectional StudySetting: Anatomy dissection laboratoryParticipants: 40 fibulas from 20 adult cadaversRESULTS: Morphometric examination showed the mean length of the harvested fibulas was 33.5 cm. The mean horizontal (a-d) and vertical (b-c) widths of the proximal cross-section (point B) were 15.1 ± 0.28 mm and 9.9 ± 0.15 mm respectively. The mean horizontal (a-d) and vertical (b-c) widths of the distal cross-section (point D) were 15.4 ± 0.24 mm and 10.3 ± 0.49 mm, respectively. The mean cortical thickness of the anterior (a), lateral (b), posterior (c) and medial (d) aspects of the proximal cross-section (point B) were 5.2 ± 0.1 mm, 3.2 ± 0.04 mm, 3.6 ± 0.01 mm, and 2.9 ± 0.06 mm, respectively. The mean cortical thickness of the anterior (a), lateral (b), posterior (c) and medial (d) aspects of the distal cross-section (point D) were 5.1 ± 0.21 mm, 3.1 ± 0.11 mm, 3.5 ± 0.04 mm, and 2.9 ± 0.09 mm, respectively.CONCLUSION: Our findings show that the Filipino fibulas studied have dimensions that are ideal for mandibular reconstruction.

Late-onset anterolateral thigh free flap failure in buccal carcinoma reconstruction

OBJECTIVE: To report a case of late-onset anterolateral thigh free flap failure in reconstruction of a defect from excision of buccal carcinoma.METHODS:Design: Case ReportSetting: Tertiary Government Training HospitalPatient: OneRESULTS: A 57-year-old man with well-differentiated buccal squamous cell carcinoma underwent wide excision with segmental mandibulectomy, bilateral neck dissection and anterolateral thigh free flap reconstruction. Complete failure of the anterolateral thigh free flap was documented on the 29th post-operative day.CONCLUSION: Late-onset flap failure is mainly non-vascular in etiology. However, flap failure is more likely multifactorial. Frequent follow-up after hospital discharge is recommended to monitor flap viability.

Thyroid gland invasion in laryngeal carcinoma

OBJECTIVE: To determine the prevalence of, and describe transglottic cancer with thyroid cartilage invasion as a possible risk for, thyroid gland invasion in a series of patients with laryngeal carcinoma who underwent total laryngectomy with thyroidectomy.METHODS:Design: Retrospective Case SeriesSetting: Tertiary Government Training HospitalParticipants: 61 laryngeal carcinoma patients who underwent total laryngectomy with hemi- or total thyroidectomy from January 2010 to August 2017.RESULTS: Out of 61 patients with laryngeal carcinoma, 11 patients had supraglottic, 11 glottic, 2 subglottic and 37 had transglottic involvement. Eleven had thyroid cartilage invasion, all of whom had transglottic tumors. Of these 11 patients, only 1 had thyroid gland invasion. This was a case of a 78 year-old male patient with poorly differentiated SCC stage IVa transglottic tumor with thyroid cartilage invasion.CONCLUSION: Thyroid gland invasion was uncommon in our sample of laryngeal carcinoma patients who underwent laryngectomy and thyroidectomy. Although transglottic involvement with thyroid cartilage invasion may increase the risk of thyroid gland invasion, it could not be confirmed by our series. Perhaps thyroidectomy should not be routinely performed on all patients with laryngeal carcinoma who undergo total laryngectomy but more rigorous studies are needed to establish this.

A second branchial cleft cyst presenting as a dumbbell-shaped anterior neck mass

Branchial cleft anomalies are among the most common causes of congenital anterior neck masses in the pediatric population. They present as epithelial-lined, single cysts. The definitive management is surgical excision. However, failure to remove the entire cyst and tract may lead to recurrence of the mass. Unusual presentations of this condition may lead to incomplete excision if inadequately evaluated. There is a scarcity of material documenting atypical presentations of branchial cleft anomalies-- in particular, presentation as 2 distinct cysts in one region. In our literature search of PubMed, Google Scholar and HERDIN using the terms: "congenital mass," "branchial cleft cyst," and "multiple cysts," only 3 similar cases were found. We report a case of a second branchial cleft anomaly presenting as a dumbbell-shaped mass (two cystic structures, connected by a tubular structure) in the right lateral neck, the subsequent management and outcomes.

Accuracy of fine needle aspiration biopsy in diagnosing parotid gland malignancy

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> To determine the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of FNAB in detecting parotid malignancies in our institution.<br /><strong>METHODS:</strong><br /><strong>Design:</strong> Restrospective Chart Review<br /><strong>Setting:</strong> Tertiary Government Hospital<br /><strong>Participants:</strong> Postoperative records of seventy six (76) patients with tumors of the parotid gland preoperatively diagnosed by FNAB. <br /><strong>RESULTS:</strong> The sensitivity of FNAB was 46%. The specificity and positive predictive value were both 100% and negative predictive value was 90%. Overall accuracy in diagnosing malignant parotid tumor was 91%.<br /><strong>CONCLUSION:</strong> FNAB in this institution is a poor predictor of malignancy, having a sensitivity rate of only 46%. While this may serve as a basis for not recommending pre-operative FNAB for patients with parotid tumors in the interim, other factors should also be considered, including concerns with the actual performance and interpretation of FNAB in our institution.<br /><br /> </p>

Chemodectoma and tetralogy of fallot

@#<p style="text-align: justify;"><strong>OBJECTIVES:</strong> To describe a rare case of chemodectoma, its clinical features and management, and to discuss its relationship chronic hypoxia from Tetralogy of Fallot.<br /><br /><strong>METHODS:</strong><br /><strong>Design:</strong> Case Report<br /><br /><strong>Setting:</strong> Tertiary Government Hospital<br /><br /><strong>Patient:</strong> One<br /><br /><strong>RESULTS:</strong> A 23-year-old woman presented with a painless, slow growing, movable right submandibular mass, initially diagnosed as a lipoma by fine needle aspiration biopsy.  Computed tomography scan showed a solid nodule with ill-defined margins from the angle of the mandible to the level of the hyoid bone along the carotid sheath. There was also an incidental finding of patent ductus arteriosus and Tetralogy of Fallot on pre-operative clearance. Excision of the mass under general anesthesia revealed adherence to the posterior portion of the carotid trunk enveloping both the internal & external carotid artery. Final histopathological diagnosis was chemodectoma.<br /><br /><strong>CONCLUSION:</strong> Although rare, chemodectoma should be considered as one of the differentials in a patient with a submandibular mass. Hyperplastic chemodectoma may result from chronic hypoxia due to Tetralogy of Fallot.  Surgical excision is the treatment of choice.</p>

Unilateral pedunculated polyp of the palatine tonsil

@#<p style="text-align: justify;"><strong>OBJECTIVES:</strong> To report a benign tonsillar lesion presenting as a pedunculated polyp and discuss its diagnosis and management.<br /><strong>METHODS:</strong><br /><strong>Design:</strong> Case Report<br /><strong>Setting:</strong> Tertiary Government Hospital<br /><strong>Patient:</strong> One<br /><strong>RESULTS:</strong> A 14-year-old lad presented with a seven-year history of an elongated right tonsillar mass without  associated  bleeding, pain,  dysphagia or obstructive sleep  apnea.  Physical  examination revealed  a  pedunculated  mass  about  2  x  1  x  0.5cm  in  size  located  in  the  superior  pole.  After unilateral  tonsillectomy, histopathological  examination  revealed  lymphangectatic  lipomatous fibrotic polyp.<br /><strong>CONCLUSION:</strong> Lymphangiomatous polyp of the palatine tonsils  is  an  unusual benign lesion of the head and neck. These  are  commonly  present  as  unilateral,  polypoidal  mass  that  cannot be clinically  differentiated  from  other  benign  tonsillar  lesions. Tonsillectomy  is  the  recommended surgical  approach  for  both  diagnostic  and  therapeutic  purposes.  Histopathological  study  must be done to confirm diagnosis.</p>

Reconstruction of a large through and through defect of the oral cavity using a double anterolateral thigh free flap

Objective@#To present our application of a double anterolateral thigh (ALT) free flap in reconstruction of a large full thickness defect of the oral cavity, cheek and cervical area.@*Methods@#Design: Case Report Setting: Tertiary Government Hospital Patient: One@*Results@#A 77-year-old male with a 20 x 25 cm full thickness soft tissue defect on the facial and cervical area contiguous with a 6 x 6 cm buccal defect resulting from wide tumor ablation of a Stage IVA (T4aN2bM0) squamous cell carcinoma of the buccal mucosa underwent reconstruction using two ALT free flaps. An ALT flap was designed to cover the intraoral and cheek defect, while another ALT flap was used for external coverage of the cervical defect. The first ALT flap measured approximately 8 x 22 cm while the second ALT flap measured 6 x 22 cm harvested from the left and right thigh respectively. Temporary venous congestion was observed on the inferiorly placed ALT flap due to neck edema that spontaneously resolved on the 2nd post-operative day. Minimal donor site complications observed were linear scars, and a 1 x 4 cm dehiscence on the right thigh that healed spontaneously by secondary intention.@*Conclusion@#The utilization of a double anterolateral thigh free flap allowed single-stage reconstruction of the large soft tissue head and neck defect with little donor site morbidity, shorter operating time and shorter hospital stay.

Intraoperative distance between the main trunk of the facial nerve and surgical landmarks used in parotidectomy: A prospective study

@#p style=text-align: justify;strongOBJECTIVE:/strong To determine the mean distance of the main trunk of the facial nerve from two commonly employed surgical landmarks (tragal pointer and tympanomastoid suture line) among a sample a Filipino adults undergoing parotidectomy.METHODS:br /Design:/strong Prospective descriptive studybr /strongSetting: /strongTertiary Government Training Studybr /strongSubjects:/strong 22 patients without facial paralysis undergoing surgery for parotid neoplasms were evaluated intraoperatively.RESULTS/strong: The main trunk of the facial nerve was found to be 9.0 mm (standard deviation of 2.8 mm) from the tragal pointer and 6.1 mm (standard deviation of 2.0 mm) from the tympanomastoid suture line.CONCLUSION/strong: The mean distance from the main trunk of the facial nerve to two of the most commonly utilized landmarks in identification of the nerve during parotidectomy was 9.0 mm (standard deviation of 2.8 mm) from the tragal pointer and 6.1 mm (standard deviation of 2.0 mm) from the tympanomastoid suture line. These may serve as reference values for surgeons in safer identification and preservation of the facial nerve during parotidectomy.

Drain versus no drain after thyroidectomy: A preliminary prospective randomized controlled trial

@#p style=text-align: justify;strongOBJECTIVE:/strong To evaluate the necessity of placing a drain in post-thyroidectomy patients, we aimed to determine whether insertion of a passive drain as compared to no drain in post-thyroidectomy patients would significantly affect hematoma formation, wound infection, wound dehiscence and length of hospital stay.METHODS:br /Design:/strong Prospective randomized controlled trialbr /strongSetting:/strong Tertiary government training hospitalbr / strongSubjects:/strong Patients who underwent thyroidectomy for various pathologies were divided into two postoperative treatment arms: one group with insertion of a passive drain, and another group without a drain. Hematoma, wound infection, wound dehiscence and length of hospital stay were the outcomes measured per treatment arm.RESULTS:/strong A total of 66 patients were evaluated. There were 54 females (81.81%) and 12 males (18.18%). The mean age for the drain group was 44.88 years and 43.67 years for the no drain group. Four patients developed complications in the drain group and two developed complications in the no drain group. The rate of complications between both groups was not statistically significant. The mean hospital stay of the drain group was 3.15 days which in the no drain group was 2.51 days. The difference in length of hospital stay was statistically significant.CONCLUSIONS:/strong There was no difference in the development of complications among the drain and no drain group. Thyroidectomy without surgical drains was associated with a significant reduction in hospital stay compared to thyroidectomy with routine placement of drains./p

Transorbital removal of foreign body in the sphenoid sinus

@#OBJECTIVES: To report a case of foreign lodged within the sphenoid sinus and its extraction.METHODS:Design: Case report Setting: Tertiary Government Hospital Patient: OneRESULTS: An 11-year-old girl was hit in the eye by an unknown object from an improvised slingshot. She had loss of vision of the left eye and headache without loss of consciousness. A plain craniofacial Computed Tomography (CT) scan showed a round opaque foreign body abutting the left sphenoid sinus, left posterior ethmoid cells and medial aspect of the left orbital region with adjacent soft tissue densities extending into the apparently ruptured, irregular left globe. The left posterior part of the lamina papyracea was not visualized probably fractured or ruptured. Transorbital enucleation of the left eye and endoscopy-assisted removal of the foreign body (a glass marble) were performed with no intra-operative and post - operative complications.CONCLUSION:Foreign body of the sphenoid sinus is a rare condition. Adequate imaging is important for localization and planning the optimal surgical approach. Endoscopic guidance may aid in extraction.

Kimura's disease initially diagnosed as malignancy then extra-pulmonary tuberculosis

Objective@#To describe a rare case of Kimura’s disease initially misdiagnosed as malignancy then tuberculosis.@*Methods@#Design: Case report Setting: Tertiary Private Hospital Patient: One @*Results@#A 30-year-old male with a 6-year history of gradually-enlarging right infra-auricular mass revealed an enlarged mass in the right infraauricular area and multiple cervical lymphadenopathies on physical examination. Initial fine-needle aspiration biopsy was interpreted as pleomorphic adenocarcinoma but succeeding work-ups and imaging studies led to treatment for tuberculosis. Subsequent biopsies finally led to the proper histopathologic diagnosis of Kimura’s disease and the patient was shifted to appropriate treatment with oral prednisone. @*Conclusion@#Kimura’s disease is rare and may be confused with other diseases such as malignancy or tuberculosis. Histopathologic diagnosis is necessary as its treatment differs from tuberculosis and other diseases.

Intraparotid facial nerve schwannoma with temporal bone extension

Objective@#To present a rare case of facial schwannoma manifesting as a parotid mass and discuss its diagnosis and treatment. @*Methods@#Design: Case Report Setting: Tertiary Government Hospital Patient: One @*Results@#A 48-year-old female was seen for a 2-year progressive left hemifacial paralysis and a 5-month gradually enlarging left infraauricular mass with episodes of tinnitus but intact hearing and balance. Physical examination showed a left-sided House Brackmann grade VI facial paralysis and a 5 x 4 x 3 cm soft, ill-defined, slightly movable, nontender, left infraauricular mass. Gadolinium-enhanced magnetic resonance imaging revealed a 5 cm heterogeneouslyenhancing lobulated mass centered within the deep lobe of the left parotid gland extending to the left mastoid, with facial nerve involvement. A diagnosis of a facial nerve tumor, probably a schwannoma, was entertained. Pure tone audiometry revealed normal hearing thresholds for both ears with dips at 6-8 KHz on the left. The patient underwent total parotidectomy with facial nerve tumor resection via transmastoid approach, with simultaneous facial – hypoglossal nerve anastomosis reconstruction. Histopathologic findings confirmed the diagnosis of a schwannoma. Postoperative facial function was Grade VI. Hearing and hypoglossal nerve function were preserved. @*Conclusion@#A progressive hemifacial paralysis of chronic duration with or without the presence of an infra-auricular mass should raise the suspicion of a facial nerve tumor. Gadolinium-enhanced magnetic resonance imaging is valuable since intraparotid facial nerve schwannomas are mostly diagnosed intraoperatively when the neoplasm and the nerve are exposed and determined to be contiguous. The clinician should be aware that not all parotid masses are salivary gland in origin.