Squamous Cell Carcinoma Arising in Breast Implant Capsules.

ABSTRACT: Breast augmentation and reconstruction utilizing implants are among the most common plastic surgery procedures performed in the United States. A small proportion of these implants are removed each year. We report 2 cases where routine pathologic evaluation of capsulectomy specimens revealed squamous cell carcinoma associated with the breast implant capsule and discuss the possible pathogenesis of this unusual entity. Both patients had long-standing implants (>10 years) and presented with acute unilateral breast erythema and swelling. Intraoperatively, the capsules for both cases appeared thickened and calcified, containing extensive granulomatosis and keratinaceous debris invading into the chest wall. Extensive workup failed to find an occult primary. One patient died from a malignant pleural effusion secondary to tumor invasion during chemotherapy, and the second patient obtained stabilization of the mass after 5 weeks of chemotherapy but subsequently declined further surgical intervention. A thorough literature review was performed, and 5 similar reports were identified, involving 6 patients. All patients presented with similar clinical presentations as ours and had poor outcomes. The mean reporting age at diagnosis was 60 years, and the average time from initial implant to diagnosis was 25 years. Due to the small numbers of squamous cell carcinomas associated with breast implant capsules, the true association between the 2 is unknown. It is postulated that chronic inflammation/irritation from the breast implant and epithelialization of the capsule play a significant role in the disease process. This may represent a new entity of "chronic inflammatory capsular malignancies." Increased awareness of this entity may allow for earlier suspicion, diagnosis, and management.

Intraoperative Image-Guided Navigation in Craniofacial Surgery: Review and Grading of the Current Literature.

INTRODUCTION: Image-guided navigation has existed for nearly 3 decades, but its adoption to craniofacial surgery has been slow. A systematic review of the literature was performed to assess the current status of navigation in craniofacial surgery. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) systematic review of the Medline and Web of Science databases was performed using a series of search terms related to Image-Guided Navigation and Craniofacial Surgery. Titles were then filtered for relevance and abstracts were reviewed for content. Single case reports were excluded as were animal, cadaver, and virtual data. Studies were categorized based on the type of study performed and graded using the Jadad scale and the Newcastle-Ottawa scales, when appropriate. RESULTS: A total of 2030 titles were returned by our search criteria. Of these, 518 abstracts were reviewed, 208 full papers were evaluated, and 104 manuscripts were ultimately included in the study. A single randomized controlled trial was identified (Jadad score 3), and 12 studies were identified as being case control or case cohort studies (Average Newcastle-Ottawa score 6.8) The most common application of intraoperative surgical navigation cited was orbital surgery (n = 36), followed by maxillary surgery (n = 19). Higher quality studies more commonly pertained to the orbit (6/13), and consistently show improved results. CONCLUSION: Image guided surgical navigation improves outcomes in orbital reconstruction. Although image guided navigation has promise in many aspects of craniofacial surgery, current literature is lacking and future studies addressing this paucity of data are needed before universal adoption can be recommended.

Air travel with known pneumocephalus following outpatient sinus surgery.

BACKGROUND: Intracranial air is a common finding after many neurosurgical procedures and trauma to the head. In patients requiring transport via air to reach a destination there is risk of expansion of the intracranial air and development of neurological complications. Though relatively uncommon after functional endoscopic sinus surgery (FESS), pneumocephalus may be encountered. CASE REPORT: We describe one of our patients in whom intracranial air was introduced during FESS. Following the procedure she required commercial air transportation from our center to her home. A 45-min commercial flight to the destination was safely completed without the patient experiencing any neurological sequellae. DISCUSSION: This case highlights the controversy surrounding air travel with pneumocephalus and provides an example of safe commercial air travel after diagnosis of post-FESS pneumocephalus.

Craniosynostosis Associated With Novel TUBG1 Mutation (NM_001070.4:c.821C>T) (p.Thr274Ile).

TUBG1, a tubulin gene, plays an important role in neurodevelopment. Here we describe a case of a novel TUGB1 mutation (NM_001070.4:c.821C>T) (p.Thr274Ile). This patient presented similarly to previous cases with features including microcephaly, epilepsy, and speech and motor delay. Unique characteristics were also present such as trigonocephaly, tethered frenulum, scoliosis, nystagmus, and a concurrent FBXW7 mutation. This case expands our breadth of knowledge on TUBG1 genotypic and phenotypic variation. However, further work is needed to fully understand this rare mutation and the associations between TUBG1 and FBXW7 mutations.

Tumescent technique for split-thickness skin graft donor sites: A systematic review of randomized controlled trials.

BACKGROUND: Split-thickness skin grafting (STSG) is widely used for reconstructive wound management. This review aimed to use level I evidence to determine if tumescent techniques were safe and effective compared to other interventions for STSG donor sites. It was hypothesized that tumescent techniques were safe and effective for STSG donor sites. METHODS: Five databases (MEDLINE via PubMed, Embase, Cochrane Library, Web of Science, and Scopus) were searched to identify studies concerning the use of tumescent solutions for STSG. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and Cochrane's guidelines were strictly followed. RESULTS: Nine randomized controlled trials met the criteria. Included studies were published from 2001 to 2021, with results from 40 of 121 possible queried outcomes and complications. Outcomes included patient demographics, formulations of tumescent solutions, tumescent technique, hemodynamics, pain, perfusion, graft take, healing time, and postoperative complications. The tumescent technique reduced estimated blood loss (standard mean differences [SMD]: -2.68, 95%CI: -3.41 to -1.94; participants = 72; studies = 2; I2 = 96%; p < 0.001), and postoperative analgesic use within 24 hours (SMD: -1.75, 95%CI: -2.09 to -1.41; participants = 202; studies = 2; I2 = 96%; p < 0.001), without increasing graft loss/take (SMD: 0.29, 95%CI: -0.02 to 0.61; participants = 158; studies = 3; I2 = 41%; p = 0.07) and infection (risk ratios [RR]: 0.52, 95%CI: 0.08 to 3.54; participants = 87; studies = 3; I2 = 0%; p = 0.58) complications compared to other interventions. CONCLUSIONS: Level I evidence demonstrated tumescent techniques were safe and effective for STSG donor sites. Tumescent techniques reduced blood loss and postoperative analgesic use within 24 hours without increasing graft loss/take and infection complications compared to other interventions. Inconsistencies between studies limit conclusions and emphasize the need for standardized protocols regarding tumescent solution formulations, techniques, and reported outcomes.

Aspirin-Exacerbated Respiratory Disease and the Unified Airway: A Contemporary Review.

Aspirin-exacerbated respiratory disease (AERD) is characterized by abnormal arachidonic acid metabolism leading to chronic rhinosinusitis with nasal polyposis (CRSwNP), asthma, and upper and/or lower respiratory symptoms after ingestion of cyclooxygenase-1 inhibiting nonsteroidal antiinflammatory drugs. Diagnosis is clinical and may involve an aspirin challenge. Inflammatory biomarkers may be useful for diagnosis and treatment monitoring. Conventional medical management for asthma and CRSwNP is often inadequate. Endoscopic sinus surgery followed by continued medical management with or without aspirin desensitization frequently improves symptoms and objective disease measures. Biological agents targeting eosinophilic inflammation are promising alternatives to conventional management.

Improved Success Rate with Corticocancellous Block Compared to Cancellous-Only Trephine Technique in Alveolar Bone Grafting from the Iliac Crest.

BACKGROUND: Alveolar bone grafting is an important component of cleft lip and palate treatment, with iliac crest as the most common donor site. Although studies have attempted to quantify alveolar bone graft resorption, few have directly compared the outcomes of graft techniques. This study compared the long-term success rates of corticocancellous block to trephine cancellous-only alveolar bone grafting from the iliac crest. METHODS: A retrospective review of all cleft lip and palate patients undergoing alveolar bone grafting over 14 years was performed. Power analysis was performed to determine sample size. Data including patient demographics, surgical technique, need for repeated grafting, complications, length of hospitalization, and follow-up were collected. Statistical analyses of outcomes were performed based on initial graft technique. RESULTS: A total of 106 initial operations met criteria, with 73 using trephine technique, 30 using corticocancellous block, and three undergoing open cancellous harvest. The overall regraft rate was 40 percent, with an average follow-up of 43.5 months. Patients with corticocancellous block grafting had significantly lower rates of repeated grafting compared to trephine technique (16.7 percent versus 47.9 percent; p < 0.001). There was no significant difference in complication rates or length of admission between treatment groups. CONCLUSIONS: The use of corticocancellous block alveolar bone grafting demonstrated significantly higher success rates when compared to cancellous-only trephine techniques, with no difference in complication rates. Although this must be weighed against the minor disadvantages of open iliac harvest, surgeons should consider incorporating en bloc corticocancellous bone to optimize outcomes in alveolar bone grafting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Multidisciplinary Treatment of a Pediatric Orbital Roof Fracture: Case Report and Literature Review.

Pediatric orbital roof fractures are a relatively rare trauma. In children, fractures of the facial skeleton can be associated with significant morbidity. Potential complications of orbital roof fracture include both neurosurgical complications such as frontal lobe injury, dural tears, or herniation, and ophthalmologic and reconstructive surgery problems such as proptosis, diplopia, and extraocular muscle entrapment. In most cases, surgical intervention is unnecessary, as these fractures are minimally displaced. When surgery is warranted, however, for displaced fractures or those associated with complications, a multidisciplinary approach is often indicated. Here, we report a case of a 10-year-old boy with a superiorly displaced orbital roof fracture resulting from a bicycle brake handle injury. The primary fragment was intracranially displaced and embedded in the inferior frontal lobe, causing frontal lobe herniation and left globe proptosis. A transcranial approach was performed using an autologous bone graft. In our case, a multidisciplinary surgical approach facilitated repair of both the dural and orbital injuries and multi-layer separation of the 2 spaces.

HPV-Related Multiphenotypic Sinonasal Carcinoma: A Case Report and Literature Review.

OBJECTIVES: Human papilloma virus-related multi phenotypic sinonasal carcinoma (HMSC), a recently characterized sinonasal malignancy, is discussed including histology, clinical presentation, and treatment outcomes. STUDY DESIGN: Case report with literature review. METHODS: A case of HMSC is reported, as well as a retrospective review of all cases of HMSC reported in the English literature from January 2000 through May 2018 in the MEDLINE, EMBASE, and Scopus databases. Case data from selected articles was pooled along with the presented case and analyzed. RESULTS: Including the present case report, a total of 57 cases of HMSC were identified through literature review. Of the 42 cases with staging information, 25 (60%) presented as early-stage disease (T1/T2). No nodal metastasis or disease-specific mortalities were reported. Among the 44 cases with posttreatment follow-up data, 16 cases (36.4%) developed local recurrence. The majority of recurrences occurred 24 to 60 months posttreatment, although reports of recurrence 10 and 29 years posttreatment exist. Local recurrence occurred in 40% and 60% of patients with perineural invasion and bone invasion, respectively. Patients who developed local recurrence had a longer disease-free interval when treated with adjuvant radiotherapy, which approached statistical significance. CONCLUSIONS: HMSC is a distinct entity with paradoxically aggressive morphology paired with an indolent clinical course characterized by high rates of local recurrence but no reported disease-specific mortalities to date. Surgery with or without adjuvant radiotherapy is the most common treatment modality, and adjuvant radiotherapy may be associated with an increased disease-free interval among patients with local recurrence. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:106-110, 2021.

External iliac artery dissection secondary to endofibrosis in a cyclist.

Endofibrosis of the external iliac artery is an uncommon disease affecting primarily young, otherwise healthy, endurance athletes. Thigh pain during maximal exercise with quick resolution postexercise is characteristic of the so-called cyclist's iliac syndrome. We report an unusual case in which the typical endofibrotic plaque was accompanied by dissection of the external iliac artery. The patient was treated surgically with excision of the affected artery segment and placement of an interposition graft. This case highlights an unusual finding in association with external iliac artery endofibrosis and provides an opportunity to briefly review the literature on the subject.

Intraoperative Three-dimensional Virtual Reality and Computed Tomographic Guidance in Temporomandibular Joint Arthroplasty of Syndromic Craniofacial Dysostoses.

Bony ankylosis of the temporomandibular joints (TMJ) occurs in up to 28% of patients with syndromic mandibular dysostoses. Release of complete osseous ankylosis is particularly challenging due to the lack of tissue planes separating the mandible from the skull base and the presence of congenital skeletal abnormalities. One recent advance in surgical imaging technology is three-dimensional virtual reality (3D VR), now in common use in neurosurgical resections. In this study, we describe the usage of 3D VR in TMJ arthroplasty and compare 3D VR to traditional computed tomographic (CT) guidance. Pediatric patients with syndromic mandibular micrognathia including Treacher Collins, Nager, and cerebrocostomandibular syndrome were retrospectively evaluated between 2008 and 2016. Patient characteristics, complications, inpatient times, and operative times were recorded. Of the 29 children with syndromic mandibular micrognathia treated between 2008 and 2016, 7 were diagnosed with TMJ ankyloses. Four consecutive pediatric patients (mean 8.7 years) undergoing interpositional TMJ arthroplasty with Matthews device placement were retrospectively evaluated. Two patients underwent traditional CT-guided versus 3D VR-guided temporomandibular joint arthroplasty (TMJA). No statistically significant differences were found among the age, complications, or inpatient hospitalization times. The average operative time in the traditional CT guidance group was 300 minute versus 134 minutes in the 3D VR group. Three-dimensional VR is a useful preoperative planning and intraoperative guidance tool. The major difference between VR and older technologies is the improved imaging in 3 dimensions for guidance, thereby potentially decreasing operative times.

Middle turbinate manipulation and postoperative sinus obstruction after endoscopic endonasal skull-base surgery.

BACKGROUND: Inadvertent lateralization of the middle turbinate (MT) after endoscopic sinus surgery (ESS) is cited as a common complication that results in both outflow tract obstruction and recurrent symptoms. In endoscopic endonasal skull-base surgery, the MT is frequently lateralized during the parasagittal approach. Little is known about whether this strategy has unintended consequences on the adjacent paranasal sinuses. Intentional lateralization vs surgical resection of the MT were compared for radiographic evidence of sinus obstruction in this patient population. METHODS: A retrospective evaluation was conducted of pre- and postoperative Lund-MacKay (LM) scores in patients who underwent an endoscopic endonasal approach (EEA) for resection of a pituitary tumor or craniopharyngioma (transsellar or suprasellar approach) between 2012 and 2014. Side-specific LM scores were calculated at 0-3 months, 3-6 months, and >6 months. MT lateralization vs resection sides were compared. RESULTS: Of the cases reviewed, 122 met the inclusion criteria. There were no statistically significant differences in LM scores of the adjacent paranasal sinuses between resected MTs as compared with surgically lateralized MTs at 3-6 months or >6 months (p = 0.551) postoperatively. Time-point of assessment was statistically significant with regard to the outcome of LM = 0 (p < 0.001), with earlier postoperative imaging correlating with higher LM scores. CONCLUSION: Unlike after ESS, MT lateralization does not appear to be correlated with higher LM scores after EEA. Postoperative radiographic sinus outflow obstruction was similar in patients at all measured intervals despite differences in technical management of the MT.

Air pollutants may be environmental risk factors in chronic rhinosinusitis disease progression.

BACKGROUND: Little is known about the role of environmental exposures in the pathophysiology of chronic rhinosinusitis (CRS). In this study, we measured the impact of air pollutants (particulate matter 2.5 [PM2.5 ] and black carbon [BC]) on CRS with nasal polyposis (CRSwNP) and CRS without nasal polyposis (CRSsNP). METHODS: Spatial modeling from pollutant monitoring sites was used to estimate exposures surrounding residences for patients meeting inclusion criteria (total patients, n = 234; CRSsNP, n = 96; CRSwNP, n = 138). Disease severity outcome measures included modified Lund-Mackay score (LMS), systemic steroids, number of functional endoscopic sinus surgeries (FESS), and 22-item Sino-Nasal Outcome Test (SNOT-22) score. PM2.5 and BC exposures were correlated with outcome measures. RESULTS: Mean PM2.5 and BC findings were not significantly different between CRSwNP and CRSsNP patients or patients with and without asthma. Among those with CRSsNP, PM2.5 was significantly associated with undergoing FESS. For each unit increase in PM2.5 , there was a 1.89-fold increased risk in the proportion of CRSsNP patients who required further surgery (p = 0.015). This association was not identified in CRSwNP patients (p = 0.445). BC was also significantly associated with SNOT-22 score in the CRSsNP group. For each 0.1-unit increase in BC, there was a 7.97-unit increase in SNOT-22 (p = 0.008). A similar, although not significant, increase in SNOT-22 was found with increasing BC in the CRSwNP group (p = 0.728). CONCLUSION: Air pollutants correlate with CRS symptom severity that may be influenced by exposure levels, with a more pronounced impact on CRSsNP patients. This study is the first to demonstrate the possible role of inhalant pollutants in CRS phenotypes, addressing a critical knowledge gap in environmental risk factors for disease progression.

The association of air pollutants and allergic and nonallergic rhinitis in chronic rhinosinusitis.

BACKGROUND: There has been little investigation regarding air quality and rhinitis in the pathophysiology of upper airway disease. In this study, we assessed the impact of inhalant pollutants (particulate matter 2.5 [PM2.5 ] and black carbon [BC]) on allergic rhinitis and chronic rhinosinusitis (CRS) disease severity. METHODS: CRS patients with nasal polyps (CRSwNP) and without polyps (CRSsNP) were identified. Spatial modeling from pollutant monitoring sites was used to estimate exposures for patients meeting the inclusion criteria (total, n = 125; CRSsNP, n = 67; CRSsNP, n = 58). Skin-prick, intradermal dilutional, and in-vitro testing methods were utilized to determine aeroallergen sensitization. Disease severity indicators were measured by modified Lund-Mackay score (LMS), the 22-item Sino-Nasal Outcome Test (SNOT-22), systemic steroid therapy, and number of functional endoscopic sinus surgeries (FESS). RESULTS: Thirty-six percent (n = 45) of patients who described rhinitis symptoms demonstrated no reactivity to aeroallergen testing. Sixty-four percent (n = 80) tested positive for at least 1 allergen, with no differences found between CRSsNP and CRSwNP (62.1% vs 67.2%). There were significant differences in air pollutants between patients testing negative and positive for allergies (nonallergic vs allergic: PM2.5 , 11.32 vs 11.07 µg/m3 , p = 0.030; BC, 0.81 vs 0.76 absorbance, p =0.044). Nonallergic CRSwNP demonstrated higher PM2.5 compared with allergic counterparts (11.48 vs 11.09 µg/m3 , p = 0.032). A similar pattern was observed with BC (0.82 vs 0.75 absorbance, p = 0.017). In CRSsNP, BC correlated significantly with SNOT-22 (r = 0.55, p = 0.042). CONCLUSION: Our results suggest that small inhalant pollutants may contribute to nonallergic symptomatology in patients with and without nasal polyps. Regardless of allergy status, BC may play a role in CRS symptom severity.

Rising incidence of oropharyngeal cancer and the role of oncogenic human papilloma virus.

OBJECTIVES/HYPOTHESIS: To document the increasing incidence of oropharyngeal (OP) cancer and to provide evidence that this increase is caused by oncogenic human papilloma virus (HPV). STUDY DESIGN: Epidemiologic review and retrospective case series analysis. METHODS: We collected data from Colorado and the United States comparing the average annual age-adjusted incidence rates of OP and non-OP head and neck cancer between the periods 1980 to 1990 and 1991 to 2001. We obtained data on 72 patients with OP cancer from a single county in Colorado, from 1980 through 2004. HPV status was determined by DNA-polymerase chain reaction. We assessed disease-specific survival. RESULTS: The average annual age-adjusted incidence of OP cancer in males in Colorado increased from 2.54 per 100,000 to 3.47 (P < .05) or 36.6%, whereas the U.S. rate increased from 4.34 to 4.81 (P < .05) or 10.8%. The rates in females and the rates of non-OP head and neck cancer decreased. Of the 72 cases, 50 (69%) were positive for HPV subtype 16. The ratio of HPV-positive to HPV-negative cases prior to 1995 was 0.72 (8:11) but was 3.81 (42:11) afterward. Survival was positively affected by HPV status (hazard ratio of 0.15, confidence intervals 0.07-0.36, P < .001). Disease-specific survival was 83% in the HPV-positive patients and 15% in the HPV-negative group. CONCLUSIONS: OP cancer incidence is increasing in Colorado males and to a lesser extent in U.S. males. The HPV-positive OP cancer cases were more frequent in the later years of the study. Disease-specific survival was much better in the HPV-positive patients, confirming that HPV testing defines a unique subset of patients. These findings suggest that HPV oncogenesis accounts for the increase in average annual age-adjusted incidence of OP cancer.

Monoclonal Antibodies for the Treatment of Nasal Polyps.

Biologics are novel therapeutic medications developed for the targeted therapy for a variety of inflammatory conditions. The biologics currently investigated for the treatment of chronic rhinosinusitis (CRS) with nasal polyps modulate specific inflammatory pathways involved in the pathogenesis of disease. Investigations have focused on the most severe form of the disease, namely, CRS with nasal polyps. It is hoped that specific targeted therapies using these biologics can significantly modulate the immune system, offering both disease control and symptomatic relief. This review summarizes those therapies that have been used to treat nasal polyps.

A systematic review of sinonasal oncocytomas and oncocytic carcinomas: Diagnosis, management, and technical considerations.

BACKGROUND: Oncocytomas and oncocytic carcinomas are rare tumors of the sinonasal cavity with the propensity for local invasion. This report and systematic review details a case of a nasal oncocytoma involving the lacrimal sac and provides an update of the current literature. METHODS: A systematic literature review was performed using PubMed and Ovid databases. The data obtained from published articles with sinonasal oncocytoma/oncocytic carcinoma as the primary diagnosis included patient demographics, presentation, radiographic and histologic findings, management, and recurrence rates. RESULTS: Twenty cases were identified. The most common symptoms were epistaxis (n = 11) and nasal obstruction (n = 11). Involvement of the nasal cavity was most common (n = 17), followed by the paranasal sinuses (n = 13) and nasolacrimal apparatus (n = 4). Recurrence occurred in 55% of cases. Recurrence was associated with invasion or infiltration found on histology or the presence of both invasion/infiltration and mitotic figures/pleomorphism (p < 0.05), with no significant relationship between recurrence and age at diagnosis (p = 0.42), sex (p = 0.65), and location of tumor (p = 0.14). The authors present the case of a 73-year-old woman with a 5-month history of worsening epistaxis and biopsy-proven oncocytoma. Complete surgical resection of the tumor using combined endonasal endoscopic and anterior orbitotomy approach is described. CONCLUSION: Oncocytomas and oncocytic carcinomas are rare tumors of the sinonasal cavity with a high rate of local recurrence and orbital involvement. Surgical resection is the treatment of choice and complete resection can be achieved with an endoscopic endonasal approach.

A Case Report and Systematic Review of Eosinophilic Angiocentric Fibrosis of the Paranasal Sinuses.

OBJECTIVE: There is a paucity of literature discussing prognostic factors or comparing outcomes in eosinophilic angiocentric fibrosis (EAF). This review aims to analyze tumor and patient characteristics as possible prognostic markers and compare surgical approaches. METHODS: Systematic literature review and case report analyzing available cases of EAF located within the paranasal sinuses. RESULTS: The literature search yielded 39 articles meeting criteria for a total of 59 cases (including 1 from our institution). Median patient age was 46 years. The most common presenting symptoms were nasal obstruction (69%, n = 41) and change in external nasal appearance (39%, n = 32). The majority of cases (85%) were treated with surgical resection alone or in combination with medication. Of surgical patients, 62% underwent a complete resection with a recurrence rate of 20%. Median follow-up duration was 2 years. Endoscopic approach showed a significant positive correlation with complete resection ( P = .045). Patient sex ( P = .6), tumor location (range, P = .32-.98), lateral rhinotomy ( P = .26), septoplasty ( P = .84), and external rhinoplasty ( P = .28) were not significantly correlated with total resection. Insufficient sample size precluded calculation of predictors of recurrence following surgery. CONCLUSION: This review suggests that an endoscopic approach to EAF tumor is a viable option, frequently yielding complete resection.