Comparison of treatment modalities for non-tuberculous mycobacterial cervicofacial lymphadenitis in children.

PURPOSE: We aim to compare the different treatment modalities of non-tuberculous cervicofacial lymphadenitis in children, by means of a retrospective study conducted in the University Hospitals of Leuven of patients treated between 2012 and 2022. METHODS: For this retrospective cohort study, data were collected and pseudonimised from 52 patients with non-tuberculous cervicofacial lymphadenitis, who were treated in our hospital between January 2012 and December 2022, either conservatively, antibiotically, surgically, or with a combination of these options. We only included patients who were considered immunocompetent. All of the included patients were below 10 years at time of treatment. We collected data regarding time to resolution and adverse effects, i.e., skin discoloration, excessive scar formation, fistula formation, persistence of adenopathies after treatment, need for additional treatment, facial nerve paresis/paralysis, or systemic side-effects due to antibiotic treatment. RESULTS: The mean time to resolution (in days) when looking at primary treatments, was shortest in partial excisions (16), followed by complete excisions (19), antibiotic therapy (129), incision and drainage (153), curettage (240), and finally conservative management (280). Taking into account isolated treatments (i.e., both primary and adjuvant), we also observed consistently faster time to resolution in surgical and antibiotic treatments when compared to conservative treatment. Antibiotic therapy (p = 0.003), incision and drainage (p = 0,004) were associated with a significantly higher need for adjuvant treatment. Curettage was associated with a higher incidence of fistula formation (p = 0,006) and higher number of adjuvant treatments (p = 0,002). CONCLUSIONS: This study shows a faster resolution of nontuberculous mycobacterial cervicofacial lymphadenitis in children when treated surgically, more specifically when treated with partial or complete lymph node excision. Antibiotic treatment also leads to faster resolution than conservative management. There was a low rate of complications, and no permanent facial nerve damage was reported.

Personal protection and delivery of rhinologic and endoscopic skull base procedures during the COVID-19 outbreak.

On March 11th 2020, the World Health Organization (WHO) declared COVID-19 pandemic, with subsequent profound impact on the entire health care system. During the COVID-19 outbreak, activities in the rhinology outpatient clinic and operation rooms are limited to emergency care only. Health care practitioners are faced with the need to perform rhinological and skull base emergency procedures in patients with a positive or unknown COVID-19 status. This article aims to provide recommendations and relevant information for rhinologists, based on the limited amount of (anecdotal) data, to guarantee high-quality patient care and adequate levels of infection prevention in the rhinology clinic.

Classification of parotidectomies: a proposal of the European Salivary Gland Society.

The objective of this study is to provide a comprehensive classification system for parotidectomy operations. Data sources include Medline publications, author's experience, and consensus round table at the Third European Salivary Gland Society (ESGS) Meeting. The Medline database was searched with the term "parotidectomy" and "definition". The various definitions of parotidectomy procedures and parotid gland subdivisions extracted. Previous classification systems re-examined and a new classification proposed by a consensus. The ESGS proposes to subdivide the parotid parenchyma in five levels: I (lateral superior), II (lateral inferior), III (deep inferior), IV (deep superior), V (accessory). A new classification is proposed where the type of resection is divided into formal parotidectomy with facial nerve dissection and extracapsular dissection. Parotidectomies are further classified according to the levels removed, as well as the extra-parotid structures ablated. A new classification of parotidectomy procedures is proposed.

Salivary acinic cell carcinoma: reappraisal and update.

Epidemiologic and clinicopathologic features, therapeutic strategies, and prognosis for acinic cell carcinoma of the major and minor salivary glands are critically reviewed. We explore histopathologic, histochemical, electron microscopic and immunohistochemical aspects and discuss histologic grading, histogenesis, animal models, and genetic events. In the context of possible diagnostic difficulties, the relationship to mammary analog secretory carcinoma is probed and a classification is suggested. Areas of controversy or uncertainty, which may benefit from further investigations, are also highlighted.

Penetrating and blunt trauma to the neck: clinical presentation, assessment and emergency management.

Penetrating and blunt trauma to the neck: clinical presentation, assessment ana emergency management. In Belgium, and even in Western Europe, penetrating and blunt injury to the neck is relatively uncommon in both the civilian and military populations. Pre-hospital and emergency assessment and management will therefore always prove challenging, as individual exposure to this specific type of injury remains low. Historically, the neck has been divided into three anatomical zones with specific landmarks to guide the diagnostic and therapeutic approach to penetrating neck injuries. Most penetrating injuries need to be explored surgically, although with the advent of multi-detector computed tomographic angiography (MDCTA), which yields high diagnostic sensitivity, this inflexible approach has recently changed to a more targeted management, based on clinical, radiographic and, if deemed necessary, endoscopic findings. However, some authors have addressed their concern about this novel, 'no-zone' approach, since the risk of missing less apparent aerodigestive tract injuries may increase. It is recommended, therefore, that all patients with penetrating neck injuries be closely observed, irrespective of the initial findings. The incidence of blunt neck injury is much lower, and this makes risk assessment and management even more difficult in comparison with penetrating injuries. Again, MDCTA is most often the first diagnostic tool if a blunt neck injury is suspected, due to its good sensitivity for blunt cerebrovascular injuries (BCVI) as well as for aerodigestive tract injuries. Specific patterns of injury and unexpected neurological and neuro-radiological findings in trauma patients should always warrant further investigation. Despite ongoing debate, systemic anticoagulation is recommended for most BCVI, sometimes combined with endovascular treatment. Aerodigestive tract injuries may present dramatically, but are often more subtle, making the diagnosis more difficult than other types of neck injuries. Treatment may be conservative if damage is minimal, but surgery is warranted in all other cases.

Complex intubation, cricothyrotomy and tracheotomy.

Complex intubation, cricothyrotomy and tracheotomy. Successful management of a difficult airway begins with recognizing the potential problem. When the patient cannot breathe spontaneously, oxygenation and ventilation should start first with bag-valve ventilation, with or without an airway adjunct such as a Mayo cannula, followed by an orotrache4l intubation attempt, performed by an experienced emergency doctor. If orotracheal intubation fails, a quick decision must be made regarding surgical options. In a "cannot intubate, cannot ventilate" situation, a surgical cricothyrotomy should be considered. When orotracheal intubation is impossible, but bag-valve or laryngeal mask ventilation is possible, an urgent surgical tracheostomy should be performed. In the long run, patients in need of longterm artificial ventilation will need a percutaneous or open tracheostomy. This review provides an update of all aspects of immediate and long-term airway management.

Early experience in transoral robotic surgery (TORS) for non-oropharyngeal head and neck malignancies: a review of functional and oncologic outcomes.

OBJECTIVE: To review and summarize functional and oncologic outcomes after transoral robotic surgery (TORS) for non-oropharyngeal head and neck malignancies. DATA SOURCES: The MEDLINE database and bibliographies of relevant studies were searched through December 2014. METHODS: Search strategy was ((transoral) AND surgery) AND robotics) OR TORS. Abstracts and titles were screened for relevance and full articles of the selected records were evaluated and critically appraised after inclusion. Data concerning functional and oncologic outcomes as well as adverse effects were collected. RESULTS: 22 records were eventually included in the review. For TORS in the treatment of glottic, hypopharyngeal ands supraglottic cancer we retained 3 case series (26 patients), 5 case series (36 patients) and 6 case series (67 patients) respectively. 8 case reports/series (14 patients) assessing safety and feasibility of TORS for tumours in the parapharyngeal space, nasopharynx and skull base were also evaluated. In general, treatment of laryngeal and hypopharyngeal cancer by means of TORS seems to be feasible and safe with satisfying functional and short-term oncologic results. For treatment of malignant tumours in the parapharyngeal space, nasopharynx and skull base, the benefits of TORS, when compared to classic surgical techniques, are still uncertain and are particularly based on theoretical advantages. CONCLUSION: TORS offers an interesting new approach for treating non-oropharyngeal head and neck malignancies. However, long-term results are still not reported and TORS should be directly compared to existing therapeutic options in randomized controlled trials. Until then, its use should be subject to critical appraisal.

Superficial circumflex iliac artery perforator flap for reconstruction of oral defects after tumor resection.

BACKGROUND: The superficial circumflex iliac artery perforator (SCIP) flap, which is the most recent advance in free flap surgery, is described as an evolution of the conventional free groin flap. It has been applied to limb and penile reconstruction. The SCIP flap is versatile and has many advantages, but there are few reports on the application of the SCIP flap to head and neck defects. CASE REPORT: We used a SCIP flap for reconstruction after resection of an oral malignant tumor in two women, aged 43 and 55 years, who presented between 2010 and 2012 with squamous cell carcinoma of the right floor of the mouth and tongue. After resection, the SCIP flap was elevated and used to reconstruct the defect Both flaps survived well. CONCLUSIONS: We confirmed that the SCIP flap is an ideal thin, pliable, and reliable skin flap for reconstructing intra-oral soft-tissue defects with minimal donor-site morbidity.

Review: Facial endophenotypes in non-syndromic orofacial clefting.

Cleft lip and/or palate (CL/P) is one of the most frequent congenital malformations, with a frequency of 1 in 700 live births. Non-syndromic orofacial clefting is a multifactorial condition, with both a genetic and an environmental component. Although numerous studies have been published addressing the genetic etiology of CL/P, this factor remains incompletely understood. A promising approach to find candidate gene regions for CL/P is the investigation of endophenotypes, which are characteristics associated with a certain condition and that can be an expression of underlying susceptibility genes. This review focuses on the known facial endophenotypes in CL/P (such as distortion of the orbicularis oris muscle and facial features in non-affected relatives of patients with CL/P) and genes that could be associated with these characteristics. Possibilities for further endophenotype-related studies in the field of non-syndromic CL/P are discussed.

Evaluation of transverse maxillary expansion after a segmental posterior subapical maxillary osteotomy in cleft lip and palate patients with severe collapse of the lateral maxillary segments.

Objective : The purpose of this longitudinal retrospective study was to evaluate transverse maxillary expansion after a Schuchardt or segmental posterior subapical maxillary osteotomy (SPSMO) in patients with cleft lip and palate (CLP). A second aim was to compare these data with data for adult patients without CLP who were receiving a surgical assisted rapid palatal expansion (SARPE). Method : The study group comprised 19 patients with CLP and a severe transversally collapsed maxilla who were treated with SPSMO followed by hyrax expansion at the University Hospitals Leuven. Dental casts of the 19 patients were analyzed before treatment, at maximum expansion, during orthodontic treatment, at the completion of orthodontic treatment. and 2 years after orthodontic treatment and were measured at the canine, premolar, and molar levels. Adult patients without CLP who were enrolled in a prospective study served as the control group. Results : Maxillary expansion within the study group was significantly greater (P < .05) at all measured levels compared with the maxillary arch before treatment. No significant relapse was measured in the study group 2 years after orthodontic treatment. When comparing the study and control groups, the only statistical difference was that canine expansion was significantly greater in the study group. Conclusion : SPSMO followed by maxillary expansion and orthodontic treatment is an appropriate treatment option to correct a severe transversally collapsed maxilla in patients with CLP. The overall treatment effect of SPSMO expansion is comparable with the effects of SARPE, although canine expansion was greater in the SPSMO group.

Evaluation of Transverse Maxillary Expansion After a Segmental Posterior Subapical Maxillary Osteotomy in Cleft Lip and Palate Patients With Severe Collapse of the Lateral Maxillary Segments.

Objective : The purpose of this longitudinal retrospective study was to evaluate transverse maxillary expansion after a Schuchardt or segmental posterior subapical maxillary osteotomy (SPSMO) in patients with cleft lip and palate (CLP). A second aim was to compare these data with data for adult patients without CLP who were receiving a surgical assisted rapid palatal expansion (SARPE). Method : The study group comprised 19 patients with CLP and a severe transversally collapsed maxilla who were treated with SPSMO followed by hyrax expansion at the University Hospitals Leuven. Dental casts of the 19 patients were analyzed before treatment, at maximum expansion, during orthodontic treatment, at the completion of orthodontic treatment. and 2 years after orthodontic treatment and were measured at the canine, premolar, and molar levels. Adult patients without CLP who were enrolled in a prospective study served as the control group. Results : Maxillary expansion within the study group was significantly greater (P < .05) at all measured levels compared with the maxillary arch before treatment. No significant relapse was measured in the study group 2 years after orthodontic treatment. When comparing the study and control groups, the only statistical difference was that canine expansion was significantly greater in the study group. Conclusion : SPSMO followed by maxillary expansion and orthodontic treatment is an appropriate treatment option to correct a severe transversally collapsed maxilla in patients with CLP. The overall treatment effect of SPSMO expansion is comparable with the effects of SARPE, although canine expansion was greater in the SPSMO group.

Incidence of multiglandular disease in sporadic primary hyperparathyroidism.

OBJECTIVES: Multiple, minimally invasive surgical techniques have been developed over the last few decades for the management of sporadic primary hyperparathyroidism (PHTP). However, in cases with multiglandular disease, bilateral cervical exploration remains the gold standard. Therefore, it is important to have an accurate estimation of the incidence of multiglandular disease in sporadic PHTP. METHODOLOGY: 698 patients were treated for PHTP between 1993 and 2010 at the University Hospitals Leuven, using the bilateral cervical exploration method. After excluding cases of multiple endocrine carcinoma syndrome, the incidences of double adenoma and multiple gland hyperplasia were investigated in these patients. Age, gender, imaging results, serum calcium and parathyroid hormone concentrations were analyzed and compared to the data of 50 randomly-selected, PHTP patients with solitary adenomas. RESULTS: 6.6% and 2.4% of the patients with sporadic PHTP had double adenomas and multiple gland hyperplasia, respectively. The female/male ratio was 4.8 (38/8) and 1.8 (11/6), and the average age was 63 and 52 yrs for patients with double adenomas and multiple gland hyperplasia, respectively. The patients with solitary adenomas had a female/male ratio of 3.5, and an average age of 60 yrs. There were no significant differences in serum calcium or parathyroid hormone concentrations between patients with multiglandular disease and those with solitary adenomas. CONCLUSIONS: Multiglandular disease occurs in 9% of patients with sporadic PHTP, and cannot be excluded before surgery. This incidence must be considered when using minimally invasive techniques for treatment of sporadic PHTP. In cases of multiglandular disease, bilateral cervical exploration is indicated.

Learning curve in tracheal allotransplantation.

The first vascularized tracheal allotransplantation was performed in 2008. Immunosuppression was stopped after forearm implantation and grafting of the recipient mucosa to the internal site of the transplant. Nine months after forearm implantation, the allograft was transplanted to the tracheal defect on the radial blood vessels. Since then, four additional patients have undergone tracheal allotransplantation, three (patients 2-4) for long-segment stenosis and one (patient 5) for a low-grade chondrosarcoma. Our goal was to reduce the time between forearm implantation and orthotopic transplantation and to determine a protocol for safe withdrawal of immunosuppressive therapy. Following forearm implantation, all transplants became fully revascularized over 2 months. Withdrawal of immunosuppression began 4 months after graft implantation and was completed within 6 weeks in cases 2-4. Repopulation of the mucosal lining by recipient cells, to compensate for the necrosis of the donor mucosa, was not complete. This resulted in partial loss of the allotransplant in patients 2-4. In patient 5, additional measures promoting recipient cell repopulation were made. The trachea may be used as a composite tissue allotransplant after heterotopic revascularization in the forearm. Measures to maximize recipient cell repopulation may be important in maintaining the viability of the transplant after cessation of immunosuppression.

Medullary thyroid cancer: prognostic factors for survival and recurrence, recommendations for the extent of lymph node dissection and for surgical therapy in recurrent disease.

BACKGROUND: We reviewed our experience with MTC (medullary thyroid cancer), focusing on recurrence and survival, recommendations for the extent of lymph node (LN) dissection and surgery for recurrent disease. METHODS: Of 51 MTC patients treated between 1988 and 2008 at the University Hospitals Leuven, 38 previously untreated patients were analysed. RESULTS: Overall and disease-specific (DSS) five-year survival rates were 75% and 82%. Variables univariately associated with DSS were age, pN, stage, vascular invasion, pre-operative recurrent laryngeal nerve function and last calcitonin level. Recurrence occurred in 10 patients (26%). For recurrence, age was no longer a prognostic factor and post-operative calcitonin, number of positive LN and of positive compartments proved to be prognostic factors. Of 21 clinical NO patients, 2 out of 6 (33%) undergoing a prophylactic central neck dissection (ND) based on per-operative palpatory suspicion proved pN+, and 2 out of 9 patients (22%) undergoing a prophylactic lateral ND were pN+. Five patients surgically treated for recurrence did not achieve long-term normalisation of calcitonin, but remained alive with locoregional control. CONCLUSION: Overall survival and DSS rates are within the range reported in the literature. The results confirm that (1) total thyroidectomy and central compartment dissection is the treatment of choice in the cN0 patients, (2) additional ipsilateral lateral ND is needed for cN+ disease in the ipsilateral lateral compartment, and (3) in the clinically uninvolved contralateral lateral neck, per-operative inspection should serve as a basis for a decision about further ND. Locoregional control and prolonged survival is achieved in surgically treated locoregionally recurrent MTC.

Adenocarcinomas of the sinonasal tract: current opinion.

Malignant tumours of the sinonasal tract represent a rare condition, accounting for only 0.5-1% of all malignancies in the Western population. Patients with malignant tumours of the nasal cavity and sinuses form a heterogeneous group when it comes to histology and treatment protocols. This review of adenocarcinoma of the sinonasal tract aims to provide a comprehensive overview of aetiological factors, histological subtypes, diagnostic workup, currently available treatment options, survival analysis and prognostic factors for treatment outcome. The current treatment of choice is surgical resection, using whichever approach allows access for the removal of the entire tumour with a curative intent.

Pre-operative imaging in primary hyperparathyroidism with ultrasonography and sestamibi scintigraphy.

PROBLEM/OBJECTIVE: Resection of pathological parathyroid glands is the only curative therapy in primary hyperparathyroidism. Adequate pre-operative localization of the pathological glands is very useful, whichever surgical technique is preferred. OBJECTIVES: The aim of our study was to evaluate and compare high resolution ultrasonography and sestamibi scintigraphy as pre-operative imaging techniques and to explore their relationship with certain demographic and biochemical variables. PATIENTS AND METHODS: Data from 368 patients with primary hyperparathyroidism referred for surgery were retrospectively analysed. The results of pre-operative imaging were compared with the operative findings and the anatomopathological report. RESULTS: In predicting the correct side of the lesion (right or left), ultrasonography had a positive predictive value (PPV) of 84%, whereas sestamibi imaging had a PPV of 93%. If both imaging techniques had a concordant positive result, the PPV was 99%. The PPV in predicting the correct quadrant, however, was only 61% for sestamibi scintigraphy and 40% for ultrasonography. CONCLUSIONS: In our study, sestamibi imaging was better than ultrasonography as a single pre-operative localization imaging method for primary hyperparathyroidism. A concordant positive result was exceedingly reliable in indicating the side of the lesion. It seemed far more difficult to predict the quadrant correctly, especially because of misinterpretation of the upper adenomas.

Cyclophosphamide, doxorubicin, and cisplatin in advanced salivary gland cancer.

OBJECTIVES: Advanced salivary gland cancer is a rare disease that comprises different histopathological tumour types; correspondingly, data on palliative systemic treatment are scarce. Combination chemotherapy with cyclophosphamide, doxorubicin, and cisplatin (CAP) has been reported to induce a reasonable response rate, although fewer than 100 cases have been described. We conducted a retrospective review of advanced salivary gland cancer patients treated with CAP. METHODOLOGY: Fifteen consecutive patients with recurrent, locally advanced, or metastatic progressive salivary gland cancer treated with CAP were identified over a five-year period. The mean age at start of treatment was 53.5 years, and the male/female ratio was 11/4. The most common histological subtypes were adenoid cystic carcinoma and adenocarcinoma not otherwise specified (NOS), with the parotid gland as the most frequently affected anatomical site. RESULTS: A response rate of 60% was achieved, with one complete and eight partial responses and six stable diseases according to RECIST criteria. No patient progressed under treatment. An average of 5.4 treatment cycles were administered; median time to progression after ending CAP was 6.6 months, and median overall survival was 15.1 months. Patients with adenocarcinoma NOS appeared to benefit more than patients with adenoid cystic carcinoma, but had a shorter time to progression. Except for neutropenia with neutropenic fever and alopecia, no NCI-CTC grade III or IV toxicity was observed. CONCLUSION: This retrospective study confirms the clinically meaningful efficacy of CAP in advanced adenocarcinomas NOS of the salivary gland in routine practice, with acceptable safety levels.

Unique approach to secondary cleft-lip rhinoplasty in facial plastic surgery.

Rhinoplasty occupies a unique position in facial plastic surgery due to the central position of the nose in the face and the vital functions of the nose. Among facial plastic surgeons, secondary rhinoplasty in adult cleft-lip patients is considered to be one of the most challenging surgical interventions due to the congenital distortion of the cartilaginous and bony nasal pyramid, with consequences for both nasal aesthetics and breathing. In spite of the challenging nature of the procedure, post-operative satisfaction is high, matching that of non-cleft-lip patients, as long as appropriate surgical techniques are applied. Specific rhinoplasty methods are used in unilateral or bilateral cleft-lip patients with extensive grafting, combined efforts for aligning the nasal dorsum and the creation of symmetry in the nasal tip, medialisation of the anterior nasal spine with augmentation of the premaxilla, correction of nasal vestibulum stenosis and specific post-operative care with a nasal vestibulum device. This review aims to address some specific surgical issues relating to cleft-lip rhinoplasty, resulting in the high subjective satisfaction rate reported by cleft patients operated upon in the University Hospitals Leuven.

The role of radioactive iodine in the management of patients with differentiated thyroid cancer - An oncologic surgical perspective.

With improved understanding of the biology of differentiated thyroid carcinoma its management is evolving. The approach to surgery for the primary tumour and elective nodal surgery is moving from a "one-size-fits-all" recommendation to a more personalised approach based on risk group stratification. With this selective approach to initial surgery, the indications for adjuvant radioactive iodine (RAI) therapy are also changing. This selective approach to adjuvant therapy requires understanding by the entire treatment team of the rationale for RAI, the potential for benefit, the limitations of the evidence, and the potential for side-effects. This review considers the evidence base for the benefits of using RAI in the primary and recurrent setting as well as the side-effects and risks from RAI treatment. By considering the pros and cons of adjuvant therapy we present an oncologic surgical perspective on selection of treatment for patients, both following pre-operative diagnostic biopsy and in the setting of a post-operative diagnosis of malignancy.

Surgical findings and post-operative parathormone levels in patients with secondary hyperparathyroidism.

OBJECTIVE: The peri-operative and immediate post-operative outcome of secondary hyperparathyroidism treated with subtotal parathyroidectomy is reported. METHODS: We studied 100 patients with chronic renal failure who underwent subtotal parathyroidectomy at our department. Surgical eligibility was based on hyperparathyroidism stage, defined by symptoms of osteodystrophy and/or the presence of hypercalcemia and hyperphosphatemia refractory to medical treatment. Parathormone levels were measured pre-operatively and during the first post-operative days. RESULTS: During surgery, four parathyroid glands were identified in 86% of patients, five glands in 1%, and less than four glands in 13%. The ratio of hyperplastic to normal glands was 93:7. No correlation was found between anatomic location of the glands and the presence of hyperplasia. Parathormone decreased to normal or very low values in 93% of the patients. In seven cases, the lowest post-operative parathormone value was above 30 pg/ml, although four glands were removed in four of these patients. In 95% of the patients with four or more identified glands, post-operative serum parathormone levels decreased to normal or very low values. In 23% of the patients with less than four glands, parathormone levels remained too high. On the other hand, post-operative parathormone values normalized in 10 patients who had less than four glands identified during surgery; in two of them, parathyroid tissue was found during postoperative pathological examinations of the resected thyroid lobe. CONCLUSIONS: Subtotal parathyroidectomy is an acceptable treatment in patients with refractory hyperparathyroidism. Our results indicate that there was not a perfect correlation between the number of identified glands and post-operative parathormone in a subset of patients.