Annals of Otolaryngology and Rhinology: September 2015

Wednesday 30 September 2015

Effect of Intratympanic Dexamethasone in Intractable Unilateral Meniere’s Disease

Pradeep Pradhan, Kanwar Sen and Priti Lal

Abstract:
Objective: To evaluate the effectiveness of Intratympanic dexamethasone in controlling vertigo and sensor neural hearing loss in intractable Meniere’s disease.
Methods: 30 patients with intractable Meniere’s disease were treated with intratympanic dexamethasone injections. Post treatment pure tone audiograms and dizziness scores were compared with the pretreatment audiogram and dizziness scores respectively.
Results: Improvement in mean vertigo score was noticed from 91.58 (range 80 -100) (pretreatment) to 49.295 (p=0.351) at 6 months and to 60.4 (p= 0.974) at the end of 2 years after intratympanic injection. 9 (40.90%) and 5 (25%) patients were found to be free of vertigo at the end of 06 months and 2 years respectively. None of the patients showed any significant improvement in hearing (>10dB) at the end of 2 years of follow-ups. Only one patient was found with a small central perforation at the end of 1 month of treatment.
Conclusion: Intratympanic steroid is a safe and an effective method of treating intractable Meniere’s disease. Although improvement in vertigo was more pronounced in the short term, 25% of the patients were detected free of vertigo at the end of 2 years. No significant improvement in hearing was noticed after 2 years of treatment.]

Endoscopic Assisted Neck Dissection via Retro Auricular Approach Versus Conventional Technique

Phakdee Sannikorn* and Nut Niyomudomwatana

Abstract:
Background Most standard surgical treatment of cervical lymph node metastasis of Head and neck cancer is Conventional neck dissection. Recently, the skin incision has been modified to smaller incision than previous by using a special technique such as Robotic surgery system. In unavailable special system, we have to apply our instruments to do neck dissection via modified incision. The aim of our study was to compare surgical outcomes of Endoscopic assisted neck dissection and conventional neck dissection.
Method From March 2013 to August 2013, 70 patients with cervical lymph node metastasis of head and neck cancer were enrolled in this study. Of these patients, 10 patients desired the endoscopic assist retro-auricular neck dissection, and 60 patients were done conventional approach. Demographic data were recorded. Total excised lymph nodes and total operation time of both groups were compare.
Result The mean total excised lymph nodes was no statistical different between two groups. However, mean total operative time of endoscopic assisted technique was longer than conventional approach, but there was no statistical different between two groups. Patients with retro auricular neck dissection are better aesthetic outcome and less local skin flap swelling.
Conclusion In unavailable Robotic surgery system situation, we can apply existing instrument to do endoscopic assisted retro-auricular which gave us a good aesthetic outcome but do not compromise to the disease control outcome.

Tumor of the Temporal Bone Mimicking Acute Mastoiditis

Julian Küstermeyer*, Helmut Ostertag, Jörg Hattingen and Hans-Jürgen Welkoborsky

Abstract:
Background: Tumors of the temporal bone in general and particular in children are extremely rare. The anatomical conditions of that special anatomic region can cause misleading symptoms. Diagnosis of rare tumor entities of the skull base in children is a challenging interdisciplinary task.
Objective: The purpose of the present article is to describe the diagnostic process of a rare pathologic condition and review the literature with current opinions of diagnostic and therapeutic methods with respect to angiosarcomas.
Methods: We report about a 13 years old boy with an angiosarcoma of the temporal bone. A review of the literature with particular emphasis on the diagnostic procedures was performed.
Results: The clinical and histological characteristics are reported in here. To date less than 20 cases of angiosarcomas of the temporal bone are published in the literature. Although a large variety of diagnostic methods is available, diagnosing and grading of such a rare tumor is still challenging.
Conclusion: Angiosarcoma of the temporal bone is extremely rare. The symptoms are unspecific, and can mimicking, like in this case, an acute mastoiditis. Diagnosis is challenging and only possible by Immunohistochemical examinations. Diagnosis of such rare pathologic conditions requires an interdisciplinary teamwork and collaboration of different institutions. Current technologies allow an easy exchange of knowledge all around the world for characterizing diseases precisely, and getting the experience of specialists together. This is crucial for a targeted and effective treatment.

Crushed Septal Cartilage Graft in Rhinoplasty and Nasal Septal Surgery: Clinical Outcomes and Complications

Deepak Verma and Neeraj Narayan Mathur*

Abstract:
Objectives: To assess clinical outcomes and complications with the use of crushed septal cartilage graft in rhinoplasty and nasal septal surgery.
Method: A prospective clinical study has done at a tertiary referral centre included 32 patients who underwent crushed cartilage grafting during rhinoplasty and nasal septal surgery with autogenous septal cartilage as the graft material. Slight or moderately crushed septal cartilage grafts were used to augment nasal dorsum, nasal tip and for septal correction. Photographic and endoscopic assessment was done preoperatively and postoperatively at 10th day, 1, 3 and 6 months to assess clinical outcomes and complications including graft resorption, warping, extrusion and any postoperative deformity.
Result: Among 32 patients, 19 underwent rhinoplasty and rest 13 nasal septal correction. Complications encountered were postoperative deformity in 3 patients of rhinoplasty and persistent septal deviation in 2 patients of septoplasty. There was no graft resorption, rejection, or extrusion.
Conclusion: Crushed cartilage appears to be a good graft material to conceal nasal irregularities and fill nasal dorsal defects in rhinoplasty and to obtain good functional outcomes in septoplasty.

The Use of Autologous Fascia Lata Graft Aided with Pedicled Muscle Flap in the Repair of Pharyngeal Tears

Tiba M*, Hasaballah M, Askoura A and Kassamy H

Abstract:
Introduction: Management of pharyngo-esophageal tears is challenging as it can end in mediastinitis and/or carotid blow out. Pharyngo-esophageal tears accompanied by suppuration or other neck’s vital structures injuries are more complicated.
Patients and Methods: This study addressed the use of non-vascularized autologous fascia lata graft in addition to a pedicled sternomastoid flap as a second layer in the repair of wide, primary irreparable pharyngeal tears. This was done to four patients with pharyngeal tears at Ain Shams University Hospitals, Cairo, Egypt. Pre and post-operative laryngeal examination, CT scan neck with contrast swallow were done.
Results: All patients showed complete closure of the pharyngeal tear. The harvesting of the grafts produced neither functional deficits nor complications at the donor site.
Discussion: The procedure was found to be effective with complete sealing of the tear as proved clinically and radiologically.

Comparative Histological Analysis of Collagen and Elastic Fibers Present in the Ventricular Folds and the Vocal Folds of Cadaveric Larynges

André Silva Luca, Devandir Antonio de Souza Júnior, Rui Celso M Mamede, Maria Célia Jamur

Abstract:
Introduction: Knowledge of the structural features of the vocal fold and the ventricular fold may help to understand the phonation process, and consequently may facilitate the use of the ventricular fold in phonation after laryngeal damage. Objective: To compare the histology and the distribution of collagen and elastic fibers between the ventricular folds and the vocal folds.
Methods: Hemilaringes from 14 male cadavers were collected, processed for histology, sections stained for collagen and elastic fibers and analyzed.
Results: The major part of the ventricular fold was lined with pseudostratified ciliated columnar epithelium containing goblet cells. In the ventricular folds the collagen fibers are homogeneously distributed in layers. In contrast, in the vocal fold the collagen fibers are unorganized and have a heterogeneous distribution. The percent of total collagen and of type I and type III collagen is similar between the vocal fold and the ventricular fold. However, the percent of type I collagen is increased in the ventricular fold in comparison to type III collagen. In the ventricular fold the elastic fibers are found in all layers of lamina propria, while in the vocal fold these elastic fibers are preferentially found in the deep layer of the lamina propria. The percent of elastic fibers is similar between the vocal folds and the ventricular folds.
Conclusion: The percentage of collagen fibers and elastic fibers is similar between the vocal fold and the ventricular fold. However, in the ventricular fold the percentage of type I collagen is greater than type III collagen.

Complicated Pansinusitis Masquerading Orbital Apex Syndrome

M. Silva*, JC. Ribeiro, J. Romão and A. Paiva

Abstract: Orbital Apex Syndrome is a very rare clinical diagnosis presented to ENT surgeons. Intraorbital extramedullary plasmacytoma is extremely rare and there are a few cases reports in the literature. Very unusually it develops a secondary leukemic transformation to a plasma cell leukemia which is a very rare and aggressive type of acute leukemia (in our tertiary hospital, Hematology Department had previously 3 cases in the last fifteen years).
Orbital apex syndrome is a rare but potentially fatal situation rarely seen initially by ENT surgeons. We report an even rarer case of an intraorbital extramedullary plasmacytoma that caused orbital apex syndrome, initially masqueraded by a complicated pansinusitis.
An immunosuppressed 78-year-old female presented with a progressive left side reduced best corrected visual acuity, pansinusitis and orbital involvement, imaging showed opacification of all paranasal sinuses, cavernous sinus involvement and left intraorbital mass lesion. After an initial improvement with antibiotics, sudden clinical deteriotion occurred. Biopsy of the intraorbital mass showed a monoclonal lymphoid neoplasm and laboratory findings led us to the diagnosis of plasma cell leukemia.
We advocate for a multidisciplinary approach ab initio in all cases of complicated rhinosinusitis to minimize or prevent deterioration of vision and optimize clinical outcomes.

Huge Sublingual Ranula: A Closer Look to Effective Surgical Removal

Tan SN, Ramli R and Primuharsa Putra SHA

Abstract: Ranulas are uncommon cystic type of lesion which resulted from mucus filled cavity in the floor of the mouth that is unique to the sublingual gland. This article highlights a case report on management of sublingual ranula in a 16-year-old male with emphasis on the effective method of surgical removal.

Lateral Canal Benign Paroxysmal Positional Vertigo: A Review of its assessment and Treatment Options

L. Califano*, F. Salafia, MG. Melillo and S. Mazzone

Abstract: Benign paroxysmal positional vertigo (BPPV) is the most common vestibular syndrome. It is characterized by short lasting spelling of vertigo when patient change his/her head position in the space. The putative pathogenesis is the dislodgement of otoliths from the utricular macula to semicircular canals. The most frequent form is posterior canal BPPV, whereas lateral canal BPPV is reported in about 20% of cases. Various forms of lateral canal BPPV are reported: geotropic variant, apogeotrophic variant and, more recently, a Direction-fixed nystagmus variant, which is the rarest form. Mechanisms other than canalar lithiasis could be involved in the pathogenesis of lateral canal BPPV, namely situations of “heavy cupula’’ and “light cupula”. Liberatory therapy is very effective and the shift from an apogeotrophic form to a geotropic form is considered useful for a better outcome. Aim of the paper is to present a review of current pathophysiological hypothesis about lateral canal BPPV, its assessment and therapeutic options.

CHAT about CHAT (Childhood AdenoTonsillectomy)

Stuart G. MacKay and Nicholas W. Stow

Abstract: Following the publication of a randomized controlled trial (RCT) of adenotonsillectomy (TA) for obstructive sleep apnea (OSA) in 464 children aged 5 to 9 years [1], some discussion has been inaccurately negative in regards to interpretation of the study’s findings [2]. This commentary seeks to explore the misinterpretations and highlight the critical strengths and limitations of the RCT in question.

Circumferential Elevation of Tympanomeatal Flap: A Novel Technique for subtotal and Anterior Perforation Closure

Pradeep Pradhan*, Abhimanyu Amant and Priti Lal

Abstract:
Background: Circumferential elevation of tympanomeatal flap is considered to be an effective surgical procedure for tympanic membrane grafting. Here we have demonstrated its technique and compared its results between subtotal and anterior perforations by placing the graft medial and lateral to handle of malleus respectively.
Material and methods: 34 patients with chronic otitis media underwent type I underlay tympanoplasty with circumferential elevation of tympanomeatal flap. Temporalis graft was placed medial and lateral to handle of malleus in 18 (group A) and 16 (group B) patients respectively. The results were compared between two groups after 06 months.
Results: TM closure was found in 84% and 93% patients in group A and group B respectively (p=0.58) at the end of 6 months. In group A, the air bone (AB) closure was 9.44 dB and in group B it was 8.70 dB (p=1.00). Overall mean AB closure was found to be 9.09 dB. There were no major postoperative complications noticed in both the group.
Conclusion: Circumferential flap elevation in subtotal and anterior perforation is an effective surgical technique in type I tympanoplasty with successful outcome. Media or lateral placement of graft to handle of malleus did not significantly affect the final outcome.

A Case of Maxillo Palatal Mid Face Fracture

Selman Karaci* and Rustu Kose

Abstract: The maxilla located in the mid face between strong frontal bars and the andibula. The maxilla consists of a body and four processes: Frontal, zygomatic, palatine, and alveolar processes. The body involves a space to form the maxillary sinus. Different, patterns of maxillary fractures were defined by René Le Fort, which he designed ‘‘lines of weakness'' and he also described sagittal fractures of the maxilla and palate.
In our case, the intensity and direction of the impact caused to a whole fragment. The fractured bones that were laid in the same unit. The nasal-maxillary triangle and alveolar processes and teeth of the maxilla and a half shelf of the palate. The presented case is of interest because of the maxillary and midline sagittal fracture of the palate, in a monoblock form displaced excessively posteriorly, it has satisfactorily restored preinjury occlusal relationship. Stabilization is achieved by applying plate fixation.
The split palate and sagittal maxillary fractures are less commonly encouraged than the other types of Le Fort fractures. Palatal fractures have been classified by a number of authors on the basis of fracture location, surgical approaches to be employed and stabilization preferences. The involvement of maxillary alveolus in the fracture results in difficulties in the maintenance of maxillary dental alignment post-fracture fixation.

An En plaque Meningioma of the Temporal Bone, Complicating with a Cholesteatoma, Chronic Otitis Media and an Intracranial Abscess

Riste Saat*, Laura J. Lempinen, Anu Laulajainen-Hongisto, Antti Markkola and Jussi Jero

Abstract: We describe an initially misdiagnosed case of a meningioma en plaque of the temporal bone. The tumor had obliterated the external ear canal, induced a chronic inflammation and a cholesteatoma of the external and middle ear, and complicated with an external fistula and intracranial abscess formation. Massive bone involvement and scarce soft tissue component of the skull base meningioma en plaque often pose differential diagnostic challenges in imaging. We hereby review some typical CT and MRI characteristics that could help making the correct diagnosis.

High Risk Cutaneous Squamous Cell Carcinomas of the Pinna with Dissemination to the Temporal Bone Contemporary Oncological Management

Isaac Zucker, Barry O'Sullivan, Rory McConn Walsh and James Paul O'Neill*

Abstract:
Background: Temporal Bone Malignancies (TBMs) are a rare but distinct set of neoplasms with a multifactorial etiology.
Case Presentation: We report a case of a present a case of 62 year old male with high risk squamous cell carcinoma of the pinna which despite primary surgery and adjuvant radiation disseminated into the temporal bone requiring combined salvage surgery.
Discussion: The Etiology, symptoms, staging system and surgical procedure of TBMs are discussed along with a detailed review of the three-team approach involving a neuro-otology surgeon, head and neck oncologic surgeon and plastic surgeon, are discussed in approaching surgery of TBMs.
Conclusion: In our center a multidisciplinary approach including a neuro-otology surgeon, head and neck oncologic surgeon and plastic surgeon are essential for surgical salvage resection and reconstruction of TBMs.

Spontaneous Atraumatic Posterior Mediastinal Hemorrhage: A Rare Case Report and Review of Literature

Deepak Verma*, Himani Lade, Gul Motwani, Anupal Deka and Noor Malik

Abstract:
We are reporting a rare case of spontaneous atraumatic mediastinal hematoma in a previously apparently healthy middle aged female who presented with acute onset dysphagia, increasing neck swelling and spontaneous neck and chest bruising. Plain chest radiograph showed widening of the mediastinum. Contrast CT scan of neck and chest revealed a soft tissue swelling in retropharyngeal space causing esophageal compression anteriorly confirming the diagnosis of Posterior Mediastinal Hemorrhage. There are only few cases of posterior mediastinal hemorrhage reported in the literature. The etiology remains uncertain and the treatment modalities can be classified into 2 broad categories: conservative and operative management. We present this rare condition and its management discussed.

Unusually Large Pilomatrixoma in the Neck

Anish Abrol*, Matthew M Smith and Alvin B Ko

Abstract:
A 55-year-old Hispanic woman presented with a slow growing right-sided neck mass that was intermittently painful over the last year. There were no complaints of difficulty swallowing or breathing. Physical examination identified a four centimeter mobile, painless right submandibular neck mass. Computed tomography (CT) revealed a 3.1 cm lesion superficial to the platysma and fine needle aspiration was non-diagnostic. Excision of the mass confirmed a grey, well circumscribed mass with gritty consistency. Pathological examination revealed an epithelial neoplasm arranged in a nest of basaloid cells forming shadow cells among a multinucleate giant cell reaction. This neck mass was believed to be a pilomatrixoma, a rare, benign neoplasm arising from hair cortex cells. These masses most commonly arise in children, but can occur at any age in both males and females. Typically, pilomatrixomas are located on the eyebrows, scalp, trunk, and upper extremities. Symptoms typically include pain, tenderness, and inflammation from a solitary mass ranging from 0.5 to 3 centimeters. CT scan, ultrasound, and Magnetic Resonance Imaging (MRI) can all be used in the diagnosis, but fine needle aspiration is usually the test of choice. Pathology typically demonstrates ghost cells, basaloid cells, and calcium deposition. Treatment is complete surgical excision, and recurrence is as a low as 1% following excision.

Anatomical and Hearing Outcomes of Endoscopic Assisted Atticotomy with Cartilage Tympanoplasty in Cases of Limited Mastoid Disease

Pradeep Pradhan*, Swagatika Samal and Santanu Mandal

Abstract:
Objective: To study the anatomical and hearing outcomes in endoscopic assisted atticotomy with cartilage tympanoplasty in patients with limited mastoid disease (involving attic, antrum).
Material and methods: Study was conducted in a tertiary care referral hospital between July 2012 and April 2015. Total 28 patients with limited mastoid diseases were included in the study. All underwent endoscopic assisted atticotomy and cartilage tympanoplasty. Patients were evaluated at 3 months, 6 months and 12 months after surgery to assess the graft uptake and hearing outcome. In postoperative period, ≥10 dB closure of air bone gap was considered significant improvement in hearing.
Result: Of 28 patients, cholesteatoma involving attic was found in 13(45%) patients, posterorsuperior mesotympanum in 7(25%) patients and 8(30%) patients presented with attic retraction. Out of 28 patients, 8(28.57%) were undergone type I tympanoplasty, 16(57.14%) were undergone type IIIB tympanoplasty and 4(14.28%) were undergone type IIIC tympanoplasty. The mean AB closure were 11.13 dB, 9.56 dB, and 8.0 dB in type I, type IIIB and type IIIC cartilage tympanoplasty respectively after 12 months. 75% of patients with type 1 tympanoplasty, 6(37.50%) patients with type IIIB tympanoplasty showed significant improvement in hearing (≥10.00 dB). 2 patients had residual perforation after 3 months of surgery and none of them had postoperative retraction.
Conclusion: Atticotomy supplemented with otoendoscopy is an effective surgical technique for the management of limited mastoid disease and autologous conchal cartilage is an ideal autograft considered for the reconstruction of the attic and for cartilage tympanoplasty associated with satisfactory outcomes.

Long Term Effects of L'Aquila Earthquake on Tinnitus

Alberto Eibenstein, Matteo De Luca, Alessandra Barbara Fioretti, Theodoros Varakliotis*, Sara Cisternino, Luisa Crosta and Maria Lauriello

Abstract:
Aim: The aim of this study was to deeply investigate the relationship between tinnitus, hyperacusis, sleep disorders and perceived stress levels in a study group of patients with tinnitus exposed to a traumatic event (earth quake) and a control group of patients with tinnitus not exposed to a traumatic event.
Methods: We studied 83 patients with tinnitus. The study group was composed by 47 patients exposed to earthquake. The control group was composed by 36 patients not exposed to the earthquake. Each patient was studied with clinical history, ENT examination and audiological tests. The following questionnaires were carried out: Tinnitus Sample Case History (TSCH), Tinnitus Handicap Inventory (THI), Pittsburgh Sleep Quality Index (PSQI), Khalfa's questionnaire and Brief Symptom Inventory (BSI 53).
Results: The psychological screening used in the study need to have confirmation of further more specific investigations to evaluate the possible correlation between PTSD and tinnitus. It is possible that the exposure to a traumatic event, such as the earthquake, may have had an influence in the genesis of tinnitus. Analysis of the study group has revealed higher scores in the PSQI test and in the BSI test components of anxiety, somatization and depression.
Conclusion: The connection between psychopathology, tinnitus and treatment is complex and, perhaps not sufficiently investigated with adequate methodologies. Psychiatric comorbidity in subjects affected by tinnitus is frequent, even if this study showed that the relationship between psychopathology and tinnitus is not linear.

Primary Laryngeal Amyloidosis and its Response to Surgical Treatment

Pradeep Pradhan, Abhishek Bhardwaj* and Venkatachalam VP

Abstract:
We have reported two male patients presenting with hoarseness and stridor respectively to the outpatient department, with later requiring emergency tracheostomy as life saving procedure. Endoscopic excision biopsies of the laryngeal lesions were performed and histopathological examination revealed amyloidosis. In the first patient, endoscopic excision of the mass was done with cold knife and in the second, treated with staged endoscopic coblation followed by decannulation. There was no recurrence of disease in both patients at one year of follow up.

Double Posterior Based Flap Technique in Primary Endoscopic Dacrocystorhinostomy with and without use of Lacrimal Stent

Pradeep Pradhan*, Swagatika Samal, Priti Lal and VP Venkatachalam

Abstract:
Objective: To demonstrate the double posterior based flap technique in primary endoscopic dacrocystorhinostomy and to compare the long-term surgical outcomes between patients with and without use of lacrimal stent in chronic nasolacrimal duct obstruction.
Material method: Total 28 patients with chronic nasolacrimal duct obstruction were included in the study from September 2012 to august 2014. All patients underwent Endoscopic dacrocystorhinostomy with posterior based double lacrimal and mucosal flap technique. In 14 patients lacrimal stents were put for 2 weeks, and in rest 14 patients were operated without using the stent. Patients were evaluated 1 month, 3 months and 1 year after the surgery to check the lacrimal patency and to look for the complications associated with the procedure.
Results: Out of 28 cases, recurrences of symptoms were noted in 2 (7.14%) cases, 1(7.14%) from stenting group and 1(7.14%) from non stenting group at the end one month and 3 months. At the end of 1 year, only 24 patients attended the outpatient clinic (11 from non stenting group and 13 from stenting group) and of them 1(9.09%) from non stenting group and 2(15.38%) from stenting group had recurrence of symptoms. The success rate of procedure in non stent group was 90.91% as compared to the stent group which was 84.62% at the end of 1 year. None of the patients in both groups had any major intraoperative or postoperative complications.
Conclusion: Double posterior based mucosal and lacrimal flap technique in Primary EDCR is an effective surgical technique associated with satisfactory outcome. No significant difference in the results (p=0.588) and complications were noted between non stenting group stenting group.

Tranexamic Acid in the Management of the Post Adeno-Tonsillectomy Phase

Barbara Pittore*, Carlo Loris Pelagatti, Lisa Fraser, Mauro Cau, Francesco Deiana, and Giovanni Sotgiu

Abstract:
Objective: To evaluate if oral Tranexamic Acid can decrease the proportion of individuals with secondary bleeding in the post-operative adeno-tonsillectomy phase.
Study design: Observational, retrospective epidemiological study.
Setting: San Francesco Hospital, Nuoro, Italy
Patients and methods: Over 20 months 236 children underwent elective adeno-tonsillectomy for chronic tonsillitis and/or otitis media and/or adenotonsillar hypertrophy. Two groups of patients were identified: the first one included 149 patients who took oral Tranexamic Acid (20 mg/Kg daily) for 10 days in the post-operative period, whereas the second one was characterized by 87 patients who did not take Tranexamic Acid.
Results: Only 6/236 (2.54%) cases of secondary bleeding were reported; 3/149 (2.01%) belonged to the group taking Tranexamic Acid, whereas 3/87 (3.44%; p-value: 0.5) belonged to the group not exposed to Tranexamic Acid. They were admitted and followed-up for 48 hours; no surgical interventions were performed.
Conclusion: Oral Tranexamic Acid did not significantly decrease the proportion of post-adenotonsillectomy bleeding episodes in our cohort. New prospective, randomized, controlled trials are needed to test the effectiveness of that drug in the management of post-adenotonsillectomy hemorrhages episodes.

Trans-Cricothyroid Injections for Intractable Mutism

James P. Dworkin-Valenti*, Nathan Vandjelovic and Samba S.R. Bathula

Abstract:
Objectives: To discuss the relationship between the physiologic and psychologic control of laryngeal function.
Study design: Single subject retrospective research investigation.
Methods: Here we present the case history of a highly intelligent, normally developing teenager from a middle-class family background who suffered idiopathic recurrent bouts of mutism, which were originally and erroneously diagnosed as manifestations of a paradoxical vocal fold movement disorder. The patient was refractory to standard respiratory retraining and voice therapy exercises. Based on our previous experiences and research with other patients, we employed trans-cricothyroid Lidocaine and saline injections on separate occasions to restore functional voice control.
Discussion: The physiology of normal voice production depends upon discreet integration of complex cortical, auditory, sensori-motor, and end organ activities. There is a subset of patients with non-organic dysphonia who exhibit respiratory and laryngeal muscle hypertension as a consequence of underlying psychological disequilibrium. Voice difficulties in this clinical population may range from intermittent harsh vocal quality to protracted aphonia. Lidocaine injection after the first and second occurrence of mutism and saline injection after the third manifestation had immediate and demonstrably positive results following each treatment session. Alternative physiogenic versus psychogenic explanations for these outcomes are presented.
Conclusion: There is a complex and poorly understood relationship between the physiologic and psychologic factors leading to conversion reaction mutism. We found that disruption of a potentially dysfunctional sensori-motor feedback loop, via trans-cricothyroid injections, quickly resulted in return of normal voice.

Assessment of the Neck in Head and Neck Skin Cancer

Michiel W.M. van den Brekel*, Charlotte A.H. Lange, Wouter V. Vogel, Marianne B. Crijns, Remco de Bree and Charlotte L. Zuur

Abstract:
In this review summarizes the workup and management of the N0 neck in head and neck Merkel cell carcinomas, melanomas and aggressive squamous cell carcinomas (SCC) of the skin. Of all imaging modalities, ultrasound guided aspiration cytology (US-FNAC) has the highest accuracy. CT, MRI as well as PET-CT have a lower accuracy, mainly because of a lower specificity. The sensitivity of all modalities is in the range of 50-60%. Recently published literature suggests that in high-risk skin cancers either elective treatment or sentinel node procedures are the way to go. Sentinel node biopsies (SNB) can have a very high sensitivity, but only when performed by well trained surgeons and using modern guidance systems such as SPECT, intraoperative scintigraphy and fluorescence. The most logical routine approach in high-risk skin cancer is to select patients for SNB using US-FNAC.

A Stutterer's Search for Fluency: A Case Report

Raymond H. Hull*

Abstract: This case report is written for speech-language pathologists and other health services providers by a certified speech-language pathologist in order to provide others who provide services on behalf of those with fluency disorders with insights that may prove to be valuable as they develop their strategies for working with their patients. The article presents a chronology of events that lead from the early childhood to adulthood of a severe stutterer. In this article, the young stutterer works to analyze the reasons for his severe dysfluencies, and as he subsequently develops strategies to achieve fluency, he eventually reaches his goal of speaking fluently.

Abducent Nerve Palsy in Petrositis: A Review of Three Different Cases and Management Protocol

Pradeep Pradhan*, Abhishek Bhardwaj and Ashish Vashishth

Abstract:
Objective: To discuss the management and outcome of abducent nerve palsy in patients of apical petrositis associated with otitis media.
Results: Three cases of abducent nerve palsy with petrositis have been reported. Computed tomography (CT) scan of temporal bone demonstrated soft tissue opacification and expansion of mastoid and petrous air cells without bone erosion. Two patients recovered completely from diplopia by medical management and one underwent transcanal infracochlear hypotympanic approach for drainage of petrous apex because it did not respond to medical treatment. All patients had complete resolution of sixth nerve palsy.
Conclusion: With advancement of antibiotics, medical treatment should be initially offered to all patients of petrositis. Surgical intervention is reserved for patients, not responding to medical management. Transcanal infracochlear hypotympanic approach is an effective and safe method for drainage of petrous apex with complete recovery of sixth nerve with hearing preservation.

Inflammatory Myofibroblastic Tumour of the Trachea in a Child with Asthmatic Symptoms

Bjarke Baisner Laursen, Ulrik Pedersen, Thomas Kjærgaard*

Abstract:
We here present a case of an 8-year old girl with an inflammatory myofibroblastic tumour of the trachea. She was initially referred due to stridor, dyspnea, and low functional status. Diagnostic work-up revealed a cauliflower-like tumour in trachea, which was initially removed endoscopically and subsequently by tracheal resection. The patient was previously diagnosed with idiopathic thrombocytopenia, which resolved spontaneously postoperatively.
Inflammatory myofibroblastic tumours also known as inflammatory pseudo tumours are very rare primary tumours of the trachea and considered by the WHO to represent intermediate grade of malignancy. Any association between this condition and idiopathic thrombocytopenia has so far only been described sporadically.

Spontaneous Cyst of the Cervical Segment of the Thoracic Duct: Literature Review

Roger V*, Babin E Hitier M, Capovilla M and Blanchard D

Abstract:
Objective: Cervical cysts are common pathologies in Otorhinolaryngology head and neck surgery. Cysts of the cervical segment of the thoracic duct are poorly understood, but require very specific treatment, as there is a risk of complications. In this work, we outline the particularities of this pathology and the debate surrounding its management.
Materials and Methods: Personal experience of one case and a literature review.
Results: Thirty-four cases of cervical cysts of the thoracic duct have been reported. They are characterized by dilation of the terminal portion of the thoracic duct, just above the left subclavian jugular confluence or in one of the two vessels of which it is composed. They are typically asymptomatic and discovered by chance. Diagnosis of these cysts is based on MRI, perioperative observation (cysts that communicate with the thoracic duct) and anatomopathologicial examination (vascular wall of the cyst). Their treatment remains controversial. Surgical excision becomes an option if the cysts are symptomatic, unsightly or if they are at risk of rupture. Identification and ligation of the thoracic duct are then essential in order to prevent lymphorrhea.
Conclusion: Cervical cysts of the thoracic duct are benignant but must be recognized by the ENT surgeon in order to avoid iatrogenic complications.

Vocal Fold Lipo Injection: New Potentials from Regenerative Medicine

Leandro Ribeiro¹*, Eugénia Castro¹, Manuela Ferreira¹, Pedro Carvalho², Manuela Gomes² and Artur Conde¹

Abstract:
Introduction: Vocal fold lipoinjection (VFLI) has been used in glottal insufficiency rehabilitation, although with inconsistent results due to unpredictable fat resorption. Recent studies demonstrate that platelet-rich plasma (PRP), obtained from autologous venous blood, increases graft stability, stimulating the proliferation of adipose stem cells (ASC).
Objective: The objective of this work is to confirm the presence of ASC in the adipose tissue and verify the possible effect of PRP on graft stability and survival.
Material and Methods: To this end the abdominal fat samples of two patients with unilateral vocal fold paralysis who had undergone VFLI were analysed by immunofluorescence, using monoclonal antibodies to specific CD markers, and flow cytometry. Simultaneously the authors searched the published literature, chose relevant references and extracted and systematized the data to make a study protocol for application of PRP on VFLI.
Results: The authors confirmed the presence of ASC in adipose tissue.
Conclusion: PRP should improve graft survival, enhancing de functional and long-term results of VFLI.

Evaluation of the Effect of the Facial Nerve Monitoring in Mastoid Surgery

Abhishek Bhardwaj, Neeraj Narayan Mathur*

Abstract:
Objectives: 1.To evaluate role of facial nerve monitoring in mastoid surgeries. 2. To define the cutoff limit for electrical dehiscence of facial nerve.
Methodology: 60 patients of chronic otitis media undergoing mastoid surgery were divided into 30 each for intra-operative facial nerve monitoring (group A) and those without monitoring (group B). Minimum level of current strength for stimulation of facial nerve was noted. Post operative facial nerve status and disease clearance was compared between two groups.
Results: In group A, 10 exhibited surgical dehiscence of facial nerve and responded to electrical stimulation of 0.5mA or less. Hence, we defined the facial nerves that responded to electrical stimulation of 0.5 mA or less with a constant, unipolar current with a frequency of 3 pulses/ second for 200 µs as “electrically dehiscent”. Total “electrically dehiscent” cases were 16 (53.3%) Disease could not be cleared completely in 1 patient in group A and 3 in group B. Facial nerve integrity was maintained in all patients in group A but injured in 1 in group B.
Conclusions: Facial nerve monitor is a useful tool to be used in mastoid surgery as it reassures the surgeon when in doubt. All facial nerves which get stimulated with a current of 0.5mA or less can be taken as electrically dehiscent.

Complex, Computer Assisted Skull Reconstruction Using Patient Specific Implants after Resection of an Intraosseous Meningioma – A Case Report

A Zeller*, M Neuhaus, M Nakamura, NC Gellrich¹ and M Rana

Abstract:
Background: Resection defects of the skull have long been reconstructed using autogenously and alloplastic materials[1]. Complex reconstructions of the orbit have been reported to benefit from patient specific implants [2].Due to new algorithms planning procedures for these implants have recently improved significantly. Rapid production methods such as selective laser melting and rapid prototyping have now been introduced into the clinical routine[3].
Case Report: We report a case of a 49-year old woman presenting with a recurrence of a previously surgically resected meningioma. The lesion had grown from the lateral sphenoidal bone towards the orbit and compromised her appearance and vision. The surgical procedure included resection and alloplastic reconstruction using a patient specific implant (PSI) planned by our department and manufactured by selective laser melting (SLM). We focus on the process of implant planning and its interaction with the production process.
Conclusion: Patient specific implants provide the treating surgeons with a superior method of anatomically correct, alloplastic skull reconstruction, which is able to contribute to an improved clinical outcome.

Granular Cell Tumor of the Tongue: A Case Report and Literature Review

Cristofaro Maria Giulia, Allegra Eugenia*, Trapasso Serena and Conforti Francesco

Abstract:
Background: The granular cell tumor (GCT), or Abrikossoff’s tumor, is a rare benign neoplasm of soft tissue a characterized by clusters of cells with abundant presence of cytoplasmic granules. It can affect any area of the body; in the head and neck, it has a predominance ranging from 45% to 65%; in 70% of these cases, it has intra-oral localization (tongue, oral mucosa, hard palate).
Case presentation: We describe a case of GCT of the tongue in a 47-year-old man presenting like a papillomatous lesion.
Discussion: Histopathological features, differential diagnosis, and therapeutic implications of GCT of the oral cavity are discussed, together with a review of the recent literature.
Conclusion: Immunochemistry besides helping to establish the correct diagnosis has allowed one to improve the knowledge of the controverter origin of this tumor, especially when clinical diagnosis is uncertain.

Patient Specific Mandibular Reconstruction using CAD/CAM Procedures – A Case Report

Neuhaus M*, Zeller A, Steigenberger C, Gellrich NC and Rana M

Abstract: Mandibular reconstruction today is still one of the larger challenges in cranio maxillofacial surgery. Quality of life can be extremely reduced by tissue defects in the mandible region, whether caused by trauma or tumour; it is a central concern of all CMF surgeons to improve mandibular reconstruction. Over the last few years rapid progress in CAD/CAM techniques were made. Patient specific reconstruction has become a standard procedure. In the now presented case a young patient underwent ablative surgery of a keratocystic odontogeneous tumour resulting in loss of mandibular continuity. Reconstruction was performed with a patient specific mandible implant. For the first time the donor site of the iliac bone graft was also supplied with a patient specific implant in order to reduce postoperative morbidity and risk of spontaneous pelvic fractures.

Papaverine Shortage: Verapamil-Nitroglycerin Solution as a Substitute

Rahul Seth*, Ali Razfar, Christine Ha, Rasnik K. Singh, P. Daniel Knott, Vishad Nabili and Keith E. Blackwell

Abstract:
Objective: Papaverine is a topical agent commonly used during microvascular surgery to inhibit undesired vasoconstriction. There is a national shortage of papaverine due to ceased production by the only manufacturer within the United States. Establishment of an alternative vasodilator is critically important. This study aims to assess the experience of a solution of verapamil and nitroglycerin (VG solution), a potentially suitable alternative pharmacologic vasodilator.
Study Design: Retrospective chart review
Methods: 188 consecutive free flaps were performed for head and neck defect reconstruction between February 11, 2013 and February 28, 2015. The topical vasodilator of VG solution was used during these cases. Charts were reviewed for patient and flap characteristics, intraoperative patient and flap complications, and postoperative complications.
Results: Flaps performed (n=188) included fibula, radial forearm, subscapular system, anterolateral thigh, and rectus abdominis. There were no vascular thromboses, free flap failures, or hematomas. Specific to topical application of the VG solution, there were no intraoperative cardiac events or abnormalities secondary to application of the solution, including obvious endothelial damage or irreversible arterial vasospasm. No vessels demonstrated intraoperative vasospasm after VG solution application.
Conclusion: Use of a VG solution for pharmacological vasodilation during microvascular free tissue transfer did not result in any adverse events and an acceptable vasodilation was witnessed, yielding a potentially acceptable papaverine substitute.

Orbital Subperiosteal Abscess at Pediatric Age

João Laffont¹, Sandra Augusto¹, Lígia Cardoso², João Carlos Ribeiro¹* and Antonio Paiva¹

Abstract:
Introduction: The incidence of orbital subperiosteal abscess (OSA) in pediatric population is 15% of the orbital infections, being acute sinusitis the most frequent cause of this complication. The diagnosis of OSA is based on clinical examination and imaging. Treatment usually includes IV antibiotics, nasal decongestants and surgical drainage if necessary. If inadequately treated, orbital cellulitis may progress to intracranial complications, blindness and even death.
Case presentation: A 10 year old child, presented with left palpebral edema with eye proptosis, ocular pain, gaze restriction, diplopia, conjunctival hyperemia and headache following three days of fever and URTI. CT imaging revealed pansinusitis with left OSA of the medial wall, compressing the eye globe with anterior-lateral deviation and exophthalmia. Functional endoscopic sinus surgery (FESS) decompression was performed after 48h of medical treatment without improvement. Ophthalmology examination improved dramatically the day after surgery. Patient was discharged completely asymptomatic after 8 days with a normal visual function after 2 years of follow-up.
Conclusion: When managing OSA, an early diagnosis and adequate infection control is of upmost importance. CT orbital scan is a reliable diagnostic method and initial IV antibiotic therapy may be possible. As demonstrated in this case report, if surgical approach of a medial OSA is necessary, FESS is a valid, adequate and effective solution at short and long term.

Percutaneous Tracheotomy in Emergency Situation Setting

Sandra Schmitz, Michel Van Boven and Marc Hamoir*

Abstract: While Percutaneous Tracheotomy (PT) has become a standard procedure to ensure airway patency in elective indications, it is not yet accepted as standard for the management of emergency airway situations, despite more and more reports highlighting its use in this setting. After comparing PT with other emergency airway access techniques, we report a new approach performed under general anesthesia for the management of patients with major airway obstruction leading to « no ventilation, no intubation » situations.

Can Gamma Knife Radiosurgery be an Alternative Treatment Modality to Surgery for Vestibular Schwannomas?: A Case Report with Critical Review of the Literature

Osman Ilkay Ozdamar, Gul Ozbilen Acar*, Muhammet Tekin and Mahmut Tayyar Kalcioglu

Abstract: Development of more sophisticated magnetic resonance imaging scans, the chances of finding asymptomatic patients with vestibular schwannomas as with other intracranial pathologies are increasing.
Gamma Knife radiosurgery for vestibular schwannomas has been documented as an efficient and safe procedure based on the treatments in worldwide literature. Preservation of hearing, but not tinnitus, is currently achieved by this minimal-invasive, alternative treatment method.
A 55 year-old female patient had applied with complaints of intractable tinnitus and hearing loss on her left ear for six months. Audiologic examination of the patient had revealed a severe degree sensorineural hearing loss on left ear (Average air threshold level: 78 dB, average bone threshold level: 68 dB). Then, magnetic resonance imaging with contrast agent was performed to the patient to detect any suspected lesion. On magnetic resonance imaging, the dimensions of the mass were detected as 15x17x16 mm at the left pontocerebellar angle that was compatible with vestibular schwannoma. Gamma knife radiosurgery was applied to the vestibular schwannoma in a referred center. A single-shot with a MRI-targeted dose (Leksell Gamma Knife, Model B, Gamma Plan 8.32) was applied as 12.5 Gy for 50% (range 42-50%) isodose field (maximal dose: 25 Gy) to cover at least 92% of the lesion.
In this paper, we discuss the effectiveness and outcomes of gamma knife radiosurgery, introduced recent few decades as a therapeutic method, with review of the literature for vestibular schwannoma’s management with this case.

Juvenile Ossifying Fibroma: Successful Endoscopic Gross Total Resection of a Rare Sinonasal Tumor in an Adolescent Male

Kaelan Black, Iman Naseri, Philipp Aldana, Jeffrey Goldstein and Gary D. Josephson*

Abstract: Juvenile ossifying fibroma is a rare tumor of the sinonasal cavity in pediatric patients. Large tumors involving the orbit and cranial fossa have traditionally been resected using an open craniofacial approach, with an open transcranial and endonasal endoscopic approach for smaller tumors. We describe a case in which visualization with straight and angled telescopes and endoscopic instrumentation allowed high confidence resulting in a gross total resection of this very large tumor. We believe this approach by an experienced endoscopist can offer equal success in treatment outcome with lower morbidity and quicker recovery than the traditional open procedures for this tumor.

Surgery of Tympanojugular Paragangliomas – Long Term Results

Surgery of TympanojugularParagangliomas – Long TermResults

Skrivan Jiri*, Zverina Eduard, Kluh Jan, Plzak Jan, Padr Radek and Chovanec Martin

Abstract: Tympanojugular paragangliomas are benign and slow growing lesions of the lateral skull base. Due to their locality and vascularity, they represent a surgical challenge. Treatment modalities include preoperative embolization of feeding vessels and a tumour mass, then surgical removal and irradiation. In our group, 19 patients with large tympanojugular paragangliomas have been operated on in the period of the last 10 years. Surgical removal was achieved in 63% of cases, in the rest of patients the tumour remnants were either irradiated or left without any treatment in a wait-end-rescan approach. According to the benign character of the tumour, removal is not always the highest goal, since this may be accompanied by a high degree of a postoperative morbidity.

Nerve Monitoring During Thyroid and Parathyroid Surgery

Johnny Cappiello*

Routine identification of the recurrent laryngeal nerve (RLN) with or without intraoperative neuromonitoring (IONM) has decreased the rates of temporary or permanent palsy, ranging from 6 to 1 % of cases in more experienced centers, in which trained surgeons perform more than 100 procedures per year, out of these criteria the percentage of neural injuries exceed 10%, particularly in reoperative cases.

Percutaneous Endoscopic Gastrostomy Dependence in Head and Neck Cancer Patients: A 7-Year Retrospective Cohort Study

Vihas Patel*, Xiaoxia Liu, Danielle Margalit, Robert Haddad and Guilherme Rabinowits

Abstract:
Aim: Percutaneous endoscopic gastrostomy (PEG) use in head and neck cancer (HNC) patients undergoing surgery followed by adjuvant or definitive concurrent chemo radiation therapy (AD-CRT) is controversial due to concerns of tube-related complications including long-term dependence. We sought to determine the predictors of PEG dependency at 6 months and 1 year in HNC patients undergoing multimodality therapy (MT).
Methods: Retrospective cohort study, 2005-2011
Results: PEG was considered early if inserted prior to or within 2 weeks of radiation therapy (RT) initiation. The 223 (87%) patients who received early PEG were younger (57.3 versus 61.6 years) and had a higher body mass index (27.2 versus 25.3 kg/m2). Both groups were comparable in terms of tobacco and alcohol exposure and disease stage. Oral cavity tumors as well as oncologic resection were more commonly seen in the late PEG group. After adjusting for covariates, early PEG was associated with a lower PEG dependency rate (OR 3.5 [95% CI 1.3, 9.3]) and overall infection rate (OR 5.7 [95% CI, 1.7 to 19.1]).
Conclusions: We found that early PEG in HNC patients undergoing MT was associated with decreased PEG dependency and overall infection rates. These findings need to be confirmed prospectively.

Hearing Loss and Retinitis Pigmentosa: Usher Syndrome?

Hearing Loss and RetinitisPigmentosa: Usher Syndrome?

Daniela de Carvalho Tasso*, Bárbara Lucia Azevedo L. A. da Silva, TammyFumiko M. Takara, Edi Lúcia Sartorato, Guilherme Machado de Carvalho, Brazílio de Carvalho Tasso and Carlos Eduardo Leite Arieta

Abstract:
Introduction: Usher Syndrome is a rare syndrome caused by an autosomal recessive genetic disorder and is the most common cause of blindness and deafness combined, representing more than 50% of cases.
Objective: This article aims to review the literature on Usher syndrome along with the presentation of a clinical picture.
Methods: Review of the medical literature in PubMed and SciELO / Lilacs, using the MeSH terms:”Usher syndrome”, “genetic hearing loss” and “retinitis pigmentosa”.
Case report: A case presents a 37-year-old woman patient detected with Usher syndrome. She reported hearing and visual loss since childhood. The onset was with nyctalopia evolving to peripheral field deprivation in both eyes a few years ago. She underwent ophthalmologic examination with dynamic refraction, ocular applanation tonometry,retinography, fluoresce in angiography and computerized visual field, the electroretinography was requested but was not available in the service. Eye fundus biomicroscopy revealed mild temporal pallor of the optic disk, diffuse retinalblood vessel narrowing, retinal sparse hyperpigmentation. The patient uses hearing aids (HA) since adolescence and a audiometric test was performed good adaptation. No alterations were found in the search for mutations in the GJB2 gene and mitochondrial mutations A155G.
Discussion: The diagnosis of Usher syndrome is difficult and genetic testing can support this evaluation. We believe that its early diagnosis can bring several benefits, as genetic counseling and better rehabilitation, reducing the damage caused by this syndrome, which has no direct treatment. Unfortunately there is no cure for the disease.
Conclusion: This syndrome should be considered as a differential diagnosis in patients who have combined loss of visual acuity and hearing.

Primary Downbeat Spontaneous Nystagmus and Severe Hypomagnesemia: Monitoring and Follow-Up

Francesco Comacchio*, Vera Markova, Daria Accordi, Francesca Covizzi and Paola Magnavita

Abstract: Primary spontaneous down-beat nystagmus (PDBN) is characterized by slow upward ocular drifts and fast downward phases, and is the most common form of acquired ocular movements overcoming fixation. PDBN is essentially due to lesions at the cranio-cervical junction, or diseases of the lower brainstem and cerebellum. Intoxication due to lithium or anti-epileptic drugs, abuse of toluene, and metabolic disturbances such vitamin B1, B12 deficiency, have also been reported. Hypomagnesemia has rarely been reported as another possible cause of PDBN. We report here a case of reversible high-intensity PDBN, due to severe hypomagnesaemia with ataxia, objective vertigo and oscillopsia, although initial cerebellar MR imaging was normal. Monitoring of nystagmus according to magnesemia is reported and discussed.

The Posterior Muscles of the Auricle: Anatomy and Surgical Applications

Rivka Bendrihem, Christian Vacher* and Jacques Patrick Barbet

Abstract:
Objective: Prominent ears are generally considered as primary cartilage deformities, but some authors consider that posterior auricular muscles malposition could play a role in the genesis of this malformation.
Study design: Auricle dissections of 30 cadavers and histologic sections of 2 fetuses' ears.
Methods: Posterior area of the auricle has been dissected in 24 cadavers preserved with zinc chlorure and 6 fresh cadavers in order to describe the posterior muscles and fascias of the auricle. Posterior auricle muscles from 5 fresh adult cadavers have been performed and two fetal auricles (12 and 22 weeks of amenorhea) have been semi-serially sectioned in horizontal plans. Five µm-thick sections were processed for routine histology (H&E) or for immuno histochemistry using antibodies specific for the slow-twitch and fast-twich myosin heavy chains in order to determine which was the nature of these muscles.
Results: The posterior auricular and the transversus auriculae muscles looked in most cases like skeletal muscles and they were made of 75% of slow muscular fibres. The histologic sections of the auricle in the fetus suggest that the transversus auriculae plays a role in the constitution of the antihelical fold. The obliquus auriculae muscle was rather a fascia than a muscle in adult dissections and in fetuses auricle sections. Conclusion: Some cases of prominent ears are related to anomalies of the posterior muscles of the auricle.

Refinement and Modification of Free Jejunal Graft for Pharyngeal Reconstruction after Total Laryngopharengectomy for Post Cricoid Carcinoma

Refinement and Modification of Free Jejunal Graft for Pharyngeal Reconstruction after Total Laryngopharengectomy for Post Cricoid Carcinoma

Adel Denewer, Ashraf Khater, Osama Hussein, Fayez Shahhto, Sameh Roshdy, Mohammed Hafez, Khaled Abdel Wahab, Adel Fathi, Fathy Denewer and Emad Hamed

Abstract: Hypo pharyngeal carcinoma is relatively uncommon. No single surgical technique is superior in achieving the best oncologic and functional results.Reconstruction of the digestive tract to restore postpharyngectomy continuity is challenging. Free jejunum transfer remains the most reliable option. Micro vascular techniques minimize partial flap necrosis and the subsequent salivary fistula and are superior to pedicled flaps. Improving the results of free jejunum pharyngeal substitute is thus of utmost importance to the success of treatment of patients with hypo pharyngeal carcinoma.
Methods:
Refinement plan: Considerations for organ preservation determine the choice of therapy in the majority of cases. Most patients present with stage III or resectable stage IV tumors. Combined surgery and chemo-irradiation is essential for these patients. A few of our patients present as early cancers (stage I, II).
Surgical ablative phase: the majority of patients need formal total laryngectomy, pharyngectomy, thyroidectomy and bilateral modified block dissection (i.e. neck emptying).
Reconstructive phase
The jejunal loop is harvested through an abdominal midline incision. Careful dissection of the mesentery exposes the primary branches of the superior mesenteric artery (SMA). The free flap is based on the second and third branches of SMA. Refinement in the technique includes
The distal jujeno-esophageal anastomosis is performed with a circular (EEA) stapler.
Double vascular pedicle is used in the irradiated neck.
A jejunal window is always used in the irradiated neck.
Results: In total, mortality rate was 8.3% (4 patients). The most common causes of operative death were pulmonary embolism and sepsis syndrome. Hospital stay ranged from 10-22 days. Three flaps were lost out of 28 traditional flaps and the remaining 25 flaps were evaluated for technique-related morbidity. One flap was lost after 20 modified procedures and 19 patients were evaluated for technique-related morbidity.
Conclusion: Free jejunal transfer remains the most effective method of reconstruction of the hypopharynx. Several modifications have been recently introduced to refine the technique and maximize the chance of rapid recovery and improved function of these debilitated patients.

Perceptual Evaluation and Acoustic Findings in Female Patients with Goiter

Perceptual Evaluation and Acoustic Findings in Female Patients with Goiter

Abdul-latif Hamdan, Georges Ziade, Maher M. Kasti, Jad Jabbour, Jihad Nassar, Iyad El-Dahouk and Sami Azar*
Abstract: The aim of the study is to describe the vocal characteristics of a group of female patients with goiter. For this purpose, a total of 43 female patients with goiter presenting to the endocrinology clinic and another age-matched group of controls were recruited. Patients underwent acoustic analysis and perceptual evaluation of their voice using the GRABS classification. Zero was considered normal, and 1, 2 and 3 as mild, moderate, severe deviation from normal, respectively. The mean score of each parameter was computed and the distribution of severity of each perceptual parameter was listed. The results of the study showed no significant difference in any of the acoustic variables between patients and controls. There was also no significant difference in the mean score of any of the perceptual evaluation parameters between the two groups except for straining. Goiterous patients had a significantly higher straining score comparing to controls, 0.48±0.59 vs. 0.13 ±0.35, with a p value of 0.039. The means of all the perceptual parameters were less than 1 indicating a relatively mild or minimal deviation from normal. Therefore, female patients with goiter seen in a clinical set up have more vocal straining compared to controls, however, the amount of straining is minimal. Acoustic analysis failed to reveal any significant difference compared to controls.