Head and Neck

Surgical resection of cervical schwannoma and paraganglioma: Speech and swallowing outcomes

August 26, 2015     Noah P. Parker, MD; Noel Jabbour, MD; Amy Anne Lassig, MD; Bevan Yueh, MD, MPH; Samir S. Khariwala, MD
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Abstract

We conducted a retrospective study (1999 to 2009) at our tertiary care institution to evaluate speech and swallowing outcomes after the resection of cervical schwannoma or paraganglioma. Of 6 patients treated for schwannoma, 5 (83.3%) had immediate dysphonia and dysphagia. All patients with deficits received primary reinnervation (n = 2) or subsequent medialization laryngoplasty (n = 3). At 6 months, 4 patients (66.6%) still had dysphonia and dysphagia. At final follow-up (median: 10 months; range: 8 to 12 months), 4 patients (66.7%) had dysphonia and 2 (33.3%) had dysphagia. Of 10 patients treated for paraganglioma, 6 (60.0%) had immediate dysphonia and dysphagia. Four patients received subsequent medialization laryngoplasty; none had primary reinnervation. At 6 months, 3 (30%) still had dysphonia and dysphagia. At final follow-up (median: 15.5 months; range: 1.25 to 48 months), 2 (20.0%) had dysphonia and dysphagia. All patients with deficits received speech and swallowing therapy. We conclude that cervical schwannoma and paraganglioma resection was associated with high rates of immediate postoperative dysphonia and dysphagia. Schwannoma had higher initial rates and poorer recovery. Primary and/or subsequent laryngeal procedures combined with therapy led to symptom resolution in some patients.

Unusual sites of metastasis of papillary thyroid cancer: Case series and review of the literature

August 26, 2015     Rafael Antonio Portela, MD; Garret W. Choby, MD; Andrea Manni, MD; David Campbell, MD; Henry Crist, MD; David Goldenberg, MD
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Abstract

Papillary thyroid cancer (PTC) is the most common malignancy of the thyroid gland. It typically spreads via lymphatic extension. The rate of regional PTC metastasis to the neck is relatively high, while metastases outside the deep cervical chain are rare. Distant metastases are found in only 1% of patients with PTC at the time of surgery; the two most common sites are the lung and bone. We report 4 cases of PTC metastasis to unusual sites: (1) the occipital skull and internal jugular vein, (2) the parapharyngeal space, (3) the sternocleidomastoid muscle, and (4) the right atrium of the heart. It has been well documented that aggressive distant metastasis is a characteristic of PTC, and it is known to be an indicator of a poor prognosis. Some of our patients' sites of metastatic disease have not been previously reported. Patients in this series exhibited aggressive histologic findings, including columnar cell and follicular variants of papillary disease. In addition, all 4 patients demonstrated “PET-avid” disease with decreased iodine avidity.

A study of neck and shoulder morbidity following neck dissection: The benefits of cervical plexus preservation

August 26, 2015     Massimiliano Garzaro, MD; Giuseppe Riva, MD; Luca Raimondo, MD; Laura Aghemo, MD; Carlo Giordano, MD; Giancarlo Pecorari, MD
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Abstract

We conducted a study to evaluate the hypothesis that the preservation of cervical root branches of the cervical plexus is associated with greater shoulder mobility, less loss of face and neck sensation, and better quality of life (QoL) following functional neck dissection in which the spinal accessory nerve is spared. We also investigated the impact of postoperative physiotherapy on these three outcomes. Our study population was made up of 54 patients-47 men and 7 women, aged 34 to 78 years (mean: 53.4)-who had undergone functional neck dissection as a treatment for head and neck cancer over a 3-year period at our institution. Patients were divided into two groups: 23 patients whose cervical root branches were preserved during surgery (preservation group) and 31 whose branches were removed (removal group). Shoulder mobility was measured by the Arm Abduction Test (AAT), face and neck sensation was assessed by fingertip touch in eight areas of the head and neck, and QoL was determined by the University of Washington-Quality of Life questionnaire (UW-QoL4). The AAT revealed that the preservation group had significantly better shoulder mobility. The fingertip touch evaluation revealed significantly less loss of sensation in Saffold regions A and D. Analysis of the UW-QoL4 results revealed that the preservation group experienced significantly less pain, significantly fewer shoulder complaints, and significantly fewer limitations on activities and recreation, as well as significantly better health-related and overall QoL. The preservation group also had a significantly better composite score, global score, social function score, and mood and anxiety score on the UW-QoL4 assessment. Finally, we found that physiotherapy improved both QoL and shoulder mobility, although these improvements were not statistically significant. We conclude that preservation of the cervical root branches significantly improves outcomes in patients who undergo functional neck dissection.

Missed skull base injury during sinonasal surgery: A dangerous scenario still existing

August 26, 2015     Mohamed H. Hassab, MD; Ahmed Z. Eweiss, MD, FRCS(ORL-HNS); Ahmed A. Ibrahim, MD
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Abstract

Skull base injury is a known complication of sinonasal surgery. Cerebrospinal fluid (CSF) rhinorrhea has been reported to occur in 0 to 2.5% of these procedures. More extensive skull base injury may result in more serious complications. In this retrospective case series, we report on 7 cases of iatrogenic skull base injury due to sinonasal surgery that was missed by the operating surgeons. Included were 5 male and 2 female patients. Six patients sustained the skull base injury during endoscopic sinus surgery, and 1 patient was injured during septoplasty. Two patients presented with CSF rhinorrhea alone, 2 patients had repeated episodes of meningitis, 2 patients had other neurologic sequelae, and 1 patient had exotropia due to associated orbital injury. We conclude that skull base injury due to sinonasal surgery is still being missed; this oversight may lead to potentially fatal results. The true incidence of this complication is probably still unknown.

Base of tongue schwannoma

August 26, 2015     Gautam Bir Singh, MS; Rubeena Arora, MS; Sunil Garg, MS, DNB; Kiran Aggarwal, MD
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On T1-weighted MRI, these lesions appear hypointense or isointense relative to the tongue muscle.

Using ultrasonic preoperative thyroid volume to determine incision length for minimally invasive thyroid surgery

August 26, 2015     Austin P. Daly, MD; Massi Romanelli-Gobbi, MD; Jeffrey L. Miller, MD; David Rosen, MD; David M. Cognetti, MD; Edmund A. Pribitkin, MD
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Abstract

The determination of the volume of a diseased thyroid lobe or an entire gland by preoperative ultrasonography may enable surgeons to select candidates for a minimally invasive approach to thyroid lobectomy or total thyroidectomy. We retrospectively reviewed the charts of 71 adults who had undergone minimally invasive nonendoscopic thyroid surgery at our hospital from January 2007 through May 2009. We compiled data on ultrasonic preoperative thyroid volumes and operative incision lengths. Of the 71 patients, 40 had undergone lobectomy and 31 had undergone total thyroidectomy. The lobectomy group was evenly subdivided into two groups based on the median volume of the affected lobe; 20 patients had a volume of <28.32 ml and 20 had a volume of >28.32 ml. The incision length ranged from 2.0 to 3.8 cm (mean: 3.1 ± 0.53) in the smaller-volume lobectomy group and from 2.5 to 5.0 cm (mean: 3.7 cm ± 0.71) in the larger-volume lobectomy group; the difference was statistically significant (p < 0.01). The 31 patients in the total thyroidectomy group were subdivided on the basis of the median volume of the entire thyroid gland; 16 patients had a volume of <49.24 ml and 15 had a total volume of >49.24 ml. The incision length in those two groups ranged from 2.5 to 4.0 cm (mean: 3.4 ± 0.53) and 3.6 to 6.0 (mean: 5.1 ± 0.99), respectively; again, the difference was statistically significant (p < 0.001). The findings of our study suggest that preoperative ultrasonographic thyroid lobe volume or total thyroid gland volume can be used to determine the appropriate minimum length for the surgical incision.

Oncocytic mucoepidermoid carcinoma of the parotid gland: A case report and review of the literature

July 20, 2015     Deepali Jain, MD; Nabeen C. Nayak, MD
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Abstract

Oncocytic metaplasia rarely has been reported in mucoepidermoid carcinomas. Most salivary gland lesions with oncocytic change are benign; therefore, it is important to distinguish mucoepidermoid carcinoma from other entities that may show prominent oncocytic change. We report a rare case of oncocytic mucoepidermoid carcinoma in a 65-year-old woman.

Two cases of thyroid rupture after blunt cervical trauma

July 20, 2015     Ji Hoon Shin, MD; Yong Bae Ji, MD; Jin Hyeok Jeong, MD; Seung Hwan Lee, MD; Kyung Tae, MD
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Abstract

The consequences of thyroid gland rupture following blunt cervical trauma can be quite grave. Almost all of these cases are associated with preexisting thyroid lesions; the traumatic rupture of a previously normal thyroid gland is very rare. Both surgical and nonsurgical management techniques have been advocated for thyroid injuries, but there is still no consensus on treatment. We report cases of thyroid gland rupture following blunt cervical trauma in 2 patients: a 24-year-old man with a previously normal thyroid and an 8-year-old boy with a preexisting thyroid nodule. The man was treated surgically and the boy was treated conservatively. Based on our experience with these cases and our review of the literature, we propose treatment guidelines for thyroid injuries.

Cervical lipoblastoma: An uncommon presentation

July 20, 2015     Rohaizam Jaafar, MD; Tang Ing Ping, MS(ORL-HNS); Doris Evelyn Jong Yah Hui, MS(ORL-HNS); Mohammad Zulkarnaen Ahmad Narihan, MPath
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Abstract

Lipoblastoma is extremely rare and mainly occurs in children younger than 3 years old. It is predominantly found in the extremities and trunk. Head and neck region occurrences are rare; only 4 such cases involving patients who presented with stridor have been previously reported. We report the fifth case of lipoblastoma of the neck with stridor in a 9-year-old girl, which had gradually worsened over the previous year. Imaging showed a retrotracheal mass extending superiorly to the thyroid level and inferiorly to below the carina of the trachea. Total resection of the tumor was performed, and the histopathologic findings were consistent with lipoblastoma. Postoperatively, the patient was well with no complications.

Cervical necrotizing fasciitis as a complication of acute epiglottitis managed with minimally aggressive surgical intervention: Case report

July 20, 2015     Rajesh Babu Gollapalli, MBBS, MS(ENT), DORL; Ana Nusa Naiman, FRACS; David Merry, FRACS
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Abstract

Cervical necrotizing fasciitis secondary to epiglottitis is rare. The standard treatment of this severe condition has long been early and aggressive surgical debridement and adequate antimicrobial therapy. We report the case of an immunocompetent 59-year-old man who developed cervical necrotizing fasciitis as a complication of acute epiglottitis. We were able to successfully manage this patient with conservative surgical treatment (incision and drainage, in addition to antibiotic therapy) that did not involve aggressive debridement.

Sweet syndrome: A case report and review of the literature

July 20, 2015     Robert B. Contrucci, DO; Donna Bilu Martin, MD
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Abstract

Sweet syndrome (acute febrile neutrophilic dermatosis) is a disorder of unknown etiology. It has been associated with autoimmune processes, malignancies, infections, drug reactions, and gastrointestinal disorders such as inflammatory bowel disease. We describe the case of a 51-year-old man who presented with severe pain in his tongue and throat and referred pain in his right ear, along with odynophagia, fever, and hoarseness of 48 hours'duration. An oral and oropharyngeal examination revealed the presence of aphthous ulcerations, as well as a 3 x 3-cm raised inflammatory lesion on the right anterior lateral tongue and a 5 x 5-mm bulla on the hard palate in the midline. In addition, erythematous papules and macules were noted on his face, neck, and extremities. Cultures, a biopsy, and laboratory tests yielded a diagnosis of Sweet syndrome. The patient was prescribed oral prednisone, and his signs and symptoms resolved within 2 months. Although Sweet syndrome is uncommon, even in dermatology practice, its head and neck and oral manifestations and its association with paraneoplastic disease warrant the need for otolaryngologists to be aware of the condition.

Post-thyroidectomy hypocalcemia: Impact on length of stay

July 20, 2015     Joe Grainger, FRCS; Mohammed Ahmed, MRCP; Rousseau Gama, FRCPath; Leonard Liew, FRCS; Harit Buch, FRCP; Ronald J. Cullen, FRCS
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Abstract

Hypocalcemia is a recognized complication following thyroid surgery. Variability in the definition of hypocalcemia and different opinions on its management can lead to unnecessary patient morbidity and longer hospital stays as a result of inappropriate or untimely treatment. Therefore, we developed a management guideline for the recognition and treatment of post-thyroidectomy hypocalcemia, and we conducted a retrospective study to assess its impact on length of stay (LOS). Between April 1, 2007, and March 31, 2009, 29 adults had undergone a total or completion thyroidectomy at our large district general hospital. Of this group, postoperative hypocalcemia (defined as a serum calcium level of <2.00 mmol/L) developed in 13 patients (44.8%) during the first 3 postoperative days. Our guideline went into effect on July 1, 2009, and from that date through June 30, 2010, 18 more adults had undergone a total or completion thyroidectomy. Of that group, hypocalcemia developed in 7 patients (38.9%); the guideline was actually followed in 5 of these 7 cases (71.4%). In the preguideline group, the development of hypocalcemia increased the mean LOS from 2.0 days to 7.0 days (p < 0.001). The management of postoperative hypocalcemia in these cases was highly variable and was dictated by variations in practice rather than patient needs. In the postguideline group, postoperative hypocalcemia increased the mean LOS from 2.7 days to only 3.7 days (p = 0.07). While the difference between LOS in the two hypocalcemic groups did not reach statistical significance, we believe it merely reflects the relatively small number of patients rather than any lack of guideline efficacy. The implementation of a simple flowchart guideline for the management of postoperative hypocalcemia in our hospital has resulted in more uniform management and a reduced LOS.

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