Head and Neck

Duplication of the right internal jugular vein: A case report

June 4, 2015     Srinivasalu Bathala, FRCS(ORL-HNS); Zvoru G. Makura, FRCS(ORL-HNS)
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Abstract

We present a case of duplication of the right internal jugular vein (IJV) in a patient who underwent neck dissection as part of the management of carcinoma of the larynx. The patient was a 63-year-old man who presented to the otolaryngology department with a 7-month history of hoarseness and a 3-week history of noisy breathing. Flexible endoscopy detected a transglottic tumor that had extended beyond the vocal folds. The patient underwent a total laryngectomy and bilateral selective neck dissection at levels II-VI. Intraoperatively, the right IJV was noted to be duplicated. The duplicate segment was approximately 10 cm in length, and it rejoined the normal vein before the normal vein joined the subclavian vein.

Maggot infestation of an ulcerated neck wound

June 4, 2015     Sidharth V. Puram, MD, PhD; Margaret S. Carter, MD; Daniel Deschler, MD, FACS
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The presence of maggots was hardly deliberate in this case, but these larvae successfully debrided a locally recurrent necrotic lymph node.

Guidelines for squamous cell carcinoma of the head and neck: A systematic assessment of quality

April 27, 2015     Yanming Jiang, MD; Xiao-Dong Zhu, PhD; Song Qu, PhD; Ling Li, MD; Zhirui Zhou, MD
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Abstract

We conducted a study to evaluate the quality of guidelines for squamous cell carcinoma of the head and neck (SCCHN) with the exception of nasopharyngeal cancer. Electronic searches were conducted of the U.S. National Guideline Clearinghouse, the Canadian Medical Association Infobase, the Guidelines International Network, the Scottish Intercollegiate Guidelines Network, the China Biology Medicine disc, PubMed, and Embase. Two independent reviewers assessed the eligible guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. The degree of agreement among these sources was evaluated by using the intraclass correlation coefficient (ICC). A total of 514 articles were found to be clinical-guideline-related, and 49 guidelines were included in our analysis. Scores were assigned for each of the AGREE II domains: scope and purpose (mean: 71.63% ± 2.80; median: 75%; ICC: 0.76), stakeholder involvement (mean: 43.37% ± 2.96; median: 50%; ICC: 0.93), rigor of development (mean: 45.63% ± 3.84; median: 42%; ICC: 0.83), clarity of presentation (mean: 68.08% ± 2.53; median: 72%; ICC: 0.85), applicability (mean: 32.41% ± 3.03; median: 29%; ICC: 0.92), and editorial independence (mean: 42.55% ± 4.57; median: 42%; ICC: 0.95). We considered a domain score of greater than 60% to represent an acceptable level of quality. We conclude that, overall, the quality of SCCHN guidelines is moderate in relation to international averages. Greater efforts are needed to provide high-quality guidelines that serve as a useful and reliable tool for clinical decision making in this field.

Parathyroid localization using 4D-computed tomography

April 27, 2015     Darrin V. Bann, PhD; Thomas Zacharia, MD; David Goldenberg, MD, FACS; Neerav Goyal, MD, MPH
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To decrease the risk of iatrogenic cancers associated with 4D-CT, several groups have used one- or two-phase imaging protocols to identify parathyroid adenomas.

Giant Stensen duct calculus

April 27, 2015     Wen-Sen Lai, MD; Jih-Chin Lee, MD; Yueng-Hsiang Chu, PhD; Ying-Nan Chang, MD
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A sialolith in the anterior third of a Stensen duct usually can be extracted in a minimally invasive manner via trans-oral sialolithotomy to avoid the morbidity associated with a sialadenectomy.

Perineural spread of cutaneous squamous cell carcinoma along the great auricular nerve

April 27, 2015     Daniel Thomas Ginat, MD, MS; Diana Bolotin, MD, PhD; Alexander J. Langerman, MD
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Although perineural tumor spread in the head and neck most commonly involves the cranial nerves, particularly the trigeminal and facial nerves, the spinal nerve branches can also be affected.

Massive myiasis in an advanced metastatic neck tumor

April 27, 2015     Tomasz Rowicki, MD, PhD; Mirosława Pietniczka-Załęska, MD, PhD
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Abstract

Only a small number of cases of myiasis have been previously reported in patients with a head and neck malignancy; most of these occurred in patients with primary or metastatic skin cancer. We report a case of massive Lucilia sericata myiasis in the neck of a 57-year-old man with primary squamous cell carcinoma of the larynx and hypopharynx that metastasized to the neck lymph nodes. The neck disease manifested as necrosis and skin involvement. Clinical examination revealed an extensive wound within the neck tumor at levels II and V on the right that was heavily infested with maggot larvae. Removal of larvae clusters was performed, and the isolated larvae were subsequently identified as L sericata. To the best of our knowledge, this is the first report of an infestation of L sericata myiasis in a metastasis to the neck lymph nodes.

Multifocal inverted papillomas in the head and neck

March 2, 2015     Jyoti Sharma, MD; David Goldenberg, MD; Henry Crist, MD; Johnathan McGinn, MD
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Abstract

Inverted papilloma is a rare benign neoplasm that usually originates in the lateral nasal wall. It can be a locally aggressive lesion and invade nearby structures. While primarily a nasal neoplasm, cases of an inverted papilloma involving the temporal bone, pharynx, nasopharynx, and lacrimal sac have been reported. We describe the case of a 67-year-old man with a history of nasal inverted papilloma who presented with a recurrent nasal mass and a large mass on the left side of his upper neck. The patient's history included inverted papillomas in multiple locations: the temporal bone, the sinonasal tract, and the nasopharynx. The new neck mass raised a concern for malignant degeneration and metastasis, but pathology demonstrated that it was a benign inverted papilloma. No clear etiology for the new neck lesion was evident except for an origin in salivary gland tissue. However, there was no physical connection between the neck mass and the submandibular gland identifiable on pathologic evaluation. This case illustrates the need for an aggressive primary resection to minimize local recurrence, as well as adequate surveillance to address recurrences early. Given the potential for multicentricity, patients with a typical sinonasal inverted papilloma should undergo a complete head and neck examination as part of their follow-up.

Protracted hypocalcemia following post-thyroidectomy lumbar rhabdomyolysis secondary to evolving hypoparathyroidism

March 2, 2015     Usman Y. Cheema, MD; Carrie N. Vogler, PharmD, BCPS; Joshua Thompson, PharmD; Stacy L. Sattovia, MD, FACP; Srikanth Vallurupalli, MD
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Abstract

Rhabdomyolysis is characterized by skeletal muscle breakdown. It is a potential cause of serious electrolyte and metabolic disturbances, acute kidney insufficiency, and death. Recently, rhabdomyolysis has been increasingly recognized following certain surgical procedures. We discuss the case of a morbidly obese 51-year-old woman who developed postoperative rhabdomyolysis of the lumbar muscles following a prolonged thyroidectomy for a large goiter. We discuss how her morbid obesity, the supine surgical position, the duration of surgery (including prolonged exposure to anesthetic agents), and postoperative immobility contributed to the development of rhabdomyolysis. Immediately after surgery, the patient developed hypocalcemia, which was likely due to rhabdomyolysis since her serum parathyroid hormone level was normal. Later, however, persistent hypocalcemia despite resolution of the rhabdomyolysis raised a suspicion of iatrogenic hypoparathyroidism, which was confirmed by a suppressed parathyroid hormone level several days after surgery. In post-thyroidectomy patients with risk factors for rhabdomyolysis, maintaining a high degree of clinical suspicion and measuring serum creatine kinase and parathyroid hormone levels can allow for an accurate interpretation of hypocalcemia.

Common carotid artery dissection: A rare cause of acute neck swelling

March 2, 2015     Muhammad Adil Abbas Khan, MBBS, MRCS, DOHNS, FCPS(Plast); Alasdair Moffat, MBBS; Waseem Ahmed, MBBS, MRCS, DOHNS; Julian Wong, MBBS, FRCS(Vasc); Changez Jadun, MBBS, FRCR
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Abstract

Spontaneous carotid artery dissection is a rare condition with potentially devastating consequences. Internal carotid artery and vertebral artery dissections have been implicated as the cause of 20% of strokes occurring in patients younger than 45 years. We describe a very rare case of a nontraumatic common carotid artery dissection in a 45-year-old man that was initially misdiagnosed as a sternocleidomastoid hematoma. This case highlights the need for vigilance for this often-missed diagnosis, as well as the indication for noninvasive imaging in unidentified neck swellings.

Thyroid gland follicular carcinoma

March 2, 2015     Lester D.R. Thompson, MD
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The recommended treatment is lobectomy or total thyroidectomy, with or without radioablation. The choice depends on the size and stage of the tumor, extent of lymphovascular invasion, and patient's age.

Previous gastric bypass surgery complicating total thyroidectomy

March 2, 2015     Bianca Alfonso, MD; Adam S. Jacobson, MD; Eran E. Alon, MD; Michael A. Via, MD
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Abstract

Hypocalcemia is a well-known complication of total thyroidectomy. Patients who have previously undergone gastric bypass surgery may be at increased risk of hypocalcemia due to gastrointestinal malabsorption, secondary hyperparathyroidism, and an underlying vitamin D deficiency. We present the case of a 58-year-old woman who underwent a total thyroidectomy for the follicular variant of papillary thyroid carcinoma. Her history included Roux-en-Y gastric bypass surgery. Following the thyroid surgery, she developed postoperative hypocalcemia that required large doses of oral calcium carbonate (7.5 g/day), oral calcitriol (up to 4 μg/day), intravenous calcium gluconate (2.0 g/day), calcium citrate (2.0 g/day), and ergocalciferol (50,000 IU/day). Her serum calcium levels remained normal on this regimen after hospital discharge despite persistent hypoparathyroidism. Bariatric surgery patients who undergo thyroid surgery require aggressive supplementation to maintain normal serum calcium levels. Preoperative supplementation with calcium and vitamin D is strongly recommended.

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