Migration of Broken Dental Needle Through the Internal Jugular Vein in the Parapharyngeal Space.

Accidental broken dental needles during dental blocks have become a rare occurrence but still occur. Although the treatment for such occurrence is controversial, an increasing body of literature demonstrates that migration of such needles is possible. In this case, we report on a 48-year-old male with migration of a broken dental needle from an inferior alveolar block. Over the course of 2 years, we demonstrated radiological documentation of the course of migration with penetration of the internal jugular vein at the jugular foramen which was subsequently successfully retrieved through a transcervical approach without neurovascular injury. This case is unique given the location of migration to the skull base as well as radiologically documented time course. Furthermore, it highlights the need for prompt retrieval of broken dental needles given the high potential of migration and injury to neurovascular structures.

Total Auricular Rehabilitation: Combined Cosmetic and Functional Lateral Temporal Bone Reconstruction.

OBJECTIVE: The aim of the study was to describe 3 cases of total auricular rehabilitation, including the novel use of iliac crest bone grafts to support bone-anchored auricular prostheses. STUDY DESIGN: This study is a retrospective case series from a single institution. RESULTS: Three cases with large lateral temporal bone and soft tissue defects were successfully treated with total auricular rehabilitation. Rehabilitation included the following: soft tissue coverage with an anterolateral thigh microvascular free flap, iliac crest-free bone graft with staged placement of a bone-anchored auricular prosthesis into the bone graft, and audiologic rehabilitation with a bone-anchored hearing aid (BAHA). All of the cases with grafts and flaps survived and were without significant donor site morbidity. Bone-anchored hearing aid abutment skin overgrowth was seen in 2 cases and was revised under local anesthesia. All of the patients had expected functional recovery on postoperative audiologic testing. Each patient continues to consistently wear his/her auricular prosthesis and BAHA during 3 years of follow-up. CONCLUSIONS: Total auricular rehabilitation is a complex task involving reconstruction of extensive soft tissue defects, bony defects, and the hearing apparatus. Acceptable cosmetic and functional outcomes and high patient satisfaction is possible in committed patients.

Voice outcomes after total thyroidectomy, partial thyroidectomy, or non-neck surgery using a prospective multifactorial assessment.

BACKGROUND: Voice alteration remains a significant complication of thyroid surgery. We present a comparison of voice outcomes between total thyroidectomy (TT), partial thyroidectomy (PT), and non-neck (NN) surgery using a multifactorial voice-outcomes classification tool. STUDY DESIGN: Patients with normal voice (n = 112) were enrolled between July 2004 and March 2009. The patients underwent TT (n = 54), PT (n = 35), or NN (n = 23) surgery under general endotracheal anesthesia as part of a prospective observational study involving serial multimodality voice evaluation preoperatively, and at 2 weeks, 3 months, and 6 months postoperatively. Patients with adverse voice outcomes were grouped into the negative voice outcomes (NegVO) category, including patients with objective (abnormality on videolaryngostroboscopy and substantial voice dysfunction) and subjective (normal videolaryngostroboscopy but with notable voice impairment) NegVO. Voice outcomes were compared among study groups. RESULTS: Negative voice outcomes occurred in 46% (95% CI, 34-59%) and 14% (95% CI, 6-30%) of TT and PT groups, respectively. No NegVOs were observed after NN surgery. Early NegVOs were more common in the TT group than in the NN or PT groups (p < 0.001). Most voice disturbances resolved by 6 months (TT 84%; PT 92%) with no difference in NegVO among all groups (p = 0.23). Black race and significant changes in certain voice outcomes measures at the 2-week follow-up visit were identified as predictors of late (3 to 6 months) NegVO. CONCLUSIONS: This comprehensive voice outcomes study revealed that the extent of thyroidectomy impacts voice outcomes in the early postoperative period, and identified risk factors for late NegVO in post-thyroidectomy patients who should be considered for early voice rehabilitation referral.

Primary squamous cell carcinoma of the thyroid gland: a case report and review.

BACKGROUND: Primary squamous cell carcinoma (SCC) of the thyroid gland is a rare malignancy that presents with advanced disease and poor prognosis. METHODS: A 75-year-old woman with a history of Hashimoto thyroiditis presented with 6 months of dysphagia and stridor. Imaging revealed a thyroid mass invading the larynx. Primary SCC of the thyroid was diagnosed by histopathologic and immunohistochemical evaluation. Total thyroidectomy, total laryngectomy, bilateral modified neck dissection, and adjuvant radiotherapy (RT) were performed. Radiologic follow-up at 21 months demonstrated no disease and total length of survival was 31 months. RESULTS: Despite an aggressive T4aN0M0 tumor, survival in this case was more than double the median survival rate previously reported. Concomitant Hashimoto thyroiditis is rare and histopathologic and immunohistochemical evaluation is imperative for an accurate diagnosis. CONCLUSION: The case and literature reported here support that a thorough diagnostic workup of primary SCC of the thyroid with aggressive locoregional surgery and adjuvant RT may improve the length of survival.

The role of listener experience on Consensus Auditory-perceptual Evaluation of Voice (CAPE-V) ratings of postthyroidectomy voice.

PURPOSE: To determine whether experienced and inexperienced listeners rate postthyroidectomy voice samples similarly using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). METHOD: Prospective observational study of voice quality ratings of randomized and blinded voice samples was performed. Twenty-one postthyroidectomy patients' voices, representing a wide range of severities, were rated using a custom-automated version of the CAPE-V. Ten male and 11 female voices were rated by 10 experienced and 10 inexperienced listeners. Experienced listeners consisted of 5 otolaryngologists (ENTs) and 5 speech-language pathologists (SLPs); inexperienced listeners were medical professionals with no formal training or experience in voice disorders. RESULTS: Inexperienced listeners rated voices as more severely impaired than experienced listeners for all CAPE-V parameters (p < or = .003). Those without experience in voice disorders had lower intra- and interrater reliability (e.g., r = .838 and .528, respectively, for overall severity) than those with experience in voice disorders (e.g., r = .911 and .722, respectively, for overall severity) for all parameters. Among experienced listeners, ENTs and SLPs rated voices similarly for most parameters. CONCLUSIONS: Experienced and inexperienced listeners judged voice quality differently given minimal training with the use of the CAPE-V. SLPs and ENTs rated postthyroidectomy voice quality similarly. These findings indicate that the CAPE-V can be used reliably and similarly by professionals who specialize in voice disorders.

Prospective trial of voice outcomes after thyroidectomy: evaluation of patient-reported and clinician-determined voice assessments in identifying postthyroidectomy dysphonia.

BACKGROUND: Reliable voice grading systems to identify postoperative voice dysfunction by surgeons are needed. PURPOSE: To examine the utility of patient-reported and clinician-determined voice assessment in identifying postthyroidectomy voice dysfunction. PATIENTS AND METHODS: Fifty patients enrolled in a prospective observational trial evaluating voice function perioperatively by patient-reported symptoms (Voice Case History [VCHx]) and perceived voice handicap (Voice Handicap Index [VHI]), clinician-determined judgment of voice quality (Consensus Auditory-Perceptual Evaluation--Voice [CAPE-V]), and laryngeal examination via video laryngoscopy (VLS). Voice dysfunction at first postoperative visit in symptomatic patients was defined by objective laryngeal abnormalities on VLS. Postoperative changes from baseline in voice parameters were compared between patients with and without voice dysfunction using the Wilcoxon rank sum test. Receiver operating characteristics were evaluated to determine area under the curve (AUC) for tested parameters. RESULTS: Eight (16%) had early transient and 1 (2%) had permanent postoperative voice dysfunction. VCHx symptoms had negative (NPV) and positive (PPV) predictive values of 96%-100% and 39%-53%, respectively for voice dysfunction. The rating of overall severity from the CAPE-V was highly predictive (AUC = 0.96), and a change in severity from preoperative baseline >or=20% at 1-2 weeks had a PPV of 86% and NPV of 95% for postoperative dysphonia. Patient-reported total VHI score was most predictive (AUC = 0.97) and a change in VHI from preoperative baseline >or=25 early postoperatively had a PPV of 88% and NPV of 97% for postoperative dysphonia. CONCLUSION: Patient self-assessment of voice handicap using the VHI reliably identifies voice dysfunction after thyroidectomy. Patients with a change in VHI >or=25 from preoperative baseline warrant early referral to speech pathology and laryngology.

Squamous cell carcinoma of the oropharynx and hypopharynx.

Oropharyngeal and hypopharyngeal squamous cell carcinomas require an interdisciplinary approach to manage patients appropriately. Tumor stage and histology, functional outcome, and patient comorbidities are important factors to consider. Various surgical approaches as well as chemotherapy and radiation therapy alone or in combination remain the mainstay of therapy.

Tumors of the accessory lobe of the parotid gland: a 10-year experience.

OBJECTIVES/HYPOTHESIS: The differential diagnosis of midcheek masses include pathology arising from normal anatomic structures or from variations of normal accessory parotid gland tissue. Accessory parotid gland tissue has been described as salivary tissue adjacent to Stenson's duct that is separate from the main body of the parotid gland. We report our 10-year experience with the diagnosis and treatment of eight accessory parotid gland neoplasms that have been followed by the senior authors. STUDY DESIGN: This is a retrospective review of our experience with eight accessory parotid gland neoplasms. METHODS: A literature review and retrospective chart review of our experience with accessory parotid gland tumors over the past 10 years. The presentation, evaluation, management, treatment, and outcome were recorded. RESULTS: Eight cases of accessory lobe parotid tumors were identified, which have been followed since the date of initial treatment. All of the patients presented with a slowly growing cheek mass. There was one case of carcinoma expleomorphic adenoma, one case of undifferentiated carcinoma (small cell carcinoma), one case of basal cell adenocarcinoma, one case of benign salivary cyst, two cases of pleomorphic adenoma, and two cases of monomorphic adenoma. A standard facelift approach or modified Blair incision was used to excise these tumors. CONCLUSIONS: Neoplasms of the accessory parotid gland are rare. Management of these tumors include a high index of suspicion, good understanding of the anatomy, and meticulous surgical approach.

Current concepts in lip reconstruction.

PURPOSE OF REVIEW: Approximately 25% of all oral cavity carcinomas involve the lips, and the primary management of these lesions is complete surgical resection. The management of the resulting lip defect remains a significant reconstructive challenge, requiring meticulous preoperative planning and surgical technique to optimize the functional and cosmetic outcome. Reviewed here are the accepted techniques of lip reconstruction, as well newer techniques that have been reported. RECENT FINDINGS: There have been no major advances in lip reconstruction; rather, continued improvement on accepted techniques. The main goals of reconstruction remain the restoration of oral competence, maintenance of oral opening, and the restoration of normal anatomic relations such that both the active (smile) and passive (form) cosmetic outcome is acceptable. The reconstruction should be tailored to the individual needs of the patient and should take into account the patient's condition, local tissue characteristics, previous treatment(s), and functional needs (eg, denture use), in addition to the size and location of the defect. SUMMARY: The lips play a key role in facial expression, speech, and eating. This requires meticulous attention to preoperative planning and surgical technique to maximize the functional and cosmetic outcome. It is important to assess local tissue characteristics (skin laxity) and previous treatment (surgery and/or irradiation) before the surgical plan is made final. Local tissue should be used whenever possible to provide the least donor site morbidity and the best overall tissue color and texture match. Whenever possible, dynamic reconstruction should be attempted. Careful preoperative assessment and planning will allow the surgeon to reach an acceptable balance between form and function with the reconstruction.

Use of the anterolateral thigh flap for reconstruction of the head and neck.

PURPOSE OF REVIEW: The anterolateral thigh free flap has achieved recent popularity in North America for the reconstruction of head and neck defects after ablative surgery. The flap is most often based on either the septocutaneous or musculocutaneous perforators of the descending branch of the lateral circumflex femoral artery. Its versatility allows for a subcutaneous, fasciocutaneous, myocutaneous, or adipofascial flap to be obtained. RECENT FINDINGS: Recent publications have described the utility of the anterolateral thigh flap for reconstruction of head and neck defects. It has been used successfully in the reconstruction of the laryngopharynx, oral cavity, oropharynx, external skin, and maxilla. Furthermore, when a thinner flap is needed, a suprafascial anterolateral thigh flap may be raised or the flap may be thinned after it is obtained. SUMMARY: The anterolateral thigh flap is a highly versatile and reliable flap for use in the reconstruction of various soft tissue defects of the head and neck. This flap has gained great popularity in mainland China, Taiwan, and Japan given its versatility, ability for a two-team approach, and minimal donor site morbidity. However, it has not met the same enthusiasm in Europe and North America because of the relative difficulty in perforator dissection, reported variations of the vascular anatomy, and the presumed increased thickness of the anterolateral thigh tissue in the Western population in comparison with the patient population of the Far East. These obstacles may be overcome by increased surgical experience and by the ability to create a thinner suprafascial flap or thinning the flap after it has been obtained.

Gaze-evoked amaurosis: a report of five cases.

OBJECTIVE: To highlight the various causes of gaze-evoked amaurosis. DESIGN: Retrospective noncomparative interventional case series. PARTICIPANTS: Five patients treated at our facility over the past 6 years. METHODS: Clinical presentation, radiologic studies, surgical management, and postsurgical results are presented. MAIN OUTCOME MEASURES: Visual acuity, clinical findings of gaze-evoked amaurosis. RESULTS: Only two patients had classic intraorbital etiologies, one with an intraconal cavernous hemangioma and one with an intraconal foreign body. Three patients had extraorbital processes, two with orbital fractures and one with a sinus tumor. Only two of our patients initially were aware of the gaze-evoked amaurosis at presentation. Appropriate surgery was curative in all cases. CONCLUSIONS: Gaze-evoked amaurosis is a rare condition, classically implicating intraconal orbital pathology. In one of the largest case series published to date, we found extraorbital etiologies are also capable of producing gaze-evoked vision loss. Gaze-evoked amaurosis should be suspected and tested for in any orbital condition.