Endovascular Management of Patients with Head and Neck Cancers Presenting with Acute Hemorrhage: A Single-Center Retrospective Study.

PURPOSE: Acute hemorrhage associated with cancers of the head and neck is a life-threatening condition that requires immediate action. The aim of this study was to assess the safety and efficacy of endovascular embolization for acute hemorrhage in patients with head and neck cancers. MATERIALS AND METHODS: Data were retrospectively collected from patients with head and neck cancers who underwent endovascular embolization to treat acute hemorrhage. The primary endpoint was the rate of immediate control of hemorrhage during the first 24 h after embolization. The secondary endpoints were technical or clinical complications, rate of re-hemorrhage 24 h after the procedure, time from embolization to re-hemorrhage, hospitalization time, mortality rate, and time from embolization to death. RESULTS: Fifty-one patients underwent endovascular embolization. The primary endpoint was achieved in 94% of patients. The rate of technical complications was 5.8%, and no clinical complication was observed. Twelve patients (23.5%) had hemorrhage recurrence after an average time of 127.5 days. The average hospitalization time was 7.4 days, the mortality rate during the follow-up period was 66.6%, and the average time from embolization to death was 132.5 days. CONCLUSION: Endovascular embolization to treat acute hemorrhage in patients with head and neck cancers is a safe and effective method for the immediate control of hemorrhage and results in a high rate of hemorrhage control. Larger studies are necessary to determine which treatment strategy is best for improving patient outcomes.

Cephalometric analysis of modifications of the pharynx due to maxillo-mandibular advancement surgery in patients with obstructive sleep apnea.

Cephalometry has been used to measure hard and soft facial tissues, as well as the pharyngeal air space for the diagnosis of obstructive sleep apnea (OSA). The changes occurring in the pharynx due to maxillo-mandibular advancement (MMA) have not been established or quantified. The objective of this study was to identify the anatomical changes of the pharynx and of hard tissues that occur in patients with OSA after MMA. 19 patients with a polysomnographic diagnosis of OSA were submitted to cephalometric analysis before and 6 months after surgery in order to evaluate the changes produced by MMA in the pharynx and soft tissues. Cephalometry was standardized in order to obtain descriptive measurements of the dimensions of the airways, the position of the hyoid bone, and maxilla-mandibular relations. The modifications of the pharynx due to MMA showed a significant relation obtained by cephalometry. For each millimeter of maxillary and mandibular bone advancement there was a 0.76mm increase in the retropalatal region and a 1.2mm increase in the pharynx in the retrolingual region. In addition, MMA promoted a significant repositioning of the hyoid bone in the cranial direction.

Effect of dentofacial deformity on maximum isometric tongue strength.

The objective of this study was to determine whether dentofacial deformities (class II and class III) influence maximum isometric tongue strength compared with a group without deformities. A total of 126 adult patients participated in the study. Of these, 45 had a class II diagnosis (14 men and 31 women) and 81 a class III diagnosis (35 men and 46 women), all of them with indication of orthognathic surgery. Fifty adult volunteers (17 men and 33 women) with no changes in dental occlusion (class I) and with no clinical signs of dysfunction of the temporomandibular joint represented the control group. Tongue strength (in N) was measured with a dynamometer. The maximum strength of the anterior portion was determined with the instrument positioned on the retroincisor region and the maximum strength of the dorsum with the instrument positioned in the region of the hard palate. Data were analysed statistically by analysis of variance (anova) and by the Pearson correlation test. No significant difference (P > 0·05) in tongue strength in the anterior or dorsal region was observed between the groups with dentofacial deformities or between these groups and the control. The tongue strength of the anterior and dorsal regions was not influenced by the dentofacial deformity.

Treatment of caustic ingestion: an analysis of 239 cases.

The objective of the present study was to analyze a 37-year historical series of patients who had ingested caustic substances, and who were treated in a teaching hospital, to assess the effectiveness of the therapy administered during this period. We studied 239 patients who ingested caustic soda (NaOH) from 1957 to 1994. Data were collected from the medical records of the patients and from interviews with them and analyzed by software and by statistical tests of association. The results showed that more women than men ingested caustic substances (57%, n=153). Ingestion was associated with suicidal intent in 60% of cases and was accidental in 37.2% of cases. The amount of substance ingested ranged from a trace to as much as three tablespoons, with the amount tending to be larger in the suicide attempts. Of the 215 patients for whom information about complications due to ingestion was available, 88.4% (190) presented lesions of the esophagus (73% with stenosis), 1% died during the acute phase, and 10.6% did not present complications. The data revealed that the presence and severity of stenosis were correlated with the amount of caustic substance ingested. The treatment received by the patients in the study sample varied over the years according to the prevailing literature recommendations. Based on our review, we conclude that neither the use of an antidote nor early treatment immediately after ingestion is effective. Treatment with a corticosteroid (1.5-2 mg/kg/day prednisone), an antibiotic, and a high-protein and hypercaloric diet seems to be beneficial for patients who ingest small or medium amounts of caustic soda. When 2-3 tablespoons are ingested, corticosteroids, in addition to being unable to prevent the formation of esophageal stenosis, increase the risk of other complications.

Time necessary for neovascularization of a tracheal segment by the sternohyoid muscle.

INTRODUCTION: The reimplantation of a complete tracheal segment (CTS) as an autograft or homograft often results in total or partial necrosis of the CTS. However, previous experiments suggested that when the CTS is first vascularized by the sternohyoid muscle (SM) 21 days before the reimplantation, the CTS can be reimplanted without ischemia or stenosis. However, it is not clear if the CTS requires 21 days to attain full revascularization. GOAL: This study aims to ascertain the minimum time necessary for revascularization of the 6 rings CTS by the SM allowing reimplantation free of ischemia. METHODS: Fifteen mongrel dogs, divided into 3 groups were submitted to 2 sequential surgical procedures. In the first procedure, a SM flap was used to envelop 6 rings CTS in all dogs. After periods of 21 days (group 1, n = 5), 14 days (group 2, n = 5) and 7 days (group 3, n = 5), the compound flaps (CTS and SM) were neovascularized. Each CTS was transected and mobilized from the trachea and then replaced again in its original site, as an autoflap. RESULTS: After a period of at least 60 days, none of dogs presented any respiratory alteration. Macroscopic and microscopic analyses demonstrated adequate viability and no stenosis. CONCLUSION: Our findings suggest that it is possible to neovascularize the CTS using a SM flap within a period as short as 1 week.

Ingestion of caustic substances and its complications.

CONTEXT: Caustic substances cause tissue destruction through liquefaction or coagulation reactions and the intensity of destruction depends on the type, concentration, time of contact and amount of the substance ingested. OBJECTIVES: To analyze the complications in patients who ingested caustic substances and correlate them with the amount of caustic soda ingested. DESIGN: Retrospective study. SETTING: University hospital, a referral center. PARTICIPANTS: A total of 239 patients who ingested caustic soda. MAIN MEASUREMENTS: The amount of granulated caustic substance ingested was measured as tablespoonfuls and the following complications were analyzed: esophagitis, esophageal stenosis and progression to cancer, fistulas, perforations, stomach lesions, brain abscesses, and death. Stenosis was classified as mild, moderate or severe according to the radiological findings. RESULTS: We observed an 89.3 % incidence of esophagitis; 72.6 % of the cases involved progression to stenosis and 1 per cent died during the acute phase. Stenosis was mild in 17.6 % of cases, moderate in 59.3 % and severe in 23 %. The incidence of stenosis was 80.8 per cent in women and 62.5 % in men. The incidence of stenosis was 46.9 % in the group that ingested "fragments" and 93.6 % in the group that ingested one or more tablespoonfuls of caustic substances. Among subjects who ingested one or more tablespoonfuls, 32.2 % developed lesions of the stomach-duodenum, whereas the ingestion of "fragments" was not sufficient to induce these lesions. There was no correlation between the intensity of lesions of the esophagus and of the stomach. Progression to cancer of the esophagus occurred in 1.8 % of cases, death during the chronic phase in 1.4 %, perforations in 4.6 %, fistulas in 0.9 %, and brain abscesses in 1.4 %. CONCLUSIONS: The complications were related to the amount of caustic soda ingested. Small amounts caused esophagitis or stenosis and large amounts increased the risk of fistulas, perforations and death.

The management of laryngeal fractures using internal fixation.

BACKGROUND: Laryngeal fracture is a rare injury with the potential to affect all functions of the larynx. Restoration of the laryngeal framework is critical for the rehabilitation of laryngeal function. OBJECTIVE: To ascertain the efficacy of adaptation plate fixation (APF) to repair the laryngeal skeleton. STUDY DESIGN: Retrospective review of the clinical data of all patients who underwent APF of laryngeal fractures from January 1989 to September 1999. RESULTS: Our series consisted of 16 men and 4 women presenting with laryngeal fractures caused by blunt (n = 16) or penetrating (n = 4) trauma. Most of these patients presented with severe fractures classified as category III (n = 6), IV (n = 10), or V (n = 1), according to the Schaefer-Fuhrman classification. All patients who required a tracheotomy (n = 13) were de-cannulated. Nineteen of the 20 patients recovered a social voice. The exception was a patient with aphasia secondary to head trauma No patient had aspiration problems. We encountered no complication associated with the use of APF. CONCLUSION: APF is an effective and well-tolerated method to repair laryngeal fractures.

Effect of gastroesophageal reflux on hypertrophy of the base of the tongue.

The objective of this study was to determine a possible association between pharyngolaryngeal signs of gastroesophageal reflux (GER) and hypertrophy of the lymphoid follicles at the base of the tongue (HBT). For this purpose, 306 patients submitted to videolaryngoscopy were studied retrospectively and classified according to the presence and size of follicles on the base of the tongue. HBT was considered to be present when the follicles prevented the view of the vallecula. The patients were grouped according to the presence of videolaryngoscopic signs of GER and further subdivided according to the presence of esophageal, pharyngolaryngeal, and esophagopharyngolaryngeal symptoms, with an attempt made to relate these symptoms to the presence of HBT. HBT was detected in 62.4% (63/101) of the patients with signs of GER and in 29.3% (60/205) of patients with no signs of GER. When HBT incidence was studied according to the symptoms reported by the patient, the condition was found to be present in 57.2% (8/14) of patients with exclusively esophageal symptoms, in 63.6% (21/33) with esophagopharyngolaryngeal symptoms, and in 75% (15/20) with exclusively pharyngolaryngeal symptoms. We conclude therefore that HBT is associated with GER.

Use of a platysma myocutaneous flap for the reimplantation of a severed ear: experience with five cases.

CONTEXT: The traumatic loss of an ear greatly affects the patient because of the severe aesthetic deformity it entails. The characteristic format of the ear, with a fine skin covering a thin and elastic cartilage, is not found anywhere else in the human body. Thus, to reconstruct an ear, the surgeon may try to imitate it by sculpting cartilage and covering it with skin. OBJECTIVE: To use a platysma myocutaneous flap for the reimplantation of a severed ear in humans. DESIGN: Case report. SETTING: Emergency unit of the university hospital, Faculty of Medicine, Ribeirão Preto - USP. CASE REPORT: Five cases are reported, with whole ear reimplantation in 3 of them and only segments in 2 cases. The surgical technique used was original and was based on the principle of auricular cartilage revascularization using the platysma muscle. We implanted traumatically severed auricular cartilage into the platysma muscle. The prefabricated ear was later transferred to its original site in the form of a myocutaneous-cartilaginous flap. Of the 5 cases treated using this technique, 4 were successful. In these 4 cases the reimplanted ears showed no short- or long-term problems, with an aesthetic result quite close to natural appearance. In one case there was necrosis of the entire flap, with total loss of the ear. The surgical technique described is simple and utilizes the severed ear of the patient. Its application is excellent for skin losses in the auricular region or for the ear itself, thus obviating the need for microsurgery or the use of protheses or grafts.

Tracheal neovascularization: a method involving mobilization of a complete tracheal neovascularized segment using a sternohyoid muscle flap.

Tracheal segmental free grafts always tend to undergo necrosis with consequent occlusion of the airway. Revascularized grafts are impossible to carry out, since the trachea is devoid of a major vascular pedicle that would permit microvascular reconstruction. On the other hand, neovascularized grafts carry a potential for success but have not been sufficiently studied. Neovascularization of a six-ring circumferential tracheal segment (CTS) was studied in dogs using a sternohyoid muscle (SM) flap. Three different procedures were carried out. In group 1 the six-ring CTS was inside a free graft. In group 2 the SM was freed from its proximal connection and rotated to wrap a corresponding six-ring CTS; it was then sutured and left in place for 21 days. After this period it was again approached, and the six-ring CTS was sectioned and sutured back in place, leaving the distally pedicled SM untouched. In group 3 an identical procedure was carried out, but the SM flap was left with a proximally rather than a distally based flap. All surviving animals were followed up for at least 1 year, and the results were analyzed by clinical and tracheoscopic observations and by macroscopic and microscopic studies after the animals were killed. All animals in group 1 died within 18 days; the studies showed necrosis and occlusion of the CTS. In groups 2 and 3 there was no degenerative change of the CTS, whose aspect was close to normal on macroscopic and microscopic examination. We conclude that the free CTS graft is totally inviable. In contrast, neovascularization of the CTS occurs when the segment is first wrapped around with an SM flap. This ensures CTS viability and opens new perspectives for homotransplantation.

Rupture of the aorta due to a malpositioned tracheal cannula in a 4-month-old baby.

Complications of tracheostomy are not rare and are even more common in children. They may be acute or chronic and sometimes may have serious consequences. We report here a rare situation in which a malpositioned tracheal cannula in a false tract from the neck to the mediastinum induced necrosis and rupture of the aorta and of the left carotid artery with fatal hemorrhage.

Use of the platysma myocutaneous flap for cervical trachea reconstruction: an experimental study in dogs.

Cervical trachea reconstruction with a non-stented platysma myocutaneous door flap (NPMCF) was studied in 23 dogs. Window defects involving 5, 10, or 15 rings and the whole anterior tracheal wall were produced in 3 different groups of animals. A segmentary defect involving the resection of 3 tracheal rings but preserving the posterior membranous wall was created in another group. The results were evaluated by clinical follow-up of up to 100 days, by tracheoscopy 1 week after surgery, and by macroscopic and microscopic examination after the animals' natural death or sacrifice. The NPMCF proved to be adequate for the reconstruction of window defects limited to 5 and 10 rings, with success rates of 100% and 75%, respectively. The use of the NPMCF for tracheal reconstruction had the following main advantages: 1. relatively simple, easy, and expeditious surgery; 2. use of a single operative field; 3. availability of large amounts of donor tissue; 4. adequate thickness; 5. reliable irrigation; 6. resistance to environmental exposure as evidenced by absence of infection; and 7. 100% take rate with no granulomas or scar stenosis at the suture lines. However, luminal occlusion due to flap collapse was a 100% fatal complication when the NPMCP was used either for reconstruction of larger window tracheal defects (15 rings-group 3) or segmentary defects (group 4); this was the main limitation of the method, followed by hair growth with accumulation of secretions, which can be easily dealt with. It can be anticipated that this method has a potential for application in well-selected patients.