Long-term outcome of pre- and perinatal management of congenital head and neck tumors and malformations.

INTRODUCTION: Congenital head and neck pathology may cause direct postnatal airway obstruction. Prenatal diagnosis facilitates safe delivery with pre- and perinatal airway assessment and management and Ex-Utero-Intrapartum-Treatment (EXIT) if necessary. Fetoscopic airway evaluation can optimize the selection of patients in need of an EXIT procedure. METHODS: Description of 11 consecutive fetuses, born with a potential airway obstruction between 1999 and 2011 and treated at the University Hospitals Leuven, with a long-term follow-up until 2018. An algorithm including fetoscopic airway evaluation is presented. RESULTS: In utero imaging revealed seven teratomas, one fourth branchial pouch cyst, one thymopharyngeal duct remnant, one lymphatic malformation and one laryngeal atresia. A multidisciplinary team could avoid EXIT in eight patients by ultrasonographic (n = 2) or fetoscopic (n = 6) documentation of accessible airways. Three patients needed an EXIT-to-airway-procedure. Neonatal surgery included tracheostomy during EXIT (n = 2) and resection of teratoma (n = 7) or branchiogenic pathology (n = 3). All patients do well at long-term (minimum 54 months) follow-up. CONCLUSIONS: Combining prenatal imaging and perinatal fetoscopy, EXIT-procedure and neonatal surgery yields an optimal long-term outcome in these complex patients. Fetoscopy can dramatically reduce the number of EXIT-procedures.

Tracheal transplantation.

PURPOSE OF REVIEW: This review discusses the important advances in the reconstruction of airway wall defects resulting from stenosis and tumor resection. RECENT FINDINGS: Recent insights concerning regeneration, revascularization, and transplantation of the trachea are presented. The current study reviews tracheal transplantation as a new treatment modality. SUMMARY: This will enable wider application of tracheal allotransplantation for patients in need of complex reconstructive surgery for airway defects that are not amenable to standard methods of repair. Ongoing research suggests that tracheal allotransplantation may become available as a new treatment modality. Additional data are needed to define optimal withdrawal of immunosuppressants without loss of airway lumen.

Tracheal autotransplantation: guidelines for optimal functional outcome.

OBJECTIVES/HYPOTHESIS: Tracheal autotransplants can repair extensive hemilaryngectomy defects. This technique was introduced into the clinic some 10 years ago as a means of avoiding the mutilation of a total laryngectomy in selected patients with laryngeal cancer. Our goal was to give the morphometric guidelines that guarantee an optimal functional outcome. STUDY DESIGN: Retrospective case study. METHODS: We morphometrically evaluated the structure and function of the larynx after autotransplantation. The close anatomic relationship between the larynx and the trachea made it possible to perform a morphometric analysis of the defect and the repair tissue before and after transplantation. Computed tomography images were used to measure the laryngeal and tracheal airway lumen and the length and width of the tracheal autotransplant. A 4-cm long cartilaginous tracheal transplant was available for reconstruction. RESULTS: Laryngeal repair was achieved with optimal restoration of the airway lumen at all laryngeal levels. We used the maximal amount of trachea that might reasonably be available for autotransplantation. This optimal morphologic repair led to the restoration of speech, swallowing, and respiratory functions. CONCLUSIONS: This study highlights a standardized approach for repairing a hemilaryngeal defect and selecting the appropriate amount of repair tissue. A unique characteristic of vascularized cartilaginous trachea is that it restores the airway lumen after extensive hemilaryngectomy. Tracheal autotransplantation should be included in the armamentarium of reconstructive laryngeal procedures.

Extramammary myofibroblastoma in the head and neck region.

BACKGROUND: Mammary myofibroblastoma is a benign mesenchymal tumor of the breast. Extramammary location is very rare and usually occurs along the embryonic milk-line. METHODS AND RESULTS: In this article, we present a case of a woman with an infra-auricular swelling. A diagnosis could not be made on CT scans, so the mass was surgically removed. Histological examination showed spindle cells in clusters, with CD34, desmin, and actin expression. The diagnosis of extramammary myofibroblastoma was made. CONCLUSION: We describe this case because of the unusual location of this rare tumor. Furthermore, we want to highlight the possible relationship between (extra)mammary myofibroblastoma and spindle cell lipoma (SCL). SCL has a predilection site in the posterior neck. Both tumors show the same clinical behavior, a close histological resemblance, and their cells are both immunoreactive for CD34 and CD10. The loss of RB/13q14 and FKHR/13q14 loci, which is typically found in SCL cells, was also shown in this case.

Submucosal purse-string suture as a treatment of leakage around the indwelling voice prosthesis.

BACKGROUND: Leakage around the indwelling voice prosthesis is an annoying complication of tracheoesophageal speech. METHODS: Twenty patients, who experienced peripheral leakage of the tracheoesophageal fistula, were treated with a purse-string suture. Our aim was to get the patients free of leakage without losing their voice prosthesis. The technique was considered successful if this objective was reached and unsuccessful if eventually closure of the fistula was required. RESULTS: Immediately after the procedure, no patients showed residual leakage. At 1 month, 2 patients experienced recurrent leakage. At a mean follow-up of 19.4 months, the method was successful in 16 patients and unsuccessful in 4 patients. CONCLUSIONS: If peripheral leakage is not amenable to simple downsizing of the indwelling voice prosthesis, we feel the purse-string suture is the first-choice treatment because of its safety, efficiency, low cost, and ease of application.

Correlation of local outcome after partial laryngectomy with cartilage abnormalities on CT.

BACKGROUND AND PURPOSE: The prognostic significance of laryngeal cartilage abnormalities, as seen on CT or MR imaging, in laryngeal or hypopharyngeal cancer, is unclear. The purpose is to determine whether cartilage abnormalities as seen on preoperative CT in laryngeal and pyriform sinus cancer are predictive of local outcome after partial laryngectomy. METHODS: The preoperative CT studies in a consecutive series of 16 patients who underwent extended hemilaryngectomy for squamous cell carcinoma of the glottis (n = 12), supraglottis (n = 1), or pyriform sinus (n = 3) were reviewed retrospectively. Cartilage abnormalities were defined as asymmetric cartilage sclerosis, lysis of ossified cartilage, or tumor visible on both sides of the cartilage. Tumor volume was calculated by using the summation-of-areas technique. Seven patients underwent postoperative radiation therapy. All patients had a follow-up of at least 24 months after treatment or until local recurrence. RESULTS: Eleven patients showed cartilage abnormalities. In six patients, only a single cartilage was abnormal, whereas three patients showed involvement of two cartilages and two patients of three cartilages. The overall average tumor volume was 2.7 mL; the average tumor volume was 1.5 mL in the patients without and 3.3 mL in those with cartilage involvement on CT (P > .05). Two patients suffered a local recurrence. One patient (tumor volume, 1.5 mL) did not show any cartilage abnormalities. The other patient (tumor volume, 1.9 mL) showed abnormalities in all three cartilages and also had evidence of early transcartilaginous tumor spread. CONCLUSION: In patients whose cancer is anatomically suitable for partial laryngectomy, cartilage abnormalities on CT do not preclude speech-preserving surgery.

Tubes of vascularized cartilage used for replacement of rabbit cervical trachea.

This study was performed to evaluate the healing process of vascularized cartilage tubes after reconstruction of circumferential tracheal defects in rabbits. Vascularized cartilage was obtained by applying ear cartilage to a vascularized fascia flap in the lateral thoracic area in 10 animals. Five animals (control group) were used to evaluate the viability of the vascularized cartilage after 2 weeks. Circumferential tracheal defects were reconstructed in 5 animals by means of tubes of vascularized cartilage with preservation of the established blood supply around the grafts. The experimental animals were followed until signs of dyspnea became apparent. After follow-up and euthanasia, cartilage viability and regeneration of respiratory epithelium were evaluated. A viable plate of cartilage that was intensely attached to the vascularized fascia flap was found in the control animals. The animals from the experimental group showed dyspnea after a mean follow-up period of 22.6 days because of cartilage necrosis with loss of airway support. Cartilage graft revascularization and remucosalization were limited to 18.1% of the initial surface area of the cartilage tube. Mucosal coverage was seen at the anastomoses, whereas the middle part of the cartilage tube underwent necrosis. We conclude that tubes of autologous cartilage show problematic healing when placed inside the airway. Migration of vascularized connective tissue, migration of respiratory epithelium, and preservation of the viability of the cartilaginous graft were limited to a short segment at the anastomotic sites.

Functional treatment of a large laryngeal chondrosarcoma by tracheal autotransplantation.

Chondrosarcoma of the cricoid cartilage poses difficult therapeutic challenges. The tumor necessitates resection of parts of the cricoid cartilage with a resulting defect that is difficult to repair. We wanted to improve the functional outcome after resection of a lateralized chondrosarcoma by applying the technique of tracheal autotransplantation. The technique involves a 2-stage procedure, because the trachea needs at least 2 weeks for revascularization. Tracheal revascularization is the first stage, and is accomplished by wrapping the trachea in vascularized fascia (radial forearm). The second stage, performed after 14 days, consists of a hemilaryngectomy with tracheal autotransplantation. A case of a large unilateral chondrosarcoma of the cricoid cartilage with involvement of 1 cricoarytenoid joint is reported. The tumor was removed by hemicricohemilaryngectomy. After 2 weeks of tracheal revascularization, the cervical trachea was used to repair the laryngeal defect. The tumor was completely resected, and all laryngeal functions (swallowing, voice, respiration without tracheostomy) were restored. The patient remains tumor-free after a follow-up period of 3 years. Tracheal autotransplantation improves the functional treatment of lateralized chondrosarcomas of the cricoid cartilage.

Tracheal autotransplantation as a new and reliable technique for the functional treatment of advanced laryngeal cancer.

OBJECTIVES/HYPOTHESIS: Tracheal autotransplantation allows for reconstruction of extended hemilaryngectomy defects (including half of the cricoid cartilage) after resection of laryngeal or hypopharyngeal cancer. A series of 38 patients underwent the operation. The technique involved a two-stage procedure (stage 1, tracheal revascularization; stage 2, hemilaryngectomy and tracheal autotransplantation) because the trachea requires at least 2 weeks for revascularization. The objective was to improve the oncological reliability of the procedure by performing a one-stage tumor resection. STUDY DESIGN: Five patients who underwent a one-stage tumor resection are presented. They had T2 (n = 3) to T3 (n = 2) N0 laryngeal tumors. METHODS: Neck dissection, tumor resection, and tracheal revascularization were all performed during the first operation. The radial forearm fascia flap was designed with a distal fascial paddle and a proximal skin paddle. A 4-cm segment of cervical trachea was wrapped with the fascial paddle for revascularization, and the skin paddle was used for temporary closure of the extended hemilaryngectomy defect. The definitive reconstruction consisted of tracheal autotransplantation and was performed 4 months after the first procedure. Medical records were reviewed to determine time to oral intake, time to decannulation, length of hospital stay, and postoperative complications. RESULTS: After the first operation the skin paddle of the radial forearm flap succeeded in a restoration of the sphincteric function. The mean time to oral intake for solids was 9.0 days (SD = 2.6 d) and the mean length of hospital stay was 11.2 days (SD = 2.2 d). All patients were able to speak with the tracheal cannula in place. All laryngeal functions were restored after the second operation. The mean time to oral intake for solids was 8.2 days (SD = 5.2 d). The mean time to oral intake for liquids was 16.6 days (SD = 6.3 d), and the mean length of hospital stay was 9.6 days (SD = 2.3 d). The mean time to closure of the tracheostomy and removal of the gastric tube was 27.0 days (SD = 5.8 d). CONCLUSION: Tracheal autotransplantation allows for a functional treatment of advanced laryngeal cancers and is compatible with a one-stage tumor resection.

Arteria lusoria identified on preoperative CT and nonrecurrent inferior laryngeal nerve during thyroidectomy: a retrospective study.

BACKGROUND: To evaluate surgical identification of nonrecurrence of the inferior laryngeal nerve (NRILN) during thyroidectomy in patients with an aberrant subclavian artery (a. lusoria) as seen on CT. MATERIAL AND METHODS: The medical files of patients treated by thyroidectomy between January 1998-December 2000 (n = 583) were retrospectively reviewed for preoperative and postoperative mobility of the vocal cords and perioperative identification of NRILN. The available preoperative CT studies (n = 163) were reviewed for presence of a. lusoria. RESULTS: In five patients, the CT study revealed an a. lusoria (3.16%). In one of five of these patients, an NRILN was surgically detected; the overall detection rate of NRILN was 0.21%. In one of four patients with nonidentification of this nerve during surgery, immediate unilateral and permanent vocal cord paralysis were present after surgery. No permanent vocal cord paralysis occurred in any of the other patients. CONCLUSION: The identification of a. lusoria should alert the radiologist and surgeon that a NRILN is present, allowing an anticipating surgical technique, reducing the risk of neural injury.