The Human Laryngeal Innervation Revisited-The Role of the Neural Connections.

In spite that vascular inconvenients or immunological rejections have been solved in relation with larynx transplant, a successful functional reinnervation has not been achieved. Some studies have suggested that laryngeal nerve connection may contain motor fibers, which could explain unexpected evoked responses in electromyographic studies or the different positions adopted of the vocal folds after similar nerve lesions. Ten patients with unexpected evoked responses after laryngeal nerve stimulation were selected. All the patients underwent a total laryngectomy due to oncological causes. In every case, laryngeal nerve connections were observed. All of them were morphologic and histologic processed for choline-acetyltransferase immunohistochemistry. The presence of motor axons in the nerve connections has been demonstrated, which would explain that the motor innervation to the laryngeal muscles could be dual through these variable connections. This also would justify the difficulty of carrying out laryngeal nerve reinnervation procedures. Anat Rec, 302:646-651, 2019. © 2018 Wiley Periodicals, Inc.

Anatomical Variations of the Intrapetrous Portion of the Facial Nerve.

The intrapetrous facial nerve has the second longest intraosseous course of all cranial nerves, after the mandibular nerve. But it is by far the most complex considering the anatomical structures closely related to it. The auditory and vestibular portions of the inner ear, the dura of the middle fossa and posterior fossa, the sigmoid sinus and jugular bulb, and the internal carotid artery are close enough to merit attention. This article includes an anatomical study on 100 temporal bones with anatomical references as seen from the middle fossa and from the transmastoid approaches that may help identifying the facial nerve and protecting surrounding structures. Anatomical variability was present and noteworthy when considering the venous drainage system through the temporal bone and the mastoid pneumatization. The distance from the geniculate ganglion to the hiatus falopii offered the highest variability with a range of 0 to 7.75 mm and a mean of 3.30 mm. The geniculate ganglion was dehiscent in 20.8% of the specimens and the superior semicircular canal was spontaneously blue-lined in 27% of the cases. Through the transmastoid approach, the highest variability was found regarding the distance between the vertical portion of the facial nerve and the jugular bulb (range from 1.5 to 10.0 mm), the sigmoid sinus (range from 0 to 13.25 mm) and the internal carotid artery (range from 6.0 to 15.0 mm). This study highlights the importance of the relative variability of the facial nerve to other surrounding structures within the petrous portion of the temporal bone. Anat Rec, 302:588-598, 2019. © 2018 Wiley Periodicals, Inc.

Peritonsillar and deep neck infections: a review of 330 cases.

INTRODUCTION: Deep neck infections are defined as suppurative infectious processes of deep visceral spaces of the neck. OBJECTIVE: The aim of this study is to review different factors that may influence peritonsillar and deep neck infections and may play a role as bad prognosis predictors. METHODS: We present a retrospective study of 330 patients with deep neck infections and peritonsillar infections who were admitted between January 2005 and December 2015 in a tertiary referral hospital. Statistical analysis of comorbidities, diagnostic and therapeutic aspects was performed with Excel and SPSS. RESULTS: There has been an increase in incidence of peritonsilar and deep neck infections. Systemic comorbidities such as diabetes or hepatopathy are bad prognosis factors. The most common pathogen was S. viridans (32.1% of positive cultures). 100% of the patients received antibiotics and corticosteroids, 74.24% needed surgical treatment. The most common complications were mediastinitis (1.2%) and airway obstruction (0.9%). CONCLUSION: Systemic comorbidities are bad prognosis predictors. Nowadays mortality has decreased thanks to multidisciplinary attention and improvements in diagnosis and treatment.

Síndrome del primer mordisco: presentación de 2 casos / First bite syndrome: report of two cases

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Manejo práctico de fugas periprótesis en pacientes rehabilitados con prótesis fonatorias tipo Provox(R)2 tras laringectomía total / Practical management of periprosthetic leakage in patients rehabilitated with a Provox(R) 2 voice prosthesis after total laryngectomy

Introducción y objetivos: La fuga periprótesica de líquidos es una complicación frecuente en pacientes rehabilitados con prótesis fonatorias. Nuestro objetivo es describir y revisar los resultados de procedimientos para el tratamiento de la fuga periprotésica. Materiales y métodos: Análisis retrospectivo de 41 pacientes rehabilitados con prótesis fonatorias Provox® 2 entre 1997 y 2015. Descripción de 3 técnicas: colocación de arandela de silicona periprótesis, inyección de ácido hialurónico en la pared traqueal y la combinación de ambas técnicas. Se presenta un método para reducir el diámetro de la fístula fonatoria mediante retirada de la prótesis y colocación de sonda nasogástrica a través de la fistuloplastia. Resultados: En los 3 grupos tratados mediante arandela de silicona (n = 5, 13 procedimientos), inyección de ácido hialurónico (n = 5, 9 procedimientos) y la combinación de ambas técnicas (n = 3, 5 procedimientos), observamos un aumento de la vida útil de las prótesis en una media de 56 días (rango 7 a 118 días), 32 días (rango de 3 a 55 días) y 63 días (rango 28 a 136 días) respectivamente. La reducción del diámetro fistuloplastia se produjo en el 100% (n = 6) de los pacientes tratados. Conclusiones: El uso de arandelas de silicona, inyección de ácido hialurónico en la pared traqueoesofágica y la combinación de ambas técnicas, para el tratamiento de la fuga periprótesis de líquidos aumenta la vida útil de las prótesis. La retirada protésica temporal y la colocación de sonda nasogástrica también se ha mostrado efectiva en nuestra experiencia. Estas técnicas son sencillas, económicas y reproducibles y reducen el gasto sanitario (AU)

Introduction and objectives: Periprosthetic leakage of liquids is a common complication in patients rehabilitated with voice prostheses. Our objective was to describe and review the results of procedures for treating periprosthetic leakage. Materials and methods: This was a retrospective analysis of 41 patients rehabilitated with Provox® 2 voice prostheses between 1997 and 2015. We describe 3 techniques: periprosthetic silicon collar placement, injection of hyaluronic acid into the tracheoesophageal wall and the combination of the 2 techniques. We present a method to reduce the diameter of the tracheoesophageal fistula by removing the voice prosthesis and placing a nasogastric tube through the fistula. Results: In the 3 groups treated with silicone collar (n = 5, 13 procedures), hyaluronic acid injection (n = 5, 9 procedures) and the combination of both techniques (n = 3, 5 procedures), we observed an increase in prosthesis lifespan of an average of 56 days (range 7-118 days), 32 days (range 3-55 days) and 63 days (range 28-136 days), respectively. The tracheoesophageal fistula diameter reduction was performed in 100% (n = 6) of patients. Conclusions: The use of silicone collars, injection of hyaluronic acid into the tracheoesophageal wall and the combination of both techniques for the treatment of periprosthesis leakage increase the lifespan of the prosthesis. Temporary prosthesis removal and placement of nasogastric tube has also been shown effective in our experience. These techniques are simple, inexpensive and reproducible, thereby reducing healthcare costs (AU)

Tratamiento quirúrgico del schwannoma vestibular. Revisión de 420 casos / Surgical treatment of vestibular schwannoma. Review of 420 cases

Introducción y objetivos: El schwannoma vestibular es el tumor más frecuente en el ángulo ponto-cerebeloso. El objetivo de nuestro estudio es reflejar nuestra experiencia en el tratamiento quirúrgico de este tumor. Material y métodos: Estudio retrospectivo de 420 schwannomas vestibulares intervenidos en nuestro centro entre 1994-2014. Se incluyen el tamaño tumoral, la audición preoperatoria, los abordajes quirúrgicos utilizados, el resultado definitivo de la función facial y auditiva y las complicaciones derivadas de la cirugía. Resultados: Un total de 417 pacientes con 420 tumores fueron analizados, siendo 209 mujeres (50,1%) y 208 varones (49,9%). La edad media fue de 49,8±13,2 años. La mayoría de los tumores se resecaron mediante abordaje translaberíntico (80,2%). La resección tumoral completa tuvo lugar en 411 tumores (98,3%), y la conservación de la integridad anatómica del nervio facial en 404 (96,2%). El resultado definitivo del facial fue grado I y II de House-Brackmann en el 69,9%, siendo significativamente mejor en los tumores de menos de 20mm. Entre las complicaciones se incluyen 3 casos de fístula (0,7%) y 16 acúmulos retroauriculares de líquido cefalorraquídeo (3,8%), 5 de meningitis (1,2%), 4 sangrados intracraneales (0,9%) y exitus en 3 pacientes (0,7%). Conclusiones: El tratamiento quirúrgico del schwannoma vestibular sigue siendo el de elección en la mayoría de los casos. En nuestra experiencia, la tasa de complicaciones es baja, siendo el tamaño tumoral el principal factor influyente en la función facial postoperatoria (AU)

Introduction and objectives: Vestibular schwannoma is the most frequent cerebellopontine angle tumor. The aim of our study is to reflect our experience in the surgical treatment of this tumor. Material and methods: Retrospective study of 420 vestibular schwannomas operated in our hospital between 1994-2014. We include tumor size, preoperative hearing, surgical approaches, definitive facial and hearing functional results, and complications due to surgery. Results: A total of 417 patients with 420 tumors were analyzed, 209 female (50.1%) and 208 male (49.9%). Mean age at diagnosis was 49.8±13.2 years. The majority of the tumors were resected through a translabyrinthine approach (80.2%). Total tumor removal was achieved in 411 tumors (98.3%), and anatomic preservation of facial nerve in 404 (96.2%). Definitive facial nerve outcome was House-Brackmann grade I and II in 69.9%, and was significantly better in tumors under 20mm. Surgical complications included cerebrospinal fluid leakage in 3 patients (0.7%) and retroauricular subcutaneous collection in 16 (3.8%), 5 cases of meningitis (1.2%), 4 patients with intracraneal bleeding (0.9%), and death in 3 patients (0.7%). Conclusions: Surgery is the treatment of choice for vestibular schwannoma in the majority of patients. In our experience, the complication rate is very low and tumor size is the main factor influencing postoperative facial nerve function (AU)

Practical management of periprosthetic leakage in patients rehabilitated with a Provox® 2 voice prosthesis after total laryngectomy. / Manejo práctico de fugas periprótesis en pacientes rehabilitados con prótesis fonatorias tipo Provox®2 tras laringectomía total.

INTRODUCTION AND OBJECTIVES: Periprosthetic leakage of liquids is a common complication in patients rehabilitated with voice prostheses. Our objective was to describe and review the results of procedures for treating periprosthetic leakage. MATERIALS AND METHODS: This was a retrospective analysis of 41 patients rehabilitated with Provox® 2 voice prostheses between 1997 and 2015. We describe 3 techniques: periprosthetic silicon collar placement, injection of hyaluronic acid into the tracheoesophageal wall and the combination of the 2 techniques. We present a method to reduce the diameter of the tracheoesophageal fistula by removing the voice prosthesis and placing a nasogastric tube through the fistula. RESULTS: In the 3 groups treated with silicone collar (n=5, 13 procedures), hyaluronic acid injection (n=5, 9 procedures) and the combination of both techniques (n=3, 5 procedures), we observed an increase in prosthesis lifespan of an average of 56 days (range 7-118 days), 32 days (range 3-55 days) and 63 days (range 28-136 days), respectively. The tracheoesophageal fistula diameter reduction was performed in 100% (n=6) of patients. CONCLUSIONS: The use of silicone collars, injection of hyaluronic acid into the tracheoesophageal wall and the combination of both techniques for the treatment of periprosthesis leakage increase the lifespan of the prosthesis. Temporary prosthesis removal and placement of nasogastric tube has also been shown effective in our experience. These techniques are simple, inexpensive and reproducible, thereby reducing healthcare costs.

Management of vagal paragangliomas: review of 17 patients.

Vagal paragangliomas are very rare benign vascular tumors of neuroendocrine nature, and are much less frequent than carotid and jugulo-tympanic tumors. The goal of this retrospective study is to review the clinical and genetic findings, surgical treatment, and complications of vagal paragangliomas, as well as to discuss the management options. During the period 1990-2013, 17 patients with vagal paragangliomas were referred to our institution. There were ten patients with isolated tumors, and seven with multicentric paragangliomas. There were nine women and eight men. Mean age of patients was 51.4 years. Five cases had a positive family history of paraganglioma (29.4 %). Germline mutations of SDH genes were found in six of our patients (35.3 %). Many options were considered in the management of vagal paragangliomas. Surgical treatment was performed in 11 young patients (64.7 %) using different approaches: in 4 patients the tumor was resected through a transcervical approach; in 3 through a transcervical-transmandibular approach; in 1 it was resected using a transcervical-transmastoid approach, and in 3 a type A infratemporal fossa approach was performed. In all operated cases, the removal of the tumor led to sacrificing of the vagus nerve. Postoperative hypoglossal nerve deficit was reported in 4 cases (36.3 %). In six elderly patients (35.3 %), we decided to "wait-and-scan" in order to avoid creating greater morbidity than that of the tumor itself. Many factors should be considered in the treatment of vagal paragangliomas: the age and general condition of the patient, the biological behavior of the tumor, tumor size, genetic results, bilaterality, multicentricity, lower cranial nerve function, and of course the potential morbidity of the surgical treatment itself. Rehabilitation and, possibly surgery, are necessary to treat postoperative lower cranial nerve deficits.

Manejo conservador del schwannoma vestibular / Conservative management of vestibular schwannoma

Introducción: El schwannoma vestibular (SV) es un tumor benigno de lento crecimiento originado en el VIII par craneal, en cuyo tratamiento entran a formar parte la microcirugía, la radioterapia estereoatáxica, y el manejo conservador de los tumores con controles radiológicos periódicos. Material y métodos: Estudio retrospectivo de pacientes con SV siguiendo un manejo conservador en un hospital de tercer nivel entre los años 1993-2013.Un total de 73 pacientes fueron incorporados a nuestro protocolo de seguimiento de SV. La edad media al diagnóstico fue de 59,7 años. El tamaño medio de 11,9 mm (4-27 mm), siendo el 58,9% intracanaliculares y el 41,1% extracanaliculares. El periodo de seguimiento medio fue de 35,75 meses. Resultados: En el 87,7% no hubo evidencia de crecimiento tumoral. Un total de 9 (12,3%) tumores incrementaron sus dimensiones. La velocidad media de crecimiento fue de 0,62 mm/año. El porcentaje de tumores extracanal que crecieron (20%) fue mayor que el de los tumores intracanal (7%). Siete pacientes experimentaron cambios significativos en su sintomatología (9,5%) y 6 de estos una pérdida de la audición útil (8,2%). Seis pacientes salieron del seguimiento y fueron intervenidos quirúrgicamente (8,2%). Conclusión: El seguimiento del SV con controles periódicos de resonancia magnética nuclear representa una opción válida de manejo, dado que la mayoría de los tumores de pequeño tamaño experimentan poco o nulo crecimiento a lo largo del tiempo (AU)

Introduction: Vestibular schwannoma (VS) is a benign, slow-growing tumour originating in the 8 th cranial nerve. The treatment includes microsurgery, stereotactic radiotherapy and conservative management of tumours with periodic radiological tests. Methods: This was a retrospective study of patients with VS following conservative management in a tertiary hospital between 1993 and 2013. A total of 73 patients were enrolled in our protocol. The mean age at diagnosis was 59.7 years. The average size was 11.9 mm (4-27 mm); 58.9% of the tumours were intracanalicular and 41.1%, extracanalicular. The mean follow-up period was 35.75 months. Results: In 87.7% of patients there was no evidence of tumour growth. A total of 9 tumours (12.3%) increased in size. The average growth rate was 0.62 mm/year. The percentage of extracanalicular tumours that grew (20%) was higher than that of intracanalicular tumours (7%). Seven patients (9.5%) experienced significant changes in their symptoms and 6 of these (8.2%) experienced a loss of useful hearing. Six patients (8.2%) left follow-up and underwent surgery. Conclusions: Periodic monitoring of vestibular schwannomas with magnetic resonance imaging represents an option for management, because most small tumours experience little or no growth over time (AU)

Conservative management of vestibular schwannoma.

INTRODUCTION: Vestibular schwannoma (VS) is a benign, slow-growing tumour originating in the 8th cranial nerve. The treatment includes microsurgery, stereotactic radiotherapy and conservative management of tumours with periodic radiological tests. METHODS: This was a retrospective study of patients with VS following conservative management in a tertiary hospital between 1993 and 2013. A total of 73 patients were enrolled in our protocol. The mean age at diagnosis was 59.7 years. The average size was 11.9mm (4-27mm); 58.9% of the tumours were intracanalicular and 41.1%, extracanalicular. The mean follow-up period was 35.75 months. RESULTS: In 87.7% of patients there was no evidence of tumour growth. A total of 9 tumours (12.3%) increased in size. The average growth rate was 0.62mm/year. The percentage of extracanalicular tumours that grew (20%) was higher than that of intracanalicular tumours (7%). Seven patients (9.5%) experienced significant changes in their symptoms and 6 of these (8.2%) experienced a loss of useful hearing. Six patients (8.2%) left follow-up and underwent surgery. CONCLUSIONS: Periodic monitoring of vestibular schwannomas with magnetic resonance imaging represents an option for management, because most small tumours experience little or no growth over time.

Hyaluronic acid gel weight: a nonsurgical option for the management of paralytic lagophthalmos.

OBJECTIVES/HYPOTHESIS: Management of lagophthalmos should be a priority in the treatment of patients with facial palsy. The aim of the study was to evaluate the safety and efficacy of injecting hyaluronic acid gel into the upper eyelid as a nonsurgical alternative for patients with temporary facial palsy. METHOD/STUDY DESIGN: Retrospective study of 26 patients treated with hyaluronic acid gel injected into the pretarsal region of the upper eyelid. Measurements taken before and after treatment were standardized and compared using digitized photographs. Patients were followed up for 1 year, and overall outcomes were assessed. RESULTS: All patients initially demonstrated improvement in lagophthalmos, which decreased to 0.0 mm. After 1 month, a significant increase in lagophthalmos was observed in two patients (initial fissure of 8 and 9 mm), and a platinum weight was implanted to control keratopathy. The remaining patients (initial lagophthalmos below 6.5 mm) maintained the improvement until facial restoration. Only three patients had recurrent lagophthalmos (2 mm) due to resorption, which was resolved by injecting an additional 0.3 cc. The mean improvement in lagophthalmos was 4.6 mm (range, 3.5-6.5 mm). Complications included transient ecchymosis and minimal blepharoptosis due to nonreabsorption in five patients. These patients were successfully treated with hyaluronidase. CONCLUSIONS: Hyaluronic acid gel has proven effective in reducing paralytic lagophthalmos and controlling keratopathy in patients with temporary facial palsy, especially those with palpebral fissure with attempted closure no greater than 6.5 mm. Injection of hyaluronic acid gel is safe, quick, and easily performed. In addition, it is more cost-effective than surgery.

Cerebral salt wasting syndrome: postoperative complication in tumours of the cerebellopontine angle.

Cerebral salt wasting (CSW) is a rare complication in posterior fossa tumour surgery. We present two patients with cerebellopontine angle (CPA) tumours who developed cerebral salt wasting postoperatively. Both patients deteriorated in spite of intensive fluid and salt replacement. On CT scan the patients presented mild to moderate ventricular dilation, which was treated with an external ventricular drainage. After the resolution of hydrocephalus, fluid balance rapidly returned to normal in both patients and the clinical status improved. Identification and treatment of secondary obstructive hydrocephalus may contribute to the management of CSW associated to posterior fossa tumour surgery.

Cerebral salt wasting syndrome: postoperative complication in tumours of the cerebellopontine angle

Cerebral salt wasting (CSW) is a rare complication in posterior fossa tumour surgery. We present two patients with cerebellopontine angle (CPA) tumours who developed cerebral salt wasting postoperatively. Both patients deteriorated in spite of intensive fluid and salt replacement. On CT scan the patients presented mild to moderate ventricular dilation, which was treated with an external ventricular drainage. After the resolution of hydrocephalus, fluid balance rapidly returned to normal in both patients and the clinical status improved. Identification and treatment of secondary obstructive hydrocephalus may contribute to the management of CSW associated to posterior fossa tumour surgery (AU)

El síndrome pierde sal cerebral (CSW, en sus siglas en inglés) es una complicación rara en la cirugía de los tumores de la fosa posterior. Presentamos a 2 pacientes con tumores del ángulo pontocerebeloso que desarrollaron un CSW posquirúrgico. Ambos pacientes tuvieron un empeoramiento pese a la fluidoterapia y la reposición de sal intensivas. La tomografía computarizada (TC) mostraba una dilatación ventricular leve a moderada que fue tratada mediante un drenaje ventricular externo. Tras la resolución de la hidrocefalia el balance hidroelectrolí-tico se normalizó rápidamente en ambos pacientes y su situación clínica mejoró. La identificación y el tratamiento precoz de la hidrocefalia obstructiva pueden contribuir al tratamiento del síndrome pierde sal asociado a la cirugía de tumores de la fosa posterior (AU)

Functional role of human laryngeal nerve connections.

OBJECTIVES/HYPOTHESIS: Current knowledge of the functional role of human laryngeal nerves is based on traditional laryngeal neuroanatomic descriptions or contradictory electromyographic studies. The aim of this study was to clarify the functional role of neural connections between laryngeal nerves by correlating the different electromyographic patterns observed after laryngeal stimulation and the existence of different neural connections. STUDY DESIGN: Descriptive. METHODS: Electromyographic and morphologic study in 13 patients during total laryngectomy procedure. RESULTS: Seven patients showed an additional evoked response from the cricothyroid muscle after recurrent laryngeal nerve stimulation. External laryngeal nerve stimulation resulted in additional responses from the posterior cricoarytenoid muscle in three cases and from the arytenoid muscle in one. The presence of a neural connection was confirmed in all patients who showed an unexpected electromyographic response. CONCLUSIONS: The different connections between laryngeal nerves are at least partially of motor nature and play a role in the mobility of vocal folds.