Total Thyroidectomy while on Extracorporeal Membrane Oxygenation for Thyroid Storm.

Thyroid storm is an acute life-threatening condition of hyperthyroidism that can present with cardiac failure, requiring extracorporeal membrane oxygenation (ECMO). We present the first case reported of total thyroidectomy successfully performed while on ECMO for thyroid storm in a 32-year-old male. This case highlights the challenges of managing refractory thyroid storm with multi-organ failure. We demonstrate that total thyroidectomy may still be safely performed while on ECMO for thyroid storm, if steps are taken to optimise the patient perioperatively, with careful surgical and anaesthesia planning. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-04430-9.

Boosted abscopal effect from radiotherapy and pembrolizumab in anaplastic thyroid cancer: a mini-review and case report.

BACKGROUND: The abscopal effect, in which radiation induces a systemic anti-tumour immune response, has been demonstrated with radiotherapy. Immunotherapy boosts the abscopal effect by facilitating the immune response to radiation. Radiotherapy and programmed cell death protein 1/programmed cell death ligand 1 (PD-1/PD-L1) blockade has resulted in the boosted abscopal effect in solid cancers, but its role in anaplastic thyroid cancer (ATC) is unknown. In this mini-review, we describe the abscopal effect and summarise its proposed underlying mechanisms. We then present a potential case of boosted abscopal effect in ATC. CASE DESCRIPTION: In our case presentation, we describe a 51-year-old female who presented with 3 weeks of rapidly enlarging thyroid mass. Examination revealed a 3-cm thyroid nodule which was Bethesda V on fine needle aspiration cytology (FNAC). Intraoperatively, there was a gross extrathyroidal extension into the cricoid cartilage. After total thyroidectomy, post-operative histopathology showed widely invasive follicular thyroid cancer with anaplastic transformation (>50%). Immunohistochemistry showed high PD-L1 expression [combined positive score (CPS) >70%]. Due to residual cricoid cartilage disease and several peri-hilar and lung metastases on positron emission tomography-computed tomography (PET-CT) scan, she underwent post-operative palliative radiotherapy and pembrolizumab. After two cycles of pembrolizumab, repeat PET-CT scan showed complete response (CR) of local and distant disease. She remained well for 32 months, before recent discovery of a right mandible bony metastasis planned for radiotherapy. CONCLUSIONS: This case demonstrates exceptional response to radiotherapy and anti-PD-1 immunotherapy in ATC, potentially illustrating the first known abscopal effect in ATC with this treatment.

The chimeric medial sural artery perforator flap as the ideal for partial tongue reconstruction: A case series and technical refinements.

BACKGROUND: The medial sural artery perforator free flap (MSAP) has gained increasing popularity in head and neck reconstruction. Its slightly bulkier nature than the radial forearm flap, combined with negligible donor site morbidity, makes it an ideal candidate for the reconstruction of partial glossectomy defects. The ability to harvest the MSAP as a chimeric flap with a portion of the medial gastrocnemius muscle gives it greater flexibility in soft tissue reconstruction. METHODS: A retrospective study of patients with partial glossectomy defects reconstructed using the MSAP by a single surgeon was performed. Perioperative data, donor and recipient site characteristics, complications, and outcomes were analyzed. A video is included to show technical points for the harvest of the flap. RESULTS: A total of 10 patients were included. The average age was 59.1 years, with a mean of 43.5% of the tongue resected. All flaps survived, with no major complications. At follow-up, the patients had regained an average of 86.5% of original speech, with none requiring NG feeding. The average MSAP skin flap thickness was 7.8 mm, with 6 flaps being harvested as chimeric fasciocutaneous muscle flaps. Five flaps incorporated 2 perforators. Two case examples are presented. CONCLUSION: The chimeric MSAP perforator allows for more robust partial glossectomy reconstruction with improved postoperative functional outcomes. It should be considered as the workhorse flap for partial tongue reconstruction.

A novel treatment for CI extrusion with vacuum-assisted closure device.

OBJECTIVE: To assess if a vacuum-assisted closure device initially utilised as a temporising measure to dress a wound defect over a cochlear implant prior to definitive surgical intervention could instead be used to close the soft tissue and avoid surgery. METHOD: This is a case report describing the novel use of VAC (Vacuum-Assisted Closure Device) in the successful closure of a wound defect with cochlear implant hardware exposure post soft tissue infection during the Covid-19 pandemic. RESULTS: While the VAC system was initiated for temporary wound coverage, it was observed at each dressing change to be successfully decreasing the soft tissue defect for our patient. This resulted in complete epithelisation of the soft tissue defect at Day 35 and avoidance of a surgical procedure. The patient was able to restart wearing her device on Day 50 and Cochlear MAPping performed on Day 58 showed minimal changes in patient's current requirements compared to her settings pre-infection. CONCLUSION: The use of V.A.C dressing for a small soft tissue defect over an extruded cochlear implant seems promising as exemplified by our case study. However, due to the lack of literature, more studies should be done to prove its usefulness in such an application.

Superficial temporal vessels, both anterograde and retrograde limbs, are viable recipient vessels for recurrent head and neck reconstruction in patients with frozen neck.

BACKGROUND: Reconstruction of recurrent head and neck malignancy especially in the presence of a frozen neck is challenging. The superficial temporal vessels would be ideal as recipient vessels because they lie out of the previous surgical and radiation field. METHODS: We conducted a retrospective case-control study based on our database between January 2013 and June 2016. A total of 581 primary cases were selected as controls. The 60 test group patients had (a) recurrent head and neck reconstruction, (b) previous surgery and irradiation, (c) frozen neck, and (d) superficial temporal vessels as recipients. RESULTS: There was no significant difference between vascular compromise rates of superficial temporal vessels (anterograde and retrograde limbs) and controls (P > .05). Flap success rate of the test and control group is comparable, 95% vs 98% respectively. CONCLUSION: Superficial temporal vessels, both anterograde and retrograde, should be the first consideration for recurrent intraoral, facial, and scalp reconstruction with frozen necks.

Spontaneous multilevel airway haemorrhage in acquired haemophilia A.

BACKGROUND: Acquired haemophilia A is caused by the development of an autoantibody to factor VIII in a person with previously normal haemostasis. The most common clinical presentation in hereditary haemophilia is intra-articular bleeding. In contrast, acquired haemophilia more commonly presents with skin, soft tissue and mucosal haemorrhages. METHODS: We present a case of a patient with idiopathic acquired haemophilia A, whose initial presentation was that of spontaneous submental and submandibular haematoma which rapidly progressed to involve multiple sites in the airway, ultimately necessitating an emergent tracheotomy. In view of the extremely rare occurrence of this phenomenon, a systematic review and summary of all previously reported cases is also presented. RESULTS: The diagnostic and management dilemmas encountered in this case are presented from an otolaryngologist's perspective. CONCLUSIONS: Otolaryngologists' awareness of underlying haematological pathologies and their natural course of disease in cases of severe airway haemorrhage is of paramount importance in anticipating evolving issues in management of these patients.