Venous valves in the neck: implications for microvascular free flap reconstruction.

Successful microvascular free flap reconstruction requires adequate arterial inflow and venous outflow. We report 4 cases that demonstrate the not uncommon occurrence of locating valves in veins during microvascular head and neck reconstructive procedures. Failure to recognize these valves could have compromised the venous anastomosis. The anatomical literature states that veins in the head and neck lack valves, allowing bidirectional blood flow. As a result, there is potential significant flexibility in the selection of recipient veins for the microvascular anastomosis during free flap reconstruction. The unrecognized presence of a venous valve, however, could cause thrombosis of the venous anastomosis and, ultimately, flap failure. This report of venous valves should speak caution to the head and neck microvascular surgeon when he or she is selecting recipient veins in the neck.

First report of Hürthle cell carcinoma revealed by octreotide scanning.

Octreotide is an 8-chain amino acid analog of somatostatin. Somatostatin and its receptors occur naturally in multiple sites within the body and serve a suppressive role in endocrine hormone release. When octreotide, which has a considerably longer half-life than somatostatin, is combined with a radioactive isotope, receptor-based imaging can be performed to visualize tumors with high concentrations of somatostatin receptors. Tumors of neural crest origin -- pituitary adenomas, islet cell tumors, medullary thyroid carcinomas, pheochromocytomas, carcinoids, and paragangliomas -- all express high levels of somatostatin receptors. We present the first reported positive octreotide scan of a Hürthle cell carcinoma of the thyroid and, more important, discuss the role of octreotide scanning in otolaryngology, which has not yet been reviewed by our literature.

Third branchial anomalies. Avoiding recurrences.

Lateral cervical cysts, sinuses, and fistulas have been described as anomalies of the normal development of the branchial apparatus. Third branchial apparatus anomalies are rare and constitute less than 1% of all such cases. Three cases of third branchial cleft cysts and sinus tracts are presented. Two patients had previously undergone multiple attempts at extirpation. Complete removal of recurrent branchial anomalies is difficult because of scarring and fascial plane disruption. Recurrences were often the result of inadequate excision, possibly of the tract communicating with the piriform sinus. To avoid this we advocate endoscopy prior to initial resection of a suspected branchial cleft anomaly to identify any pharyngeal communication. A combined, simultaneous endoscopic identification of the piriform sinus tract with a lateral external cervical dissection facilitates complete resection. In recurrent cases, wide-field extirpation of the cyst, tract, and scar tissue is necessary to ensure complete removal of the branchial cleft anomaly. A review of the literature and of branchial apparatus embryology is also presented.

Middle-ear lipoma as a cause of otomastoiditis.

We present a case report which describes a rare cause of a common clinical problem; eustachian tube dysfunction. A seven-year-old child presented with a history of chronic draining ears, despite rigorous medical therapy and multiple ventilation tubes. At myringotomy a mass was noted in the middle ear, and she was taken to the operating room for exploration. The patient was found to have a pedunculated lipoma arising from the anterior medial aspect of the middle-ear cleft producing intermittent obstruction of the eustachian tube orifice. This case represents the fourth case of a middle-ear lipoma in the world literature. We present a review of the literature and an exploration of possible aetiologies of this unusual entity in the differential diagnosis of eustachian tube dysfunction.