Manufacture of a Multi-Purpose Low-Cost Animal Bench-Model for Teaching Tracheostomy.

Tracheostomy is one of the most frequent procedures, performed through various techniques in the intensive care unit and emergency situations. Despite this, there is a lack of training on this procedure that affects its outcome, which is also dependent on operator's dexterity. Here, we take the specific training and simulation into consideration. This article aims to describe every step of the manufacture of a new multi-purpose low-cost animal bench-model, with the support of video and images, and to obtain an opinion about the quality of this model by administering a questionnaire to professionals with experience in the procedures. Ten experts in the technique were enrolled. The model scored an average of 3.45/5 for its anatomical realism; 4.75/5 for its usefulness as a training tool for simulation courses and assessments. The time necessary to build the model was 15 minutes, and the cost amounted to 10€. The animal bench-model was considered a very useful simulator for tracheostomy training and assessments. Therefore, it could be used as a tool for medical courses and residencies.

Isolated Hypoglossal Nerve Palsy Mimicking a Base of Tongue Tumor.

Isolated paralysis of hypoglossal nerve is uncommon, generally being associated with other neuropathies. A careful differential diagnosis is necessary to recognize the underlying diseases, some of which can be life-threatening. The authors report a patient of an 80-year-old woman presenting with an isolated hypoglossal palsy, mimicking a tongue neoplasm. Through a careful clinical workup and thanks to the aid of the imaging, it was possible to identify the presence of signal alterations due to a subacute denervation of the affected hemitongue and to exclude the presence of a tumor. The patient was clinically diagnosed as isolated hypoglossal palsy, resulting from a thrombo-embolic accident involving the nerve along its course. The authors propose some useful means for the differential diagnosis and review the literature.

Percutaneous Sclerotherapy With OK-432 of a Cervicomediastinal Lymphangioma.

The present study reports a case of percutaneous sclerotherapy of a giant cystic cervicomediastinal lymphangioma using OK-432. To the best of our knowledge, percutaneous sclerotherapy of a mediastinal lymphangioma using OK 432 has not previously been reported in the English literature.

Extramedullary Plasmacytoma of the Larynx Treated by a Surgical Endoscopic Approach and Radiotherapy.

Extramedullary plasmacytoma (EMP) is a rare variant of plasma cell myeloma that affects soft tissues. The head and neck region are the most affected sites, although others have also been described. Herein we report an uncommon case of EMP of the larynx in a 65-year-old male who presented with a history of progressive dysphonia and hoarseness. Laryngeal fiberscopy evidenced a reddish pedicled voluminous mass in the left false cords and ventricle. Microscopic suspension laryngoscopy was performed under general anaesthesia and a 4 W Acublade CO2 Laser was used for transoral resection of the lesion. This was followed by adjuvant radiotherapy, with the widely recommended doses on the supraglottic region, to achieve better local control. Diagnosis of EMP is based on immunohistochemistry and the exclusion of systemic plasma cell proliferative disorders. Diagnosis of solitary EMP can be made only if studies for disseminated disease and X-ray and/or magnetic resonance imaging of the spine, pelvis, femurs, and humerus and bone marrow biopsy are negative. As there are no internationally established guidelines, treatment of EMP is mainly based on consensus of expert opinion.

Persisting subcutaneous emphysema of eyelids mimicking orbital tumor.

Eyelids emphysema is a rare condition due to air trapping in subcutaneous tissue of the orbit. It has been clinically and radiologically documented, but histologic evaluation has not been noted. We report a case of a middle-aged woman with periorbital swelling due to self-induced Valsalva maneuver, persisting after decompressive therapy. A fine-needle biopsy was performed and showed a mixed population of osteoclastic-like giant cells and mononuclear epithelioid cells, which were suspected of pathological proliferative disease. Specimens from blepharoplasty indicated pseudocystic empty spaces surrounded by epithelioid cells and giant cell granulomas. Immunohistochemical stains favored diagnosis of benign granulomatous disease, such as subcutis cystic pneumatosis. Histologic examination represented an important tool for differential diagnosis with soft tissue neoplasms of the orbit in subcutis emphysema with unusual clinical presentation and abnormal course.

Delayed carotid pseudoaneurysm: a life-threatening complication after endoscopic sinus surgery.

Internal carotid artery pseudoaneurysm is a rare but potentially lethal complication of sinus surgery. We present 2 cases of delayed carotid pseudoaneurysm development after internal carotid laceration during functional sinus surgery for chronic sinusitis to emphasize the need to follow up the patients with profuse bleeding perioperatively and to identify when to suspect iatrogenic vascular malformations.

Intraoral transposition of pedicled temporalis muscle flap followed by zygomatic implant placement.

Despite the recent advances of sophisticated reconstructive surgical techniques, management of maxillectomy defects continues to be challenging. For a selected group of patients, who cannot sustain a sophisticated microsurgical reconstructive procedure, a prosthetic obturator is indicated to separate the oral cavity from the sinonasal cavities. After the development of the osseointegration concept, dental implants have proven to be indicated for the rehabilitation of patients who underwent maxillectomy. Recently, surgeons can use a computer-assisted software package, which enables them to insert implants after a detailed analysis of the residual bone. For some patients with limited amount of residual maxillary bone, unusual surgical sites such as the zygomatic complex have been tested. We introduce a successful 2-step surgical procedure using a pedicled temporalis muscle flap and zygomatic implant placement to reconstruct a maxillary defect after oncological resection.

Peripheral facial nerve palsy: how effective is rehabilitation?

OBJECTIVE: To review the current literature to assess the effectiveness of rehabilitation treatment for peripheral facial nerve palsy. DATA SOURCES: A review of the literature was conducted using the following database: PubMed, EMBASE, PEDro, and Scopus. All randomized or quasi randomized controlled trials, case control, cohort studies and case series greater than 6 published between 1990 and 2010 in the English language were included. STUDY SELECTION: All types of peripheral facial nerve palsy were included. We considered all the exercises or rehabilitation programs provided by a physiotherapy in outpatient or home setting and excluded trials in which a drug therapy or surgical intervention was investigated. Three reviewers independently selected the articles. DATA EXTRACTION: To rate the methodological quality of the studies the American Academy of Neurology classification of evidence for therapeutic intervention (Classes I-IV) was applied. CONCLUSION: Peripheral injury of the VIIth cranial nerve can have serious repercussions on the patient's functioning and quality of life. The recovery rate is related to the preservation of the nerve and to the cause of palsy. We obtained a third level of recommendation (level C); mime therapy could be effective to improve functional outcome in these patients. Evidence of specific treatment addressed to specific cause is lacking; likewise, no evidence is available on timing of intervention with respect to time of onset. Well-designed randomized controlled trials are required to evaluate the effect of rehabilitation in patients with facial palsy.

Evaluation of amoxicillin plasma and tissue levels in pediatric patients undergoing tonsillectomy.

OBJECTIVE: Tonsillectomy is the most common surgery performed in the pediatric and young adult populations. Although recent guidelines based on meta-analysis suggest that perioperative chemoprophylaxis plays a role in reducing bacteraemia-related post-tonsillectomy complications, there is no evidence or agreement upon which specific antibiotic, dosage or administration route should be preferred. Since few previous studies have assessed the effectiveness of prophylaxis by direct measurement of antibiotic levels both in plasma and tissue, we designed an experimental study to quantitatively evaluate amoxicillin concentrations in children ready for tonsillectomy and compare these plasma and tissue levels with the Minimal Inhibitory Concentrations (MIC) of the bacteria more commonly involved in the upper airway infections. METHODS: Thirty-three pediatric patients under 14 years of age (median 5.0, IQR 4-7, range 3-11; M:F 18:15) with recurrent tonsillitis were treated with 3 doses (established on patient's weight) of amoxicillin-clavulanic acid given orally the day before plus a further dose 2h before tonsillectomy. Amoxicillin concentrations on both homogenated tonsillar cores and plasma were measured by HPLC-UV. Bacterial epidemiology and susceptibility were derived respectively from survey data collected by Microbiology Unit and MIC according to the National Committee for Clinical Laboratory Standards (NCCLS). RESULTS: Median plasma and tissue amoxicillin concentrations were respectively 4.7 microg/ml (IQR 2.1-8.0; min-max 0.4-14.3) and 1.1 microg/g (IQR 0.4-2.1; min-max 0.4-12.9), considerably below the selected target MIC of pathogens involved in the upper respiratory tract infections (S. aureus, H. influenzae, M. catarrhalis). 20 Children showed undetectable amoxicillin levels in one or both tonsils. Interestingly, 7 out of these patients (35%) had plasma concentrations higher than the target MIC (8 microg/ml). No patient displayed plasma concentrations under the limit of sensitivity of the method. Poor core-plasma and left-right core correlation was observed among patients, suggesting that fibrosis developed after recurrent tonsillitis may hamper antibiotic penetration. CONCLUSIONS: Based upon direct measurement of antibiotic levels in plasma and tissue, this study suggests that a revision of the oral prophylaxis in children is required in order to reduce microbial charge in the operative field and accordingly improve the recovery after tonsillectomy.

Clinical and molecular features of mucosa-associated lymphoid tissue (MALT) lymphomas of salivary glands.

BACKGROUND: To analyze clinical features and to discuss the modality of investigation and treatment of a series of mucosa-associated lymphoid tissue (MALT) lymphomas. To investigate the prevalence of aberrant promoter methylation, responsible for gene inactivation, in a selected panel of genes potentially involved in the pathogenesis of B-cell malignancies as O6-methylguanine-DNA methyltransferase (MGMT), p73, death-associated protein kinase (DAP-k). METHODS: Nine patients with primary MALT lymphoma of the salivary glands were retrospectively reviewed. MGMT, p73, DAP-k apoptotic pathways were tested. RESULTS: Methylation of DAP-k was common (5/8; 63%). Histological examination ensured diagnostic confirmation, whereas fine-needle aspiration cytology was not definitively diagnostic. CONCLUSION: Histological assessment is the gold standard in the diagnosis of salivary gland lesions. Parotidectomy represents a safe and reliable diagnostic tool leading to a definite diagnosis of MALT lymphomas in all cases and curative without other treatment in early-stage MALT lymphoma.

[Prognostic factors for definitive hypoparathyroidism following total thyroidectomy]. / Factores pronósticos de hipoparatiroidismo definitivo tras tiroidectomía total.

INTRODUCTION AND OBJECTIVE: Hypocalcaemia, transient in most cases, is the main complication after thyroid gland surgery with regard to functional impairment of the parathyroid glands or other reversible factors. Sixty-seven patients who underwent thyroidectomy were evaluated to identify potential clinical, pathological and surgical factors that might be predictive for frank hypocalcaemia following total thyroidectomy. METHODS: Serum samples were taken preoperatively and postoperatively to measure total calcium levels. Patients' plasma calcium levels were recorded post-operatively along with such factors as age, gender, thyroid function, definitive pathology-based diagnosis, accidental removal and auto-transplantation of parathyroid glands, re-intervention to identify risk factors for the development of definitive hypoparathyroidism (DH). All comparisons were made between patients with hypocalcaemia and normal levels of post-operative calcaemia. RESULTS: Transient acute hypocalcaemia was identified in 25 of 67 patients (43.3 %). DH was identified in 8 (11 %) patients. CONCLUSIONS: Our study revealed that the only risk factor for DH was a calcium level of less than 7.5 mg/dL within the first 24 hours following surgery; this is a reliable, inexpensive and rapid parameter that is highly predictive of the onset of HD. No statistical significant associations were detected with other factors such as thyroid function, histology, accidental removal or autotransplantation of parathyroid glands, thus it is possible to state that careful manipulation of the parathyroid to preserve the periglandular vascularization is of vital importance to ensure correct post-operative functionality.

Factores pronósticos de hipoparatiroidismo definitivo tras tiroidectomía total / Prognostic factors for definitive hypoparathyroidism following total thyroidectomy

Introducción y objetivo: La hipocalcemia tras tiroidectomía total constituye la mayor complicación, en la mayoría de los casos, transitoria, en relación con un daño funcional de las paratiroides u otros factores reversibles. Se trata de un estudio sobre 67 pacientes sometidos a tiroidectomía total para identificar posibles factores clínicos, anatomopatológicos y quirúrgicos predictivos de hipocalcemia definitiva tras tiroidectomía total. Métodos: Recogida de valores plasmáticos de calcio en el período postoperatorio y factores como edad, sexo, funcionalidad tiroidea, diagnóstico anatomopatológico definitivo, extirpación accidental de las paratiroides y su autotrasplante, reintervención para identificar factores de riesgo para el desarrollo de hipoparatiroidismo definitivo. Las comparaciones han sido efectuadas entre los pacientes con hipocalcemia y concentraciones normales de calcemia post-operatoria. Resultados: La hipocalcemia aguda transitoria ha sido identificada en 25/67 pacientes (43,3 %). El hipoparatiroidismo definitivo ha sido identificado en 8 (11 %) pacientes. Conclusiones: En nuestro estudio ha supuesto que una calcemia después de 24 h de la intervención quirúrgica inferior a 7,5 mg/dl sea un factor altamente pronóstico de hipoparatiroidismo definitivo; esta determinación es un parámetro fiable, económico, rápido y muy predictivo del desarrollo de hipoparatiroidismo definitivo. No se han encontrado asociaciones estadísticamente significativas con otros factores, como funcionalidad tiroidea, histología, extirpación accidental o autotrasplante de las paratiroides, así que podemos afirmar que una atenta manipulación de las paratiroides conservando cuidadosamente la vascularización glandular representa un factor de fundamental importancia para garantizar una normal funcionalidad paratiroidea postoperatoria

Introduction and objective: Hypocalcaemia, transient in most cases, is the main complication after thyroid gland surgery with regard to functional impairment of the parathyroid glands or other reversible factors. Sixty-seven patients who underwent thyroidectomy were evaluated to identify potential clinical, pathological and surgical factors that might be predictive for frank hypocalcaemia following total thyroidectomy. Methods: Serum samples were taken preoperatively and postoperatively to measure total calcium levels. Patients' plasma calcium levels were recorded post-operatively along with such factors as age, gender, thyroid function, definitive pathology-based diagnosis, accidental removal and auto-transplantation of parathyroid glands, re-intervention to identify risk factors for the development of definitive hypoparathyroidism (DH). All comparisons were made between patients with hypocalcaemia and normal levels of post-operative calcaemia. Results: Transient acute hypocalcaemia was identified in 25 of 67 patients (43.3 %). DH was identified in 8 (11 %) patients. Conclusions: Our study revealed that the only risk factor for DH was a calcium level of less than 7.5 mg/dL within the first 24 hours following surgery; this is a reliable, inexpensive and rapid parameter that is highly predictive of the onset of HD. No statistical significant associations were detected with other factors such as thyroid function, histology, accidental removal or autotransplantation of parathyroid glands, thus it is possible to state that careful manipulation of the parathyroid to preserve the periglandular vascularization is of vital importance to ensure correct post-operative functionality

Contralateral cervical lymph node metastases in pyriform sinus carcinoma.

OBJECTIVE: We designed a retrospective study to evaluate the incidence of contralateral neck metastases in squamous cell carcinoma of the pyriform sinus. STUDY DESIGN AND SETTING: Sixty-three patients with strictly unilateral squamous cell carcinoma of the pyriform sinus who underwent bilateral neck dissection at the time of primary surgery were included in this study. The medical records of all patients were reviewed. A multivariate statistical analysis was performed, considering some clinical and histologic parameters of T stage and N stage in relation to contralateral neck metastases. RESULTS: Contralateral neck metastases were histopathologically confirmed in more than 20% of the cases examined (13 out of 63 patients), of whom 3 were clinically staged as N2c, 2 N2b, 5 N2a, 2 N1 and 1 N0. The percentage of occult contralateral neck metastases was 77% (10/13 cases). Poorly differentiated tumors (P= .02) and the involvement of the lateral wall (P= .036) showed a statistically significant correlation with stage pN2c. Also T size and ipsilateral N stage were associated with the presence of contralateral neck metastases. CONCLUSIONS: Our data suggest that elective bilateral neck dissection is recommended in patients with locally advanced squamous cell carcinoma of the pyriform sinus. EBM RATING: C-4.

Voice quality after treatment for T1a glottic carcinoma--radiotherapy versus laser cordectomy.

The purpose of this study was to assess the anatomic and functional outcomes and compare the voice quality in patients affected by T1a glottic carcinoma treated with curative intent with radiotherapy or laser cordectomy. Fifty-seven cases were analysed: 27 after curative radiotherapy and 30 after laser cordectomy. All patients were studied with videolaryngostroboscopy, voice analysis by narrow spectrogram, and vocal parameters (Jitter, Shimmer, noise/harmonic ratio, and diplophonia). Videolaryngostroboscopy showed severe glottic inadequacy in 25% of cases treated with radiation and insufficient compensation 'ventricular band' or 'with arytenoid hyperadduction' in 65% of cases after surgery. Severe dysphonia on the electro-acoustic analysis of voice was observed in 25% of cases after radiation and 70% after laser (p < 0.001). Fundamental frequency and vocal parameters showed more favourable results in the radiation group (p < 0.001). Voice assessment showed better results after radiotherapy compared with laser cordectomy. Voice outcome should be carefully considered in the treatment decision for T1 glottic carcinoma.

Papillary thyroid carcinoma identified after Sistrunk procedure: report of two cases and review of the literature.

Thyroglossal duct cysts represent the most common congenital cervical malformations. Carcinomas arising in the thyroglossal duct cysts are rare neoplasms characterized by a relatively non aggressive behavior with rare lymph node spread. Approximately 1% of thyroglossal cysts contain a carcinoma. The most frequent histological type is papillary carcinoma, accounting for about 80% of cases. Currently, most authors agree about their primary origin ex novo from ectopic thyroid tissue in the cyst. In most cases the diagnosis of thyroglossal duct carcinoma (TDC) is not made until histopathological examination has been performed on a resected cyst without any suspected clinical sign of malignancy. The definition of the correct surgical treatment for these carcinomas is still controversial; most authors maintain that resection of a TDC with the Sistrunk procedure can be considered oncologically adequate when dealing with a differentiated carcinoma without extracapsular invasion and/or lymph node metastases and with a normal thyroid. We present two cases of papillary thyroid carcinoma identified after resection of a thyroglossal cyst according to the Sistrunk procedure and managed with different surgical approaches according to the different sites of the tumors. In addition, we discuss appropriate therapeutic strategies in light of the most recent data in the literature.

[Nasopharyngeal tuberculosis]. / Tubercolosi rinofaringea.

Nasopharyngeal tuberculosis is a rare condition and, sometimes, associated with a cervical lymphadenopathy. The authors report a case of an isolated nasopharyngeal tuberculosis in a 69-year-old female with otological symptoms. The case is remarkable because of its coming in a non-endemic zone for the tuberculosis, and because of its probable persistence by many years.