Scalp and Forehead Injury: Management of Acute and Secondary Defects.

The primary challenges in scalp reconstruction are the relative inelasticity of native scalp tissue and the convex shape of the calvarium. All rungs of the reconstructive ladder can be applied to scalp reconstruction, albeit in a nuanced fashion due to the unique anatomy and vascular supply to the scalp. Important defect variables to incorporate into the reconstructive decision include site, potential hairline distortion, size, depth, concomitant infection, prior radiation therapy, planned adjuvant therapy, medical comorbidities, patient desires, and potential calvarium and dura defects.

Management of pembrolizumab-induced steroid refractory mucositis with infliximab: A case report.

BACKGROUND: Pembrolizumab is an anti-programmed death receptor 1 (PD-1) that was shown to have a tolerable safety profile with 17% of grade 3-4 drug-related adverse events, notable response rate of 16% with median duration of response of 8 mo, and median overall survival of 8 mo. Severe mucositis is a very rare complication with only two cases of grade 4 mucositis reported, and both cases had good response to intravenous methylprednisolone and subsequent oral prednisone tapering. We report the first case of pembrolizumab-induced severe mucositis that was refractory to steroid treatment. CASE SUMMARY: An 80-year-old woman with a past medical history of recurrent right cheek nodular melanoma status post resection and new right lung metastatic melanoma on immunotherapy presented with dysphagia and odynophagia for 2 mo. She initially received 2 doses of ipilimumab 1 year ago with good outcome, but treatment was discontinued after developing severe diarrhea and rash. Pembrolizumab was then initiated 4 mo after disease progression. Significant improvement was noted after 3 doses. However, after 6 cycles of pembrolizumab, patient developed odynophagia and malnutrition. Improvement of symptoms was noted after discontinuation of pembrolizumab and initiation of steroids. 3 mo later, patient developed pharyngeal swelling with hoarseness and new oxygen requirement due to impending airway obstruction while being on prednisone tapering regimen, finally ended up with intubation and tracheostomy. Histologic analysis of left laryngeal and epiglottis tissue showed granulation tissue with acute on chronic inflammation, negative for malignancy and infection. Patient achieved marked improvement after 2 doses of infliximab of 5 mg/kg every 2 wk while continuing on prednisone tapering course. CONCLUSION: We report the first case of pembrolizumab-induced grade 4 mucositis that had limited recovery with prolonged steroid course but had rapid response with addition of infliximab. The patient had recurrent mucositis symptoms whenever steroids was tapered but achieved complete response after receiving two doses of infliximab while continuing to be on tapering steroids. The success of infliximab in this patient with pembrolizumab-induced severe mucositis presents a potentially safe approach to reduce prolonged steroid course and accelerate recovery in managing this rare complication.

Shrinkage in oral squamous cell carcinoma: An analysis of tumor and margin measurements in vivo, post-resection, and post-formalin fixation.

PURPOSE: To quantify changes in tumor size and tumor-free margins following surgical resection and formalin fixation of oral cavity squamous cell carcinoma. MATERIALS AND METHODS: Nineteen patients were studied via cohort design. Between May and December 2011, measurements of tumor size and tumor-free margin were made in patients with squamous cell carcinoma of the oral cavity. Mucosal reference points were marked with sutures, representing tumor diameter and two separate resection margins. Measurements were recorded immediately before resection, after resection, and following fixation in formalin. RESULTS: The overall mean shrinkage in tumor size was 10.7% (95% CI 3.4-18.0, p=0.006). When comparing mean tumor measurements, most of the tumor size decrease (6.4%, 95% CI 0.4-12.4, p=0.039) occurred between pre- and post-excision measurements. To a lesser extent, tumor size decreased following formalin fixation. Comparison of tumor-free margin measurements revealed a pre-excision to post-fixation mean decrease of 11.3% (95% CI 2.9-19.6%, p=0.011), with a statistically significant decrease of 14.9% (95% CI 8.5-21.3%, p<0.001) occurring between pre- and post-excision, and no significant decrease from post-excision to post-formalin fixation. CONCLUSION: Mucosal dimensions of both tumor and tumor-free margins in oral cavity squamous cell carcinoma specimens decrease between surgical resection and pathologic analysis. Most of this decrease occurs prior to fixation, especially for margins, and may be due to intrinsic tissue properties rather than formalin effects.

Endometrioid adenocarcinoma metastatic to the thyroid, presenting like anaplastic thyroid cancer.

Metastasis of uterine cancer to the head and neck is extremely rare. We report what we believe to be the first documented case of endometrioid adenocarcinoma metastasizing to the thyroid gland. An 80-year-old woman was referred to the otolaryngology service with a rapidly growing neck mass. The mass appeared to originate from the thyroid gland. Her clinical presentation was consistent with anaplastic thyroid carcinoma. A tracheostomy was performed. An open biopsy established the diagnosis of moderately differentiated adenocarcinoma, consistent with a gynecologic primary. The patient had undergone a hysterectomy 5 years prior for endometrioid adenocarcinoma. The thyroid tumor histology and immunophenotype corresponded well with her prior endometrial carcinoma, indicating that the thyroid mass was a metastasis from the endometrial primary. Radiotherapy appears to offer good local disease control in this rare case of endometrioid adenocarcinoma metastatic to the thyroid.

The thyroid foramen: a case report and literature review of a largely unrecognized laryngeal anomaly.

A thyroid foramen is a congenital linear opening located in the lamina of the posterosuperior portion of the thyroid cartilage. Although its overall incidence is reported to be as high as 39%, few practitioners are aware of its existence. We report the case of a 19-year-old man who was involved in a motor vehicle accident. He experienced transient left true vocal fold paresis and what were initially thought to be "bilateral thyroid cartilage fractures" based on computed tomography of the neck performed as part of his trauma evaluation. On further scrutiny, however, the "fractures" were determined to be bilateral thyroid foramina. The presence of the paresis in the setting of these thyroid foramina prompted us to review the literature to examine the significance of thyroid foramina and the vessels and nerves that course through them. The average diameter of a thyroid foramen is approximately 2.5 mm. These openings appear in an oblique orientation, and they occur both unilaterally and bilaterally. In 70% of cases, an anastomotic branch connects the external and internal branches of the superior laryngeal nerve. Embryologically, thyroid foramina are believed to arise from a combined branchial and neurovascular origin. A detailed understanding of laryngeal anatomy, including its variations and their physiologic implications, is important to head and neck surgeons.

Small cell carcinoma of the head and neck: a review.

Small cell carcinoma (SCC) has become recognized as a distinct, though relatively infrequent, clinical pathology that occurs in multiple sites throughout the head and neck. Excluding cases that are considered to arise from skin, SCC in the head and neck has been found to develop in nearly all structures associated with the upper aerodigestive tract. Among the head and neck sites, the frequency of SCC is greatest in the larynx, with salivary glands and the sinonasal region comprising the other principle areas of origin. Controversy exist as to whether SCC can develop as a distinct entity in the thyroid, with most tumors that previously would have been considered as SCC now found to be lymphomas or variant forms of other types of thyroid malignancy. While there seems to be some differences among tumors arising from the various subsites, in general all SCC that originate in the head and neck have a tendency for aggressive local invasion and a strong propensity for both regional and distant metastasis. Treatment may include surgical resection, radiotherapy, chemotherapy, or some combination of these modalities. Due to the infrequency of these tumors, it is very unlikely that any large, controlled study will ever be done. For this reason, recommendations for treatment of SCC arising in the head and neck are based primarily on retrospective data from various small case series and on comparative data for treatment of SCC of bronchogenic and other extrapulmonary origin. Although patients with truly limited local disease may enjoy some prolonged survival, most patients with this tumor do poorly despite all current attempts at treatment.

Periorbital reconstruction: brows and eyelids.

The eyes and periorbital structures are principle components of the upper region of the face. A thorough understanding of orbital and periorbital anatomy and function is important for anyone wishing to perform reconstructive surgery in this region. This article discusses the unique challenges presented to the surgeon when performing reconstruction of the eyelids and periorbital structures.

Auricular reconstruction: an update.

PURPOSE OF REVIEW: One of the greatest challenges in facial plastic surgery is total auricular reconstruction. The ability to construct a fully satisfactory complete external ear has for centuries been an elusive goal. With advancing standards and expectations in plastic surgery, greater focus is being directed to this arena of reconstruction as well. RECENT FINDINGS: With advances both in surgical technique and biotechnology, an expanding range of options is available to the reconstructive surgeon who is willing to take on this still formidable task. While progress continues to be made in the detailing of costal cartilage grafts and soft-tissue rearrangement, it is also being made with the use of alloplastic implants and prostheses. The most promising field of advances, with the hope of eventual clinical utility, lies in the realm of bioengineering with cultured cartilage. SUMMARY: Review of the literature over the past year reveals several reports describing advances made in the development of cultured chondrocytes with attempts to direct special shape to the manufactured neocartilage. Though advances continue to be made, actual clinical applicability of this technology is still insufficient while expectation continues that this will eventually become integral to total auricular reconstruction.

Enhancement of auricular composite graft survival with hyperbaric oxygen therapy.

OBJECTIVE: To continue investigation regarding the efficacy of hyperbaric oxygen (HBO) therapy in improving survival of reattached auricular composite grafts. DESIGN: A prospective, randomized, double-blind study using 20 New Zealand albino rabbits randomized to a treatment or control group. The treatment group received 30 HBO treatments over 19 days following amputation and reattachment of composite auricular grafts. The control group received standard care. Ears were examined grossly and microscopically on postoperative day 21 to determine the percentage of graft survival. RESULTS: The mean percentage of graft survival for the 2 separate grafts (a larger 1.5 x 4.0-cm and a smaller 1.0 x 3.0-cm graft) in the treatment group was 26.5% and 27.9%, respectively. The mean percentage of graft survival for the larger and smaller graft in the control group was 9.7% and 14.0%, respectively. An analysis of variance test was used to evaluate this difference, which was found to be statistically significant (P =.001). CONCLUSIONS: This study represents a continued investigation following a pilot study, which suggested some enhancement of composite graft survival with the use of HBO therapy in the rabbit ear. Both experiments have demonstrated a slight survival benefit using HBO therapy in auricular composite grafts in the rabbit model.