Use of the double-paddle anterolateral thigh flap for locally advanced tongue carcinoma requiring second site reconstruction.

BACKGROUND: Advanced oral tongue carcinoma can present with extension beyond the oral cavity. Operative defects after resection may involve multiple anatomical sites and significantly impact speech and swallowing. Dependence on long-term enteral feeding is not uncommon for these patients. The anterolateral thigh (ALT) flap is one of the most reliable and flexible flaps used in the reconstruction of total and subtotal tongue defects. The double-paddle flap modification may be a more suitable option for complex oral tongue defects after advanced tumor ablation. METHODS: Case series of 31 patients with oral tongue squamous cell carcinoma that were classified as stage IV. The age of patients ranged from 32 to 63 years. We designed the double-paddle ALT flaps to reconstruct the two-site surgical defects (tongue defect and pharynx or neck skin defect). Postoperative viability of the flap was checked by clinical observation. The last examination was performed at 3-months after the completion of adjuvant chemoradiotherapy. The functional capacity of our patients was evaluated by three physicians (Head and Neck Surgeon, Radiation Oncologist, and Physiatrist) using a Speech Intelligibility Score and the Functional Oral Intake Scale. RESULTS: A total of 31 patients with surgical defects after total or subtotal tongue resection for cancer underwent double-paddle ALT flaps for reconstruction from March 2018 to December 2019. The dimension of flaps from 8 × 12 cm to 10 × 18 cm were divided into double-paddle from 8 × 5 cm to 10 × 10 cm. There was one case of pedicle thrombosis, one case of postoperative bleeding, three cases of neck infection, and six cases of salivary fistula. Our patients were seen in follow up from 6 to 36 months, with median follow-up of 23.5 months. The survival rate of ALT flap was 100%. All of our patients achieved an oral diet by 9 months after surgery. The mean score speech intelligibility was 2.74 ± 0.68 (4-point ordinal scale). The 2-year disease-free survival rate was 61.3%. CONCLUSIONS: The double-paddle ALT flap is a reliable flap suitable for oral defects involving multiple subsites after ablative procedures. The majority of patients demonstrated acceptable functional rehabilitation. CLINICAL QUESTION/ LEVEL OF EVIDENCE: Therapeutic, IV.

Vein preservation strategies to improve the survival rate of the infrahyoid musculocutaneous flap.

The infrahyoid musculocutaneous flap (IHMCF) is a good alternative in the reconstruction of moderate-sized oral cavity surgical defects. Insufficient venous drainage can significantly affect the survival rate of this flap. OBJECTIVES: Identify the survival rates of the IHMCF and evaluate the functional capacity of reconstructed patients. DESIGN: We report a case series. SETTING: This study took place at the Department of Head and Neck Surgery of Oncology Hospital Ho Chi Minh City, the largest oncology center in South Vietnam. PARTICIPANTS: One hundred and twelve patients with surgical defects after oral cavity resection for cancer underwent IHMCF reconstruction from November 2013 to November 2018. During the harvest of the flap, our modification of the surgical technique specifically attempted to preserve more secondary veins for IHMCF. MAIN OUTCOME MEASURES: Postoperative viability of the flap was checked by clinical observation. The last examination was performed at 3-months after reconstructive operation or after the completion of adjuvant radiotherapy. The functional capacity of our patients was evaluated by three physicians (Head and Neck Surgeon, Radiation Oncologist, and Physiatrist) with understandability of speech scale and the functional oral intake score items assessed. RESULTS: Two cases of partial skin necrosis (1.8%) were experienced. The majority of patients demonstrated favorable functional rehabilitation at long-term follow up. CONCLUSIONS: The IHMCF is a reliable flap suitable for moderate-sized defects of the oral cavity. Altering the surgical approach to specifically preserve more venous outflow can improve the survival rate of the flap. LEVEL OF EVIDENCE: 4.

Progressive functional improvement in hemiglossectomy defects reconstructed with radial forearm free flap at 6-months.

OBJECTIVE: The purposes of the study was to evaluate for the functional improvement of outcomes of patients undergoing surgical management for tongue cancer at varying periods after surgery. DESIGN: Case series with intervention. PARTICIPANTS: Thirty consecutive patients, from 2011 to 2015, with carcinoma of the tongue undergoing surgical resection and reconstruction with a radial forearm free flap. MAIN MEASURES: The Speech Intelligibility Test (SIT) is used for objective evaluation of speech function. The 7-point ordinal scale Functional Oral Intake Score (FOIS) was used to estimate the swallowing function. RESULTS: The patients included were 25 men and 5 women with a mean age of 50.4 years (range - 27-65). All tumors were squamous cell carcinomas and all patients underwent a hemiglossectomy. There were two complete flap failures, with a resultant flap success rate of 93.3%. The initial mean speech intelligibility scores at 1-month increased from 72.3 ±â€¯0.2 to 77.7 ±â€¯8.9 at 6-months after surgery (p = 0.05). Similarly, the mean score of swallowing function improved from 6.1 at 1-month to 6.8 at 6-months after surgery (p = 0.05). CONCLUSION: Reconstruction of hemiglossectomy defects with a radial forearm free flap offers functional benefits in speech and deglutition that demonstrate progressive improvement when 1- and 6-month post-surgical assessments are compared.

It Takes a Village: The Importance of Multidisciplinary Care.

This article explores the evolving world of cancer care that requires increasing collaboration and is focused on value, quality, and efficiency, while placing the utmost importance on patient autonomy and individualized care plans. The expanding membership of the multidisciplinary team and the role of integrated patient care units are reviewed in the context of care for the patient with head and neck cancer.

Breast cancer metastases to the head and neck: Case series and literature review.

Breast cancer is the most common cancer in women and is the second most common cause of cancer-related death. Despite the relatively high prevalence of this disease, breast cancer manifestations in the head and neck are relatively rare. Supraclavicular lymphadenopathy and bony metastases to the mandible and maxilla are the most common manifestation of breast cancer in the head and neck. Head and neck metastases are the first presentation of distant disease in approximately one-third of cases. The prognosis of breast cancer with distant metastases to the head and neck is generally poor, and the management of these lesions is controversial. Overall extent of disease and individual patient prognosis must guide treatment decisions. Atypical cases including maxillary sinus mass, jugular foramen mass, and dermal metastases are presented. Metastatic breast cancer is a rare diagnosis in the head and neck, yet metastatic disease from an infraclavicular primary deserves inclusion on any comprehensive differential diagnosis list. In women, breast carcinoma is the most common infraclavicular primary to metastasize to the head and neck.

Squamous cell carcinoma presenting with trigeminal anesthesia: An uncommon presentation of head & neck cancer with unknown primary.

BACKGROUND: The differential diagnosis of facial anesthesia is vast. This may be secondary to trauma, neoplasm, both intracranial and extracranial, infection, and neurologic disease. When evaluating a patient with isolated facial anesthesia, the head and neck surgeon often thinks of adenoid cystic carcinoma, which has a propensity for perineural invasion and spread. When one thinks of head and neck squamous cell carcinoma with or without unknown primary, the typical presentation involves dysphagia, odynophagia, weight loss, hoarseness, or more commonly, a neck mass. Squamous cell carcinoma presenting as facial anesthesia and perineural spread, with no primary site is quite rare. METHODS: Case presentations and review of the literature. CONCLUSIONS: Trigeminal anesthesia is an uncommon presentation of head and neck squamous cell carcinoma with unknown primary. We present two interesting cases of invasive squamous cell carcinoma of the trigeminal nerve, with no primary site identified. We will also review the literature of head and neck malignancies with perineural spread and the management techniques for the two different cases presented.

Granular cell tumor of the stellate ganglion presenting with Horner's syndrome.

We report a granular cell tumor (GCT) that occurred within the stellate ganglion of a 26-year-old woman who initially presented with a unilateral Horner's syndrome and progressive right upper extremity pain. We also review the literature related to the differential diagnoses of such a cervicothoracic tumor, with particular emphasis on the embryologic origin of these possibilities. GCT are rare tumors of Schwann cell origin which are more often found in subcutaneous locations than in relation to neural elements. In this woman, a mass identified on preoperative imaging was positioned anterolateral to the T1 vertebral body and displaced the vertebral artery anteriorly. During surgery, the lesion was observed within the sympathetic chain in the area of the stellate ganglion. The sympathetic chain was transected above and below the mass in order to achieve an adequate resection. The pathology demonstrated polygonal cells with diffuse eosinophilic granular cytoplasm positive for CD68 (a marker of lysosomes) and S-100 (a marker of neural crest derivatives) which established the diagnosis of GCT. This is the first patient, to our knowledge, with a granular cell tumor arising from the stellate ganglion.

Diagnosing Fish Bone and Chicken Bone Impactions in the Emergency Department Setting: Measuring the System Utility of the Plain Film Screen.

OBJECTIVES: In the emergency department, fish and chicken bone impactions are typically evaluated with screening x-rays. We sought to determine whether this modality ultimately improves system outcomes, including length of stay (LOS), cost, and radiation dosage. METHODS: We reviewed patients ≥ 18 years old presenting to an urban academic emergency department over a 4-year period who received a screening soft-tissue x-ray to determine the presence of a retained fish or chicken bone. We calculated the diagnostic accuracy of x-ray and computed tomography (CT) evaluations, respectively, in addition to system outcomes. RESULTS: Twenty-seven of the 78 patients included for analysis were ultimately positive for bone impaction. Initial x-ray interpretations demonstrated a sensitivity of 24.0% (95% CI, 9.4%-45.1%) and a specificity of 90.0% (95% CI, 78.2%-96.7%). However, initial CT interpretation (ie, a preliminary read from on-call residents) demonstrated a sensitivity of 75% (95% CI, 19.4%-99.4%) and a specificity of 100% (95% CI, 59.0%-100%). LOS, cost, and radiation dosage were not significantly different between patients who ultimately had true bone impactions and those who did not (P > .05). CONCLUSIONS: X-rays are poor screening tools in determining fish or chicken bone impactions with poor diagnostic and system utility. Further studies should be performed to evaluate the role of a low-radiation CT screen.

Benign proliferative myositis of the sternohyoid muscle: review and case report.

We report a case of a 51-year-old woman who presented with a rapidly enlarging, painful, midline neck mass that developed over a three day period. A CT scan of the neck showed a solid circumscribed mass in the sternohyoid muscle. The initial differential diagnosis included inflammation of thyroglossal duct remnant, an abnormal lymph node, and thyroid carcinoma. The patient underwent operative excision with final pathology revealing proliferative myositis. Proliferative myositis is an uncommon benign proliferation of skeletal muscle and has only been reported a limited number of times in the head and neck region.

Intramuscular myxoma of the cervical paraspinal musculature: case report and review of the literature.

CASE: A 57year old female patient presented with a painful right-sided neck mass that on MRI was shown to be adherent to the posterior aspect of the sternocleidomastoid muscle. The mass was surgically resected en bloc without complications. Histopathologic analysis revealed the mass to be a myxoma. REVIEW: To date, there have been several case reports of myxomas, although very few involving the head or neck. The majority of the literature available concurs that myxomas are benign neoplasms that exhibit characteristic qualities on MRI imaging. The definitive treatment by consensus is surgical excision. CONCLUSIONS: Although the incidence of head and neck myxomas is low, it is important to include in the differential of a neck mass with certain radiographic findings.

Primary fibrosarcoma of the trachea presenting with acute airway loss.

Primary sarcomas of the trachea are rare occurrences that present with nonspecific symptoms, making timely diagnosis difficult. We report a case of primary fibrosarcoma of the trachea that presented with acute airway loss secondary to tracheal discontinuity due to tumor destruction. This unusual clinical presentation highlights the difficulties posed in the diagnosis and management of tracheal sarcomas. A discussion of the relevant literature is presented.

Cabozantinib for progressive metastatic medullary thyroid cancer: a review.

Medullary thyroid cancer is uncommon and patients typically present with advanced disease. Treatment options for patients with progressive, metastatic medullary thyroid cancer had been limited until recently. Tyrosine kinase inhibitors have garnered increasing interest in this subset of patients. The US Food and Drug Administration recently approved cabozantinib, a tyrosine kinase inhibitor, after promising results were shown in a large Phase III clinical trial. This review summarizes the clinical pharmacology, clinical trials, and safety data for cabozantinib and concludes with a discussion of possible future directions for the treatment of medullary thyroid cancer.

Surgical management of an atypical presentation of a thyroid storm.

INTRODUCTION: Thyroid storm is a rare complication of Graves' disease that can carry a poor prognosis. In order to prevent major complications, thyroid storm must be quickly identified in patients and treatment must be promptly implemented. Medical treatment is usually initiated with antithyroid medications, such as propylthiouracil (PTU), methimazole, and beta-blockers. However, some patients may experience adverse reactions to these medications and alternate treatment options must be explored. CASE PRESENTATION: We report a case of a 30-year-old female initiated on PTU after diagnosis with Graves' disease that later presented an acute thyroid storm. DISCUSSION: Therapy was changed to methimazole, yet the patient subsequently developed angioedema and dyspnea. Medical management was discontinued and emergent thyroidectomy was performed without complication.

An unusual and rare cause of acute airway obstruction in the elderly: Forestier's disease.

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease, is an ossifying disease of unknown etiology affecting mainly elderly men. It is characterized by hypertrophic anterior vertebral osteophytes with ossification of the spinal anterior longitudinal ligament. Hypertrophic osteophytes can encroach on the aerodigestive tract, leading to significant swallowing and respiratory symptoms. OBJECTIVE: Acute stridor and respiratory compromise requiring a surgical airway have rarely been reported in patients with DISH. This entity, although rare, should be in the differential diagnosis of acute airway obstruction, particularly in the elderly. CASE REPORT: We describe a case of a 91-year-old patient who was transferred to the Emergency Department at Tufts Medical Center with acute stridor. A computed tomography scan of the neck prior to transfer revealed a large anterior cervical osteophyte causing significant airway narrowing. Fiberoptic evaluation confirmed the radiologic finding of near-complete airway obstruction. The patient's respiratory status rapidly deteriorated and he subsequently underwent an emergent awake tracheostomy to secure his airway. CONCLUSION: Given the rarity of DISH and the increase in life expectancy, clinicians should be aware of this disease entity and its potential for acute life-threatening respiratory presentation.

NUT midline carcinoma: a case report with a novel translocation and review of the literature.

NUT midline carcinoma (NMC) is a rare, genetically defined, highly lethal undifferentiated carcinoma occurring in the midline location of the neck, head or mediastinum. We present the case of a 23 year-old otherwise healthy Chinese male immigrant who presented with complaints of sore throat and right sided neck mass. The initial treatment was for likely EBV infection with streptococcal superinfection. Although continued investigation was pursued shortly after initial presentation, the mass had enlarged and become necrotic with significant nodal involvement. The mass was diagnosed as an NMC tumor with a novel three-way translocation t(9;15;19; q34;q13;p13.1). Despite aggressive treatment, the patient's condition progressed rapidly and he died within 3 months of initial diagnosis. Standard therapeutic interventions have been ineffective in the treatment of NMC. Earlier diagnosis could allow characterization of the natural progression of this entity, and allow more time for intervention or development of novel therapies, potentially related to molecular targets. This continues to require a high index of suspicion and early imaging with cytogenetic and immunohistochemical confirmation.

Dysphagia, hoarseness, and a hypopharyngeal mass.

We describe a patient who developed a hypopharyngeal mass (in the setting of a cervical osteophyte) while taking clopidogrel and aspirin for coronary artery disease. He had a 2-month history of progressive dysphagia and hoarseness. Physical examination and computed tomography scan revealed a soft tissue retropharyngeal mass of unclear etiology yet with a stable airway. He was admitted to the intensive care unit for a 48-hour clopidogrel washout followed by surgery. A hematoma and cervical osteophyte were removed with scant bleeding. This case report emphasizes the need to consider the medication history of a patient when assessing the cause of an otherwise unexpected finding.

Mycobacterial pseudotumor of the skin.

Inflammatory pseudotumors have a diverse etiology, mycobacterial pseudotumor (MP) being one of them. MP is a rare entity; it has been reported infrequently in various organs and is extremely rare in the skin. We report a cutaneous MP in an immunosuppressed liver transplant recipient. The lesion consisted mostly of spindle cells, with small numbers of lymphocytes. Conventional acid-fast bacilli (AFB) stain revealed a large number of acid-fast bacilli within spindled histiocytes and the presence of Mycobacterium avium was determined by polymerase chain reaction. Given that the patient had a prior history of cutaneous squamous cell carcinoma resected and reconstructed in the same area, establishing the diagnosis was challenging. Immunohistochemical staining for lysosome-associated membrane protein was strongly positive, suggesting the presence of numerous mature lysosomes within infected spindle cells. Mycobacterial spindle cell pseudotumors can mimic malignant or benign neoplasms and should be considered in differential diagnosis of spindle cell lesions, especially in immunocompromised patients. Further studies are needed to determine mechanisms that permit the survival of mycobacteria within the lesions and that cause this unusual manifestation of infection.

A rare presentation of a large extra-abdominal desmoid tumor of the posterior neck and back.

OBJECTIVE: To describe a difficult case of a large extra-abdominal desmoid fibroma of the posterior neck and back; to discuss the pathologic findings and treatment options of this case and to review the current literature for a rare presentation of this disease. METHOD: A case report and review of the current relevant English literature, carried out using PubMed Medline, are presented. RESULTS: We present a challenging case in which a locally invasive desmoid of the posterior neck and back had grown to such an extent that complete surgical excision in one procedure was not possible. CONCLUSION: Extra-abdominal desmoid fibromas are rare tumors with multiple treatment options. The literature supports incomplete surgical resection when necessary to reduce postoperative morbidity. Further options described for residual or recurrent disease include repeat surgical excision, radiation therapy, and possible chemotherapy. For particularly large tumors, close observation and a planned second stage procedure are an appropriate choice.

Hibernoma presenting as an asymptomatic neck mass.

BACKGROUND: Hibernomas are rare benign tumors of brown fat tissue origin. These tumors are generally found in locations where fetal fat persists (back, axilla, thorax and retroperitoneum). METHODS AND RESULTS: We report a case of a patient with an asymptomatic neck mass that initially presented for evaluation of hoarseness. Imaging and complete surgical excision of the mass were performed and revealed hibernoma. Review of the literature for the presentation of hibernoma in the neck is performed. CONCLUSION: Hibernomas are rare benign tumors that infrequently present in the neck. Complete surgical removal is curative. To date no malignant transformation or metastasis has been described.

Angiosarcoma presenting with minor erythema and swelling.

A 76-year-old man presented with slowly progressive swelling in his forehead and left upper eyelid over the course of three months. CT scanning showed non-specific enhancement of subcutaneous tissues, suggesting a low-grade cellulitis. Poor response to treatment prompted an MRI, which revealed the presence of a soft tissue lesion. Biopsy of this lesion was positive for angiosarcoma. The patient underwent chemotherapy and radiation, but unfortunately succumbed to his malignancy eight months later. This case illustrates a rare example of facial/periorbital angiosarcoma, a benign-appearing but aggressive tumor associated with a high incidence of mortality. A review of the literature and current treatment options are discussed.