Iatrogenic dorsal spinal cord herniation and repair with clip-based expansile duraplasty: a case report.

INTRODUCTION: Myelopathy arising due to dorsal herniation of the spinal cord is a rare phenomenon, particularly so in the thoracic region. Where cases of thoracic dorsal cord herniation have been reported, the aetiology has typically been non-iatrogenic. CASE PRESENTATION: We report the case of a paediatric oncology patient who presented with neurological deterioration secondary to thoracic dorsal spinal cord herniation, manifesting three months after laminectomy for biopsy of a spinal medulloblastoma lesion. We repaired the dural defect using non-penetrating titanium clips to create a secure expansile duraplasty, resulting in radiologically evident reduction of the cord herniation as well as corresponding clinical improvement. DISCUSSION: Thoracic dorsal spinal cord herniation is an extremely rare occurrence after spinal surgery. Non-penetrating titanium clips can be used to form a secure expansile duraplasty following reduction of the cord herniation. Successful repair of the dural defect re-anteriorises the cord and can confer neurological benefit.

The changing face of paediatric airway endoscopic surgery: An 8-year single surgeon review.

INTRODUCTION: As a recently established division, we sought to reflect on the development of our paediatric airway surgery service, and prospectively examine the diagnoses that underwent microlaryngobronchoscopy (MLB) to help quantify the evolving population demographics of paediatric airway disorders. MATERIAL AND METHODS: This was a prospective longitudinal study conducted of all paediatric MLBs performed by a single surgeon in a tertiary paediatric ENT centre between 2012 and 2019. RESULTS: A total of 1040 MLBs were performed in 498 patients at the paediatric ENT centre of the Royal London Hospital. Median age at first procedure was 19 months. Median follow-up was 48 months. Primary diagnoses were laryngomalacia (21%), subglottic stenosis (SGS - 18%), laryngeal cleft (13%), and normal anatomy (28.3%). Repeat procedures were needed in 39.1% patients, who underwent a median of 2 repeat procedures. SGS (57.7%) constituted majority of the repeat category, followed by laryngeal cleft (12.36%), laryngomalacia (10.15%), unilateral/bilateral vocal cord palsy(4.24%) and laryngeal papilloma(4.24%). Laryngeal papilloma constituted largest number of procedures per patient (Median = 4, IQR = 5.75), followed by subglottic web and SGS. Mean length of stay(LOS) was 0.67 ± 0.96 days(d), with laryngeal cleft cases recording longest mean LOS. There was a steady increase in proportion of day-surgeries across study period [6.9% (2012) vs 59%(2019)]. CONCLUSION: SGS constitutes the major bulk of paediatric airway surgery, reflective of increasing number of premature births and prolonged intubation among neonates. Day-case MLB is a safe and feasible option in selected patients. This long-term data provides useful information to accurately prognosticate patients regarding potential number of repeat procedures for each diagnosis.

Utility of the Milan system for reporting salivary gland cytopathology during rapid on-site evaluation (ROSE) of salivary gland aspirates.

OBJECTIVE: Rapid on-site evaluation (ROSE) is a fine needle aspiration (FNA) technique for ensuring sampling adequacy and triaging samples. The Milan system for reporting salivary gland cytopathology (MSRSGC) is a standardised reporting system which aims to improve risk stratification. There is scant literature on the diagnostic value and agreement of MSRSGC on ROSE with final cytological diagnosis in salivary gland FNAs. We aimed to assess the concordance of MSRSCG categorisation and diagnosis on ROSE with final cytological and histological diagnosis. METHODS: This prospective study included consecutive salivary gland FNAs for which ROSE was performed over a six-month period. MSRSGC category and diagnosis on ROSE were compared with the final cytological diagnosis and MSRSGC category, and histopathological diagnosis, where available. RESULTS: Sixty salivary gland aspirates were included. The adequacy rate with ROSE was 100%. Using the MSRSGC classification during ROSE, 26 (43.2%) samples were categorised as benign neoplasm, 21 (35%) as malignant neoplasm, 9 (15%) as non-neoplastic, and one each (1.7%) belonged to the remaining four categories. MSRSGC categorisation on ROSE concurred with final the cytological diagnosis in 58/60 cases (96.7%). Discrepancies in MSRSGC categories on ROSE included one atypia of undetermined significance with final report as non-neoplastic, and one non-diagnostic as suspicious for malignancy. Good correlation of MSRSGC categories on ROSE with final histopathological diagnosis (88.9% concordance) was also noted. CONCLUSIONS: MSRSGC on ROSE shows good concordance with final cytology and histopathology diagnosis, indicating that categorisation according to MSRSGC has utility in ensuring that adequate material is obtained and triaged appropriately for the diagnosis of salivary gland aspirates.

Unusual Sites for Extracranial Head-Neck Schwannomas.

Schwannomas are a frequent cause of swellings in the head and neck region. Due to the abundance of peripheral, cranial and autonomic nerves in this region, schwannomas can present in variety of locations, posing a diagnostic and therapeutic challenge to the surgeon. Unusual sites in head and neck region can have varied presentation depending on the site of origin. We identified unusual extracranial locations of head and neck schwannomas, their presenting features and surgical management. Retrospective review of cases of extracranial head and neck schwannomas operated in the Department of Otolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi, a tertiary referral centre between July 2015 and June 2019. A total of 42 cases of extracranial head and neck schwannomas were operated. Among them, 9 cases were found to arise from uncommon sites, such as parotid gland (n = 1), infratemporal fossa (n = 2), external auditory canal (n = 1), subglottis (n = 1), false vocal cord (n = 1), frontal recess (n = 1), maxillary sinus (n = 1) and retromolar trigone (n = 1). All patients underwent excision via relevant approaches. Nerve of origin was identified in 4/9 cases. One case had postoperative neurological deficit. No recurrences were noted in mean follow-up of 19 months. Schwannomas ought to be considered as a differential diagnosis for swellings/ mass in any part of head and neck region. Comprehensive evaluation with appropriate imaging and histology should be done in all cases. Preoperative counselling and consent regarding neurological deficit pertaining to possible nerve of origin is required in each case.

Synchronous Oncocytic Papillary Cystadenoma and Warthin Tumor of the Parotid Gland.

Warthin tumor (WT) is the second most common benign salivary gland neoplasm. It is also the most frequent salivary gland tumor to occur synchronously or metachronously with another salivary gland neoplasm, in the same gland or on the other side. Oncocytic papillary cystadenomas (OPCs) are rare neoplasms that are more common in minor salivary gland locations and in women. We describe in detail the case of a 73-year-old male smoker with synchronous OPC and WT of the parotid gland. On microscopy, both tumors resembled each other considerably, with the only difference being that the OPC lacked the tumor-associated lymphoid proliferation characteristic of WT. These findings highlight that OPC bears considerable similarity to WT. While this morphological similarity may lead to misdiagnosis on rare occasions, it does not affect patient management, as clinical behavior of both these tumors is similar.