Dynamic radiographic imaging following total laryngectomy

Cinepharyngoesophograms of the pharynx were obtained in 51 patients after total laryngectomy for squamous cell carcinoma. The radiological findings were correlated with operative reports and follow-up findings in 47 patients. Postoperative anatomic changes were well-demonstrated radiographically. A spectrum of radiographic findings were observed and included narrowing at the superior surgical closure site in 52% and pseudodiverticula in 47% of all patients. Cricopharyngeal prominence was observed in 15%, fistulae in 10%, and pharyngeal pouches in 6% of all cases. Increased retropharyngeal soft tissue thickness was not found to be indicative of tumor recurrence. We conclude that cineradiography is a useful method for demonstrating both functional and structural changes following laryngectomy for carcinoma.     

The surgical management of giant cervicofacial lymphatic malformations

Giant cervicofacial lymphatic malformation, a potentially life-threatening congenital malformation, historically has been removed in staged resections. However, complete surgical extirpation is desirable and can be achieved with the aid of a multidisciplinary team. The authors present the case of a 12-year-old girl who had an extensively enlarged cervicofacial lymphatic malformation. Effective treatment involved aggressive surgical excision, facilitated by mandibular osteotomies to provide access to the floor of the mouth, the tongue, and the pharyngeal wall. In addition, total removal of involved facial and neck skin was performed. The remaining soft tissue defect was reconstructed primarily with an abdominal musculocutaneous free flap. In the 5 years since the procedure, there has been no recurrence. Based on this experience, excision of involved skin and mandibular access osteotomies are important techniques to help completely remove cervicofacial lymphatic malformations with oral involvement, thus potentially reducing the number of recurrences. In addition, these cases require the best efforts of a multidisciplinary team to achieve a successful result so that complete and radical excision can be performed with the hope of avoiding the pitfalls of multiple resections.     

Necrotizing fasciitis of the face

Necrotizing fasciitis (NF) is a rapidly progressive soft tissue infection with high morbidity and mortality rates. Its occurrence in the head and neck region is uncommon, the majority of reported cases being limited to involvement of the neck, usually from infections of dental or pharyngeal origin. Involvement of the face from NF is rare; only 35 such cases have been reported in the literature since 1960. It is not only associated with a high mortality but can also result in severe disfigurement of the face, posing challenging reconstructive problems. Successful management of facial NF requires early diagnosis, prompt institution of broad spectrum antibiotics, aggressive surgical debridement to control the infection, and reconstruction of the resultant soft tissue defects. This report describes four additional cases of facial necrotizing fasciitis. One of the four patients died as a result of sepsis and multi-organ system failure. Two of the three surviving patients had significant facial disfigurement. A comprehensive review of the facial NF cases reported in the literature is also provided. Based on our experience with facial NF and the results of all previous case reports, the clinical manifestations, pathogenesis, and management of this disease are discussed.     

Spontaneous retropharyngeal haematoma attributable to Epstein-Barr virus infection

Life-threatening sequelae of Epstein-Barr virus infection are uncommon but may present as: local pharyngeal manifestations, splenic rupture, neurological and haematological disorders and altered hepatic function. We present a case of retropharyngeal haematoma with posterior hypopharyngeal wall necrosis, thrombocytopenia and altered clotting function as a result of Epstein-Barr virus infection. A review of the literature on retropharyngeal haematoma reveals this to be the only recorded case which can be directly attributed to Epstein-Barr virus infection.     

Lateral retropharyngeal node metastasis from carcinoma of the upper gingiva and maxillary sinus

Clinically unsuspected metastases to the lateral retropharyngeal nodes from carcinomas of the upper gingiva or maxillary sinus were found in five patients on follow-up CT examinations. Such uncommon metastases may follow the afferent lymphatic channels from the palate or pharyngeal region or arrive by retrograde lymphatics from positive neck nodes. Careful examination of lateral retropharyngeal nodes may be required in cancers of these primary sites.     

Omental transfer for salvage of the moribund lower extremity

Use of omental flaps is well documented in soft tissue reconstruction of the head and neck, chest wall, and abdomen. Three cases of omental transfer for soft tissue reconstruction of the lower extremities are presented. In two patients, free vascularized omental flaps were used to cover deep soft tissue defects over the lower leg and in one patient, a pedicle flap was used to cover a deep groin defect extending into the hip joint. In all patients, use of an omental graft allowed revascularization and subsequent wound healing with good cosmetic results.     

Acute cervical strain. Evaluation and short term prognostic factors

An independent examiner evaluated 179 consecutive private ambulatory litigant patients with soft tissue neck injuries (whiplash) from automobile injuries. Treatment of all patients consisted of neck and shoulder exercises with the exclusion of cervical collars, cervical traction and hospitalization. Forty-three patients had intermittent cervical traction in addition to the exercises. All patients were encouraged to resume their usual work and other activities. The presence of interscapular or upper back pain prognosticated a less favorable result. The average length of treatment was 7.4 weeks. Thirty-seven per cent of the patients with asymptomatic; 16 per cent showed no significant recovery. Older patients recovered as well as younger patients. There was no relation between X-ray findings of flattening or reversal of the cervical lordotic curve and the degree of recovery.     

Severe laryngeal injury caused by blunt trauma to the neck: a case report

Acute blunt laryngeal trauma can be a life-threatening event and often poses a difficult airway management problem. Patients may be unable to supply important anemnestic facts because of aphonia or intubation as a result of their injury. Therefore the immediate recognition and appropriate initial assessment and treatment are vital for a successful outcome. The first step is assuring an appropriate airway, either by careful intubation or temporary tracheotomy. An assessment of potential vascular and oesophageal injuries must be undertaken. The use of computerized tomography (CT) with contrast material is especially useful in identifying and localizing the damage caused by blunt neck injuries. Laryngeal fractures, air in the soft tissues and the extravasation of contrast material in the neck are all helpful in assessing the injuries before surgical intervention. Immediate initial surgery is aimed at stabilizing the cartilaginous framework and repairing the mucosa. We present a case of severe laryngeal injury caused by blunt trauma to the neck; our evaluation, treatment and the outcome.     

Intrapleural placement of a nasogastric tube: an unusual complication of nasotracheal intubation

PURPOSE: Although rare, the misplacement of nasogastric tubes into the pleural space has been described. The prognosis of such injuries is improved by prompt recognition; therefore, it is important for physicians who practice nasogastric intubation to be aware of this potential complication, and to be familiar with an approach to early diagnosis. CLINICAL FEATURES: We present a case of perforation of the cervical oesophagus by a polyvinylchloride nasogastric tube, following a traumatic attempt at nasotracheal intubation. This resulted in passage of the nasogastric tube into the pleural space. CONCLUSIONS: Our experience with this case and a review of the relevant literature suggest that such trauma may predispose to malplacement of nasogastric tubes. Clinical signs, such as aspiration of fluid from a nasogastric tube, and auscultation of air insufflated into the stomach, are unreliable; however, the presence of subcutaneous air in the neck on chest radiograph, and the presence of cervical crepitance on physical examination, are valuable signs in the early diagnosis of perforation of the cervical oesophagus. Contrast oesophagography remains the diagnostic manoeuvre of choice in confirming the diagnosis, but early diagnosis will depend on a high index of suspicion and prompt viewing of chest x-rays. The management and the prognosis of such injuries depends on the level of the perforation, delays in diagnosis, and the presence of associated mediastinitis.     

Mechanical airway obstruction secondary to retropharyngeal haematoma

Mechanical airway obstruction secondary to retropharyngeal haematoma is a life-threatening emergency and should be anticipated in all cervical spine injure patients regardless of the severity of trauma. Most retropharyngeal haematomas described in the literature have involved complicating factors such as anticoagulant therapy, tumour, aneurysm, infection or major cervical spine injury. Several authors have however described haematomas causing airway compromise with minor hyperextension injuries. We describe the case of a 19-year-old male who was involved in a motorcycle accident. He sustained an atlanto-occipital fracture-dislocation and a very large retropharyngeal haematoma which resulted in airway obstruction and a subsequent difficult intubation. We outline the normal anatomy of the retropharyngeal space, the pathogenesis of retropharyngeal haematomas, and outline techniques of intubation available.     

Spine injuries in combat troops--Panama, 1989

Operation Just Cause was until recently the largest American combat operation since Vietnam, and remains the largest nighttime parachute operation since World War II. All 252 casualties were airlifted to San Antonio, Texas, for medical treatment. Greater than 80% sustained orthopedic injuries. Sixteen patients were admitted for injuries to the back or neck. Three of the four patients with significant fractures or fracture-dislocations were paraplegic. Two of the three patients with gunshot wounds to the back required extensive reconstruction for wound management. In addition to the 252 casualties, there were 23 fatalities, among whom 7 suffered major injuries to the spine. Spine injuries represented the most significant source of long-term morbidity among those soldiers wounded in combat in Panama, and were common among the fatalities. Noteworthy in these cases was the high percentage of severe neurologic injuries in patients with significant fractures (75%), particularly fractures associated with gunshot wounds. Also of interest were the cases of major soft tissue injury associated with high-velocity gunshot wounds (66%) and the extensive soft tissue surgery needed to treat these injuries.     

Possible causes of a positive Haemoccult-II test in a population screening study for colorectal neoplasia

In the present paper, common disorders of the oral cavity and oropharynx are described with special emphasis on differential diagnostic aspects. The first part of this presentation covers different inflammatory diseases, mainly focusing on complications like peritonsillar, para- and retropharyngeal abscesses, and Ludwig's angina. These clinical entities can lead to further life-threatening complications, including deep neck infections and mediastinitis. The diagnostic value and necessity of modern imaging in these cases are emphasized. In the second part, the author reports on the incidence, etiology and clinical course of tumors of the oral cavity and oropharynx with special regard to malignancies. Tumors in these areas have been increasing in number over the past decades mainly due to changes in alcohol and nicotine consumption in the developed countries. Diagnostic management includes a thorough clinical evaluation as well as modern imaging for tumor delineation and possible bone infiltration, depending on the site of the original tumor. In addition, therapeutic considerations are discussed, focusing on surgical tumor removal and soft tissue replacement using different pedicled flaps and free flaps. It is also emphasized that postoperative radiotherapy is mandatory in most malignant tumors in this area.     

Retropharyngeal pseudomeningocele after atlanto-occipital dislocation: report of two cases

OBJECTIVE AND IMPORTANCE: We report two cases of retropharyngeal pseudomeningocele after atlanto-occipital dislocation. This is rare, with only one other reported case in the literature. CLINICAL PRESENTATION: We report two patients who presented after blunt cervical and head trauma. Plain films revealed that each patient had atlanto-occipital dislocation. Subsequent magnetic resonance imaging revealed the delayed development of retropharyngeal pseudomeningocele. Concomitant hydrocephalus was noted in both patients. INTERVENTION: The surviving patient showed marked neurological improvement and resolution of his pseudomeningocele after ventriculoperitoneal shunting. CONCLUSION: For patients with closed head injuries who develop posttraumatic pseudomeningocele, we recommend cranial computed tomography to assess for the presence of hydrocephalus. In patients with atlanto-occipital dislocation, delayed neurological deterioration warrants magnetic resonance imaging of the craniocervical junction to rule out posttraumatic pseudomeningocele.     

Intraoral defect coverage with muscle flaps

PURPOSE: This study investigated whether wound healing after the use of purely muscular flaps for intraoral defect coverage is negatively influenced by insipient muscular atrophy and the absence of a covering layer. MATERIALS AND METHODS: In an experimental study, microsurgical transplantation of muscle flaps from the anterior abdominal wall was carried out in 18 Lewis rats. A nerve anastomosis for motor reinnervation was not performed. Atrophy of the muscle flaps was determined by measuring the reduction of their size and weight after 3, 8, and 20 weeks. In the clinical part of the study, free muscle transplants from different donor regions (vastus lateralis, pectoralis major, internal oblique, and temporalis muscles) were used for defect coverage in various areas of the oral cavity. To study epithelization, punch biopsy specimens from the muscle surface were taken at periods of 2 to 4 weeks up to 6 months for histologic evaluation. Final evaluation of reconstruction results with special regard to speech, tongue mobility, mouth opening, chewing, and swallowing took place after 6 months. RESULTS: In the experimental study, average weight loss of the muscle flaps was 67% after 20 weeks, and the remaining surface area was 71%. The number of myocytes was only about 30% compared with control muscles, and parts of the flap appeared as a thin fibrous membrane. Clinically, this atrophy led to restricted mobility in such areas as the floor of the mouth, the buccal plane, and the tongue. Muscle flaps covering solid structures such as bones or reconstruction plates adapted well to the transplant bed, and the atrophy of the muscle led to no constriction of the surrounding tissue. Atrophy also did not have a negative effect when muscle flaps were placed in the region of the pharyngeal wall. Epithelization started from the edges after 2 weeks and was concluded after 8 weeks in all transplants if no additional radiation was performed. The muscle tissue was sufficiently resistant so that infection, fistulization, and necrosis did not occur. CONCLUSIONS: Muscle flaps undergo considerable atrophy with a cicatricial transformation and reduction of flexibility. Despite these disadvantages they can be used in the hard palate, the alveolar crest, and in the pharyngeal wall without causing functional restriction. Because of constriction of the surrounding tissues, mobile areas such as the buccal plane, the floor of the mouth, and the tongue are not suitable as sites for muscle transplants.     

Binding of L-branched-chain amino acids causes a conformational change in BkdR

BACKGROUND: Necrotizing soft tissue infections of the chest wall are uncommon, and they have received little discussion in the medical literature. METHODS: We performed a collective review of the literature to summarize information on etiology, prevention, treatment, complications, and outcome of chest wall necrotizing soft tissue infections. Manual, Medline, and Current Contents searches of the English-language medical literature were done. RESULTS: There were 9 reported cases of necrotizing soft tissue infection of the chest wall. Eight were complications of invasive procedures and operations. Tube thoracostomy for empyema (4 patients) was the most common antecedent procedure. Excessive soft tissue dissection during chest tube insertion was implicated in the genesis of these infections. Necrotizing infections complicated esophageal operations in 2 patients. Overall mortality was 89%. Only 3 of the 9 patients underwent early and adequate debridement. Chest wall stability and wound reconstruction were problematic in patients who survived the initial septic illness. CONCLUSIONS: Necrotizing soft tissue infections of the chest wall are highly lethal infections that require urgent and aggressive debridement. Diagnostic delay and inadequate debridement are common reasons for treatment failure. Repetitive surgical debridement is often needed to control sepsis. Wound closure is challenging in patients who survive the initial septic phase of their illness.     

Translaryngeal tracheostomy. A new era?

OBJECTIVE: Presentation of a new technique of dilation tracheostomy projected to offer a minimum risk of complication and tissue trauma. DESIGN: Prospective study carried out between July 1993 and December 1995, to evaluate the feasibility of the procedure, its possible advantages over other methods, and possible complications. SETTING: General ICU with a Paediatrics Section. PATIENTS: Uninterrupted series of 84 adults and 12 children with multifactorial respiratory insufficiency. INTERVENTION: Through a needle inserted in the trachea, a guide wire is retrogradely pushed out of the mouth and attached to a special device formed by a flexible plastic cone with pointed metal tip joined to an armoured tracheal cannula. This device is then pulled back through the oral cavity, larynx, trachea-hence the definition: TransLaryngeal Tracheostomy (TLT)- and outwards across the neck wall by applying traction on the wire with one hand and counterpressure on the neck wall with the fingers of the operator's other hand. When the cone and part of the cannula have emerged, the cone is separated from the cannula. The cannula is further extracted until its inside portion can be turned downwards to its final placement. RESULTS: A precise localisation of the stoma placement and the needle introduction are facilitated by the rigid tracheoscope and protrusion. Thanks to the very pointed cone, the piercing resistances are lowered. At the same time, every degree of traction power is allowed through the counterpressure practised by the fingers. The channel is very regular with a strong adherence to the cannula that secures a virtual lack of bleeding and local inflammation. We observed this in the fifty cases, in which the final version of our technique was applied. Trachea CT scan and endoscopic control did not show late lesions of the airway. CONCLUSIONS: TLT is characterised by highest inherent safety and lowest tissue traumatism, that it can also be performed in patients who would risk complications from any other tracheostomy techniques.     

Lateral neck cysts--the branchial theory revisited. A critical review and clinicopathological study of 97 cases with special emphasis on cytokeratin expression

Theories regarding the origin of lateral neck cysts (LNC) range from congenital branchial pouch abnormalities to acquired salivary gland inclusions within lymph nodes. We analyzed 97 LNC histologically and evaluated their cytokeratin (CK) profile in a search for their derivation. 77/97 LNC were located in soft tissues, 20/97 within lymph nodes. LNC of young patients and of recent symptomatic presentation in older patients were lined by respiratory epithelium with scant lymphoid tissue, with expression of "simple epithelial" CK in ciliated cells and bimodal expression of "simple" and "stratified-epithelial-type" CK in basal cells. In longer standing symptomatic LNC, respiratory epithelium alternated with transitional-type pseudostratified epithelium with intraepithelial Langerhans cells and lymphoid hyperplasia, or consisted exclusively of squamous epithelium. We propose that respiratory epithelium is the "native" epithelium of LNC and squamous metaplasia results from inflammation induced stem cell hyperplasia in respiratory epithelium, evidenced by co-expression of "simple" and "stratified-epithelial-type" CK in all cells of transitional-type pseudostratified epithelium, the early stage in metaplastic transformation. Respiratory epithelium predominates in early LNC, lines pharyngeal tonsils and the recessus tonsillo-tubalis, and is a minor constituent of palatine tonsil but is not present in salivary glands. None of the LNC contained dysplasia, atypia, or carcinoma, or were associated with a primary carcinoma of tonsils or head and neck. We demonstrate that LNC arise from developmental remnants (congenital) of the 2nd branchial pouch, which may lie dormant for many years. Symptomatic enlargement, squamous metaplasia and lymphoid hyperplasia ensue as a consequence of immunologic stimulation a development reflected in hyperplastic palatine tonsils.     

Circulating levels of nitric oxide in fertile women in relation to the menstrual cycle

Impalement occurs when a portion of the body is penetrated by a rigid object. These injuries incorporate aspects of both blunt and penetrating type injuries in that the object or the body at time of impact is traveling at relatively low velocity and the energy is dissipated over a short distance. Impalement injuries have been described for most body cavities. Evaluation of these injuries can be uniquely challenging. We present a case of impalement of the neck from an object previously unreported in the literature, a golf club shaft.     

Low prevalence of human papillomavirus in a geographic region with a high incidence of head and neck cancer

BACKGROUND: The main purpose of this study was to determine the prevalence of human papillomavirus (HPV) infection in patients with head and neck carcinomas from Brazil. MATERIALS AND METHODS: Forty-five patients with head and neck squamous cell carcinoma were included in the study, from 1995 to 1996. Forty-two were male and 3 female, with age ranging from 32 to 82 years (median 61). Five patients (11%) did not have previous history of use of tobacco and 38 (90.5%) were heavy smokers. Tumor sites were pyriform sinus, 10; tongue, 11 (oral, 6; base, 5); larynx, 7; floor of mouth, 3; tonsil, 6; retromolar area, 3; inferior gingiva 2; buccal mucosa, 2; and maxillary sinus in 1 patient. Twenty-five were stage IV, 17 stage III, and 3 stage II. RESULTS: The presence of HPV DNA was detected in 5 of 45 patients (11%), all of them with HPV 16. Two patients had HPV DNA in normal mucosa and tumor tissue, 1 patient had HPV DNA only in the normal mucosa and tumor tissue, 1 patient had HPV DNA only in the normal mucosa, and 2 patients were positive for HPV DNA in tumor tissue. Four patients were male and 1 was female; 2 patients were nonsmokers. Three patients had tonsil carcinoma, 1 patient had a tongue carcinoma, and 1 patient had a pyriform sinus cancer. CONCLUSIONS: The role of chemical carcinogens seems to be more important in the genesis of head and neck cancer than is HPV infection. The presence of HPV DNA in 5 of 45 patients stimulates further investigation to determine the role of HPV as a risk factor for head and neck carcinoma.     

A cephalometric comparative study of the soft tissue airway dimensions in persons with hyperdivergent and normodivergent facial patterns

PURPOSE: This study was performed to compare the dimensions of the nasopharynx, oropharnynx, and hypopharynx of persons with hyperdivergent and normodivergent facial types, and to determine whether any variations exist. PATIENTS AND METHODS: Lateral cephalometric records of a population with a normodivergent facial pattern (n = 23) and a group with a hyperdivergent facial pattern (n = 27) as evidenced by increased mandibular plane angle were used to compare the soft tissue airway dimensions. Statistical analysis consisted of Student's t-tests, Wilcoxon rank sums, and chi2. Statistical significance was set .05. RESULTS: Overall the hyperdivergent group had a narrower anteroposterior pharyngeal dimension than the normodivergent control group. This narrowing was specifically noted in the nasopharynx at the level of the hard palate and in the oropharynx at the level of the tip of the soft palate and the mandible. In addition, the posterior pharyngeal wall had a thinning at the level of the inferior border of the third cervical vertebrae, and there was a more obtuse palatal angle. The tongue was also positioned more inferiorly and posteriorly in the hyperdivergent group, as evidenced by the increased distance between the hyoid bone and the mandibular plane and the increased distance between the soft palate tip and the epiglottis. The hyperdivergent group had more retruded maxillary and mandibular apical bases and a higher Class II skeletal discrepancy. CONCLUSIONS: The narrower anteroposterior dimension of the airway in hyperdivergent patients may be attributable to skeletal features common to such patients, that is, retrusion of the maxilla and the mandible and vertical maxillary excess. Other features, such as an obtuse soft palate and low-set hyoid, also may be contributory factors. The relatively thin posterior pharyngeal wall observed in hyperdivergent patients might be a compensatory mechanism.