Early postoperative imaging and image-guided procedures on patients with face transplants

Face transplantation is being performed with increasing frequency. Facial edema, fluid collections, and lymphadenopathy are common postoperative findings and may be due to various etiologies, some of which are particular to face transplantation. The purpose of this study was to demonstrate how postoperative imaging and image-guided minimally invasive procedures can assist in diagnosing and treating complications arising from face transplantation. Retrospective evaluation of 6 consecutive cases of face transplantation performed at Brigham and Women's Hospital between April 2009 and March 2014 was performed with assessment of postoperative imaging and image-guided procedures, including aspiration of postoperative fluid collection, lymph node biopsy, and treatment of salivary gland leak. Through these cases, we demonstrate that early postoperative imaging and image-guided procedures are key components for the management of complications following face transplantation.

Treatment of oropharyngeal squamous cell carcinoma with IMRT: patterns of failure after concurrent chemoradiotherapy and sequential therapy

BACKGROUND

The optimal management of oropharyngeal squamous cell carcinoma (OPSCC) is controversial. Modern radiotherapy typically employs intensity-modulated radiation therapy (IMRT), and herein, we report the Dana-Farber Cancer Institute (DFCI) experience with IMRT-based treatment of OPSCC.

DESIGN

Retrospective study of all patients treated at DFCI for OPSCC with definitive or adjuvant IMRT between 8/04 and 8/09. The primary end point was overall survival (OS); secondary end points were locoregional control (LRC) and freedom from distant metastases (FFDM). Propensity score matching was used to create concurrent chemoradiotherapy (CCRT) and sequential therapy (ST) cohorts equally balanced for patient and disease characteristics.

RESULTS

One hundred and sixty-three patients were included with 75% presenting with stage IV disease. Fifty-six patients (34%) were treated with ST. The three-year actuarial OS, LRC, and FFDM rates for the entire cohort/ST subset were 86%/89%, 86%/87%, and 88%/93%, respectively. There were no differences in OS, LRC, or FFDM between CCRT and ST in the propensity-matched cohort.

CONCLUSIONS

IMRT was associated with excellent OS, LRC, and FFDM. Although the results following ST were superb, there was no obvious benefit to ST after adjustment for selection bias. We recommend that ST be reserved for medically fit patients with a high risk of distant metastases.

Effect of rehabilitation facility location on outcomes in head and neck surgical patients

The objective of this study was to determine the significance of in-hospital rehabilitation facility vs. distant rehabilitation facilities in the outcomes and complications of post-operative head and neck surgical patients. Retrospective review of head and neck surgical patients was conducted over a 5-year period at a tertiary care medical centre. Fifty patients met criteria for this study (35 males, 15 females). Forty-two patients had a primary squamous cell carcinoma and eight patients had other primary malignancies of the head and neck. Thirty-two patients were placed in an in-hospital rehabilitation facility and 18 patients were placed in distant rehabilitation facilities (average distance 40.9 miles). Seventeen patients (34%) had complications including infection/drainage (seven patients), fistula (six patients), pneumonia (two patients), wound dehiscence (two patients) and other minor complications. The difference complication rate among the two groups was not statistically significant (37.5% in-hospital rehabilitation, 27.8% distant rehabilitation; P=0.496). The rate of hospital re-admission was not statistically significant (25% in-hospital rehabilitation patients, 16.7% distant rehabilitation patients; P=0.505). The average length of stay of patients without complications was 18.5 days (SD=5.8) for in-hospital rehabilitation and 12.9 days (SD=17) for distant rehabilitation. This difference was not statistically significant (P=0.346). In summary, one-third of post-operative head and neck surgical patients developed complications while in a rehabilitation facility. The length of stay, hospital re-admission rate and frequency of complications does not correlate with the proximity of the rehabilitation facility to the hospital where the patients received their surgery.

Preliminary clinical results of window partial laryngectomy: a combined endoscopic and open technique

Endoscopic laser resection for anterior commissure glottic carcinoma is difficult, because of inadequate exposure and close proximity to the underlying cartilage. A technique combining endoscopic carbon dioxide laser incision and an external approach creating a window in the thyroid cartilage was initially tested in a canine study and then performed in 5 patients. All patients were men, with T1 or T2 glottic or supraglottic cancer involving the anterior commissure, and had failed radiation treatment. The true or false vocal fold tumors were excised along with the paraglottic space and adjacent cartilage, with preservation of the remaining thyroid framework. The reconstruction was accomplished with placement of a sternohyoid muscle flap, by use of either a bipedicled muscle flap with overlying skin or a unipedicled muscle flap with a graft of free mucosa. The graft was secured in place with fibrin glue and laser soldering. Follow-up ranged from 11 months to 4 years and included biopsies. All patients had voice recordings before and after surgery. A tracheostomy was avoided in all patients. The hospital stays were 4 to 13 days. The voice quality was good after surgery. One patient died of unrelated causes 18 months after his surgery without evidence of recurrence. The other patients are still alive with no evidence of disease. The only complication was subcutaneous neck emphysema in 1 patient that spontaneously resolved. The results showed a satisfactory anatomic reconstruction and acceptable functions. We believe that this new combined technique is oncologically sound, may overcome the limited access seen with the endoscopic technique and the excessive cartilage resection seen with external partial laryngectomy, avoids a tracheostomy, and shortens hospital stays.

Kaposi's sarcoma of the larynx

Kaposi's sarcoma (KS) is a neoplastic vascular disorder, classically arising in the skin of the lower extremities. As a consequence of the acquired immunodeficiency syndrome (AIDS) epidemic, an increasing number of patients have been found to have KS. In AIDS patients, KS appears to exhibit a more diffuse nature and frequently affects the head and neck. Mucosal lesions are most often seen, commonly involving the oral cavity. Only rare cases of laryngeal involvement have been recorded in the literature. We report 2 cases of KS of the supraglottic larynx. Our first patient, an elderly man of Mediterranean descent, complained of voice change and throat discomfort. Endoscopy with biopsy for diagnosis allowed conservative treatment with chemotherapy. Our second patient was a younger man with AIDS who presented with symptoms of airway obstruction. Management with carbon dioxide laser epiglottectomy was successful in relieving that patient's symptoms. Although rare, KS may present in both healthy and immunocompromised patients, and must be considered in the differential diagnosis of all violaceous lesions of the larynx.

Midfacial fractures in pediatric patients. Frequency, characteristics, and causes

OBJECTIVE

To determine the frequency, characteristics, and causes of midfacial fractures in children.

DESIGN

A retrospective review of the patients' medical charts and radiographs.

SETTING

Tertiary referral center.

PATIENTS

Fifty-four patients under 16 years of age, with midfacial fractures diagnosed and treated in the Helsinki (Finland) University Central Hospital from 1980 through 1992.

MAIN OUTCOME MEASUREMENTS

The data examined included sex, age, time and cause of the accident, type and location of the fractures, the presence and location of associated injuries, complications, and treatment methods.

RESULTS

The male-to-female ratio was 1.16:1. Motor-vehicle accident was the most common cause of injuries. The frequency of injuries was in decreasing order: (1) maxillary alveolar bone, (2) zygoma, and (3) Le Fort fractures of the maxilla. The majority of injuries occurred in subjects who were 13 to 15 years old. In children less than 6 years old, only alveolar fractures occurred. For the other age groups, no significant difference in the fracture pattern was found. No fatalities occurred in this patient series.

CONCLUSIONS

Midfacial pediatric fractures are rare. A high velocity force, such as that from a motor-vehicle accident is a factor producing the injury. Owing to the high impact, associated injuries are common. The severity of the insult is more essential than the age of the patient and the development of the paranasal sinuses.

Embryology and anomalies of the external ear

Malformations of the auricle are not uncommon and occur in 1 out of 12500 births. They can occur alone or can be associated with genetically determined syndromes. Most congenital malformations in the human occur during the third to twelfth weeks of embryonic life. During this period, the external ear is undergoing development and can be affected in many ways. There are three parts to the external ear: the auricle, the cartilaginous external auditory canal, and the bony external canal. The auricle (pinna) and the cartilaginous canal are closely related and probably develop from the same anlage. The bony canal is derived from the tympanic ring which is an incomplete cylinder of membranous bone. It must be clearly understood that, although this article is primarily concerned with the morphogenesis and dysmorphogenesis of the auricle, the rest of the external ear, specifically the external auditory canal, is developing simultaneously. Therefore, maldevelopment of the external canal and the auricle will frequently occur together.

Distraction osteogenesis for reconstruction of mandibular symphyseal defects

OBJECTIVE

We investigated the feasibility of arched trifocal distraction osteogenesis for reconstruction of mandibular symphyseal defects.

DESIGN

Four adult canine subjects were used. An external apparatus was designed to allow trifocal distraction around an arc. An anterior mandibulectomy was performed between the third premolars bilaterally. The bony defect was regenerated using trifocal distraction osteogenesis at a rate of 1 mm a day bilaterally. New arced bone was produced over a period of 20 to 35 days. The apparatus functioned as an external fixator for the ensuing 6 weeks. The apparatus was then removed, the dogs were returned to their preoperative diet, and were killed after 2 weeks of observation.

MAIN OUTCOME MEASURES

Grossly a smooth arc of bone was formed measuring 4.5 to 5.5 cm in length, 2.2 to 3.0 cm in height, and 1.3 to 1.5 cm in width. Histologically all specimens demonstrated direct membranous bone growth. Radiographically opaque columns were seen streaming in the direction of distraction.

CONCLUSIONS

Symphyseal bony defects resulting from oncologic resection, trauma, and congenital deformities create tremendous cosmetic and functional handicaps and have remained extremely challenging to surgically reconstruct. This study demonstrates the ability to use arced trifocal distraction osteogenesis to reconstruct anterior mandibulectomy defects in a canine model. This method may provide a satisfactory solution to a difficult problem in human mandibular reconstruction.

Treatment of adductor laryngeal breathing dystonia with botulinum toxin type A

Adductor laryngeal breathing dystonia (ALBD) is a rare disorder in which patients have persistent inspiratory stridor, usually normal voice, and cough. Physical exam is characterized by paradoxical movement of the vocal cords on inspiration. These patients have involuntary action-induced spasms of the adductor laryngeal muscles on inspiration. There has been no uniformly satisfactory treatment for the disease. Speech therapy, psychotherapy, and pharmacotherapy have all had limited success. We report the successful use of botulinum toxin type A in seven patients with adductor laryngeal breathing dystonia. All patients received bilateral thyroarytenoid injections. All patients had toxin effect within 72 hours, reaching maximal effect within 2 weeks with sustained improvement for an average of 13.8 weeks. Adverse effects included breathy voice and mild choking on liquids. Both resolved, on average, within 2 weeks. This retrospective study supports the safe and effective use of botulinum toxin type A in the treatment of adductor laryngeal breathing dystonia.

Vincristine-induced recurrent laryngeal nerve paralysis

Vincristine-sulfate-related vocal cord paralysis has been reported infrequently in the literature. The neurotoxicity of the vinca alkaloids is well-known; however, the potential for cranial nerve involvement is not widely recognized. Given the complexity of the typical patient receiving such a chemotherapeutic agent, the potential for misdiagnosis is high. Many patients have primary tumors or metastatic lesions in sites that could cause the clinician to overlook this reversible cause of neurologic dysfunction. This study describes the first three reported pediatric cases of vincristine-induced vocal cord paralysis. Two patients developed increasing stridor secondary to bilateral vocal cord paralysis; the third developed a unilateral vocal cord paralysis. All resolved spontaneously upon withdrawal of the vincristine. Vinca-alkaloid-induced vocal cord paralysis is a potentially dangerous but reversible lesion. Otolaryngologists should be aware of the association between these agents and cranial nerve neuropathies.

A rare cause of nasal obstruction: a solitary neurofibroma

This case represents a peripheral nerve sheath tumor as a cause of nasal obstruction. Nerve sheath tumors are relatively uncommon; however, most otolaryngologists will encounter them. These tumors develop from cranial and spinal nerve roots and from peripheral nerves. In total, approximately 25% to 44% of nerve sheath tumors occur in the head and neck region. Although the most important are cranial nerve tumors--the majority being acoustic neuromas arising from the vestibular nerve--they may also develop in the nasal cavity.