David D. Hamlar

Carotid stenting and "extarterectomy" in the management of head and neck cancer involving the internal carotid artery: technical case report.

OBJECTIVE AND IMPORTANCEHead and neck cancer that invades the internal carotid artery (ICA) represents a significant management challenge. We describe a novel technique that allows for aggressive tumor removal without disrupting blood flow through the affected ICA. CLINICAL PRESENTATIONA 62-year-old man was referred to our institution for management of a neck malignancy involving the ICA. Cerebral angiography suggested that there was good collateral flow from the opposite hemisphere, but the patient reported visual loss in the ipsilateral eye during balloon test occlusion of the ICA. INTERVENTIONA self-expanding stent was deployed in the ICA; it spanned the entire length of the artery involved by tumor. One month later, the patient underwent tumor resection. During surgery, a long ICA arteriotomy was performed directly down to the mesh of the stent. A neoendothelium had formed within the stent, which prevented arterial bleeding. The carotid wall was dissected from the stent without difficulty and removed en bloc with the surrounding tumor. The exposed stent was wrapped circumferentially with a synthetic patch material. The patient tolerated the procedure well, and postoperative angiography demonstrated normal filling of the ICA. CONCLUSIONWe describe a novel approach to a patient with head and neck cancer involving the cervical ICA. Preliminary stenting, which allows time for endothelialization before surgery, may permit aggressive tumor resection without interrupting flow through the ICA. This technique obviates the need for complicated carotid reconstruction procedures and avoids the risk of delayed ischemia from carotid sacrifice.

Fine-needle aspiration diagnosis of unusual cutaneous neoplasms of the scalp in HIV-infected patients : A report of two cases and review of the literature

We report on two unusual, non‐AIDS‐defining scalp neoplasms, Merkel‐cell carcinoma (MCC) and malignant melanoma, in 2 men with acquired immunodeficiency syndrome (AIDS). In the first patient, metastatic MCC was initially diagnosed by fine‐needle aspiration (FNA) of a posterior cervical lymph node, based on the cytomorphology and the characteristic immunohistochemical and ultrastructural features. No skin lesion was initially apparent, but a 0.3‐mm scalp primary was found during the ensuing neck dissection. In the second patient, recurrent and metastatic malignant melanoma from a Breslow 1.3‐mm scalp primary was diagnosed by FNA. Both patients developed generalized disease in a relatively short time, despite their small primaries. These cases illustrate the occurrence of Merkel‐cell carcinoma and melanoma in AIDS patients, and stress the need to consider these unusual cutaneous neoplasms when evaluating lymph node FNA samples from HIV‐positive patients, especially since both may present as metastases from clinically occult primaries. Diagn. Cytopathol. 2001;24:186–192.

A Comparison of Anterior vs Posterior Isolated Mandible Fractures Treated With Intermaxillary Fixation Screws

OBJECTIVE To compare complication rates after use of intermaxillary fixation (IMF) bone screws for anterior (ie, symphyseal/parasymphyseal) and posterior (ie, body and angle) mandible fractures. METHODS A retrospective analysis of isolated mandible fractures treated with intraoperative IMF bone screws at 2 major level 1 trauma centers within the Department of Otolaryngology-Head and Neck Surgery at the University of Minnesota. From January 1, 2003, through January 31, 2006, we accrued 53 patients with 67 isolated mandible fractures treated with intraoperative IMF bone screws. These patients had at least 6 weeks of follow-up. RESULTS Twenty-one patients had anterior mandible fractures and 32 had posterior mandible fractures. In the anterior group, there was 1 incident of wound dehiscence, resulting in a total complication rate of 5%. In the posterior fracture group, there was 1 infection (3%), 4 malunions/malocclusions (12%), and 1 nonunion (3%), for an overall complication rate of 19%. The difference between groups for malocclusion rates (12% vs 0%) was significant (P < .001). CONCLUSIONS The IMF bone screw system has a superior speed and safety profile. It produces better occlusion results in anterior mandible fractures and might have a lower overall complication rate compared with arch bars. Given this, IMF bone screws are the preferred modality of intermaxillary fixation in properly selected mandible fractures.

Genioglossal Advancement, Hyoid Suspension, Tongue Base Radiofrequency, and Endoscopic Partial Midline Glossectomy for Obstructive Sleep Apnea.

Surgical intervention for obstructive sleep apnea (OSA) is a complex topic. The discussion involves intricate procedures targeting specific areas of the upper airway. Because of the wide variety of physiologic and anatomic causes of this disorder it is important to tailor the treatment to offer the patient the best possible outcome. Genioglossus, hyoid, and tongue base procedures should be considered among theses treatment options.

Mass Originating From the Maxillary Alveolar Crest in an Infant

An infant presented with a large mass protruding from the right maxillary alveolar ridge. Themasswas first notedat2monthsof age and was initially thought to be an odontogenic cyst. The mass expandedrapidlyover thenextseveralmonthsandwasassociatedwith intermittent increased work of breathing, feeding difficulty, and a 4.5-kgweight loss. Intraoral examination revealeda large, firm, gray mass originating from the rightmaxillary alveolar ridge (Figure, A). Contrast computed tomographic imaging showed an expansile multilobulated heterogeneously enhancing mass measuring 4.1 × 4.8 × 4.4cmoriginating fromthe rightmaxillary alveolar ridge withdisplacementof the floorof themaxillarysinus.Within themass therewasacentral “sunburst” representingnewboneformation.The patientwas initially takento theoperating roomforopenbiopsy.The specimen consisted of small blue cells with a neuroblastic appearance and cuboidal cells with variable melanin pigmentation forming glandlike epithelial structures within a background of dense fibrous stroma (Figure, B and C). Immunohistochemical analysis revealed thatboth theepithelial andneural componentswerepositive for neuron-specific enolase. The epithelial cells stained positive for cytokeratinAE1/AE3 (Figure,D), tyrosinase, andS-100,while the neuroblastic cells stained positive for synaptophysinwith 20% Ki-67positivity.Thepatient’surinaryvanillylmandelicacid levelswere within reference range. What is your diagnosis? A B