Edward W.H. To

Nasopharyngectomy for Recurrent Nasopharyngeal Carcinoma: A Review of 31 Patients and Prognostic Factors

Objectives/Hypothesis Nasopharyngectomy is a well‐established treatment option for recurrent nasopharyngeal carcinoma. Over a period of 4 years and 3 months, in a total of 43 patients, 45 nasopharyngectomies were performed. Thirty‐one patients with follow‐up ranging from 12 to 58 months were studied. Twenty‐two patients (58%) survived; of these, 18 patients (82%) remained disease free. All patients who developed repeat recurrence or died (n = 12) had a high recurrent T‐stage tumor, skull base involvement, multiple recurrences, positive surgical margins, or concurrent neck node metastasis. These factors are poor prognostic parameters and might mitigate the indications for aggressive salvage surgery. However, low recurrent T‐stage tumor without neck metastasis carries a good prognosis. Modern minimally invasive surgery carries minimal morbidity.

Total airway obstruction during local anesthesia in a non-sedated patient with a compromised airway

PurposeTo report a case of complete upper airway obstruction after topicalization with lidocaine in a completely conscious patient with partial upper airway obstruction.Clinical featuresA 69-yr-old man with a history of neck cancer and radiation presented for resection of recurrent neck tumour. No preoperative sedation was given. He had inspiratory and expiratory stridor but had no history of aspiration or swallowing problem. Phonation was distorted but effective. The surgeon was reluctant to perform an awake tracheostomy under local anesthesia. In preparation for a fibrescope-assisted orotracheal intubation, the non-sedated patient was given topical upper airway lidocaine during which he developed total airway obstruction and hypoxemia. He was immediately intubated with a fibrescope. His vocal cords were not edematous although the supraglottic structures appeared to be. The vocal cords were abducted and their movement was limited and not paradoxical. Tumour resection was uneventful upon successful tracheal intubation and general anesthesia. Tracheostomy at the end of the case was difficult, as expected. The patient tolerated the procedures and regained consciousness with no neurologic sequelae.ConclusionDynamic airflow limitation associated with local anesthesia of the upper airway may lead to complete upper airway obstruction in a compromised airway. The main cause may be the loss of upper airway muscle tone, exacerbated by deep inspiration during panic.RésuméObjectifPrésenter un cas d’obstruction complète des voies aériennes supérieures après pulvérisation de lidocaïne chez un patient tout à fait conscient mais souffrant déjà d’obstruction respiratoire partielle.Éléments cliniquesUn homme de 69 ans aux antécédents de cancer du cou et de radiothérapie s’est présenté pour la résection d’une tumeur récurrente au cou. Aucune sédation préopératoire n’a été administrée. Il présentait un stridor inspiratoire et expiratoire, mais n’avait pas d’antécédent de trouble d’aspiration ou de déglutition. La phonation était déformée mais efficace. Le chirurgien était réticent à réaliser une trachéotomie vigile sous anesthésie locale. Pendant la préparation de l’intubation orotrachéale fibroscopique, de la lidocaïne topique a été administrée dans les voies aériennes supérieures du patient éveillé chez qui s’est développée une obstruction totale des voies aériennes et de l’hypoxémie. Il a été immédiatement intubé avec un fibroscope. Ses cordes vocales n’étaient pas œdémateuses même si les structures supraglottiques semblaient l’être. Les cordes vocales étaient écartées et leur mouvement était limité mais non paradoxal. La résection tumorale s’est bien déroulée sous intubation trachéale réussie et anesthésie générale. Comme prévu, la trachéotomie a été difficile à réaliser à la fin de l’opération. Le patient a bien toléré les interventions et s’est réveillé sans séquelles neurologiques.ConclusionUne limitation dynamique du débit d’air associé à l’anesthésie locale des voies aériennes supérieures peut conduire à une obstruction complète des voies respiratoires supérieures en cas d’ob-struction partielle préalable. La principale cause pourrait être la perte du tonus musculaire des voies respiratoires supérieures, exacerbée par l’inspiration profonde pendant les moments de panique.

Retrospective study on the need of intensive care unit admission after major head and neck surgery

Background: The present article aims to study the pattern and need of Intensive Care Unit admission after major head and neck operations.

Basal Cell Adenocarcinoma of the Salivary Gland

BACKGROUND: Basal cell adenocarcinoma of the parotid is rare and prone to recur. CASE: A 54-year-old woman had a history of a facial mass 12 years earlier that had been excised and was diagnosed as low grade adenocarcinoma of the parotid. Over the years, the patient had multiple local and lymph node recurrences. Histology of the excised local recurrent tumor showed basal cell adenocarcinoma, and FNAC of a separate recurrent nodule was performed. The aspirate showed moderate cellularity of basaloid cells with mildly pleomorphic nuclei, small nucleoli and occasional mitotic figures The cells were mostly single, but some formed clusters with a rosettelike pattern of tumor cells surrounding central eosinophilic globules. A second, less prominent population of smaller cells with darkstaining nuclei was also noted. The differential diagnosis included adenoid cystic carcinoma, polymorphous low grade adenocarcinoma, and basal cell and pleomorphic adenoma. CONCLUSION: The cytologic features of basal cell adenocarcinoma are not distinctive, but the presence of two cell populations with moderate pleomorphism and a rosettelike pattern with central, eosinophilic globules may assist with its differentiation from other salivary gland neoplasms.

Fibromatosis of the Head and Neck Region

OBJECTIVE: Five cases of head and neck fibromatosis were analyzed. The imaging and pathologic findings, surgical management, and clinical outcome were discussed. STUDY DESIGN AND SETTING: A retrospective study of 5 adult head and neck fibromatosis cases, evaluating long-term follow-up results of conservative treatment. RESULTS: The 5 patients (2 male and 3 female) ranged in age from 16 to 51 years. The lesion size ranged from 1 to 8 cm. Four cases had limited surgical resection; 1 case was followed only. One of the surgically treated cases had a recurrence that was irradiated. All patients were well for a follow-up period of 2 to 8 years. CONCLUSION: Aggressive excision of head and neck fibromatosis cannot be achieved easily. Vigilant follow-up with or without conservative surgical excision achieves good disease control. Low dose radiotherapy can be used for inoperable cases. SIGNIFICANCE: Judicious conservative treatment should be attempted for head and neck fibromatosis to achieve optimal functional preservation.

Burn injuries during paint thinner sniffing

Thinner sniffing is popular among school children in Asian countries because it is readily available at low cost. Besides its toxicity to major organs, thinner inhalation is associated with various burn accidents. Four teenagers were admitted to the Burns Unit of the Prince of Wales Hospital over the period of 1996-1997. They sustained 3-25% TBSA flame burn and two of them had inhalation injuries as a result of the ignition of a cigarette during thinner sniffing. None of them had evidence of thinner intoxication as shown by blood tests. In the management of their acute burn injuries, their hidden social and family problems were explored. With the cooperation of different disciplines, early psychosocial intervention was given and their behavioral and psychological disturbances were successfully managed.

Arteriovenous fistula induced by a peribulbar nerve block.

Arteriovenous fistula (AVF) of the head and neck region is an uncommon clinical condition that can be of congenital or acquired etiology. We report a case of AVF of the left supraorbital vessels that developed after a peribulbar nerve block was given for cataract surgery.

Mucoepidermoid carcinoma expleomorphic adenoma of the submandibular gland.

We described a rare case of carcinoma expleomorphic adenoma in which mucoepidermoid carcinoma arise from a previous incompletely excised pleomorphic adenoma of the submandibular gland. The tumor was surgically resected along with a modified radical neck dissection and postoperative radiotherapy. The patient remained disease free 3 years after the last operation. The pathology showed concurrent presence of Warthins tumor in the specimen. The concurrent presence of mucoepidermoid carcinoma, pleomorphic adenoma, and synchronous Warthins tumor make this case unique, and such a combination associated with the submandibular gland has not been documented in the literature before.

Reconstruction Challenge — Combined Use of Pectoralis Major and Gastric Pull-up Flaps for Massive Naso-oropharyngeal/Oesophageal Defects

Massive defects of the upper aerodigestive tract present a reconstructive challenge. We report a case in which a large defect of the naso-oropharyngeal and oesophagus was reconstructed with a combination of a gastric pull-up and a pectoralis major muscle flap. Postoperative function was good and survival was in excess of 16 months. The history of such reconstructions and possible alternative techniques are also discussed.

Nasogastric‐tube‐induced unilateral vocal cord palsy

Decontamination of medical equipment, the combination of cleaning, disinfecting and/or sterilisation is used to render a reusable item safe for further use. The alternative is single use followed by disposal. There is currently much variation in decontamination practice for laryngoscopes and the majority of hospitals do not have local guidelines [1]. General guidelines for the decontamination of medical equipment are available [2] but, as Ballin and McCluskey have pointed out, these do not specifically refer to laryngoscopes [3]. The Editor of this Journal has announced that the Association of Anaesthetists has formed a group to advise on appropriate decontamination procedures for laryngoscopes [3]. While we welcome this move, we write to warn that times are changing and that new guidance is urgently needed, not only in relation to laryngoscopes, but for all reusable airway equipment. We now face the presently unquantified risk of our equipment transmitting variant Creutzfeldt±Jakob disease (vCJD). The transmissible agent, an altered form of prion protein, has been isolated from tonsillar and lymphoreticular tissue of human victims [4]. It has also been found in the appendix removed from a patient who subsequently developed the disease [5]. The prion protein is remarkably resistant to common techniques of decontamination, with complete removal considered very difficult [6]. The Department of Health has recently announced that they will follow the advice of the Spongiform Encephalopathy Advisory Committee and introduce single-use instruments for tonsil surgery [7]. Tonsillectomy is currently one of the most frequently performed surgical procedures in the United Kingdom, amounting to about 20% of all ENT operations [8] and this announcement may have major implications for anaesthetic practice. The mainstay of our practice involves airway control, currently using reusable equipment such as laryngoscopes and laryngeal mask airways. Soiling of this equipment with blood is common during ENT procedures such as tonsillectomy. It has been suggested that laryngoscopes used on patients with suspected vCJD are destroyed [1]. In light of the recommendation of single-use surgical equipment for tonsil surgery, we believe that there is an urgent need for national guidance on best practice regarding the decontamination of all airway equipment and advice on the need for singleuse, disposable equipment.