Jack Hsu

Management of respiratory compromise caused by cervical osteophytes : a case report and review of the literature

BACKGROUND CONTEXT Diffuse idiopathic skeletal hyperostosis (DISH) is a common condition in the aging spine. DISH is associated with large anterior osteophytes of the cervical spine, which can cause complications by compressing adjoining structures. Dysphagia is reported in up to 28% of patients, but respiratory compromise is rare. There have been no published recommendations for treatment. PURPOSE To report that resection of cervical osteophytes, without cervical fusion, can be successful in the treatment of severe respiratory distress. STUDY DESIGN This report describes the management of a patient with DISH and severe respiratory distress resulting from large anterior cervical osteophytes. METHODS A team approach was used with collaboration between the orthopedic spine surgeons and the otolaryngologists. RESULTS This patient was found to have compression of her posterior pharyngeal wall by the osteophytes. Tracheostomy was required for the management of the airway. The patient was dependent on the tracheostomy until the osteophytes were resected. The patient was then able to breathe normally. Treatment recommendations were developed based on this case of osteophyte-induced respiratory compromise as well as the previously published accounts of osteophyte-induced dysphagia. CONCLUSIONS Airway obstruction resulting from DISH can be treated according to the same principles as dysphagia resulting from DISH: surgical excision of osteophytes if conservative support fails.

Radiotherapy for the clinically negative neck in supraglottic laryngeal cancer.

PURPOSEThe supraglottic larynx has rich lymphatic drainage, resulting in a high incidence of occult cervical metastases, and the optimal treatment of the clinically uninvolved neck in supraglottic laryngeal cancer remains controversial. Selected retrospective series report a greater than 20% regional failure after treatment by radiotherapy alone, and some investigators recommend routine prophylactic neck dissection. We report on our series of patients who received radiotherapy as sole treatment to the clinically negative neck, either to the bilateral neck for NO disease or to the contralateral neck for ipsilateral lymphatic involvement. PATIENTS AND METHODSBetween 1971 and 1998, 150 patients with supraglottic laryngeal cancer received radiotherapy alone to the clinically negative neck. Fifty-two patients had ipsilateral lymph node metastases (N1 = 16, N2a = 12, N2b = 20, N3 = 4), and 98 patients had no clinical nodal involvement. The primary site (T1/T2 = 74, T3/T4 = 76) was treated with radiotherapy (N = 91) or laryngectomy plus radiotherapy (N = 59). Neck dissection was performed on the involved neck in 36/52 node-positive patients for either multiple involved nodes (N = 20) or size > 3 cm (N = 16). Radiotherapy was delivered in standard fractionation and field arrangement. The median dose to the clinically negative neck was 5000 cGy (range: 4860–6000 cGy). RESULTSWith a median follow-up of 48 months, the clinically negative neck was the first site of failure in 3.3% of patients. The contralateral neck remained disease free in all patients. Five failures occurred in the NO neck, and the median time to recurrence was 12 months (range: 5–30 months). Salvage therapy was neck dissection for the NO neck failures. The 5-year locoregional control, disease-specific survival, and overall survival were 69%, 74%, and 61%, respectively. DISCUSSIONOur data support the use of radiotherapy as a prophylactic treatment for the clinically negative neck. Tumor control in the clinically uninvolved cervical lymphatics is comparable to that in surgical series, suggesting that routine neck dissection may not be necessary. Prospective trials are necessary to further define the role of radiotherapy in this patient population.

Gastric choristoma of the hypopharynx presenting in an infant: a case report and review of the literature

Normal gastric mucosa has been found throughout the alimentary tract, ranging from scattered rests of cells to well formed mucosa with submucosal smooth muscle. Many terms have been applied to these collections; however, the term gastric choristoma seems most appropriate. We present a case of hypopharyngeal gastric choristoma presenting with dysphagia and frequent emesis. Our literature review reveals that this is the seventh reported case of gastric choristoma found in the hypopharynx, and the first to present in an infant in the absence of respiratory distress. Excision or CO(2) laser ablation is useful for symptom relief; however, complete removal often requires multiple attempts.

Central condylar displacement with brain abscess from chronic mandibular osteomyelitis

In this case report, we describe a unique long‐term complication from undiagnosed mandibular osteomyelitis. A 53‐year‐old female who underwent a dental extraction complicated by chronic postoperative odontogenic infection and cutaneous parotid fistula formation 2 years earlier presented with acute mental status change, gradual unilateral facial nerve palsy (House‐Brackmann score V), and nontraumatic dislocation of the condylar head into the middle cranial fossa. The patients chronic mandibular osteomyelitis led to glenoid fossa erosion, middle cranial fossa penetration, and temporal lobe abscess formation. A combined middle cranial fossa approach through a burr hole placed in the squamous temporal bone near the zygomatic root and intraoral mandibular approach to ipsilateral condylar head was performed to complete partial mandibulectomy, including condylectomy. The patient was treated with 6 weeks of meropenem perioperatively. Four months after the surgery, the patient had complete resolution of skull base osteomyelitis, parotid fistula, and neurologic deficits and full recovery of facial nerve function (House‐Brackmann score of I)

Long-term survival in a patient with metastatic oropharynx squamous cell carcinoma to liver

The traditionally held view is that the patients with metastatic disease cannot be cured and should be treated palliatively as it was believed that the patients will eventually succumb to the disease progression due to lack of effective treatments for systemic disease. In this article, we report our experience in a patient who was diagnosed with metastatic oropharynx squamous cell carcinoma to the liver, who has now survived five years since the original diagnosis, and is three years disease free. This case report illustrates the curative potential in selected patients with limited burden of metastatic disease with aggressive local therapy to all known sites of disease. It underscores the importance of imaging modalities in monitoring progression of disease, and most importantly illustrates the importance of multidisciplinary care for oncology patients.