Jason E. Cohn

Treatment of an obstructive, recurrent, syncytial myoepithelioma of the trachea with tracheal resection and reconstruction

Myoepithelioma is a rare occurrence in the trachea and respiratory tract with only 11 cases reported in the literature. We present a case report of a 10-year-old female who was found to have an anterior tracheal mass causing near total obstruction of the airway on bronchoscopy. Characteristics of the mass were consistent with syncytial myoepithelioma. The patient experienced multiple recurrences requiring tracheal resection with end-to-end reanastomosis. To date there have not been any reported cases of myoepithelioma of the trachea in a child and no reports of syncytial myoepithelioma in the trachea or respiratory tract.

The radial forearm free flap for scalp and forehead reconstruction: A 20-year experience

1.The ideal free flap for scalp reconstruction has adequate thickness, surface area, and vascular pedicle length 2.The simplest possible method of reconstruction should be considered in all patients while achieving adequate resection and a good functional outcome. 3.The radial forearm free flap provides excellent texture, color, pedicle length, and reliability. It provides for outstanding coverage of the forehead, temple, vertex, and occiput reconstruction. 4.In our experience, it is as hardy as the latissimus dorsi flap in withstanding postoperative adjuvant radiation, and confers multiple advantages over the latissimus dorsi free flap including faster healing times and shorter hospital stays. This article is protected by copyright. All rights reserved.

Identifying eustachian tube dysfunction prior to hyperbaric oxygen therapy: Who is at risk for intolerance?

PURPOSE Determine whether specific risk factors, symptoms and clinical examination findings are associated with hyperbaric oxygen therapy (HBOT) intolerance and subsequent tympanotomy tube placement. MATERIALS AND METHODS A retrospective case series with chart review was conducted from 2007 to 2016 of patients undergoing HBOT clearance at a tertiary care university hospital in an urban city. Eighty-one (n=81) patient charts were reviewed for risk factors, symptoms and clinical examination findings related to HBOT eustachian tube dysfunction and middle ear barotrauma. Relative risk was calculated for each variable to determine risk for HBOT intolerance and need for tympanotomy tube placement. Risk factor, symptom, physical examination and HBOT complication-susceptibility scores were calculated for each patient. RESULTS Mean risk factor, clinical and HBOT complication-susceptibility scores were significantly higher in patients who did not tolerate HBOT compared to patients who tolerated HBOT. Patients reporting a history of otitis media, tinnitus, and prior ear surgery were at a higher risk for HBOT intolerance. Patients reporting a history of pressure intolerance and prior ear surgery were more likely to undergo tympanotomy tube placement. Patients noted to have otologic findings prior to HBOT were at a higher risk for both HBOT intolerance and tympanotomy tube placement. CONCLUSIONS A thorough otolaryngological evaluation can potentially predict and identify patients at risk for HBOT intolerance and tympanotomy tube placement.

In Reference to “Informed Consent in Pediatric Otolaryngology: What Risks and Benefits Do Parents Recall?”

Recently Pianosi et al evaluated parental recall of surgical risks and benefits in pediatric otolaryngology while also assessing factors that may influence this recall. They were able to identify that parents were more likely to recall benefits rather than risks associated with surgery. One limitation that was mentioned by the authors was the homogeneous study population. The population consisted mostly of relatively educated Caucasian Canadian parents. It is evident that this study population is not representative of the entire pediatric otolaryngology patient population. We would be interested in seeing a similar study conducted at our institution, which has a different population with a variety of ethnicities, races, and education levels. An important point to consider regarding this paper is the impact that parental recall has on health care outcomes and costs. Pediatric tonsillectomy can result in significant patient morbidity with visits to health care providers for dehydration, fever, hemorrhage, poorly controlled pain, gastrointestinal discomfort (ie, nausea/vomiting), and respiratory complications. The mean emergency room cost for a postoperative adenotonsillectomy patient was

Telangiectasias in Osler-Weber-Rendu Syndrome

1420. Another study identified particular risk factors for unplanned return visits after adenotonsillectomy. These risk populations included children with increased severity of illness, those insured with Medicaid, and children of Hispanic ethnicity. This reiterates the point that a different population needs to be studied. It would be helpful to study whether proper informed consent translates to more favorable health care outcomes and costs. For example, one could hypothesize that more effective informed consent will result in fewer visits to the emergency department. Furthermore, it could be determined how cost-effective a more formidable informed consent process would be. Proper, well-executed informed consent can be costly and time-consuming due to extensive verbal counseling, as well as counseling with pamphlets and multimedia devices. However, the benefits of properly consenting parents in such crucial situations may outweigh these costs. We believe that the paper by Pianosi et al has uncovered only the tip of the iceberg regarding informed parental consent. The pediatric surgical consent process is a unique phenomenon that still needs to be perfected and studied further.

In reference to “Stomal maturation does not increase the rate of tracheocutaneous fistulas”

A 72-year-old woman presented with recurrent epistaxis and symptomatic anemia periodically for the past 3 years. The epistaxis was attributed to apixiban; however, she had recurrent epistaxis prior to medication use. She also reported bright red blood per rectum, which was attributed to hemorrhoids and fissures. Upon examination, mucosal bleeding was observed from both sides of the anterior nasal septum. However, no discrete telangiectasias were noted. Epistaxis was managed with cauterization and absorbable nasal packing. Further examination of the face revealed a plethora of telangiectasias on the malar surfaces, chin, tongue, and lips (Figure 1). Telangiectasias were also seen on the fingers (Figure 2). Upper endoscopy was performed, which revealed 2 nonbleeding angioectasias in the stomach, which were treated with argon plasma coagulation. Based on the evidence collected, the diagnosis of Osler-Weber-Rendu syndrome (aka hereditary hemorrhagic telangiectasia [HHT]) was made. The patient was scheduled for additional outpatient workup to further support our diagnosis. This submission has received exemption from the Main Line Hospitals Institutional Review Board.

A Pediatric Patient With an Orbital Respiratory Epithelial Cyst

Levi et al. recently published an article discussing their 10-year experience with pediatric tracheostomy, with attention to the rates of tracheocutaneous fistula (TCF) with and without stomal maturation. They reported similar rates of TCF between both groups. When you examine the other literature, certain studies concluded that stomal maturation had no effect on TCF rates, whereas others did. Higher TCF rates also have been linked to longer cannulation periods and younger tracheostomy age. Additionally, younger patients demonstrated higher rates of suprastomal granulation tissue, tracheitis, and additional surgical procedures for a tracheostomy-related complication. Given the surgical technique of stomal maturation, one may expect a higher rate of TCF in this group despite the current literature. Given the need for further investigation, we were happy to read the article by Levi et al. We similarly were interested in studying this controversial topic at our institution and decided to vet our own data to contribute in this debate. We gathered data from our institution, a tertiary care pediatric hospital, between 2011 and 2016. Of the 73 patients who were decannulated, 30 (41.1%) had undergone stomal maturation, whereas 43 (58.9%) had not. Although a higher rate of TCF was observed with stomal maturation, it was not statistically significant (P 5 0.351). Additionally, there were no differences between the two groups for suprastomal granulation tissue, tracheitis, glottic web, and subglottic stenosis (P 5 0.250, 0.729, 0.709, and 0.404, respectively). We also found that age at tracheostomy, ethnicity, cannulation time, and type and size of tracheostomy tube did not significantly affect TCF rates (P 5 0.071, 0.485, 0.149, 0.708, and 0.502, respectively). Given our quick, snapshot analysis in conjunction with already published results, we believe that this debate somewhat can be laid to rest. It appears that stomal maturation does not result in higher rates of TCF. This is an important conclusion because stomal maturation provides favorable outcomes, such as lower rates of accidental decannulation and stomal granulation tissue. However, our matured stoma cohort did not have a significantly lower rate of granulation tissue. Additionally, we did not observe higher TCF rates in relation to patient age, ethnicity, cannulation time, and type and size of tracheostomy tube. We recommend that institutions still should keep record of tracheostomy-related complications and publish this data. However, the decision to perform stomal maturation will continue to be based on surgeon preferences and patient needs.

Cranioplasty Using a Mixture of Biologic and Nonbiologic Agents

Abstract Respiratory epithelial cysts are rare orbital cysts that can arise secondary to choristomatous rests of respiratory epithelium. Approximately 15 congenital cases have been described in the literature, making it a rare disease entity. We present a case of a 14-month-old Middle Eastern male with a right infraorbital respiratory epithelial cyst. Magnetic resonance imaging of the brain and orbits revealed a right infraorbital cyst hyperintense on T1-weighted images and followed fluid density on T2-weighted images. This cyst was noted to displace the globe superiorly and inferior rectus muscle laterally. This cyst was excised using a transconjunctival approach. Histologically, the cyst wall was lined by ciliated columnar cells with interspersed mucus-containing cells and ciliated transitional epithelium was present, establishing the diagnosis of respiratory epithelial cyst. To our knowledge, this is the youngest patient with a respiratory epithelial cyst of the orbit reported in the literature.

Novel case examples of the submental island flap in pediatric head and neck reconstruction

Importance A surgeon faces challenges with cranioplasty techniques to achieve a successful result with relatively few complications. Objective To describe a unique technique for incorporating both biologic autologous bone and nonbiologic allograft materials for defect coverage in cranioplasty with favorable outcomes and low occurrence of complications. Design, Setting, and Participants A retrospective medical records review of all 26 patients who underwent primary cranioplasty procedure with a modified technique between January 2011 and December 2015 at a high-volume head and neck oncologic reconstructive practice was conducted; data analysis was also performed during that period. After several years of experience with traditional cranioplasty maneuvers, the modified technique has evolved to incorporate both autologous bone grafts and alloplastic materials in the formation of a shapeable on-lay material. Data were collected on demographics, need for cranioplasty, materials used, outcomes, and risk factors. Main Outcomes and Measures Rates of infection, hematoma, flap loss or resorption, cerebrospinal fluid leak, hardware exposure or malfunction, and repeated reconstruction. Results Of the 26 patients, 21 (81%) were men; mean (SD) age was 65.8 (14.3) years. Eight (31%) patients had a history of diabetes, 4 (15%) patients were receiving immunosuppressive drugs, and 5 (19%) patients were active smokers at the time of surgery. Neoplasia was the most common cause of the calvarial defect seen, responsible for 20 of 28 (71%) operative defects and necessitated procedures. All but 1 patient achieved successful mineralization following primary cranioplasty with the modified technique; this success was verified based on physical examination and follow-up imaging. Complications were rare and involved only 3 patients who developed postoperative infection; 1 (4%) of these patients lost the integrity of the cranioplasty. Thus, the rate of infection was 11% and loss rate was 4%. Preoperative and postoperative radiotherapy appeared to have no bearing on graft survival. Conclusions and Relevance The results using a unique technique for incorporating both biologic autologous bone and nonbiologic allograft materials for defect coverage in cranioplasty are favorable, with satisfactory aesthetic outcomes and limited postoperative complications. Level of Evidence 4.

Myoepithelioma of the Parotid Gland: A Case Report with Review of the Literature and Classic Histopathology

The submental island flap was first described as a tool for facial reconstruction after tumor resection. It is now widely used for reconstructing numerous structures in the head and neck region of adults. Pediatric surgical reconstruction is a challenging task that continues to evolve over time. We describe two novel uses of this flap in the pediatric population. The submental island flap is an excellent option for reconstruction in pediatrics given its ease of elevation, excellent cosmetic outcomes, and low donor site morbidity.