Maria Beatriz Nogueira Pascoal

Prevalência dos sintomas otológicos na desordem temperomandibular: estudo de 126 casos

Introducao: A presenca de sintomas otologicos associados a desordem temporomandibular (DTM) e discutida ha seis decadas; entretanto, sua etiologia ainda permanece obscura. Forma de estudo: Prospectivo clinico randomizado. Objetivo: Neste estudo foram avaliadas a prevalencia de sintomas otologicos na DTM, sua correlacao com a dor muscular e a ausencia de dentes posteriores. Material e Metodo: Foram avaliados 126 pacientes portadores de DTM, atraves de questionario subjetivo dos sintomas, palpacao dos musculos de mastigacao, temporal, masseter, pterigoideo lateral, pterigoideo medial, digastrico, tendao do musculo temporal e dos musculos esternocleidomastoideo e trapezio. Foram feitas radiografias panorâmica e transcraniana e modelos de gesso das arcadas superior e inferior dos pacientes. Os dados obtidos foram analisados atraves do Teste Exato de Fisher, com percentil de significância menor que 0,05. Resultados: Houve presenca de sintomas otologicos em 80% dos pacientes, sendo que 50% apresentavam dor referida em ouvido; 52%, plenitude auricular; 50%, tinitus; 34%, tontura; 9%, sensacao de vertigem; e 10% relataram hipoacusia. O musculo pterigoideo lateral foi o musculo mais sensivel em 94% dos pacientes, seguido do musculo temporal em 69%, masseter em 62%, digastrico em 60%, pterigoideo medial em 50%, tendao do musculo temporal e esternocleidomastoideo em 49% e trapezio em 42% dos pacientes. Houve significância para dor muscular, e a presenca de sintomas otologicos, nos musculos masseter e esternocleidomastoideo. Os sintomas tinitus, plenitude auricular e dor referida em ouvido apresentaram alta correlacao de significância entre si. Nao houve significância para a ausencia de denticao e sintomas otologicos. Conclusao: 1) Dor referida em ouvido, tinitus, plenitude auricular e tontura foram prevalentes; 2) os sintomas otologicos presentes na DTM podem estar relacionados com a dor muscular em masseter e esternocleidomastoideo; 3) nao houve correlacao entre os sintomas otologicos e a ausencia de dentes posteriores.

Single transverse extended incision for radical neck dissection

OBJECTIVE to assess the efficacy of the single transverse extended cervical incision in radical neck dissection. METHOD we conducted a prospective study, from January 2008 to January 2009, with 18 patients undergoing surgical treatment of malignant tumors of the upper aero-digestive tract. The primary lesion was located in the oral cavity in eight cases, in the oropharynx in three, in the hypopharynx in three, in the larynx in two, in the maxillary sinus, and in one case, the primary injury was hidden. There were 29 neck dissections, eight bilateral and 10 unilateral (26 radical and three selective). Staging revealed nine patients with T4 tumor, one T3, six T2, one T1 and one Tx. Five patients were N0, nine N2b, one N2c and three N3. The average number of dissected lymph nodes was 34.25. We performed the neck dissection through a single incision located in the middle neck, coincident with the skinfold, with a length of about 2 to 3 cm behind the anterior edge of the trapezius muscle and 3 to 4 cm from the midline for the unilateral neck dissections. RESULTS as complications, there were myocutaneous flap necrosis in one patient with prior radiation therapy, one lymphatic fistula, one dehiscence of the tracheostomy, one cervical abscess, one salivary fistula and one suture dehiscence. CONCLUSIONS the single extended incision provides adequate exposure of the neck structures, without compromising surgical time, even in bilateral dissections. It does not compromise the resection of all cervical lymph nodes; it has excellent aesthetic and functional results and is easily associated with other approaches to resection of the primary tumor. OBJETIVO verificar a eficácia da incisão cervical única, transversa e estendida, para o esvaziamento cervical radical. MÉTODO estudo prospectivo, de janeiro de 2008 a janeiro de 2009, de 18 pacientes submetidos a tratamento cirúrgico de tumores malignos da via aero-digestiva superior. A lesão primária se situava na cavidade oral em oito casos, na orofaringe em três, no seio piriforme em três, na laringe em dois, no seio maxilar em um e em um caso a lesão primária era oculta. Houve 29 esvaziamentos, sendo oito bilaterais e 10 unilaterais (26 radicais e três seletivos). O estadiamento revelou nove pacientes com tumor T4, um T3, seis T2, um T1 e um Tx. Cinco pacientes eram N0, nove N2b, um N2c e três N3. A média de linfonodos dissecados foi de 34,25. O esvaziamento cervical foi realizado por meio de uma única incisão localizada no terço médio do pescoço, coincidente com dobra cutânea, com extensão de cerca de 2 a 3 cm para trás da borda anterior do músculo trapézio e 3 a 4 cm da linha média para os esvaziamentos cervicais unilaterais. RESULTADOS como complicações houve necrose de retalho miocutâneo em um paciente com radioterapia prévia, uma fistula linfática, uma deiscência do traqueostoma, um abscesso cervical, uma fístula salivar e uma deiscência de sutura. CONCLUSÕES a incisão única e estendida proporciona exposição adequada das estruturas do pescoço, sem comprometer o tempo cirúrgico, mesmo em esvaziamentos bilaterais. Não compromete a ressecção de todos os linfonodos cervicais, apresenta excelentes resultados estéticos e funcionais e é facilmente associada com outras abordagens para ressecção do tumor primário.

Microsurgical head and neck reconstruction: retrospective analysis of 30 free flaps

Introduction: Reconstructive head and neck surgery is a challenge for the plastic surgeon and requires a large technical arsenal, in which microsurgery plays an essential role. The objective to retrospectively analyze microsurgical head and neck reconstruction performed at the Pontifical Catholic University of Campinas over a period of 2 years. Methods: The medical charts of patients who underwent microsurgical reconstruction after head and neck surgery between June 2014 and October 2016 were reviewed to determine which flap was used, the length of the vascular pedicle, recipient vessels, microvascular anastomoses, surgical time, length of hospital stay, complications, and success rate. Results: Thirty microsurgical reconstructions were performed using 3 types of flaps: anterolateral thigh (n = 15), antebrachial radial (n = 8), and fibula (n = 7). Recipient vessels: facial artery (70%) and facial vein (50%), as 92.4% of microvascular anastomoses were end-to-end. The average operative time was 10.1 hours. The average length of hospital stay was 10.7 days. Two flaps were lost due to arterial thrombosis, resulting in a success rate of 93.3%. Conclusions: The microsurgical reconstructions were effective for the repair of complex defects as well as to partially restore the shape and function of the affected tissues. Complications were observed in less than 50% of the cases, although these presented with significant morbidity. The success rate was similar to that reported by major centers of reconstructive microsurgery. The learning curve is long, although it tends to improve with staff training and the acquisition of experience over time. ■ ABSTRACT

ASSESSMENT OF MECHANICAL AND MANUAL SUTURE IN THE SURGICAL TREATMENT OF THE PHARYNGOESOPHAGEAL DIVERTICULUM

Background: The occurrence of the pharyngoesophageal, or Zenker diverticulum is not frequent in the national scenario, and the technique of the diverticulectomy with cricomyotomy in medium and great dimension diverticula is still the most indicated. Because the resection of the diverticulum requires the suture of the pharynx, dehiscence can occur, thereafter delaying swallowing. Hence, the idea is to accomplish this surgical procedure, comparing the manual and mechanical suture, in order to evaluate the real benefit of the mechanical technique. Aim: To evaluate the results of the pharyngoesophageal diverticulectomy with cricomyotomy using manual and mechanical suture with regard to local and systemic complications. Method: Fifty-seven patients with pharyngoesophageal diverticula diagnosed through high digestive endoscopy and pharyngeal esophagogram were studied. The applied surgical technique was diverticulectomy with myotomy of the cricopharyngeal muscle, done in 24 patients (42.2%) the mechanical suture (group A) with the mechanical linear suture device and in 33 (57.8%) a manual closure of the pharynx (group B). Results: In the postoperative period, one patient of group A (4.1%) presented fistula caused by dehiscence of the pharyngeal suture, and three of group B (15.1%) presented the same complication, with a good outcome using a conservative treatment. In the same group, three patients (9.0%) presented stenosis of the suture of the pharynx, with good outcome and with endoscopic dilatations, and no patient from group A presented such complication. Lung infection was present in five patients, being two (8.3%) of group A and three (9.0%) on B, having good outcomes after specific treatment. In the late review, done with 43 patients (94.4%) of group A and 22 (88.0%) on B, the patients declared to be pleased with the surgical procedure, because they were able to regain normal swallowing. Conclusion: The diverticulectomy with myotomy and pharyngeal closure using mechanical suture was proven appropriate, for having restored regular swallowing in most of the patients, and the mechanical closure of the pharynx proved to be more effective in comparison to the manual one, because it provided a lower index of local post-surgical complications.

Case Report: Recurrent Thyroid Abscess Secondary to the Fistula of Pyriform Recess

Case Report: Recurrent Thyroid Abscess Secondary to the Fistula of Pyriform Recess Background: Acute suppurative thyroiditis is a rare event among the thyroid diseases, representing from 0, 1 to 0, 7% of the possible scenarios that can affect this organ. Pyriform recess fistula is the principal cause in children, presenting itself with an infectious process which is usually unilateral and recurrent. The authors report a case of a continuing thyroidal abscess due to pyriform recess fistula in a 16 year old patient, which is later than evidence describes. Clinical Case: In 2009, patient, 14 years old caucasian male, present hyperemia and cervical edema, on the left side and toxiinfectious signs. The ultrasound showed dense collection at the topography of the left thyroid lobe, and the diagnosis was settled in suppurative thyroiditis; treatment was conducted accordingly, through surgical drainage and antibiotics. The infectious process recurred in the following years, and further investigation of the trigger factor showed that there was a fistulous route of the left pyriform recess, setting a fourth brachial arch persistence, leading to a left thyroidal lobectomy and resection of the fistulous route. Discussion: as the main cause of suppurative thyroiditis in childhood, the pyriform recess fistula presents as an acute infectious process in an initial stage, and complementary exams will only show the consequences of this presentation, which are local collection and edema of adjacent structures, located in this case specifically more on the left side than the right. In the subacute stage of the disease, the diagnosis is determined through the pharyngo-esophagogram, which will reveal the fistulous tract, due to its contrast filling. The resection of the fistulous tract is the chosen surgical procedure, and it can partially resect the thyroid lobe or not. Conclusion: the authors conclude that the pyriform sinus fistula is a rare disease and the leading cause of childhood suppurative thyroiditis as shown in the literature review, and therefore should be investigated in cases of suppurative thyroiditis and should be treated with a thyroidectomy with resection of the tract.