P. Daniel Knott

Mesenchymal Chondrosarcoma of the Sinonasal Tract: A Clinicopathological Study of 13 Cases With a Review of the Literature†

Objectives/Hypothesis Mesenchymal chondrosarcoma of the sinonasal tract is a rare, malignant tumor of extraskeletal origin. Isolated cases have been reported in the English literature, with no large series evaluating the clinicopathological aspects of these tumors.

Outcomes of vascularized bone graft reconstruction of the mandible in bisphosphonate-related osteonecrosis of the jaws†‡

To describe the clinical entity and therapeutic challenges of bisphosphonate‐related osteonecrosis of the jaws (BRONJ). The use of vascularized bone grafts for reconstruction of the mandible in extensive BRONJ is proposed.

The impact of fiducial distribution on headset-based registration in image-guided sinus surgery

OBJECTIVE: The objective of this study was to assess registration error due to fiducial configuration for the ENT headsets for the CBYON Suite (CBYON, Mountain View, CA) and InstaTrak (GEMS Navigation and Visualization, Waukesha, WI). STUDY DESIGN: Axial CT scans (1-mm slice thickness) were obtained of for 24 cadaveric heads using the CBYON headset and for 23 cadaveric heads using the GEMS headset. The CBYON and GEMS NAV software were used to calculate the fiducial registration error (FRE). Fiducial localization error (FLE) was estimated from FRE. Theoretical target registration error (TRE) was calculated at 11 targets. RESULTS: The FRE for CBYON and GEMS NAV was 0.69 mm and 0.27 mm, respectively. The theoretical TRE for CBYON and GEMS NAV was 0.41 mm and 0.30 mm, respectively. The theoretical TRE was greater at targets posterior in the sinus cavities. CONCLUSION: Theoretical TRE values for both ENT headsets are less than clinically observed TRE. Clinically observed TRE is likely due to repositioning accuracy. EBM rating: B-2.

A Comparison of Dermabond Tissue Adhesive and Sutures in the Primary Repair of the Congenital Cleft Lip

Objective:To compare the long-term cosmesis of Dermabond (octyl-2-cyanoacrylate) and traditional skin sutures among patients undergoing primary cleft lip ± palate repair. Materials and Methods:Eleven patients underwent photographic analysis following primary cleft lip ± palate repair, including the use of Dermabond. Eleven age-matched controls who underwent cleft lip ± palate repair with traditional suture closure served as controls. Cosmesis was assessed by 3 blinded plastic surgeons using a visual analogue scale (VAS) and the Hollander Wound Evaluation Scale (HWES). Results:The overall mean VAS score for the patients treated with and without Dermabond was 70.0 (SD, 9.5) and 68.3 (SD, 13.4), respectively (P = 0.46). The overall mean HWES score for the patients treated with and without Dermabond was 1.7 (SD 1.7) (P = 0.92). Conclusions:Dermabond tissue adhesive offers equivalent mature wound cosmesis as traditional suture closure in the repair of the congenital cleft lip ± palate.

Contour and Paired-Point Registration in a Model for Image-Guided Surgery†

Objectives/Hypothesis: This study assesses target registration error (TRE) of contour‐based registration (CBR) and paired‐point registration (PPR) for endoscopic sinus surgery.

Simultaneous Anterolateral Thigh Flap and Temporalis Tendon Transfer to Optimize Facial Form and Function After Radical Parotidectomy

Background Extirpation of aggressive parotid or cutaneous facial tumors often involves facial nerve sacrifice and the creation of a large soft-tissue defect. We describe a method for single-stage reconstruction during radical parotidectomy to restore facial form and function without additional morbidity. Methods We conducted a review of immediate reconstruction/reanimation of radical parotidectomy defects with the use of anterolateral thigh (ALT) fat and fascia flaps for facial contouring, orthodromic temporalis tendon transfer (OTTT), cable grafting of the facial nerve, and fascia lata lower lip suspension. Results Five patients (mean age, 67.4 years) underwent extirpation of malignant tumors with facial nerve sacrifice resulting in large soft-tissue deficits. All patients had ALT free tissue transfer to correct facial contour defects and OTTT to restore facial form and function. Four patients underwent cable grafting of facial nerve branches. Branches of the motor nerve to the vastus lateralis harvested from the ALT surgical site were used for cable nerve grafting in 3 patients. Fascia lata from the same ALT harvest site was used for lower lip suspension to the OTTT in 4 patients. There were no donor site complications. All patients achieved midfacial symmetry at rest, oral competence with dynamic corner-of-mouth movement, and full eye closure. Conclusions Tumor clearance, symmetric facial appearance, as well as dynamic facial rehabilitation were accomplished in a single-stage procedure using the method described herein. The ALT free flap provides versatile options for soft-tissue defects as well as access to motor nerves optimal for grafting without additional morbidity. Patients undergoing extirpation of malignant tumors requiring facial nerve sacrifice can undergo immediate free tissue contour reconstruction and facial reanimation procedures with no additional morbidity.

Minimally invasive endoscopic resection of sinonasal undifferentiated carcinoma

PURPOSE The purpose of the study was to review a single-institution experience with endoscopic resection of sinonasal undifferentiated carcinoma (SNUC). MATERIALS AND METHODS Thirteen patients underwent treatment of SNUC between January 2002 and July 2009. Retrospective data were collected including demographics, tumor characteristics, surgical strategy, adjuvant therapies, local and regional recurrence, distant metastasis, overall survival, and disease-free survival. RESULTS The mean age was 51.8 years. The most common tumor stage at presentation was T4 (92%). Seven patients (53%) were treated with minimally invasive endoscopic resection (MIER) with negative intraoperative margins. Endoscopic anterior skull base resection was performed in 5 patients, and endoscopic-assisted bifrontal craniotomy was performed in 1 patient to clear the superior tumor margin. Six patients received pre- or postoperative chemoradiation. One patient underwent palliative chemoradiation, and one patient underwent open craniofacial resection. In the MIER group, simultaneous local and regional recurrence was observed in 1 patient (14%) after 30 months. Distant metastases were observed in 2 other patients (28%) without local or regional recurrence. All 3 patients with recurrences died of their disease. The remaining 4 patients were clinically, endoscopically, and radiographically free of disease, resulting in overall and disease-free survival rates of 57% with mean follow-up of 32.3 months. CONCLUSIONS These preliminary data suggest a potential role for MIER in the comprehensive management algorithm of SNUC in appropriately selected patients. Patient outcomes including local and regional recurrence, distant metastases, and overall and disease-free survival were comparable to a treatment strategy using traditional craniofacial resection. LEVEL OF EVIDENCE 2b.

A 12-Year Perspective on the Worldʼs First Total Laryngeal Transplant

On January 4, 1998, the world’s first composite head and neck transplantation, including the complete larynx, thyroid gland, parathyroid glands, five tracheal rings, and 75% of the pharynx, was performed after extensive animal model testing (1, 2). To our knowledge, this effort represents the longest continuous survival of a first organ transplant, when an immunosuppressive regimen was used. This report presents a comprehensive 12-year review of the insights obtained through the treatment of this unique individual.

Orbitomaxillary reconstruction using the layered fibula osteocutaneous flap.

OBJECTIVE To describe a surgical technique for total palatomaxillary and orbital reconstruction using a fibula osteocutaneous free flap in a layered fashion. METHODS Case series from a tertiary care facial plastic and reconstructive surgical practice including patients with postextirpative Brown 3a and 3b orbitopalatomaxillary defects undergoing immediate microvascular reconstruction. Application of the layered fibula free flap to composite maxillary defects permits single-stage, optimal reconstruction of contiguous orbitomaxillary defects, reconstitution of midface 3-dimensional contour, and restoration of the anterior alveolar arch with robust bone, thereby providing for potential sequential dental rehabilitation with osseointegrated implants. RESULTS This technique demonstrates excellent long-term symmetry, support, function, and aesthetic contour. Although patients may need minor, adjunctive procedures, this technique is flexible in design and offers reliable outcomes with a minimum of morbidity. CONCLUSION The fibula osteocutaneous free flap, because of its design flexibility and ability to provide structural support, is an excellent reconstructive option for total maxillary defects, including those that involve the orbit.

Pulsed immunosuppression with everolimus and anti-αβ T-cell receptor : Laryngeal allograft preservation at six months

Objectives: Laryngeal transplantation can restore the voice in patients who have undergone laryngectomy. However, the prospect of lifelong immunosuppression is a drawback to this procedure. We present data from a study aimed at minimizing the need for immunosuppression while maintaining graft viability through a novel pulsed-dosing protocol. Methods: Larynges were transplanted from Lewis–brown Norway (RT11+n, F1) rats to Lewis (RT11) recipients. All recipients received 7 days of treatment with everolimus and mouse anti-rat αβ T-cell receptor (anti-TCR) monoclonal antibodies beginning the day before transplantation. At 90 days after transplantation, all recipients received a pulse of the same treatment combination for 5 days. From 90 to 180 days after transplantation, the rats received no treatment (group 1, n = 5), 2.5 mg/kg everolimus per day (group 2, n = 5), or 1.0 mg/kg everolimus per day (group 3, n = 5). Results: Histologic analysis of rats that received everolimus as pulse therapy evidenced no signs of rejection, whereas animals that were untreated after 90 days had normal to mild chronic rejection. T-cell reconstitution occurred 65 days after perioperative immunosuppressive treatment, but less rapidly after pulse therapy. Also, peripheral chimerism was generated in all 3 groups. Conclusions: In the rat laryngeal transplantation model, short-term perioperative therapy with everolimus and anti-TCR followed by pulsing is a viable alternative to the concerns associated with continuous, lifelong immunosuppression.