Sanjay M. Athavale

Complications of alloderm and dermamatrix for parotidectomy reconstruction

AlloDerm and DermaMatrix are 2 acellular dermal implants currently used by reconstructive surgeons at our institution for reconstruction of parotidectomy defects. We looked at the postoperative complication rates following subcutaneous implantation of these acellular dermal implants for parotid bed reconstruction.

Osteochondroma of the skull base.

Osteochondroma, or osteocartilaginous exostosis, is the most common skeletal neoplasm. The cartilagecapped subperiosteal bone projection accounts for 20% to 50% of benign bone tumors and 10% to 15% of all bone tumors. The tumor is a benign, well-demarcated, sessile or stalked subperiosteal bone projection that is partially or totally topped by a bluish-white hyaline cartilage cap. It is histologically and behaviorally distinct from other cartilaginous tumors such as enchondromas, osteosarcomas, and chondrosarcomas. The most common symptom of an osteochondroma is a painless bump in the proximity of a joint. However, more serious presentations include symptoms related to compression of nerves, blood vessels, or tendinous insertions, which require surgical excision rather than periodic screening. A 38-year-old man presented to Tata Memorial Hospital, Mumbai, India, with a 9-month history of discomfort in the region of his hard palate, tinnitus, and persistent right-ear fullness. The patient denied any epistaxis, oral bleeding, dysphagia, or trismus. Otologic examination revealed a right serous middle ear effusion. Physical examination of his oral cavity revealed a submucosal bulging mass located at the junction of the hard and soft palates just posterior to the right upper alveolar margin. The remaining head and neck examination including cranial nerves was noncontributory. Coronal and axial CT scans of the head and neck revealed a 6 5 cm bony lesion in the right parapharyngeal space (Figs 1 and 2). There was distortion of the nasopharynx with scalloping of the medial aspect of the middle cranial fossa floor and erosion of the right lateral pterygoid plate. However, there was no intracranial invasion. The patient underwent a mandibular swing for access to the right parapharyngeal space. The tumor was then isolated and found to have its bony attachment on the skull base. The mandibular condyle and coronoid were completely free of tumor. The tumor was removed en bloc (Fig 3), and histological analysis was completed.

Perineural extension to the skull base from early cutaneous malignancies of the midface.

Objective To document the clinical progression of four patients with a past history of complete removal of early midface cutaneous malignancies that presented years later with isolated recurrence along the distribution of the infraorbital nerve, and to discuss the diagnostic role of early imaging to identify perineural invasion. Study Design The study is a retrospective chart review, review of radiographic findings, and review of the literature. Results The authors report four cases of isolated perineural invasion along the infraorbital nerve resulting from previously excised cutaneous malignancies. Conclusions Pain followed by anesthesia in the distribution of second division of the trigeminal nerve should alert the practitioner about possible perineural recurrence that may require imaging and open exploration to establish the diagnosis.

Tumors of the cervical sympathetic chain--diagnosis and management.

Tumors originating from the cervical sympathetic chain are uncommon but important entities in the differential diagnosis of parapharyngeal space masses.

An Alternative Approach for Secondary Tracheoesophageal Puncture in the Difficult Laryngectomy Neck

INTRODUCTION Restoration of speech is the ultimate goal in the rehabilitation of patients who have undergone a laryngectomy. Voice restoration using a tracheoesophageal puncture (TEP) is the current treatment of choice for postlaryngectomy speech rehabilitation. TEP and placement of a voice prosthesis was first introduced by Singer and Blom1 in 1980. The original voice prosthesis, the Blom-Singer, and a secondgeneration device, the Provox, both use a rigid esophagoscope for creation of a tracheoesophageal fistula and subsequent placement of a voice prosthesis. Although use of a rigid esophagoscope for placement of the prosthesis is the most widely used technique, variations to the procedure have been reported. These variations include the KTP laser, both rigid and flexible endoscopes, percutaneous gastrostomy sets, as well as a variety of introducer kits and clamps.2–5 Although the secondary TEP is a relatively simple procedure, there have been many reported complications, including esophageal injury, mediastinitis, creation of a false passage, and cervical spine fracture.6 Although these complications may be rare, they are very real and tend to occur at a greater frequency in patients with difficult anatomy. Therefore, alternative methods of voice prosthesis placement need to be used in patients with anatomy that does not allow for proper passage of a rigid esophagoscope to ensure safe placement of the devices. The objective of this study was to revisit a creative solution for those patients undergoing a secondary TEP whose anatomy will not accommodate a rigid esophagoscope for a multitude of reasons.

Thyroid Cancer in Pregnancy

We report a case of papillary thyroid cancer in pregnancy and discuss the various diagnostic and therapeutic challenges inherent to this condition. Several case series are reviewed. In addition, we examine the effect of pregnancy on the development and progression of thyroid malignancy.

AlloDerm and DermaMatrix implants for parotidectomy reconstruction: A histologic study in the rat model

We analyzed tissue incorporation, immune response, and neovascularization of AlloDerm and DermaMatrix in a rat model of postparotidectomy reconstruction.

Removal of Obstructing T-tube and Stabilization of the Airway

Although they are extremely effective in maintaining tracheal and subglottic patency, T‐tubes themselves can result in airway obstruction from plugging. Many practitioners educate patients on placing a small (5.0) endotracheal tube (ETT) through the tracheal limb of the T‐tube if they develop airway obstruction. Unfortunately, this can be a difficult task to complete during acute airway obstruction. In this article, we describe a simple set of steps for rapid relief of airway obstruction and stabilization of the airway in the event of T‐tube obstruction. This method requires removal of the T‐tube with a Kelly clamp and stabilization of the airway with a tracheostomy tube. Although it is simple, we hope that this technique will prevent morbidity and mortality from acute airway obstructions related to T‐tubes.

Free dermal fat graft reconstruction of the head and neck: An alternate reconstructive option

OBJECTIVES Ablative procedures of the head and neck often result in significant facial and cervical irregularities and cosmetic asymmetry. The deformity resulting from ablative procedures of the head and neck is a significant source of cosmetic morbidity and postoperative dissatisfaction. Reconstruction of post-ablative defects in the head and neck can employ a broad range of techniques, ranging from primary closure to free tissue transfer. The free dermal fat graft (FDFG) is one such option and has been used to repair volume defects of varying sizes after common head and neck procedures such as parotidectomy. However, its use is largely undocumented in the literature. We seek to further illustrate the FDFG as an alternate method of reconstruction of head and neck defects. STUDY DESIGN Non-randomized retrospective analysis. METHODS The medical records of all patients who underwent primary autologous abdominal FDFG reconstruction of head and neck defects by a single surgeon at Vanderbilt University Medical Center from January 1997 to August 2010 were reviewed. All patients were called in order to assess their post-operative cosmetic satisfaction. RESULTS Sixty-two patients were analyzed. Only three patients were found to have post-operative complications directly related to the FDFG. No complications were found at the donor site. Based on a telephone survey, the majority of patients were satisfied post-operatively with their cosmetic outcomes in the primary site and donor site. CONCLUSIONS From our experience the FDFG is a cosmetically and functionally advantageous option for reconstruction of ablative procedures of the head and neck.

Vanderbilt’s Experience with 201 Carotid Body Tumors

Objective: To discuss the evolving treatment considerations of carotid body tumors (CBT) based on a large cohort. Method: A retrospective review of 149 patients with 201 CBT treated at Vanderbilt University’s Dept. of Otolaryngology over a 25-year period (1986-2011). Patients were analyzed for preoperative deficits, familial involvement, progression under observation, operative details, and postoperative sequelae. Results: Bilateral CBTs were identified in 44%, associated vagal paragangliomas in 26%, and jugular tumors in 22% of patients. Familial inheritance was noted in 35%. A total of 163 tumors were resected from 139 patients. Preoperative embolization was utilized in 33% of tumors. Internal carotid resection-reconstruction was performed in 13%. No postoperative strokes occurred. Postoperative cranial nerve dysfunction was rare. Of patients who underwent staged resection of bilateral CBTs, 73% experienced baroreflex failure. Although transient mild first bite syndrome was common, only 30% of patients had ongoing significant symptoms. No recurrence has been noted from the CBTs resected at Vanderbilt. Conclusion: Management of CBTs requires consideration of familial inheritance and potential for multiple paraganglioma. We believe the primary treatment of CBT should remain surgical resection, which can be performed with curative intent with minimal morbidity. Slow growth patterns in paragangliomas makes temporary or long-term observation a treatment option in selected patients.