Thomas H. Nagel

Submandibular gland needle biopsy for the diagnosis of Parkinson disease

Objective: This study investigates salivary gland biopsies in living patients with Parkinson disease (PD). Methods: Patients with PD for ≥5 years underwent outpatient transcutaneous needle core biopsies (18-gauge or 16-gauge) of 1 submandibular gland. Minor salivary glands were removed via a small incision in the lower lip. Tissue was fixed in formalin and serial 6-µm paraffin sections were immunohistochemically stained for phosphorylated α-synuclein and reviewed for evidence of Lewy type α-synucleinopathy (LTS). Results: Fifteen patients with PD were biopsied: 9 female/6 male, mean age 68.7 years, mean PD duration 11.8 years. Twelve of the needle core biopsies had microscopically evident submandibular gland tissue to assess and 9/12 (75%) had LTS. Only 1/15 (6.7%) minor salivary gland biopsies were positive for LTS. Five patients had an adverse event; all were minor and transient. Conclusions: This study demonstrates the feasibility of performing needle core biopsies of the submandibular gland in living patients with PD to assess LTS. Although this was a small study, this tissue biopsy method may be important for tissue confirmation of PD in patients being considered for invasive procedures and in research studies of other PD biomarkers.

Transoral laser microsurgery for the unknown primary: Role for lingual tonsillectomy

We conducted a retrospective review of patients with unknown primary head and neck cancer who underwent a transoral laser microsurgery (TLM)‐assisted search for an occult tumor.

Oropharyngeal cancer treatment: The role of transoral surgery

Purpose of reviewThis article reviews literature pertaining to squamous cell carcinoma (SCC) of the oropharynx and the evolution of transoral surgical (TOS) techniques for its management. Oncologists are recognizing a changing pattern in the cause of oropharyngeal cancer, namely the increasing incidence of HPV-associated tumors. An effort is underway to reduce the morbidity of treatment without jeopardizing survival. This is a timely discussion for reassessment of current standards of care and opening dialogue on treatment de-escalation. Transoral approaches including transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) have revolutionized the surgical approach to SCC. Recent findingsThe incidence of HPV-related oropharyngeal SCC is increasing at epidemic rates. Although there are no studies comparing nonsurgical treatment to TOS in a randomized controlled fashion, there is an abundance of retrospective and prospective reports of TORS and TLM. Both early and advanced-stage oropharyngeal tumors can be managed successfully with surgery, with or without adjuvant therapy. SummaryAlthough there are no hard scientific differences in oncologic outcomes between primary chemoradiation protocols and primary TOS-based approaches, retrospective comparisons support an advantage of primary surgery. In addition, functional outcomes may be superior following TOS treatment. Management of oropharyngeal SCC will most likely continue to be multidisciplinary with an ongoing effort to de-escalate treatment to reduce morbidity.

Hybrid submental flaps for reconstruction in the head and neck: part pedicled, part free.

Evaluate feasibility and success of elongating only the venous pedicle of the submental flap to increase the superior arc of rotation for the “hybrid” flap allowing coverage of more distal defects.

Reconstruction of Lateral Skull Base Defects A Comparison of the Submental Flap to Free and Regional Flaps

Objectives To compare reconstructive techniques, operative times, duration of hospitalization, and need for subsequent flap revisions between reconstructive approaches to lateral skull base defects. Study Design Case series with chart review. Setting Tertiary academic referral center. Subjects Patients (n = 31) undergoing reconstruction of composite lateral skull base defects from 2002 to 2014. Methods Data were analyzed for demographics, tumor characteristics, reconstructive technique, operative time, duration of hospitalization, complications, and outcomes. Results Thirty-one patients were identified for inclusion. Lateral temporal bone defects resulted from resection of malignant lesions, including squamous cell carcinoma (n = 25), basal cell carcinoma (n = 2), and other carcinoma (n = 4). Defects were reconstructed with submental flaps (n = 16), pedicled latissimus dorsi flaps (n = 6), and free anterolateral thigh flaps (n = 9). All cases involved neurosurgery, neurotology, and head and neck surgery services. Although time of surgical resection was similar, time saving was noticed with submental reconstruction. Compared with free flaps, submental flap reconstruction was associated with significantly reduced total operative time (mean, 544 vs 683 min; P = .00817) and duration of hospitalization (4.9 vs 9.8 days; P = .02067). Submental flaps were significantly less likely to require revision debulking procedures (mean = 0.6) compared with latissimus dorsi flaps (mean, 1.3; P < .00001) and free flaps (mean, 1.6; P < .00001). There was 100% flap survival. Conclusion The musculocutaneous submental flap provides an excellent option for reconstruction of lateral skull base defects given its proximity, reliability, ease of harvest, and exceptional color match. Submental flap reconstruction was associated with reduced operative time, hospitalization duration, and flap revisions.

The evolving role of free flaps and pedicled flaps in head and neck reconstruction

Purpose of reviewThis article reviews literature pertaining to the evolution in head and neck reconstruction techniques over the past two decades, specifically the changing patterns of usage of locoregional flaps and microvascular free tissue transfer. Recent findingsMost literature demonstrates a continuing trend favoring microvascular free tissue transfer for the majority of large defects. A few pedicled flaps, some new and some resurrected, now provide expanded and sometimes superior options for certain head and neck defects. Considerations driving flap choice include defect composition, oncologic, aesthetic, and functional factors. SummaryAlthough osteocutaneous microvascular free flaps remain the standard of care for composite oromandibular defects, there may be a groundswell in the use of certain locoregional pedicled flaps for reconstructing many facial, intraoral and pharyngeal soft tissue defects. Evolution in the use of these locoregional flaps may help improve upon the standard of care for reconstructive options.

Advantages and limitations of free and pedicled flaps in reconstruction of pharyngoesophageal defects.

Purpose of reviewThe current review will focus on head and neck reconstructive techniques for the pharyngoesophagus. This article reviews the changing patterns of flap usage and will evaluate the advantages and disadvantages of selected pedicled and free flaps for pharyngoesophageal reconstruction. A number of flaps are reviewed with particular emphasis on recent developments. Recent findingsThe literature reports on a variety of options available to reconstruct pharyngoesophageal defects. Pedicled flaps have a role in partial defects and select short to moderate circumferential length defects. The standard for long segment circumferential defects continues to be the fasciocutaneous free flaps and the jejunum free flap. SummaryThe exact nature of the pharyngoesophageal defect, patient characteristics, and flap availability should be considered when choosing the best option for reconstruction.

Management of Orbital Involvement in Sinonasal and Ventral Skull Base Malignancies

The orbit may be frequently involved by sinonasal or ventral skull base malignancy. This involvement bodes a poorer prognosis for survival. Multimodality therapy with surgery and radiation therapy is usually attempted to optimize local control and overall survival. Oncologic surgical resection with negative margins is critical to local control and survival. In the past, any involvement of the orbit was deemed to necessitate orbital sacrifice. However, contemporary studies show that in carefully selected cases, orbital preservation does not adversely impact survival. In addition, novel reconstructive techniques can help minimize complications and optimize functional and aesthetic outcomes.

Median Lingual Lymph Nodes: Prevalence on Imaging and Potential Implications for Oral Cavity Cancer Staging.

Objective This study sought to estimate the prevalence of median lingual lymph node (MLLN) metastases from oral cavity squamous cell carcinoma (OCSCC) and determine the frequency with which MLLNs can be identified with magnetic resonance imaging (MRI) in control subjects. Methods Pathology reports were used to identify patients with surgically treated OCSCC who underwent preoperative positron emission tomography–computed tomography to define the prevalence of MLLN metastases. As a control group, 500 consecutive face-neck MRIs from noncancer patients were reviewed for structures consistent with MLLNs. Results In the study group, 1 (0.95%) of 105 OCSCC cases demonstrated a single MLLN metastasis from a lateral tongue tumor (T4aN2c). The MLLN exceeded 1 cm in all planes and was abnormal in morphology. The frequency of suspected MLLNs in controls was 1.0%, with a maximum measurement of 0.9 cm. Conclusions Median lingual lymph nodes are infrequently identified with MRI in controls, concordant with the low prevalence of metastases from OCSCC to this inconstant nodal group.

A novel distending laryngoscope: implications in transoral surgery

The objective is to describe an innovative laryngoscope developed to improve visualization, provide greater exposure, and enhance precision and success during transoral procedures. A retrospective review of 170 patients who underwent transoral surgery with a new distending laryngoscope was conducted. We compared and contrasted our exposure within the oropharynx, hypopharynx, and larynx using the laryngoscope with that of currently available instrumentation. Specific mechanical dimensions of the laryngoscope along with the provided working field were calculated. Experience with the new laryngoscope afforded improved exposure over currently available instrumentation. This laryngoscope was manufactured using design elements from the Steiner, Weerda, and Lindholm laryngoscopes, including an anteriorly curved distal tip, distending capability, and lateral wings to protect against tongue herniation. The panoramic view was increased allowing for wider exposure of the supraglottis and pharynx. This design provided enhanced transoral visibility and working room for improved bimanual instrumentation. Direct laryngoscopic technique and instrumentation have continued to evolve. Over the last two decades, there has been a significant movement towards minimally invasive transoral surgical techniques fueling innovative concepts and advancement in laryngoscopic design and application. We present our experience with an innovative laryngoscope allowing for improved visualization, greater exposure, and enhanced proficiency with transoral technique.