Yung-Chang Hsu

Treatment of temporomandibular joint ganglion cyst.

Ganglion cysts of the temporomandibular joint are very rare and always misdiagnosed as synovial cyst, parotid gland tumor, or other cystic lesions. They present with pain, swelling, or dysfunction. Image studies could facilitate to identify the tumor mass from the adjacent soft tissue, but a definitive diagnosis could be made from the pathologic report. A 59-year-old woman presented to the clinics with a chief complaint of a painless swelling mass in the right preauricular region of 3-month duration. Computed tomography was performed, which showed a small radiolucent lesion adjacent to the right condyle. Local excision was performed, and the specimen was sent for histologic examination. Microscopic examination showed a cystic space walled by dense fibrous connective tissue without epithelial or endothelial lining. Immunohistochemical staining of these lining cells showed positivity for vimentin and negativity for cytokeratin. These findings were consistent with the diagnosis of ganglion cyst. Ganglion cysts present as unilobulate or multilobulate cysts that arise from the collagenous tissue and is filled with highly viscous fluid. It does not communicate with the joint cavity. In contrast, synovial cyst is a true cyst lined by cuboidal or flattened cells from the synoviocytes and is filled with gelatinous fluid. It may or may not communicate with the joint cavity. Excision is the treatment of choice of symptomatic cystic lesions. Incomplete excision of these lesions may cause further recurrence or infection. Thus, injection of hydrocortisone or aspiration may be considered as an alternative management.

Functional Outcome Analysis After Anterolateral Thigh Flap Reconstruction of Pharyngoesophageal Defect.

BackgroundPharyngoesophageal defects are traditionally reconstructed with jejunal or radial forearm flaps. Recently, anterolateral thigh flaps have served for pharyngoesophageal reconstruction. We tell of our experience with anterolateral thigh flap for the reconstruction of pharyngoesophageal defect for the past 5 years. This study presents another modified flap design and refinement of surgical techniques. MethodsIn all, 45 pharyngoesophageal reconstructions were performed during 2006 to 2011, namely patch (n = 18), near-circumferential (n = 8), and circumferential defect (n = 19) reconstructed by 2 plastic surgeons with the same trapezoid anterolateral thigh flap design. ResultsTotal flap loss occurred in 2 patients (4%). Two patients experienced partial flap necrosis. Fistulas occurred in 8 patients, but only 5 of these needed further suture ligation or local flap treatment. Postoperative strictures without tumor recurrence were identified in 4 patients (9%). Forty patients (88.9%) could tolerate oral diet; 34 of these ate soft or solid food. ConclusionsAnterolateral thigh flap offers good coverage and swallowing function in the reconstruction of hypopharyngeal defect. Trapezoid drawing of anterolateral thigh flap makes the design simplified, with an accepted complication rate.

Use of the Ipsilateral Anteromedial Thigh Flap for Immediate Rescue of Nonviable Anterolateral Thigh Flaps in Head and Neck Cancer Reconstruction

Background: It is not always possible to use the anatomically variable free anterolateral thigh (ALT) flap for reconstructive surgery. An anteromedial thigh (AMT) flap serves as a good alternative, and shares the same vascular pedicle as the ALT flap. Methods: Of 698 reconstructions performed in 2006 to 2013 following head and neck tumor ablation surgery, ALT flaps were used in 653 patients. Eighteen free AMT flaps were harvested to replace variant nonviable ALT flaps. Results: The lack of a sizable perforator in the ALT flap territory was the main reason for changing the reconstruction plan. Anteromedial thigh flap size ranged from 10 × 4 to 30 × 8 cm. The flap survival rate was 100%. The follow-up period ranged from 3 to 56 months. Conclusion: During head and neck reconstruction, when no sizable perforator is available during harvest of the ALT flap, successful reconstruction can be achieved using the ipsilateral AMT flap without additional donor-site morbidity.

A ‘silent’ skull metastatic follicular thyroid carcinoma mimicking as a benign scalp tumor in a pregnant woman

Summary Thyroid cancer with cranial metastasis in a pregnant woman is very rare. In the literature, most cases are diagnosed early from neurogenic signs or symptomatic thyroid gland. Pregnancy also contributes to a hesitation toward early surgical and medical treatments. We reported a scalp tumor in a physically healthy 37-year-old pregnant female with a follicular thyroid carcinoma (FTC) with lung, bone and cranial metastasis in initial presentation. Silent neurogenic and physical examinations make an early diagnosis very challenging. Resection of scalp and intracranial tumor, a thyroidectomy, post-operative radioactive iodine therapy and tyrosine kinase inhibitors were employed as treatment. The scalp tumor was confirmed as a metastatic follicular thyroid carcinoma via positive immunoreactivity for thyroglobulin and thyroid transcription factor 1 in tumor cells. Blood examination revealed an elevated thyroglobulin level (>5335 ng/mL). The patient was discharged without any neurological deficit. An asymptomatic scalp tumor in a pregnant woman with a normal thyroid disease history needs differential diagnosis from intracranial origin. Rapid progression and an elevated thyroglobulin level are the indicators that further image study is needed. Aggressive surgical excision of resectable thyroid gland and metastatic tumor are essential for a longer survival rate. There is nothing to indicate that a post-partum operation will worsen prognosis. Learning points: Follicular thyroid cancer with cranial metastasis in initial presentation can be asymptomatic. Follicular thyroid cancer with cranial metastasis in a pregnant woman can be treated after delivery. Rapid enlargement of scalp tumor is indicated for further image study even in a patient without any neurological deficit.

Recurrent Malignant Parotid Gland Tumor, Acinic Cell Carcinoma-a Case Report and Literature Review

Background:Salivary gland tumors are relatively uncommon in the head and neck neoplasms, and majority of them are benign. Most of them, about 65% to 80%, arise in the parotid gland and 20 percent of parotid gland tumors are malignant. Compared to most commonly mucoepidermoid carcinoma, acinic cell carcinoma is very rare.Aim and objectives:Herein we present a case with this rare malignant parotid gland tumor, and share our management experience. Clinical presentation, specific histopathologic characteristics, and therapeutic management of acinic cell carcinoma in the parotid gland are discussed.Materials and Methods:A 71-year-old woman had the history of right parotid gland acinic cell carcinoma with facial nerve involvement and received superficial paroidectomy eleven years ago. After a silent period, the tumor was found to recur one month before the current treatment. A total parotidectomy was performed, and an adjuvant radiation therapy was subsequently given based on the pathology report which showed high-risk features.Results:The pathology report demonstrated parotid gland acinic cell carcinoma with clear margins. After adjuvant radiation therapy and two-year follow-up, there was no sign of recurrence, and the patient was satisfied with the functional and cosmetic outcomes.Conclusion:Parotid gland acinic cell carcinoma is a very rare neoplasm. It often has low-grade potential, and surgical extirpation is the choice of treatment when managing such a case. Post-operatively adjuvant radiation therapy is practicable if the pathology has high-grade potential or high-risk features. Parotid gland acinic cell carcinoma might recur after a long period due to its indolent nature. Thus, a long-term follow-up is necessary.

Traumatic Pseudo-Aneurysms of the Superficial Temporal Artery-2 Case Reports and Review of the Literature

Background:Pseudo-aneurysms of the superficial temporal artery (STA) are uncommon. Most cases are related to incidental traumas such as contusions from sports-related injuries, traffic accidents, gunshot wounds or stab wounds. Although imaging studies are helpful tools in diagnosing pseudo-aneurysms, the importance of history and physical examination should not be underestimated.Aim and Objectives:We present two cases to highlight the importance of taking a thorough history and paying attention to signs and symptoms. In addition, we also review the literature on pseudo-aneurysms and discuss the pathophysiology, diagnosis and treatment options.Materials and Methods:Two cases are described who were seen several weeks after having had an initial assessment in a different Unit for a blunt head injury. During initial assessment, ecchymosis was diagnosed but ignored. After taking a thorough history, doing physical examination and performing Doppler sonography in one patient, the pseudo-aneurysms of the STA was diagnosed.Result:They were both consulted by our Unit at a later date and pseudo-aneurysms were found. Both patients underwent segmental ligation of involved Superficial Temporal Artery (STA) and removal of the pseudo-aneurysm with good outcomes.Conclusion:The importance of doing a thorough history and paying attention to the physical signs and symptoms are emphasized in this paper. In particular, when patients present with closed head injuries and ecchymosis, one should have a high level of suspicion. Doppler sonography should be the first choice of imaging and surgical resection is the prefered treatment for pseudo-aneurysms.

Post-Traumatic Epidermoid Cyst of the Palm-Case Report and Review of the Clinical Characteristics and Differential Diagnosis with Tenosynovitis

Background:Epidermoid cyst is the most common cutaneous cyst, and it can occur on almost any skin surface. It often presents as a bulging, round, smooth-surfaced, and freely mobile mass with variable size.Less than 10% of epidermoid cysts occur on the extremities, and even fewer occur on the palms and soles.Aim and Objectives:Herein, we report a case with an epidermoid cyst of left palm. Sonographically, ruptured epidermoid cysts may mimic tenosynovitis. Articles about the clinical characteristics of epidermoid cysts and differential diagnosis with tenosynovitis are reviewed.Materials and Methods:A 17-year-old male patient had an accidental penetrating injury to his left palm from a compass 3 years ago, and it healed as a palpable and well-defined skin mass. He received incision and drainage about 4 months ago, but the mass still persisted with yellowish discharge. Ultrasonographic findings were in favor of tenosynovitis. We performed exploratory surgery, and the mass was excised completely.Results:The pathologic report confirmed the diagnosis of a ruptured epidermoid cyst. There was no recurrence after a one-year follow-up.Conclusion: Post-traumatic epidermoid cysts occur mainly on palms, fingers and soles. Sonographically, ruptured epidermoid cysts may mimic any other soft tissue mass or disease. A thorough history taking and physical examination are the most important factors for definite diagnosis. Complete excision is the curative treatment of choice.

Kimura Disease: A Case Report and Literature Review

Background:Kimura disease (KD) is a chronic and benign inflammatory disease and the etiology is still unknown. KD is rare and primarily seen in young Asian males. It is usually presented as painless subcutaneous masses or regional lymphadenopathy over head and neck. Patients with KD may be transferred from other departments for cosmetic need with diverse non-specific complaints. For diagnostic imaging, ultrasonography and magnetic resonance imaging (MRI) reveal more characteristic findings than computed tomography (CT). However, histopathology is the most convincible method to prove the disease.Aim and objectives:We presented a patient with a tender palpable mass over posterior scalp from clinical symptoms, laboratory data, and images to the pathological findings and reviewed the details of KD from the literature.Materials and Methods:In this paper, we reported one female patient with KD which presented a tender palpable mass over posterior scalp. Her peripheral blood data including eosinophils count and renal function were normal.Results:The mass was excised completely and histopathological investigation revealed hyperplasia of germinal centers accompanied with capillaries proliferation and rich eosinophils infiltration. Thus KD was diagnosed according to the result of histopathology. The local tenderness subsided after the mass removal. The patient was regularly followed up for 2 years without recurrent symptoms.Conclusion:Although KD is a pathological diagnosed disease, we could still find some clues by blood laboratory data and image study. Surgery is the first choice of therapy, while other conservative management such as regional or systemic corticosteroid therapy, radiotherapy and medication therapy has also been reported. Although KD has a high recurrence rate, it is definitely a benign disease which must be differentiated from malignant neoplasms.

Malignant Follicular Infundibulum Tumor-A Case Report

Background: Follicular infundibulum tumor that derived from the skin adnexa is very unusual. Most reported cases were benign tumor, rarely with malignant change in the literature. It is easily misdiagnosed because of the non-specific clinic features. Aim and objectives: Herein we present a case with this uncommon skin tumor with malignant change, and review previous literature including clinical presentation, specific histopathologic characteristics, and surgical treatment. Materials and Methods: A 98-year-old woman complained of a solitary ulcerative skin tumor over the right cheek three months ago. The tumor grew rapidly from one to three centimeters in diameter in recent two months. Radical ablative surgery was performed and the defect was reconstructed with full thickness skin graft from the right clavicle skin. Results: The pathology report was follicular infundibulum tumor with malignant transformation. After twelve months follow-up, the patient was satisfied with the functional and cosmetic outcomes. There was no sign of recurrence. Conclusion: Malignant follicular infundibulum tumor is a very rare neoplasm. It is difficult to diagnose correctly according to the clinical presentation. Histopathologic examination is necessary not only for differential diagnosis with other skin tumors but also for benign or malignant proves. Wide excision of the malignant lesion and immediate reconstruction is a considerable treatment to achieve satisfactory outcomes.

Experiences of Using the Free Gracilis Muscle Flap and Split Thickness Skin Graft for One-stage Foot Reconstruction

Background: Soft tissue reconstruction of the foot is a challenge in plastic surgery. Although many different types of free flaps have been used for foot reconstruction, the choice of an ideal free tissue transfer in complex soft tissue defect reconstruction remains controversial. Aim and objectives: In this paper, we present our experiences of using free gracilis muscle flaps for one-stage foot reconstruction. Materials and Methods: Nine patients underwent reconstruction with the free gracilis muscle flap and split thickness skin graft for foot soft tissue defects. Etiologic factors included trauma (6 patients), diabetes mellitus (2 patients), and chronic ulcer (1 patient). Four patients had concomitant fractures. The size of the gracilis muscle flap ranged from 42 to 88 cm^2 (mean, 64.8 cm^2). The anatomic regions of reconstruction were grouped as dorsum (n=6), ankle (n=2), and plantar foot (n=1). Results: Successful reconstruction was accomplished in all patients. One patient developed venous thrombosis, and there was partial skin graft loss in 2 patients. Longitudinal split of the gracilis muscles was performed in 2 patients for separate wound coverage. The concomitant open fracture in 4 patients healed without osteomyelitis complications. All patients returned to normal ambulation without assistive devices. There were no reported ulcerations in flap regions, and the patients were free of foot pain during the follow-up period. Donor-site wound healing was uneventful, and scarring was unapparent. In all patients, the muscle flap had progressive shrinkage and atrophy, therefore, debulking surgery was not performed. No patient required use of special shoes. Conclusions: The application of the free gracilis muscle flap and split thickness skin graft is a good choice for medium-sized foot defects with or without underlying bone fracture. Free gracilis muscle flaps provide stable coverage and an acceptable appearance without the necessity of secondary debulking surgery during long-term follow-up.