Long segment spinal reconstruction of C3-T1 utilizing single strut fibula free flap following debridement and corpectomy for chronic osteomyelitis

Cervical vertebral osteomyelitis (CVO) is a complex destructive pathology that presents as a significant challenge to reconstructive surgeons. Advanced cases of CVO involving neurologic deficits, spinal column instability, or refractory infection require surgical intervention with bony debridement and decompression followed by spinal reconstruction, realignment, and stabilization. Reconstruction of the spine is typically performed through an anterior approach with or without posterior instrumentation. Restoration of the anterior spinal column can be performed with titanium or PEEK cages, allograft bone or vascularized autograft bone. Anterior spine reconstruction using vascularized osseous free flaps has been well documented in the medical literature; however, to our knowledge, we report the largest osteomyelitic anterior cervical spine defect that has been reconstructed using a single strut osseous free flap. This was a complex case of cervical osteomyelitis in a patient with prior C4-C7 anterior cervical corpectomy and fusion who presented with instrumentation failure and septicemia. Anterior column reconstruction required a vascularized fibular strut spanning six vertebral levels from C3-T1, as well as a trapezius myocutaneous pedicled flap for posterior soft tissue coverage.     

Repair of esophageal perforation due to anterior cervical spine instrumentation

The complication of esophageal perforation after anterior cervical spine fusion for cervical spine disease is rare but potentially fatal. We describe two cases of esophageal perforation found by esophagoscopic visualization. In one patient, primary closure could not be achieved, and a submental island flap was used to repair the defect. In the second patient, primary closure was achieved and a pectoralis major flap was interposed between the closure and the residual instrumentation. Postoperatively, both patients had no evidence of persistent perforation and had resolution of preoperative symptoms. Laryngoscope, 2010     

The carotid-vertebral space: an 'extended' lateral window to the ventromedial cranial base and lower craniocervical junction

We describe a unique method of accessing the ventromedial skull base and lower craniocervical junction. Our method employs a trajectory between that of the more anterior transoral or retropharyngeal approaches and the various posterior or posterolateral skull base approaches. This "extended" lateral approach allows surgeons to resect very large tumors of the skull base through a single incision. The operative field is more extensive than that achieved with other approaches; it extends from the cerebellar hemisphere to the extradural ventral upper cervical spine, and it provides access to tissue outside the spinal canal, such as the ventral strap muscles. We describe our use of this approach during a single-stage resection of a large hemangiopericytoma in a 37-year-old man.     

Delayed pharyngoesophageal perforation: a complication of anterior spine surgery

Stabilization of the cervical spine is often accomplished via an anterior cervical approach. Bone grafts and/or plates and screws are used to achieve stabilization. Injuries to the pharynx and esophagus are known complications in anterior exposure of the cervical spine. These injuries are manifest in the early postoperative period. Reports of late perforations are very rare. We present four cases of delayed injury to the pharynx and esophagus that resulted in abscess or fistula. We postulate that graft displacement with resulting erosion was responsible for these serious complications. Postoperative odynophagia in patients who undergo anterior cervical fusion warrants evaluation of the bone graft location. Early surgical intervention and repair may decrease prolonged morbidity in these patients.     

Pharyngeal pouch following anterior cervical fusion

A case of an acquired pharyngeal pouch which formed as a consequence of previous anterior cervical fusion is reported. This is a rare cause of pharyngeal pouch formation with only one such case previously reported in the English language literature. In our case adhesions had formed between the posterior pharyngeal wall and the area around the screw used to hold the Senegas plate on the anterior aspect of the fifth to seventh cervical spinal vertebrae.     

An unusual recurrent intrathoracic goiter: Case report

Most intrathoracic goiters are located in the anterior mediastinum, frontal to the recurrent laryngeal nerve and anterolateral to the trachea. Posterior mediastinal goiters account for only 10 to 15% of all intrathoracic goiters and arise from the posterolateral portion of the thyroid gland. We present a case involving a 59-year-old man with history of gradual-onset dyspnea who was referred to us for evaluation of a large mediastinal mass. He had undergone bilateral thyroid lobectomy for a cervical goiter 10 years previously, with no subsequent complications. Contrast-enhanced computed tomography demonstrated a large, well-circumscribed mass extending paratracheally from the thoracic inlet to the posterior mediastinum. The mass was removed via a transcervical and transthoracic approach.     

Anterior hyperostosis of the cervical spine: diagnostic studies and surgical therapy

BACKGROUND: Dysphagia due external compression by anterior hyperostosis of the cervical spine is rare. The diagnosis may be established by conventional X-ray of the spine, esophagogram, and CT. PATIENTS: We operated on three patients with large anterior osteophytes from C3 to C7. In two cases morphologic changes of the cervical spine were the main cause of dysphagia. One patient with progressive hypopharynx cancer had hyperostosis of cervical spine as secondary findings. RESULTS: The patients were asymptomatic, post-operatively. CONCLUSIONS: Cervical osteophytes can be detected in 20-30% of the population in asymptomatic patients. The therapeutic approach depends on the extent of dysphagic complaints. Painful dysphagia is a indication for surgery. The anterolateral extrapharyngeal approach is commonly preferred with anterior hyperostosis between C4 and C7. The transoral intrapharyngeal approach has been used in patients with hyperostosis of cervical vertebra C2/C3. Interdisciplinary orthopedic and ENT surgical treatment is without complications and yields good functional results.     

An unusual complication of Cloward's procedure presenting to the otolaryngologist

We present the case of a 51-year-old lady who developed a CSF leak following a Cloward's procedure (anterior cervical surgery with fusion), which settled with conservative management. Two months following the surgery she was assessed by an otolaryngologist for persistent dysphagia and a swelling in the anterior triangle of her neck. A computed tomography (CT) scan identified a fluid-filled mass displacing the trachea and communicating with the anterior cervical vertebrae, thus confirming the persistence of a CSF leak.     

Dysphonia and dysphagia following the anterior approach to the cervical spine

BACKGROUND: Speech and swallowing dysfunctions are common following the anterior approach to the cervical spine. Despite functional morbidity and legal implications, the incidence and etiologic factors of these complications have not been adequately elucidated. OBJECTIVE: To better define speech and swallowing dysfunction both in the quantitative and qualitative sense. METHODS: A questionnaire was mailed to 497 patients who had undergone anterior cervical fusion or anterior cervical discectomy at a university hospital (study group). One hundred fifty questionnaires were sent to a control group. RESULTS: The study group response rate was 46%; the control group response was 51%. The incidence of hoarseness in the study group was 51%; the incidence in the control group was 19%. The difference was statistically significant (P<.01). Dysphagia was present in 60% of study group patients vs 23% of control group patients (P<.01). Qualitative questions revealed that constant hoarseness, pain with talking, difficulty eating solid foods, and odynophagia were significantly more common following the anterior approach to the cervical spine. CONCLUSIONS: Our findings show a much higher incidence than previously reported of both voice and swallowing impairment following the anterior approach to the cervical spine. Hoarseness and dysphagia may adversely affect recovery and the patient's sense of well-being. Preoperative counseling and postoperative evaluation are essential.     

Pharyngeal diverticulum as a sequela of anterior cervical fusion

A rarely diagnosed etiology of dysphagia is a pharyngeal diverticula occurring after anterior cervical fusion. Here we review 2 cases where patients developed pharyngeal diverticula following anterior cervical fusion. The first patient was a 28-year-old female who presented with regurgitation following C5 through C6 cervical fusion. She was diagnosed with a pharyngeal diverticulum and underwent open repair, but began to experience symptoms again a few months later. A barium swallow showed a recurrent pharyngeal diverticulum. Endoscopic repair was attempted; however, because of the thick scar band between the diverticulum and the esophagus, the operation had to be converted to an open repair with cricopharyngeal myotomy. The second case involved a 63-year-old male who presented with dysphagia and regurgitation 6 months after anterior cervical fusion. Esophagram demonstrated a small diverticulum at the right lateral border of the upper esophagus. Open repair of the diverticulum with cricopharyngeal myotomy was successfully performed. Pharyngeal diverticula after anterior cevical fusion have only been reported in 2 prior cases in the literature. Here we describe 2 additional cases at our institution, both requiring open repair. Radiographic studies demonstrate the diverticulum at the site of scarring from the cervical fusion. Because of the thick scar band and the atypical location of these diverticula, endoscopic repair with stapping (as done for Zenker's diverticula) may not be feasible. These cases highlight the importance of considering a diverticulum in the differential of posoperative patients presenting to the otolaryngologists with complaints of dysphagia following cevical spine surgery.     

Meckel’s cave access: anatomic study comparing the endoscopic transantral and endonasal approaches

Recent advances in endonasal endoscopy have facilitated the surgical access to the lateral skull base including areas such as Meckel’s cave. This approach has been well documented, however, few studies have outlined transantral specific access to Meckel’s. A transantral approach provides a direct pathway to this region obviating the need for extensive endonasal and transsphenoidal resection. Our aim in this study is to compare the anatomical perspectives obtained in endonasal and transantral approaches. We prepared 14 cadaveric specimens with intravascular injections of colored latex. Eight cadavers underwent endoscopic endonasal transpterygoid approaches to Meckel’s cave. Six additional specimens underwent an endoscopic transantral approach to the same region. Photographic evidence was obtained for review. 30 CT scans were analyzed to measure comparative distances to Meckel’s cave for both approaches. The endoscopic approaches provided a direct access to the anterior and inferior portions of Meckel’s cave. However, the transantral approach required shorter instrumentation, and did not require clearing of the endonasal corridor. This approach gave an anterior view of Meckel’s cave making posterior dissection more difficult. A transantral approach to Meckel’s cave provides access similar to the endonasal approach with minimal invasiveness. Some of the morbidity associated with extensive endonasal resection could possibly be avoided. Better understanding of the complex skull base anatomy, from different perspectives, helps to improve current endoscopic skull base surgery and to develop new alternatives, consequently, leading to improvements in safety and efficacy.     

Pharyngeal diverticulum: Iatrogenic complication of anterior cervical spine surgery

IntroductionDysphagia is a common presenting complaint and can often be due to pharyngoesophageal diverticulum, including Zenker's diverticulum. Iatrogenic pharyngeal diverticulum, occurring after anterior cervical spine surgery, is a rare cause of dysphagia.Case reportWe report the case of a 51-year-old man, with a history of anterior cervical fusion about ten years previously, who complained of chronic dysphagia and disabling episodes of aspiration. Anterolateral pharyngeal diverticulum in contact with the cervical screw plates was diagnosed on barium swallow and upper gastrointestinal endoscopy.DiscussionPharyngeal diverticulum differs from Zenker's diverticulum in terms of its position and its origin. It may occur early or late after anterior cervical spine surgery. Treatment consists of endoscopic or open surgery via a neck incision. In our case, appropriate treatment allowed complete resolution of the patient's symptoms with no complications following rigorous postoperative surveillance.     

Retrospective study of descending cervical mediastinitis

Objective Descending cervical mediastinitis can occur as a complication of oropharyhgeal and cervical space that spread to the mediastinum vis cervical space. Descending mediastinitis represent a virulent form of mediastinal infection requiring prompt diagnosis and treatment to reduce high morality associated with the disease. Surgical management and a particularly optimal form of mediastinal drainage remain controversial. Method From 1998–2004, eighteen patients were treated in our institution. Surgical treatment consisted more than 2 times. Cervical drainage associated with drainage of the mediastinum through a thoracic approach in 11 patients with pleural drainage in 8 patients. Result The outcome was favorable in eleven patients who had mediastinum drained through thoracotomy. One patient who was not drained died with tracheo-oesophageal fistula. Main culprit neck space is pre and para tracheal space which lead to anterior, superior and posterior mediastinal collection in our series. The tracheostomy is of immense help not only in opening cervical space collections and also to secure a partially compromised airway.     

Otoplasty: results after anterior versus posterior approach

Introduction and objectiveIn otoplasty, an anterior approach with sutures is commonly used, because it is not aggressive with cartilage. The aim of this study on otoplasty was to evaluate the usefulness of the anterior approach, comparing it to the results obtained after the posterior approach.Material and methodsRetrospective study on 25 otoplasties performed at a University Hospital during the period 2004-2008. Clinical records from 13 patients (25 otoplasties), between 7-41 years of age, were reviewed. In the anterior approach, the anterior surface of the auricular cartilage is scratched with a rasp. The antihelix shape is obtained and mattress sutures are placed through the anterior surface of the ear.ResultsOut of 25 otoplasties, 92% were bilateral and 8%, unilateral; 54% of the patients were children and 46%, adults; anaesthesia was local in 20% and general in 80%. We performed 11 anterior and 14 posterior approach otoplasties. After an anterior approach, complications were suture extrusion in 82%, foreign body reaction in 9%, and revision surgery was needed in 28% of 11 otoplasties performed. After a posterior approach, complications were suture extrusion in 21%, foreign body reaction in 7%, and revision surgery was needed in 7% of 14 otoplasties performed. A good aesthetic result was obtained in almost all the cases (85%). Extrusion rate was statistically more common after the anterior approach.ConclusionsIn our opinion, otoplasty is a simple technique for treatment of prominent ears, with good aesthetic results. The most common complication is suture extrusion, more frequent after an anterior approach.     

Dysphagia, hoarseness, and unilateral true vocal fold motion impairment following anterior cervical diskectomy and fusion

The charts of 100 patients who underwent anterior cervical diskectomy with fusion performed at our institution between January 1996 and February 1999 were reviewed. The incidences of hoarseness, dysphagia, and unilateral true vocal fold motion impairment were calculated. Univariate logistic regression was used to estimate the relationship of several patient and technical factors to the rates of occurrence of hoarseness and dysphagia. Patient age was found to be a significant predictor of postoperative dysphagia (p < .006), with an odds ratio of 1.113 (95% confidence limits, 1.04, 1.21) per year of age. Other factors studied were not found to be significant predictors. The overall incidence of these complications from the world literature was also calculated. The overall incidences of dysphagia, hoarseness, and unilateral true vocal fold motion impairment in the literature were calculated as 12.3%, 4.9%, and 1.4%, respectively. We conclude that dysphagia, hoarseness, and unilateral vocal fold motion impairment continue to remain significant complications of anterior cervical diskectomy with fusion. Older patients may be at higher risk for dysphagia.     

Transapical extension in difficult cerebellopontine angle tumours: preliminary report

Difficult cerebellopontine angle (CPA) tumours namely large/giant vestibular schwannomas, vestibular schwannomas with a significant anterior extension and meningiomas of the posterior surface of the petrous bone extending anterior to the internal auditory canal (IAC) have always posed a problem for the otoneurosurgeon. Modifications of the enlarged translabyrinthine approach (ETLA) specifically aimed at dealing with these tumours are not reported. The aim of this paper is to introduce the transapical extension of ETLA which involves increased circumferential drilling around the IAC beyond 270 degrees C. The extension allows enhanced surgical control over the tumour as well as the anterior aspect of the CPA including the prepontine cistern, the Vth and VIth cranial nerves. The extension is further classified into Type I and II depending upon the extent of drilling. Type I extension entails drilling around the IAC for 300-320 degrees and is indicated for large/giant vestibular schwannomas (large vestibular schwannoma extrameatal diameter 3-39 cm, giant vestibular schwannoma extrameatal diameter >or=4 cm) and vestibular schwannomas with significant anterior extension. Type II extension involves complete drilling around the canal for 360 degrees and is indicated for meningiomas of the posterior surface of the petrous bone extending anterior to the IAC.     

How we do it: the anterior thoraco‐cervical approach to tumours of the thoracic inlet

? Tumours that arise in the thoracic inlet and superior mediastinum may be benign or malignant and present the surgeon with a difficult problem of access. ? The standard approach to the thoracic inlet from below offers limited exposure to the vascular and neural structures superior to the tumours. ? The anterior thoraco‐cervical approach to the root of the neck and superior mediastinum combines the anterior cervical approach with a limited upper median sternotomy. If further access is required to achieve surgical clearance a full sternotomy split can be performed. ? The approach offers excellent exposure and helps to facilitate complete resection of benign and malignant tumours, which would otherwise be deemed inoperable or difficult to resect completely through other standard approaches. ? In contrast to previously described anterior transcervical thoracic approaches which required resection of part of the clavicle or manubrium as well as thoracotomy with increased morbidity, the anterior thoraco‐cervical approach is associated with little morbidity and the postoperative stay is short.     

Congenital midline cervical cleft: a report of 3 cases

Congenital midline cervical cleft is a rare anomaly of the anterior neck. The diagnosis is typically made on the basis of the lesion's characteristic clinical presentation at birth. It appears to occur as a result of a failure of fusion of the paired second branchial arches in the midline during embryogenesis. Surgical intervention is necessary to avoid potential long-term complications, such as contractures and limitation of neck mobility. We present 3 cases of congenital midline cervical cleft, and we discuss the embryology, presentation, and surgical management of this unusual condition.     

Incisions in tympanoplasty: anatomic considerations and indications

The endaural, postauricular and transmeatal incisions are the most commonly used surgical approaches for tympanoplasty. Each incision used in tympanoplasty has its own advantages and limitations so that no single approach is the best approach for all tympanic membrane perforations. The incision selected for tympanoplasty should be determined by the location and extent of disease. Forty adult temporal bones were studied to understand the limiting factors for each surgical approach used in tympanoplasty. The external endaural incision has been modified to permit easier visualization of the crescentic endomeatal canal incisions. The anterior external endaural incision allows direct exposure of temporalis fascia, the external meatus, bony canal and perforation involving the posterior tympanic membrane and ossicular chain. The postauricular incision gives direct exposure of the anterior tympanic membrane with preservation of the anterior canal wall skin. The transmeatal approach should be reserved for smaller central perforations with limited risk for squamous ingrowth into the middle ear. In the transmeatal tympanoplasty, the ear canal should permit the use of a speculum large enough to expose the entire perforation.