Webbed neck associated with other developmental defects

In patients with a combination of congenital webbed deformity of the neck with the Klippel-Weil syndrome, muscular hyperplasia of lateral masses of the neck and latent cerebrospinal hernias favorable cosmetic results could be obtained by an operative dissection of excessive soft tissues including the muscular and cyst ectopic cerebrospinal membrane tissues.     

Anaplastic thyroid carcinoma: risk factors and outcome.

Anaplastic thyroid carcinoma, in contrast to well-differentiated thyroid carcinoma, has a dismal prognosis, and little progress has been made in improving survival for this disease. We reviewed our experience during a 23-year period to identify risk factors and possible methods to improve outcome. Between 1966 and 1989, 340 patients with thyroid carcinoma underwent operation. Of these, 17 (5%) were undergoing operative treatment of anaplastic or undifferentiated thyroid carcinoma. The female/male ratio was 3.5:1, and mean age at presentation was 63 years. The most common presenting symptoms included neck mass, voice change, or dysphagia. Unusual presentations included symptomatic bradycardia from compression of the vagus nerve and superior vena cava syndrome. Four patients had a history of well-differentiated thyroid carcinoma. Nine patients had been diagnosed or treated in the past for "goiter" or a neck mass, and four patients had concurrent differentiated thyroid carcinoma associated with the anaplastic tumor. Thus 13 (76%) of 17 patients had a previous thyroid disorder, benign or differentiated malignant, and eight (47%) of 17 patients had previous or concurrent differentiated thyroid carcinoma. At the time of presentation, six patients had unilateral true vocal cord paralysis. At operation, 14 patients had local extension of the tumor and four required tracheostomy. Only five of 12 patients showed response to postoperative radiation therapy. Overall median survival was 12 months, and 13 (76%) of 17 patients died. The two patients alive longer than 12 months had only small foci of anaplastic carcinoma in association with well-differentiated carcinoma. Anaplastic thyroid carcinoma is a locally and systemically aggressive disease, with long-term survival seen only in those with well-localized anaplastic tumor. The major risk factor in this series is a history of previous benign or malignant thyroid disease. Because of this, a more aggressive approach to thyroid masses may be warranted. Long-standing goiters or benign nodules should be followed carefully and considered for resection if they grow or do not respond to medical therapy, and total thyroidectomy for malignant disease may obviate the subsequent development of anaplastic carcinoma. This method of early diagnosis and resection of abnormal thyroid tissue seems to be the only method currently available to improve the nearly uniform fatality of this disease.     

Vertebral artery aneurysm: case report and review of the literature.

A nontender, nonpulsatile large anterior neck mass was found at operation to be an atherosclerotic aneurysm of the vertebral artery, an extremely rare condition. Proximal control and distal control were obtained and the aneurysm was excised. Aneurysms of the vertebral artery are infrequent but well-defined complications in connective tissue disorders such as the Ehlers-Danlos syndrome, and they can develop subsequent to penetrating neck trauma. However, no cases of atherosclertic vertebral artery aneurysms have been reported recently in the English-language literature. The case presented illustrates that this rare condition should be considered in all patients who have neck masses of undetermined etiology.     

Eagle syndrome revisited: cerebrovascular complications

Cervical pain caused by the elongation of the styloid process (Eagle syndrome) is well known to otolaryngologists but is rarely considered by vascular surgeons. We report two patients with cerebrovascular symptoms of Eagle syndrome treated in our medical center in the past year. Case 1: an 80-year-old man with acromegaly presented with dizziness and syncope with neck rotation. The patient was noted to have bilateral elongated styloid processes impinging on the internal carotid arteries. After staged resections of the styloid processes through cervical approaches, the symptoms resolved completely. Case 2: a 57-year-old man presented with acute-onset left-sided neck pain radiating to his head immediately after a vigorous neck massage. Hospital course was complicated by a 15-minute transient ischemic attack resulting in aphasia. Angiography revealed bilateral dissections of his internal carotid arteries, with a dissecting aneurysm on the right. Both injuries were immediately adjacent to the bilateral elongated styloid processes. Despite immediate anticoagulation therapy, he experienced aphasia and right hemiparesis associated with an occlusion of his left carotid artery. He underwent emergent catheter thrombectomy and carotid stent placement, with near-complete resolution of his symptoms. Elongated styloid processes characteristic of Eagle syndrome can result in both temporary impingement and permanent injury to the extracranial carotid arteries. Although rare, Eagle syndrome should be considered in the differential diagnosis in patients with cerebrovascular symptoms, especially those induced by positional change.     

Management of alcohol withdrawal in microvascular head and neck reconstruction

Alcohol use is a risk factor for head and neck cancer. One of the primary therapeutic modalities is surgical tumor ablation followed by immediate reconstruction. Such therapy places patients in a controlled environment, without alcohol, creating the risk of alcohol withdrawal syndrome. The authors attempted to identify the incidence of alcohol withdrawal among patients undergoing free-flap reconstruction for head and neck cancer and were interested in the effect of alcohol withdrawal on the postoperative course of affected patients. In this retrospective review of 51 patients, six experienced alcohol withdrawal or delirium tremens. No difference in the rate of overall complications was seen between the patients who experienced withdrawal and those who did not, although patients who experienced withdrawal did have a statistically significant ratio of non-flap-related to flap-related complications. A review of the current management for alcohol withdrawal is included and places an emphasis on preoperative screening, close observation, rapid diagnosis, and immediate medical care.     

Planned neck dissection for advanced primary head and neck malignancy treated with organ preservation therapy: disease control and survival outcomes

BACKGROUND: The role of planned neck dissection after organ preservation therapy with radiotherapy or chemotherapy/radiotherapy for advanced head and neck cancers presenting with clinically positive neck disease is still being elucidated. The aim of this study is to review the outcomes of such patients treated by organ preservation therapy at our institution. METHODS: A retrospective chart review of 33 patients who underwent planned neck dissections after organ preservation therapy for advanced primary head and neck malignancy. Endpoints measured were disease-free survival and local, regional, and distant control. SETTING: Tertiary metropolitan medical center. RESULTS: Two-year actuarial disease-free survival was 61%, and neck control was 92%, with only two failures in the neck. The use of neoadjuvant chemotherapy and total dose of radiotherapy did not correlate with neck control or disease-free survival. The presence of pathologically positive nodal disease at the time of neck dissection did not correlate with recurrent neck disease, but was a predictor of local recurrence (p = .0086). CONCLUSIONS: Our data suggest that for patients undergoing planned neck dissection after organ preservation therapy, neck control is obtained in almost all cases. The presence of pathologically positive nodal disease at the time of surgery may have implications for the incidence of local recurrence.     

Octogenarian free flap reconstruction: complications and cost of therapy.

OBJECTIVE: The study goal was to document the reliability, incidence of complications, and cost of therapy for patients older than 80 years who undergo microvascular head and neck reconstruction. PATIENTS AND METHODS: Thirteen octogenarians underwent free flap reconstruction of defects resulting from the treatment of head and neck cancer at an academic tertiary care medical center. The incidence of medical and reconstructive complications and the cost of hospitalization were compared with those for 99 younger patients who were treated during the same time period. RESULTS: There were no cases of free flap failure or significant reconstructive complications in the octogenarians. The incidence of medical complications was 62% in the octogenarians and 15% in the younger patients. The average cost of therapy was $54,702 per octogenarian patient compared with $30,397 per younger patient. The increased incidence of medical complications and increased cost arose primarily from an increased severity of preoperative systemic illness in the octogenarians. However, controlling for comorbidity did not eliminate the discrepancy in medical complications between the octogenarians and the younger patients. CONCLUSIONS: Although microvascular head and neck reconstruction in the elderly is very reliable, the incidence of medical complications and the cost of therapy are significantly increased in octogenarians.     

Laparoscopic splenectomy for Evans syndrome

Evans syndrome is a rare, chronic, sometimes fatal immunologic disorder defined as Coombs' positive hemolytic anemia and immune thrombocytopenia without an underlying etiology. This syndrome has a variable clinical course, and the benefit of splenectomy is unknown. This report reviews the clinical outcome of laparoscopic splenectomy for Evans syndrome. A retrospective review was conducted of patients undergoing laparoscopic splenectomy for autoimmune hemolytic anemia and concomitant immune thrombocytopenic purpura at the Cleveland Clinic Foundation from August 1995 through August 2001. Data were collected in a prospective database and included demographic characteristics of the patients, surgical indications, operative details, and postoperative follow-up information. Five patients underwent laparoscopic splenectomy for Evans syndrome. At mean follow-up of 18 months (range, 1-31) after laparoscopic splenectomy, two patients had normal platelet counts (>100,000/microL) and required no further medical therapy. Two patients did not respond to laparoscopic splenectomy and are still undergoing medical therapy. One patient initially responded to laparoscopic splenectomy but became thrombocytopenic at 18 months and required further medical therapy. After 2 months of further medical treatment, this patient is currently (at month 10) in remission. Laparoscopic splenectomy for Evans syndrome is safe and technically feasible. The clinical outcome of splenectomy for patients with Evans syndrome is unpredictable. This select cohort of patients requires extensive long-term follow-up to determine the merits of splenectomy.     

Cavernous sinus involvement in head and neck cancer

Spread of tumor to intracranial structures is an infrequent and late manifestation of head and neck cancers. We recently encountered six patients with a distinct clinical syndrome due to involvement of the cavernous sinus, which forms the basis of this report. This syndrome was a source of significant morbidity and mortality, with a mean survival of only 4 months. The diagnosis is often elusive, but is now made more commonly than previously. Whether this reflects increased incidence (due to alterations in the natural history of disease by therapy) or improved diagnosis (due to modern imaging modalities) is unknown. Cavernous sinus involvement may be the first evidence of distant disease in head and neck cancer. Although survival is poor, palliation is worthwhile. Awareness of this syndrome can lead to earlier diagnosis and alteration of treatment.     

Tracheoesophageal displacement index and predictors of airway obstruction for fetuses with neck masses

PurposeThere are no established selection guidelines to determine which fetuses with giant neck masses may benefit from delivery using an ex utero intrapartum treatment procedure. The purposes of this study were to describe the tracheoesophageal displacement index (TEDI), a novel measurement of fetal airway displacement, and to correlate this measurement and other prenatal findings to the extent of airway obstruction at birth.MethodsThe medical records of all fetuses with giant neck masses evaluated between 2001 and 2011 were reviewed. At birth, each infant's airway was categorized as uncomplicated or complicated. Prenatal variables were correlated with airway difficulty.ResultsThere were 24 fetuses with large neck masses (11 lymphatic malformations, 10 teratomas, 3 others). One fetus died in utero, and 3 underwent pregnancy termination. Variables associated with a complicated airway at birth included polyhydramnios, teratoma diagnosis, and tracheoesophageal displacement index. Tracheoesophageal displacement index greater than 12 correlated strongly with a complicated airway (area under the curve = 0.80). All fetuses classified with an uncomplicated airway (n = 7) had a diagnosis other than teratoma and normal amniotic fluid volume.ConclusionIn fetuses with giant neck masses, the presence of polyhydramnios, teratoma diagnosis, or tracheoesophageal displacement index greater than 12 are predictive of a complicated airway at birth. Our data suggest that fetuses without any of these findings may be delivered safely without an ex utero intrapartum treatment approach.     

Carotidynia managed by surgical denervation of the carotid bulb

Carotidynia is a syndrome of pain in the neck and face accompanied by local tenderness of the carotid artery. The symptoms are often misdiagnosed due to similarities with more common syndromes involving the cervical region. Spontaneous remission is common; more severe cases generally respond to anti-inflammatory medication or prophylactic drugs used for migraine. A case of severe carotidynia, unassociated with migraine is reported. Failure to respond to medical therapy led to surgical denervation of the carotid bulb. The immediate relief of symptoms following surgery confirms earlier observations regarding the mechanism of the symptoms. In severe cases of carotidynia, surgical denervation of the carotid artery may be indicated if medical therapy has failed.     

Anatomic location and variety of nonmalignant neck masses seen in surgical practice.

During a 10-year interval, 189 patients, comprised of 121 females and 68 males ranging in age from 1 to 98 years, were surgically treated for nonmalignant neck masses. Nonmalignant neck masses were located in the thyroid or submaxillary gland in 60 per cent of these patients. Thyroid adenoma, reactive cervical nodes, and mixed tumor of the submaxillary salivary glands represented the three most commonly occurring nonmalignant pathologic conditions in this series. When stratified by age and sex, thyroid abnormalities, specifically thyroid adenoma, occurred most often in females of all ages. In males, reactive nodes were usually seen before 40 years of age; thereafter, tumors of the submaxillary salivary gland predominated. Most studies of nonmalignant neck masses indicate that reactive nodes are the most common condition in patients of all ages. Thyroid conditions were seen most frequently in this group of patients. The probable explanation is a tertiary referral pattern to surgeons. Patients with nonsurgical conditions were, presumably, identified and managed earlier and not referred further, and therefore did not appear in this group of patients.     

Complications of radical neck dissection: A survey of 788 patients

Radical neck dissection remains the keystone to modern head and neck surgery. Like any major operation, it has inherent complications. These complications become greater when the procedure is combined with resection of primary lesions of the upper food and air passages, and when it follows radiation therapy. In this series, 788 patients with head and neck cancer underwent radical neck dissection alone or in combination with resection of a primary lesion, some with and some without irradiation; the overall complication rate was 50.8%. The total rate included 16.2% of the patients having one or more major surgical complications, 33.5% having one or more minor surgical complications, and 28% having one or more medical complications. The complications are reported in detail to allow comparison with other series and to give a true indication of the overall incidence of the risks involved in major head and neck cancer surgery.     

Role of open lung biopsy in diagnosing pulmonary complications of AIDS.

Over a 4-year period, 25 patients with pulmonary complications of acquired immunodeficiency syndrome underwent open lung biopsy for diagnosis. Results of the biopsy led to a change in therapy in 15, and of this group, 8 patients improved clinically and were discharged. We believe that a select group of acquired immunodeficiency syndrome patients with pulmonary disease will benefit from open lung biopsy. Our indications for open lung biopsy are (1) a nondiagnostic bronchoscopy, (2) failed medical therapy after a diagnostic bronchoscopy, (3) failed empiric medical therapy after a nondiagnostic bronchoscopy or after a second nondiagnostic bronchoscopy, and (4) when any of the forementioned are accompanied with a worsening chest roentgenogram. Patients with acquired immunodeficiency syndrome who have a deteriorating respiratory status or require mechanical ventilation should not undergo open lung biopsy.     

The coherence between fine needle aspiration cytology and histopathology of palpable neck nodes in lower lip carcinoma patients

Obtaining a preoperative diagnosis of palpable neck nodes in head and neck carcinoma patients provides accurate staging and allows a treatment plan to be established. Fine-needle aspiration cytology (FNAC) of palpable neck nodes was performed in 26 consecutive lower lip carcinoma patients. This resulted in 100% specificity, 88.8% accurate diagnosis, and 71.4% sensitivity; 83.4% of the mobile and soft neck masses which were examined were benign nodes (r=0.834). These results showed a consistency of the histopathological findings in this very particular patient group. The outpatient FNAC of neck masses was well tolerated by our patients. This procedure is safe, quick, and does not compromise the node dissection. Furthermore, the cost-effectiveness of FNAC makes it useful in disease staging.     

Anaesthesia for patients with mediastinal masses

Anaesthesia for patients with mediastinal masses may be associated with significant respiratory and cardiovascular complications. In this review, we discuss the anatomical and pathological considerations in these adult and paediatric patients and the three types of intra-thoracic compromise that may be found: compression of the tracheobronchial tree, compression of the pulmonary artery and heart and the superior vena caval syndrome. Patient evaluation by symptom history, computerized tomography and flow-volume loops is emphasized. Preoperative thoracic radiation therapy in severely symptomatic patients is associated with a decrease in postoperative respiratory complications and an improvement in risk. During radiation therapy a small window can be created to spare some tissue for adequate histological diagnosis. Anaesthetic management techniques for these patients are discussed. Life-threatening complications can occur at any point during anaesthesia for patients with mediastinal masses. Anaesthetists should have a high degree of awareness of the underlying anatomy, pathophysiology and anaesthetic alternatives when caring for these patients.     

Multidisciplinary management of congenital giant head and neck masses: Our experience and review of the literature

Background

Large fetal head and neck (HN) masses can be life-threatening at birth and postnatally owing to airway obstruction. The two most frequent congenital masses that may obstruct the airway are lymphatic malformation (LM) and teratoma. The aim of this paper was to evaluate the results of our experience in the management of giant congenital HN masses and to conduct a literature review.

Pilomatrixoma of the head and neck in children.

OBJECTIVE: Pilomatrixomas are benign skin neoplasms of hair follicle origin. They are one of the most common superficial masses of the head and neck excised in children. Although the entity has been well studied in the literature, few studies have been undertaken to evaluate the clinical characteristics of head and neck pilomatrixomas specifically in children. The purpose of this study was to review the clinical characteristics and management of children presenting with pilomatrixomas of the head and neck at a large tertiary care pediatric hospital. STUDY DESIGN: A retrospective chart review was performed of all patients with histologically confirmed pilomatrixoma of the head and neck excised during a 6-year period (1992-1997) at the Children's Hospital of Philadelphia. RESULTS: Ninety-one cases of pilomatrixoma were confirmed in 86 patients. The age range was 5 months to 17 years. The median age at time of excision was 6.0 years. The most common sites of occurrence were the cheek (36%), neck (20%), periorbital region (14%), and scalp (9%). The male to female ratio was 1:1.5. Multiple lesions were found in 8.2% of patients. Surgical excision was curative in all cases. CONCLUSION: Pilomatrixoma is a cutaneous neoplasm that is one of most common causes of superficial head and neck masses in children. Although the presurgical diagnosis may be difficult in some cases, pilomatrixoma must be kept in the differential of superficial head and neck masses in children. Surgical excision is almost always curative.     

Recovery from posttraumatic locked-in syndrome with basilar artery occlusion

A 43-year-old woman suffered mild trauma to the head and neck in an automobile accident and subsequently developed a locked-in syndrome. Arteriography revealed abnormal retrograde filling of the distal basilar artery. Dramatic improvement occurred over two months, and she eventually recovered neurologically. This case illustrates the need for early and appropriate medical management of patients with locked-in syndrome.     

Small central cervical disc syndrome: evaluation and treatment of chronic disabling neck pain

In this retrospective study of 22 patients with severe disabling neck, interscapular, and shoulder pain we evaluated the effectiveness of magnetic resonance imaging (MRI) for the diagnosis of small central cervical disc ruptures, and anterior cervical discectomy for the treatment of this condition. Conservative therapy had failed for all patients. All had been disabled for their normal activities for at least 6 months. MRI demonstrated two patterns of mid- or parasagittal disc disease. Anterior cervical discectomy produced nine excellent, six good, five fair, and two poor results. All but one patient returned to his/her former occupation. MRI is essential in the evaluation of patients with chronic neck pain who have failed conservative therapy and present with axial rather than appendicular complaints. Anterior cervical discectomy can be useful in well-selected patients with this syndrome.