Pediatric laryngeal trauma: a case series at a tertiary children's hospital

Background

Pediatric blunt or sharp laryngotracheal injuries are infrequent because of the softer cartilages and the protection of the prominent mandible. These injuries usually occur secondary to striking furniture or via the “clothesline” injury.

Methods

We present five cases of pediatric laryngotracheal injury (thyroid cartilage, true vocal cords, cricoid cartilage, cricotracheal junction, and posterior tracheal wall).

Results

We examined the need for intubation, need for tracheostomy, length of intubation, length of hospital stay, interval until direct laryngoscopy, use of steroids, post-injury swallowing, and post-injury phonation.

Discussion

Three of the five patients were intubated either prior to arrival or upon arrival to the emergency department. Two of the patients underwent direct laryngoscopy on the day of arrival. Three patients received steroids. CT (computed tomography) was not helpful in diagnosis or decision regarding treatment. The patients with thyroid cartilage fracture, cricoid cartilage fracture, cricotracheal separation, and posterior tracheal wall tear required open repair. The tracheal wall injury, cricoid fracture, and cricotracheal separation were repaired with sutures and the thyroid cartilage fracture with a plate and screws. One tracheal stent was placed. Two open repairs were performed within 24 h of injury. The patient with posterior tracheal wall injury experienced persistent dysphagia and dysphonia, which may have been secondary to intraoperative dissection.

Conclusion

Dyspnea was not necessarily indicative of the severity of injury in our patients. CT added little information about the integrity of the larynx not already known by physical examination. Open repair was usually indicated for the blunt neck injuries in our series. Oral intubation proved less difficult than tracheostomy in our patient with cricoid cartilage fracture.     

Facial nerve mapping and monitoring in lymphatic malformation surgery

Objective

Establish the efficacy of preoperative facial nerve mapping and continuous intraoperative EMG monitoring in protecting the facial nerve during resection of cervicofacial lymphatic malformations.

Methods

Retrospective study in which patients were clinically followed for at least 6 months postoperatively, and long-term outcome was evaluated. Patient demographics, lesion characteristics (i.e., size, stage, location) were recorded. Operative notes revealed surgical techniques, findings, and complications. Preoperative, short-/long-term postoperative facial nerve function was standardized using the House-Brackmann Classification. Mapping was done prior to incision by percutaneously stimulating the facial nerve and its branches and recording the motor responses. Intraoperative monitoring and mapping were accomplished using a four-channel, free-running EMG. Neurophysiologists continuously monitored EMG responses and blindly analyzed intraoperative findings and final EMG interpretations for abnormalities.

Results

Seven patients collectively underwent 8 lymphatic malformation surgeries. Median age was 30 months (2-105 months). Lymphatic malformation diagnosis was recorded in 6/8 surgeries. Facial nerve function was House-Brackmann grade I in 8/8 cases preoperatively. Facial nerve was abnormally elongated in 1/8 cases. EMG monitoring recorded abnormal activity in 4/8 cases—two suggesting facial nerve irritation, and two with possible facial nerve damage. Transient or long-term facial nerve paresis occurred in 1/8 cases (House-Brackmann grade II).

Conclusions

Preoperative facial nerve mapping combined with continuous intraoperative EMG and mapping is a successful method of identifying the facial nerve course and protecting it from injury during resection of cervicofacial lymphatic malformations involving the facial nerve.     

Metastatic basal cell carcinoma

Objective

The purpose of this study is to review our series of metastatic basal cell carcinomas of the head and neck.

Study Design

A retrospective review was conducted for this study.

Methods

All cases of documented metastatic basal cell carcinomas arising from a primary within the head and neck region and presenting for treatment to one of the authors (Y.D.) were included in this review.

Results

Nine patients were available for review. Five patients had extension to but not transgression of the base of skull. Sites for metastatic disease included 4 lungs and 5 parotid glands. All metastatic lesions were treated with surgical excision, and 6 also received postoperative radiation therapy. No patient deaths from disease have been noted at an average follow-up of 4.7 years (range, 3-8.5 years). No evidence of further metastatic disease has been noted in any of these patients on follow-up.

Conclusions

Metastatic basal cell carcinoma arising from a head and neck primary is a rare entity. However, initial involvement of the skull base and/or dura by a basal cell carcinoma appears to warrant a complete metastatic workup and metastatic surveillance. When metastatic disease is discovered, it appears to be well treated by surgical resection with/without adjunctive radiation therapy. We do not favor chemotherapy for resectable basal cell carcinomas.     

A silicone nasal swab for the treatment of severe and recalcitrant epistaxis in hereditary hemorrhagic telangiectasia: an alternative to surgical nostril closure

Background

Epistaxis is the most common symptom in patients with hereditary hemorrhagic telangiectasia (HHT). In severely affected cases, cessation of the nasal airflow seems to be the only long-term effective treatment. Such procedure deeply affects patient's quality of life (QoL) and is sometimes refused.

Methods

This study investigated the effectiveness of a tailored silicone nasal swab on 2 patients affected by HHT and severe epistaxis.

Results

In both cases, we observed a good clinical effect, with significant reduction of epistaxis and improved QoL.

Conclusions

Our preliminary results indicate that the silicone nasal swab can be considered an effective way of treating severe epistaxis in patients with HHT. Its advantages, in terms of maintained airflow patency, reversibility, and improved QoL, are highlighted.     

Hearing results of stapedotomy and malleo-vestibulopexy in congenital hearing loss

Aims

To analyze hearing results of surgical treatment of hearing loss associated with the congenital stapes ankylosis with or without malformations of ossicular chain.

Study design

Retrospective chart review.

Methods

The charts of 1369 stapedotomies performed by senior author (JH) from 1991 to 2006 were reviewed. In 40 cases operative findings were consistent with isolated congenital stapes fixation or associated with middle ear malformations. The modified stapedotomy technique was employed in 33 cases and malleo-vestibulopexy was used in 7 cases. Operative findings were standardized according to Cremers’ classification. The outcomes of 40 surgeries were analyzed according to the 1995 AAO-HNS Committee on Hearing and Equilibrium guidelines. High frequency hearing results on 4, 8 and 12 kHz were reported in addition to standard frequencies. Results of stapedotomies and malleo-vestibulopexies were calculated separately. Surgical complications were described.

Results

The mean post-operative air conduction (AC) was 33 dB, bone conduction (BC) 22 dB and speech reception thresholds (SRT) 31 dB. Closure of the air-bone gap (ABG) to within 10 dB was achieved in 24/40 (60%) of cases. Lack of improvement was observed in 3/40 (8%) patients. In 26/32 (81%) of cases with potential for bilaterally serviceable hearing it was achieved. In 24/40 (60%) of cases symmetrical hearing with interaural difference of less than 10 dB was demonstrated.

Conclusion

Significant hearing gain in patients with congenital stapes ankylosis makes surgical treatment a valuable adjunct or an alternative to hearing aids in selected cases.     

Evaluation of pediatric subglottic cysts

Introduction

Subglottic cysts (SGCs) are increasingly recognized as a cause of upper airway obstruction in previously intubated infants. Endoscopic marsupialization with cold steel instruments or CO₂ laser has been reported to be the standardised treatment method for SGCs. SGC case series of 9 patients who were treated with endoscopic marsupialization with cold steel instruments or CO₂ laser and mechanical decompression with balloon dilatation are presented.

Patients and methods

Retrospective study of 9 cases of subglottic cysts treated between 2003 and 2010 was done. Diagnoses were made by performing flexible nasopharyngolaryngoscopy and surgical treatment was done through endoscopic marsupialization with cold steel instruments or CO₂ laser.

Results

The age range of SGC patients were between 3 months and 36 months (average 12, 11 months). Two of the patients were female (2/9), 7 of them were male (7/9). SGC diagnoses were made by flexible nasopharyngolaryngoscopy. History of intubation was noted in 3 of the patients (3/9). Duration of intubation was 28 days, 6 days, and 8 days respectively. Cysts were multiple in all cases, and located posteriorly and laterally at the subglottic area and upper trachea. The patients presented with were stridor, fail to thrive, and recurrent croup attacks. Treatment methods preferred for these patients were endoscopic marsupialization with cold steel instruments or CO₂ laser and mechanical decompression with balloon dilatation. The follow-up period after treatment ranged between 8 months and 3 years. Recurrence of the SGCs did not happen and re-evaluation under general anesthesia was reserved for the symptomatic patients.

Conclusion

Diagnostic laryngoscopy and bronchoscopy are important in diagnosing SGC. History of premature birth and intubation are not ‘sine qua non’ of SGC as SGC may be congenital as well. Symptoms of SGCs may mimic the characteristic features of chronic obstructive lung disease, so evaluation of the airway should be considered in such infants if they have stridor or hoarseness not responding to routine treatment. Laryngoscopy and bronchoscopy are routinely indicated for airway evaluation in at-risk infants.     

Snail as a novel marker for regional metastasis in head and neck squamous cell carcinoma

Objective

Previous studies have shown Snail expression integral to the epithelial-mesenchymal transition during tumor progression. However, its behavior in clinical head and neck squamous cell carcinomas (HNSCCs) is yet undefined. We therefore sought to (1) investigate clinical and histopathologic characteristics of Snail-positive HNSCC and (2) understand the link between Snail and other commonly used HNSCC tumor markers.

Study Design

A retrospective case-control study was conducted.

Setting

This study was conducted in a large-scale academic center.

Study Subjects

Of 51 consecutive HNSCC, 42 surgical resections were included.

Methods

Two separate pathologists performed standard histopathologic reviews along with immunohistochemistries (Snail, E-cadherin, p16, epidermal growth factor receptor [EGFR]) and in situ hybridization (human papilloma virus [HPV]). Medical review for all cases was performed.

Results

Twenty-two (52%) of 42 cases stained 4+ Snail (>75% staining). The remaining 20 cases were considered negative. Snail was strongly inversely related to E-cadherin expression (ρ = −0.69, P < .001), but statistically independent from HPV, p16, or EGFR expression. Snail(+) tumors were equally represented from each anatomic subsite. Snail(+) tumors were strongly associated with poor differentiation (P < .001) and basaloid classification (P = .004). Snail(+) tumors were also strongly associated with lymphovascular invasion (P = .02), but not perineural invasion. Ultimately, 11 (50%) of 22 of Snail(+) tumors demonstrated positive nodal metastasis and 11 (79%) of 14 node-positive cases were Snail(+) (P = .02).

Conclusion

This pilot study provides promising evidence of Snail' role as a molecular prognostic marker for HNSCC. Snail positivity is significantly predictive of poorly differentiated, lymphovascular invasive, as well as regionally metastatic tumors. Because Snail positivity appears independent of HPV, p16, and EGFR expression, Snail may prove to improve upon these markers' predictive limitations.     

Primary cartilage tympanoplasty: our technique and results

Cartilage has shown to be a promising graft material to close tympanic membrane perforations. However, due to its rigid quality, doubts are raised regarding its sound conduction properties. It has been suggested that acoustic benefit may be obtained by thinning the cartilage. We describe our innovative method for harvesting tragal cartilage from the same endaural incision and also describe preparation of the graft by slicing it. We present our 3-year experience of shield cartilage type 1 tympanoplasty using sliced tragal cartilage-perichondrium composite graft.

Aim

The aim of this study was to prove the success rate of our technique of shield cartilage tympanoplasty using sliced tragal cartilage graft in terms of functional and anatomic results.

Study design

Retrospective analysis of type 1 cartilage tympanoplasties using sliced tragal cartilage was carried out in MIMER Medical College and Sushrut ENT Hospital during May 2005 to January 2008 with a minimum follow-up of 2 years.

Method and materials

A total of 223 ears were operated by our technique.

Results

The overall success rate of our technique was 98.20% in terms of perforation closure and air bone gap closure within 7.06 ± 3.39 dB. The success rates in the various age group are as follows: 11 to 20 years, 97.67%; 21 to 40 years, 99.12%; and 41 to 60 years, 96.96%.

Conclusion

Our technique of type 1 cartilage tympanoplasty achieves good anatomic and functional results.     

Airway salvation after failed anterior graft in a child with long segment stenosis

Objectives

1-Recognize difficulties and review techniques in long-segment laryngotracheal stenosis repair. 2-Contribute to increasing clinical and surgical skills in pediatric airway reconstruction through reporting our experience with a novel reconstruction technique involving use of a failed anterior graft and prolonged postoperative stenting.

Methods

Case report: 10 year old male with history of burn injury who required a tracheostomy due to prolonged intubation/inhalational injury in 2005. Subglottic/tracheal stenosis was identified and he subsequently underwent anterior costal cartilage grafting involving the thyroid cartilage, cricoid cartilage, and trachea. He remained tracheostomy dependent for six years due to failed graft and postoperative complications despite several attempts to improve the airway with CO2 laser and balloon dilation. In 2011, preoperative CT with 3D reconstruction revealed a 32 mm long segment of complete stenosis. The patient underwent suprahyoid release and single stage reconstruction with cricotracheal resection and partial preservation of the anterior costal cartilage graft found in the luminal scar tissue.

Results

Postoperatively the patient was stented with a nasal endotracheal tube for 2 weeks. Bronchoscopy showed mild tracheal collapse inferior to the site of anastamosis and granulation tissue at the site of anastomosis. Granulation tissue was removed and the subglottic anastomosis site was stented with a 2 cm Dumon stent for 6 months.

Conclusion

The problem of long segment stenosis after failed cartilage graft reconstruction of the airway is evaluated and a novel technique of laryngotracheal reconstruction involving a pre-existing failed anterior graft and short segment stenting is described.     

甲状腺乳头状腺癌侵犯气管的治疗与预后

目的探讨甲状腺乳头状腺癌（papillary thyroid carcinoma，PTC）侵犯气管的治疗方式及其预后。方法回顾性分析1980-1995年间45例PTC侵犯气管患者的临床资料。根据肿瘤侵犯气管的范围和程度不同分为气管局限性受侵组（A组）行肿瘤切除术28例，肿瘤侵及气管腔内组（B组）行根治性切除术10例和肿瘤区域广泛受侵组（C组）行姑息性切除术7例。39例行颈淋巴清扫术。术后切缘病理检查有肿瘤细胞或术中肉眼观察肿瘤切除不干净的部分患者给予术后放疗，共17例。Kaplan-Meier法计算累积生存率，组问差异采用Log．Rank法检验。结果①A组5年和10年生存率分别为85．0％和62．6％。7例术后放疗，21例术后未放疗。术后放疗与术后未放疗比较，5年和10年生存率比较差异均无统计学意义（P值均〉0．05）。②B组5年和10年生存率分别为80．0％和58．3％。术后放疗6例，未放疗4例。术后放疗与否，5年和10年生存率比较差异均无统计学意义（P值均〉0．05）。③C组5年和10年生存率分别为42．9％和28．6％。4例术后放疗患者，5年和10年生存率分别为50．0％和50．0％。3例术后未放疗患者，5年生存率为33．3％，无10年生存。术后放疗与否，其5年和10年生存率比较差异均无统计学意义（P值均〉0．05）。结论PTC气管受侵尚未侵及腔内黏膜层者可采用肿瘤切除术得以根治，穿透气管腔内黏膜层者行肿瘤根治性切除可延长患者的生存。术后放疗有可能提高姑息性切除患者的生存率。     

Exploration of endonasal endoscopic repair of pediatric cerebrospinal fluid rhinorrhea

Objectives

To summarize the clinical manifestations of pediatric cerebrospinal fluid rhinorrhea (CSFR), discuss the localization of CSFR, and the surgical approaches, the graft material selection and the prognoses of endoscopic repair of CSFR.

Methods

The case data, surgical techniques and graft materials of endonasal endoscopic approach of 43 patients with CSFR who have been treated at the Second Xiangya Hospital, Central South University in the last 13 years were retrospectively analyzed. Among them, leaks in 34 cases were from the roof of the ethmoid sinuses. Other sites included frontal sinus (1), sphenoid sinus (6), and the conjunction of ethmoid and frontal sinuses (2). 37 patients were with unilateral CSF leaks, 6 were with bilateral CSF leaks. The dimensions of the defects ranged between 8 and 22 mm. For 25 cases, the procedure was as follows: first, the wound surrounding the perimeter of the defect was freshened and the leaks were plugged by myoplasm and overlaid with iliac fascia, and followed by the use of fibrin glue and nasal packing; for 5 cases, the procedure was as follows: at first, the wound was curetted and the leaks were intracranially plugged by autologous cartilage and muscle, overlaid with iliac fascia, followed by the use of fibrin glue and nasal packing; for 6 cases, the leaks were overlaid with iliac fascia only, and then fibrin and packing were used. For the rest of 7 cases, the frontal and sphenoid sinuses were filled with muscle.

Results

Of the total 43 cases, 31 had successful closure of the leaks by endonasal endoscopic repair on first attempt; 8 had successful closure of the leaks on second attempt, 3 was cured on third attempt; while, leaks in 2 patients failed to close after three attempts. Therefore, they underwent combined intracranial and transnasal endoscopic repair, one patient was cured and another one died postoperatively because of recurrent intracranial infection. At 12 month to 24 month follow-up 42 children remained leak free.

Conclusion

Endoscopic repair of CSF leaks is the optimum approach to the treatment of pediatric CSFR, featuring minor trauma, high successful rate, fewer complications and advantage of being able to carry out a revision surgery or more if needed. For children who have a large CSF leak in size and have failed to be treated successfully via endonasal endoscopic repair, combined intracranial and endoscopic repair could be performed to close the leak.     

A 13-year experience and predictors for success in transnasal endoscopic repair of congenital choanal obliteration

Objective

To express a 13-year experience in transnasal endoscopic repair of congenital choanal obliteration and to analyze the different predictors that may affect the surgical outcome.

Design

Retrospective clinical study.

Setting

Otolaryngology Department, Tanta University Hospital, Egypt.

Patients and methods

Over a 13-year period (from January 1996 to December 2008), 54 children aged between 7 day and 14 year old at the time of surgery underwent transnasal endoscopic repair of an unilateral (32 cases) and bilateral (22 cases) congenital choanal obliteration using conventional instruments and microdebrider/drill to remove the atretic plate, bony boundaries, and vomer. A laterally based mucosal flap was routinely used to resurface most of the raw areas of the lateral and superior borders of the created choana followed by shortened period stenting (5-7 days). Patients were then clinically and endoscopically monitored for nasal obstruction and healing for a mean follow-up of 46 ± 6 months. Demographic characteristics of these patients, associated anomalies, surgical technique, postoperative stenting, complications, postoperative care, and surgeons’ learning curve were discussed in the light of the findings of the surgical outcomes.

Results

There were 33 females (61.1%) and 21 males (38.9%). A total of 12 patients (22.2%) presented with associated anomalies. There were no major intra-operative or postoperative complications. The success rate for bilateral choanal obliteration was 86.4% and for unilateral choanal obliteration 96.9% with an overall success rate 92.3%. Revision surgery of the relapsed cases using the same technique without mucosal flap was successful 100%.

Conclusion

Transnasal endoscopic repair of congenital choanal obliteration is an easy and evolving technique with adequate safety and high success rate. Early diagnosis and good preparation of the patients for surgery, adequate resection of the bony boundaries of the obliterated choana and vomer, shortened period nasal stenting, strict early and late follow-up, and the growing experience of the surgeons, all were prognostic factors for success. Associated anomalies and use of mucosal flap did not seem to affect the prognosis. Inadequate bone resection, bilaterality, pure bony obliteration, the younger the age of the patient, and early developing experience of the surgeons, all were possible predictive factors for relapse.     

A model of canine tracheal stenosis induced by radiofrequency cauterization

Objective

The current methods of management of tracheal stenosis have disadvantages and are controversial, therefore ideal experimental animal models for the further studies are required. The aim of this study was to establish a new model of canine tracheal stenosis by radiofrequency cauterization.

Methods

The tracheal cartilage ring was injured by radiofrequency at the level of the sixth tracheal ring in 12 mongrel dogs. A fibrolaryngoscope was used to guide the procedure. The animals were observed after operation and examined after euthanasia. Endoscopic and histological examinations were undertaken to evaluate the progress of stenosis. The degree of stenosis was calculated using the formula: degree of stenosis = (initial lumen area − final lumen area)/initial lumen area × 100%.

Results

Tracheal stenosis had developed in all dogs by the 21st day post operation. Costal retraction was observed in all dogs after the 18th day post operation. At the end of the study, gross and endoscopic examinations showed that stenosis had been induced to a satisfactory degree and without any complications. The median of the degree of stenosis was 92%, with a range of 84-94%. Histological examination showed that cartilage was damaged and that granulation tissue and collagen fibres had formed.

Conclusions

The model of canine tracheal stenosis induced by radiofrequency cauterization is a relatively simple, reliable, and reproducible animal model. This model may be useful in the development of new methods of treatment for tracheal stenosis.     

Tissue-engineered tracheal reconstruction using chondrocyte seeded on a porcine cartilage-derived substance scaffold

Objectives

Tracheal reconstruction with tissue-engineering technique has come into the limelight in the realm of head and neck surgery. We intended to evaluate the plausibility of allogenic chondrocytes cultured with porcine cartilage-derived substance (PCS) scaffold for partial tracheal defect reconstruction.

Methods

Powder made from crushed and decellularized porcine articular cartilage was formed as 5 mm × 12 mm (height × diameter) scaffold. Chondrocytes from rabbit articular cartilage were expanded and cultured with PCS scaffold. After 7 weeks culture, the scaffolds were implanted on a 5 mm × 10 mm artificial tracheal defect in six rabbits. Two, four and eight weeks postoperatively, the sites were evaluated endoscopically, radiologically, histologically and functionally.

Results

None of the six rabbits showed any sign of respiratory distress. Endoscopic examination did not show any collapse or blockage of the reconstructed trachea and the defects were completely covered with regenerated respiratory epithelium. Computed tomography showed good luminal contour of trachea. Postoperative histologic data showed that the implanted chondrocyte successfully formed neo-cartilage with minimal inflammatory response and granulation tissue. Ciliary beat frequency of regenerated epithelium was similar to those of normal adjacent mucosa.

Conclusions

The shape and function of reconstructed trachea using allogenic chondrocytes cultured with PCS scaffold was restored successfully without any graft rejection.     

Usefulness of dextranomer/hyaluronic acid copolymer in bronchoscopic treatment of recurrent tracheoesophageal fistula in children

Objective

Endoscopic repair of recurrent tracheoesophageal fistula (RTF) in infants who underwent surgery at birth for esophageal atresia (EA) is under investigation as an alternative to open surgery, which is technically challenging and associated with high morbidity.The aims of this paper are to present the experience of a single institution in treating RTF using a novel submucosal bronchoscopic injection of biocompatible dextranomer/hyaluronic acid (Dx/HA) copolymer, and to discuss the indications and limitations of this technique.

Methods

From 2000 to 2007, 6 children (2 boys; 4 girls) aged 1-48 months, weighing 2.5-18 kg were referred to our hospital for respiratory symptoms (pneumonia and failure to thrive) secondary to suspected RTF. All infants had undergone surgery at birth for EA with inferior tracheoesophageal fistula. Bronchoscopy revealed that five infants had RTF and one had a large remnant tracheal upper-pouch fistula.The bronchoscopic intervention was performed under general anesthesia, using a pediatric rigid bronchoscope with a 0° telescope and telemonitoring. The fistula wall mucosa was gently abraded to promote adhesion, and Dx/HA was then injected at two points in the fistula submucosa to obtain a stable swelling of the wall and closure of the RTF.

Results

In two infants (aged 1 month and 18 months) complete resolution of the RTF was achieved following two separate procedures with a 1-month interval. In three children (aged 2, 18 and 25 months) complete closure of the fistula was not achieved; however, the partial closure was sufficient to address the respiratory symptoms and allow subsequent standard open thoracic surgery without requiring recovery in the intensive care unit. Complete resolution of respiratory symptoms was also obtained following a single endoscopic procedure with two Dx/HA injections in the child with residual pouch fistula.

Conclusion

Bronchoscopic treatment of RTF with Dx/HA is a simple, minimally invasive, low-risk procedure that enables complete closure of RTF or reduction and resolution of respiratory symptoms, which in turn facilitates uncomplicated thoracic surgery. The technique also provides good results in remnant tracheal upper-pouch fistula.     

Development of canal cholesteatoma in a patient with prenatal isotretinoin exposure

Purpose

To describe the clinical and radiologic findings in a case of isotretinoin embryopathy-like syndrome and discuss management of hearing loss, congenital external auditory canal (EAC) stenosis, and EAC cholesteatoma.

Methods

Review of medical, audiological, and radiological records.

Results

An 8 year old female presented with bilateral moderate conductive hearing loss, bilateral microtia, left EAC stenosis, and right EAC atresia, secondary to prenatal isotretinoin exposure. Comorbidities included developmental delay, ventricular septal defect, hypotonia, and retinal maldevelopment. The left EAC was sharply upsloping with a 2 mm-diameter meatus. Computed tomography (CT) scan of the temporal bone demonstrated normal middle and inner ears bilaterally; serial CT scans over 6 years demonstrated progressive development of left canal cholesteatoma. Implantation of a right BAHA system was performed, followed by left canalplasty and excision of cholesteatoma with facial nerve monitoring. An endaural incision was utilized to avoid compromising future microtia repair. Postoperative left-sided hearing improved to mild low-frequency conductive hearing loss rising to normal at 2000 Hz and above.

Conclusions

Despite extensive precautions for its use, isotretinoin remains a cause of major birth defects, including sensorineural, conductive or mixed hearing loss. Congenital EAC stenosis is much less common than congenital atresia or acquired stenosis; optimal surgical approaches vary depending on hearing status and facial nerve anatomy. Close monitoring for development of canal cholesteatoma is necessary.     

A surgical technique for size reduction of exceedingly large tracheal stoma

Objective

After tracheostomy some patients may develop a tracheal stoma of excessive size. Effective application of tracheostomy tube is not possible in those patients.

Patients and methods

Inserted cannula for protection from aspiration or artificial ventilatory assistance becomes easily displaced in two patients with tracheal stoma of excessive size. A simple surgical technique for treatment of large symptomatic tracheal stoma is described in the present study.

Results

A complete symptomatic improvement was noted in those patients after size reduction of the stoma using a new surgical technique.

Conclusion

Surgical size reduction could be helpful in large tracheal stoma in which tracheal tubes could not be secured from dislocation.     

Analysis of clinicopathological stage in supracricoid partial laryngectomy patients: Need for adjuvant therapy in clinically understaged cases

Objective

The aim of this study is to evaluate the impact of pre-operative T-understaging on clinical outcome in supracricoid partial laryngectomy (SCPL).

Methods

The medical records of 92 patients who underwent SCPL were evaluated. By comparing clinical and pathologic stages, the causes of pre-operative T-understaging and its relationship with local recurrence and survival were examined.

Results

Fifteen patients (16.3%) were found to be underestimated in terms of pre-operative T-stage, primarily due to failure to identify thyroid cartilage invasion (11 cases). Among these, radiation treatment at the primary site was offered in only two cases, including one case with a positive surgical margin. Among 82 patients followed for over 1 year, local recurrence occurred in seven patients (8.5%); five of these (71.4%) had been understaged pre-operatively due to failure to detect thyroid cartilage invasion. The local recurrence rate was higher and the overall survival rate was lower in patients who were understaged pre-operatively, compared to those who were staged accurately (p = 0.006 and p = 0.001, respectively).

Conclusion

SCPL should be conducted only after a thorough pre-operative evaluation in locally advanced laryngeal cancer. Additionally, adjuvant treatment is necessary to reduce local recurrence in cases where thyroid cartilage invasion is determined pathologically after SCPL.     

Tracheal diverticulum: A case report and literature review

Purpose

Tracheal diverticulum (TD) is a rare, nonspecific symptom that is commonly associated with other malformations in clinical presentation and appearance on imaging. The case presented and the literature review performed highlight the importance of combining 3 D reconstruction technology and computerized Tomography (CT) results to better characterize TD on the list of differential diagnoses of patients.

Methods

The case described is of a 44-year-old male with a 1-year history of repeatedly coughing with white phlegm. Computerized tomography and three dimension reconstruction technology were employed to diagnose tracheal abnormalities. The patient underwent surgical resection of the tracheal diverticulum. Reexamination of the neck, chest, trachea and lungs of the patient was performed with CT scan post operation.

Results

Chest CT confirmed the presence of the air cavity lesion behind the neck segment and may be the trachea cysts. Bronchoscope examination was all normal. Furthermore, HRCT scan and the tracheal reconstruction were performed (as shown in Fig. 1), which show cystic cavity lesion was on right rear trachea and a tiny tha was connected the tracheal posterior wall. Post-operation, reexamination showed that the neck, chest CT, trachea and lungs had no detectable abnormity.

Conclusion

Diagnostic techniques such as HRCT and 3D reconstruction technology may help to diagnose the tracheal diverticulum timely and accurately. Resection of the diverticulum is the proper surgery, but only for symptomatic congenital diverticulum; therefore preoperative definite classification is important (acquired or congenital diverticulum).