Spontaneous rupture of an internal laryngocele after neck dissection: a rare complication

Publication date: Available online 30 March 2016
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): Eirini Zagkou, Thomas Aldridge, Peyman Alam, Peter A. Brennan
We present a rare, and to the best of our knowledge, previously unreported complication of the spontaneous rupture of an internal laryngocele after a routine neck dissection for metastatic squamous cell carcinoma. While this caused some diagnostic confusion, the patient was managed conservatively with no further complications.



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Endoskopische Revisionschirurgie des Nasenrückens

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Endoskopische Revisionschirurgie des Nasenrückens

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The Inflammatory Response in Psoriasis: a Comprehensive Review

Abstract

Psoriasis is a chronic inflammatory autoimmune disease characterized by an excessively aberrant hyperproliferation of keratinocytes. The pathogenesis of psoriasis is complex and the exact mechanism remains elusive. However, psoriasis is thought to result from a combination of genetic, epigenetic, and environmental influences. Recent studies have identified that epigenetic factors including dysregulated DNA methylation levels, abnormal histone modification and microRNAs expressions are involved in the development of psoriasis. The interplay of immune cells and cytokines is another critical factor in the pathogenesis of psoriasis. These factors or pathways include Th1/Th2 homeostasis, the Th17/Treg balance and the IL-23/Th17 axis. Th17 is believed particularly important in psoriasis due to its pro-inflammatory effects and its involvement in an integrated inflammatory loop with dendritic cells and keratinocytes, contributing to an overproduction of antimicrobial peptides, inflammatory cytokines, and chemokines that leads to amplification of the immune response. In addition, other pathways and signaling molecules have been found to be involved, including Th9, Th22, regulatory T cells, γδ T cells, CD8⁺ T cells, and their related cytokines. Understanding the pathogenesis of psoriasis will allow us to develop increasingly efficient targeted treatment by blocking relevant inflammatory signaling pathways and molecules. There is no cure for psoriasis at the present time, and much of the treatment involves managing the symptoms. The biologics, while lacking the adverse effects associated with some of the traditional medications such as corticosteroids and methotrexate, have their own set of side effects, which may include reactivation of latent infections. Significant challenges remain in developing safe and efficacious novel targeted therapies that depend on a better understanding of the immunological dysfunction in psoriasis.

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The Inflammatory Response in Psoriasis: a Comprehensive Review

Abstract

Psoriasis is a chronic inflammatory autoimmune disease characterized by an excessively aberrant hyperproliferation of keratinocytes. The pathogenesis of psoriasis is complex and the exact mechanism remains elusive. However, psoriasis is thought to result from a combination of genetic, epigenetic, and environmental influences. Recent studies have identified that epigenetic factors including dysregulated DNA methylation levels, abnormal histone modification and microRNAs expressions are involved in the development of psoriasis. The interplay of immune cells and cytokines is another critical factor in the pathogenesis of psoriasis. These factors or pathways include Th1/Th2 homeostasis, the Th17/Treg balance and the IL-23/Th17 axis. Th17 is believed particularly important in psoriasis due to its pro-inflammatory effects and its involvement in an integrated inflammatory loop with dendritic cells and keratinocytes, contributing to an overproduction of antimicrobial peptides, inflammatory cytokines, and chemokines that leads to amplification of the immune response. In addition, other pathways and signaling molecules have been found to be involved, including Th9, Th22, regulatory T cells, γδ T cells, CD8⁺ T cells, and their related cytokines. Understanding the pathogenesis of psoriasis will allow us to develop increasingly efficient targeted treatment by blocking relevant inflammatory signaling pathways and molecules. There is no cure for psoriasis at the present time, and much of the treatment involves managing the symptoms. The biologics, while lacking the adverse effects associated with some of the traditional medications such as corticosteroids and methotrexate, have their own set of side effects, which may include reactivation of latent infections. Significant challenges remain in developing safe and efficacious novel targeted therapies that depend on a better understanding of the immunological dysfunction in psoriasis.

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Scanning Electron Microscopic Examination of the Extracellular Matrix in the Decellularized Mouse and Human Cochlea

Abstract

Decellularized tissues have been used to investigate the extracellular matrix (ECM) in a number of different tissues and species. Santi and Johnson JARO 14:3-15 (2013) first described the decellularized inner ear in the mouse, rat, and human using scanning thin-sheet laser imaging microscopy (sTSLIM). The purpose of the present investigation is to examine decellularized cochleas in the mouse and human at higher resolution using scanning electron microscopy (SEM). Fresh cochleas were harvested and decellularized using detergent extraction methods. Following decellularization, the ECM of the bone, basilar membrane, spiral limbus, and ligament remained, and all of the cells were removed from the cochlea. A number of similarities and differences in the ECM of the mouse and human were observed. A novel, spirally directed structure was present on the basilar membrane and is located at the border between Hensen and Boettcher cells. These septa-like structures formed a single row in the mouse and multiple rows in the human. The basal lamina of the stria vascularis capillaries was present and appeared thicker in the human compared with the mouse. In the mouse, numerous openings beneath the spiral prominence that previously housed the root processes of the external sulcus cells were observed but in the human there was only a single row of openings. These and other anatomical differences in the ECM between the mouse and human may reflect functional differences and/or be due to aging; however, decellularized cochleas provide a new way to examine the cochlear ECM and reveal new observations.

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Scanning Electron Microscopic Examination of the Extracellular Matrix in the Decellularized Mouse and Human Cochlea

Abstract

Decellularized tissues have been used to investigate the extracellular matrix (ECM) in a number of different tissues and species. Santi and Johnson JARO 14:3-15 (2013) first described the decellularized inner ear in the mouse, rat, and human using scanning thin-sheet laser imaging microscopy (sTSLIM). The purpose of the present investigation is to examine decellularized cochleas in the mouse and human at higher resolution using scanning electron microscopy (SEM). Fresh cochleas were harvested and decellularized using detergent extraction methods. Following decellularization, the ECM of the bone, basilar membrane, spiral limbus, and ligament remained, and all of the cells were removed from the cochlea. A number of similarities and differences in the ECM of the mouse and human were observed. A novel, spirally directed structure was present on the basilar membrane and is located at the border between Hensen and Boettcher cells. These septa-like structures formed a single row in the mouse and multiple rows in the human. The basal lamina of the stria vascularis capillaries was present and appeared thicker in the human compared with the mouse. In the mouse, numerous openings beneath the spiral prominence that previously housed the root processes of the external sulcus cells were observed but in the human there was only a single row of openings. These and other anatomical differences in the ECM between the mouse and human may reflect functional differences and/or be due to aging; however, decellularized cochleas provide a new way to examine the cochlear ECM and reveal new observations.

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Distraction Osteogenesis for Management of Severe OSA in Pierre Robin Sequence: An Approach to Elude Tracheostomy in Infants

Abstract

Background

Severe obstructive sleep apnoea (OSA) is a life threatening condition associated with Pierre Robin sequence (PRS) due to mandibular micrognathia and glossoptosis. Often these patients require tracheostomy at an early age which has high morbidity. Distraction osteogenesis (DO) is an accepted method of treatment for patients with hypoplastic mandible to achieve mandibular lengthening without need for a bone graft. It has also been used in respiratory distressed neonates and infants to avoid tracheostomy.

Case report

An eight month old baby, a diagnosed case of PRS with severe OSA and recurrent episodes of aspiration pneumonia and on nasogastric tube feeding since birth was referred to us for evaluation and possibility of therapeutic augmentation of the mandible by DO. After a thorough clinico-radiological assessment the child was operated for bilateral extraoral placement of horizontal corpus distractor. A total distraction of 12 mm was carried out and consolidation of callus was monitored by USG. Postoperatively the patient was followed up for 12 months. Presently she has normal respiratory and feeding function without any episode of aspiration pneumonia.

Conclusion

Mandibular corpus DO is a safe and effective technique that can be applied to predictably relieve severe upper airway obstruction in selected PRS cases. In order to avoid the limitations of alternative surgical procedures and the tracheostomy-associated morbidity, DO should be considered among the routine treatment modalities.

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Early Postoperative Malignant Subcutaneous Emphysema: Report and Review

Abstract

Background

Subcutaneous emphysema is defined as presence of air or gas in subcutaneous tissue layer. It may be localized or generalized due to various aetiological factors. Although SE and pneumomediastinum are self-limiting conditions, life-threatening complications may develop. Escape of air into both pleural cavity causing bilateral pneumothorax and tension pneumothorax can be termed as malignant emphysema.

Purpose

To report a case of malignant generalized subcutaneous emphysema in early postoperative phase following palatoplasty.

Case Report

A 25 year old female patient was operated for closure of residual oronasal communication using an anteriorly based tongue flap. The patient was reversed from general anesthesia and shifted to the post-operative room with the endotracheal tube in situ. Sudden swelling of the face and periorbital area was noticed which spread all over the body. A diagnosis of malignant post-operative subcutaneous emphysema was made and the patient was shifted back to the operation theatre. She was managed successfully by bilateral tube thoracotomy and tracheostomy.

Conclusion

Close observation of the patient in early postoperative stage having endotracheal tube in situ is crucial to avoid such complication. Regardless of aetiology, early recognition of the clinical features of tension pneumothorax and timely intervention are necessary for the survival of the patient.

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Enhanced recovery after surgery (ERAS) pathways in autologous breast reconstruction: a systematic review

Abstract

Enhanced recovery after surgery (ERAS) pathways aim to achieve earlier recovery and reduced hospital length-of-stay (LOS) by providing multi-modal perioperative care. The tenets of ERAS pathways include pre-operative optimisation, prevention of surgical complications, reduction of physiological stress response to surgery and rehabilitation to normal function. To date, ERAS protocols have gained broad acceptance by many surgical specialities. Contemporary literature has identified decreased LOS, improved quality of care and reduced healthcare expenditures. We aimed to systematically review the current literature and assess the current state of ERAS in autologous breast reconstruction. A systematic review of MEDLINE, EMBASE, ScienceDirect, Cochrane Libraries and Web of Science databases in October 2015 was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Articles pertaining to the use of ERAS in plastic and reconstructive surgery were included for analysis. Review articles, conference proceedings and correspondence were excluded from the assessment. Five hundred fifty-seven articles were identified, of which three suitable articles were included for assessment. Of these, one series outlined the learning curve associated with ERAS pathways and two series were comparative in nature. Meta-analytical analysis was not possible do to insufficient data and heterogeneity in outcome measures. In two of these comparative series, there was no statistical difference in rates of systemic infective (OR 0.91, 95 % CI 0.29 to 2.80, p = 0.86), total flap loss (OR 1.09, 95 % CI 0.37 to 3.19, p = 0.87), partial flap loss (OR 1.64, 95 % CI 0.66 to 4.10, p = 0.29) or wound infection (OR 1.38, 95 % CI 0.78 to 2.34, p = 0.29). LOS was significantly reduced in the ERAS group in both comparative studies from 7.4 to 6.2 days (p < 0.001) and 6.6 to 3.9 days (p < 0.001), respectively. ERAS pathways in breast reconstruction appear to consistently reduce LOS. From the available literature there were no significant detrimental effects on patient care following the implementation of ERAS pathways. Further research is required to definitively determine safety in the assessed cohort and to determine reductions in healthcare-related expenditures.

Level of evidence: Not ratable

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Asthma in Urban Children: Epidemiology, Environmental Risk Factors, and the Public Health Domain

Abstract

Asthma is the most commonly reported chronic condition of childhood in developed countries, with 6.5 million children affected in the USA. A disparate burden of childhood asthma is seen among socioeconomically disadvantaged youth, often concentrated in urban areas with high poverty rates. Host factors that predispose a child to asthma include atopy, male gender, parental history of asthma, and also race, ethnicity, and genetic and epigenetic susceptibilities. Environmental factors, such as improved hygiene, ambient air pollution, and early life exposures to microbes and aeroallergens, also influence the development of asthma. With greater than 90 % of time spent indoors, home exposures (such as cockroach, rodent, and indoor air pollution) are highly relevant for urban asthma. Morbidity reduction may require focused public health initiatives for environmental intervention in high priority risk groups and the addition of immune modulatory agents in children with poorly controlled disease.

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After Breast Reconstruction, 24 Hours of Antibiotics Is Enough

After breast reconstruction surgery, 24 hours of antibiotics to fight surgical sight infections is equivalent to an extended course, according to new research.
Reuters Health Information

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Scanning Electron Microscopic Examination of the Extracellular Matrix in the Decellularized Mouse and Human Cochlea

Abstract

Decellularized tissues have been used to investigate the extracellular matrix (ECM) in a number of different tissues and species. Santi and Johnson JARO 14:3-15 (2013) first described the decellularized inner ear in the mouse, rat, and human using scanning thin-sheet laser imaging microscopy (sTSLIM). The purpose of the present investigation is to examine decellularized cochleas in the mouse and human at higher resolution using scanning electron microscopy (SEM). Fresh cochleas were harvested and decellularized using detergent extraction methods. Following decellularization, the ECM of the bone, basilar membrane, spiral limbus, and ligament remained, and all of the cells were removed from the cochlea. A number of similarities and differences in the ECM of the mouse and human were observed. A novel, spirally directed structure was present on the basilar membrane and is located at the border between Hensen and Boettcher cells. These septa-like structures formed a single row in the mouse and multiple rows in the human. The basal lamina of the stria vascularis capillaries was present and appeared thicker in the human compared with the mouse. In the mouse, numerous openings beneath the spiral prominence that previously housed the root processes of the external sulcus cells were observed but in the human there was only a single row of openings. These and other anatomical differences in the ECM between the mouse and human may reflect functional differences and/or be due to aging; however, decellularized cochleas provide a new way to examine the cochlear ECM and reveal new observations.

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Distraction Osteogenesis for Management of Severe OSA in Pierre Robin Sequence: An Approach to Elude Tracheostomy in Infants

Abstract

Background

Severe obstructive sleep apnoea (OSA) is a life threatening condition associated with Pierre Robin sequence (PRS) due to mandibular micrognathia and glossoptosis. Often these patients require tracheostomy at an early age which has high morbidity. Distraction osteogenesis (DO) is an accepted method of treatment for patients with hypoplastic mandible to achieve mandibular lengthening without need for a bone graft. It has also been used in respiratory distressed neonates and infants to avoid tracheostomy.

Case report

An eight month old baby, a diagnosed case of PRS with severe OSA and recurrent episodes of aspiration pneumonia and on nasogastric tube feeding since birth was referred to us for evaluation and possibility of therapeutic augmentation of the mandible by DO. After a thorough clinico-radiological assessment the child was operated for bilateral extraoral placement of horizontal corpus distractor. A total distraction of 12 mm was carried out and consolidation of callus was monitored by USG. Postoperatively the patient was followed up for 12 months. Presently she has normal respiratory and feeding function without any episode of aspiration pneumonia.

Conclusion

Mandibular corpus DO is a safe and effective technique that can be applied to predictably relieve severe upper airway obstruction in selected PRS cases. In order to avoid the limitations of alternative surgical procedures and the tracheostomy-associated morbidity, DO should be considered among the routine treatment modalities.

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Early Postoperative Malignant Subcutaneous Emphysema: Report and Review

Abstract

Background

Subcutaneous emphysema is defined as presence of air or gas in subcutaneous tissue layer. It may be localized or generalized due to various aetiological factors. Although SE and pneumomediastinum are self-limiting conditions, life-threatening complications may develop. Escape of air into both pleural cavity causing bilateral pneumothorax and tension pneumothorax can be termed as malignant emphysema.

Purpose

To report a case of malignant generalized subcutaneous emphysema in early postoperative phase following palatoplasty.

Case Report

A 25 year old female patient was operated for closure of residual oronasal communication using an anteriorly based tongue flap. The patient was reversed from general anesthesia and shifted to the post-operative room with the endotracheal tube in situ. Sudden swelling of the face and periorbital area was noticed which spread all over the body. A diagnosis of malignant post-operative subcutaneous emphysema was made and the patient was shifted back to the operation theatre. She was managed successfully by bilateral tube thoracotomy and tracheostomy.

Conclusion

Close observation of the patient in early postoperative stage having endotracheal tube in situ is crucial to avoid such complication. Regardless of aetiology, early recognition of the clinical features of tension pneumothorax and timely intervention are necessary for the survival of the patient.

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Enhanced recovery after surgery (ERAS) pathways in autologous breast reconstruction: a systematic review

Abstract

Enhanced recovery after surgery (ERAS) pathways aim to achieve earlier recovery and reduced hospital length-of-stay (LOS) by providing multi-modal perioperative care. The tenets of ERAS pathways include pre-operative optimisation, prevention of surgical complications, reduction of physiological stress response to surgery and rehabilitation to normal function. To date, ERAS protocols have gained broad acceptance by many surgical specialities. Contemporary literature has identified decreased LOS, improved quality of care and reduced healthcare expenditures. We aimed to systematically review the current literature and assess the current state of ERAS in autologous breast reconstruction. A systematic review of MEDLINE, EMBASE, ScienceDirect, Cochrane Libraries and Web of Science databases in October 2015 was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Articles pertaining to the use of ERAS in plastic and reconstructive surgery were included for analysis. Review articles, conference proceedings and correspondence were excluded from the assessment. Five hundred fifty-seven articles were identified, of which three suitable articles were included for assessment. Of these, one series outlined the learning curve associated with ERAS pathways and two series were comparative in nature. Meta-analytical analysis was not possible do to insufficient data and heterogeneity in outcome measures. In two of these comparative series, there was no statistical difference in rates of systemic infective (OR 0.91, 95 % CI 0.29 to 2.80, p = 0.86), total flap loss (OR 1.09, 95 % CI 0.37 to 3.19, p = 0.87), partial flap loss (OR 1.64, 95 % CI 0.66 to 4.10, p = 0.29) or wound infection (OR 1.38, 95 % CI 0.78 to 2.34, p = 0.29). LOS was significantly reduced in the ERAS group in both comparative studies from 7.4 to 6.2 days (p < 0.001) and 6.6 to 3.9 days (p < 0.001), respectively. ERAS pathways in breast reconstruction appear to consistently reduce LOS. From the available literature there were no significant detrimental effects on patient care following the implementation of ERAS pathways. Further research is required to definitively determine safety in the assessed cohort and to determine reductions in healthcare-related expenditures.

Level of evidence: Not ratable

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Distraction Osteogenesis for Management of Severe OSA in Pierre Robin Sequence: An Approach to Elude Tracheostomy in Infants

Abstract

Background

Severe obstructive sleep apnoea (OSA) is a life threatening condition associated with Pierre Robin sequence (PRS) due to mandibular micrognathia and glossoptosis. Often these patients require tracheostomy at an early age which has high morbidity. Distraction osteogenesis (DO) is an accepted method of treatment for patients with hypoplastic mandible to achieve mandibular lengthening without need for a bone graft. It has also been used in respiratory distressed neonates and infants to avoid tracheostomy.

Case report

An eight month old baby, a diagnosed case of PRS with severe OSA and recurrent episodes of aspiration pneumonia and on nasogastric tube feeding since birth was referred to us for evaluation and possibility of therapeutic augmentation of the mandible by DO. After a thorough clinico-radiological assessment the child was operated for bilateral extraoral placement of horizontal corpus distractor. A total distraction of 12 mm was carried out and consolidation of callus was monitored by USG. Postoperatively the patient was followed up for 12 months. Presently she has normal respiratory and feeding function without any episode of aspiration pneumonia.

Conclusion

Mandibular corpus DO is a safe and effective technique that can be applied to predictably relieve severe upper airway obstruction in selected PRS cases. In order to avoid the limitations of alternative surgical procedures and the tracheostomy-associated morbidity, DO should be considered among the routine treatment modalities.

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Early Postoperative Malignant Subcutaneous Emphysema: Report and Review

Abstract

Background

Subcutaneous emphysema is defined as presence of air or gas in subcutaneous tissue layer. It may be localized or generalized due to various aetiological factors. Although SE and pneumomediastinum are self-limiting conditions, life-threatening complications may develop. Escape of air into both pleural cavity causing bilateral pneumothorax and tension pneumothorax can be termed as malignant emphysema.

Purpose

To report a case of malignant generalized subcutaneous emphysema in early postoperative phase following palatoplasty.

Case Report

A 25 year old female patient was operated for closure of residual oronasal communication using an anteriorly based tongue flap. The patient was reversed from general anesthesia and shifted to the post-operative room with the endotracheal tube in situ. Sudden swelling of the face and periorbital area was noticed which spread all over the body. A diagnosis of malignant post-operative subcutaneous emphysema was made and the patient was shifted back to the operation theatre. She was managed successfully by bilateral tube thoracotomy and tracheostomy.

Conclusion

Close observation of the patient in early postoperative stage having endotracheal tube in situ is crucial to avoid such complication. Regardless of aetiology, early recognition of the clinical features of tension pneumothorax and timely intervention are necessary for the survival of the patient.

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The Pursuit of Otolaryngology Subspecialty Fellowships

Objectives

To examine otolaryngology resident interest in subspecialty fellowship training and factors affecting interest over time and over the course of residency training

Study Design

Cross-sectional study of anonymous online survey data.

Setting

Residents and fellows registered as members-in-training through the American Academy of Otolaryngology–Head and Neck Surgery.

Subjects and Methods

Data regarding fellowship interest and influencing factors, including demographics, were extracted from the Section for Residents and Fellows Annual Survey response database from 2008 to 2014.

Results

Over 6 years, there were 2422 resident and fellow responses to the survey. Senior residents showed a statistically significant decrease in fellowship interest compared with junior residents, with 79% of those in postgraduate year (PGY) 1, 73% in PGY-2 and PGY-3, and 64% in PGY-4 and PGY-5 planning to pursue subspecialty training (P < .0001). Educational debt, age, and intended practice setting significantly predicted interest in fellowship training. Sex was not predictive. The most important factors cited by residents in choosing a subspecialty were consistently type of surgical cases and nature of clinical problems.

Conclusions

In this study, interest in pursuing fellowship training decreased with increased residency training. This decision is multifactorial in nature and also influenced by age, educational debt, and intended practice setting.

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Oral Steroid Usage for Otitis Media with Effusion, Eustachian Tube Dysfunction, and Tympanic Membrane Retraction

Objectives

Avoiding oral steroids for otitis media with effusion (OME) is endorsed as a performance measure by the National Quality Foundation, but data regarding current gaps and practice patterns are lacking. Our objectives were to evaluate oral steroid use for OME and the related diagnoses of eustachian tube dysfunction (ETD) and tympanic membrane retraction (TMR), to assess variations by visit setting, and to identify opportunities for measurable performance improvement.

Study Design

Cross-sectional analysis of a national database.

Setting

Ambulatory visits in the United States.

Subjects

Children and adults in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (2005-2010).

Methods

Data were coded for patient demographic information, potential confounders (eg, concurrent conditions managed by oral steroids), and diagnosis of OME, ETD, or TMR (OME/ETD/TMR). The latter 2 diagnoses were included to meet minimum numbers for reliability of weighted estimates, but OME constituted the majority of cases. Multivariate regression was used to determine the variables associated with oral steroid use.

Results

Among 590,772 observations representing 7,191,711,480 visits for OME/ETD/TMR, 3.2% resulted in a new prescription for oral steroid medication (2.3% for children, 7.0% for adults). Adults were more likely to receive steroids (odds ratio = 3.50, P < .001) than those with other diagnoses, but a similar association was not found for children. Patients seen by an otolaryngologist or in the emergency department were less likely to receive steroids than those seen in other settings.

Conclusions

OME/ETD/TMR is infrequently treated with oral steroids, particularly in children. Opportunities for performance improvement are limited.

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