Course variations of the internal carotid artery and their significance in pharyngeal surgery

The internal carotid artery is one of the major vessels of the neck. It usually originates from the common carotid artery at the level of the 3rd–4th cervical vertebra and continues perpendicularly to the skull base in the neurovascular bundle. During common surgical procedures in the pharynx, such as adenoidectomy or tonsillectomy, the artery is usually in a safe distance from the pharyngeal wall and the risk of injury is low. However, several anatomical variations have been described that may cause medialization of the vessel closer to the pharyngeal wall, which significantly increases the risk of injury and occurrence of life-threatening haemorrhage. Keywords: internal carotid artery – tonsillectomy – haemorrhage – adenoidectomy – vascular anomalies

Zenker Diverticulum

Zenker Diverticulum is a multifactorial disorder of the Killian’s triangle in thehypopharynx characterized by the main symptoms of dysphagia affecting theseventh and eighth decades of age and rarely under 40 years of age. The existenceof factors that cause an increase in the intraluminal pressure of the pharynx willlead to the formation of a pocket located in the Killian’s triangle, an area with weakertone of the hypopharyngeal wall and a decrease in relative pressure in theretropharyngeal space. Zenker Diverticulum was first described by Ludlow in 1769,who reported abnormal dilatation of the posterior pharyngeal wall on postmortemexamination of a patient who complained a lifelong dysphagia. Zenker Diverticulumis thought to be associated with increasing age in relation to motor musclecoordination for swallowing functions and GERD (gastroesophageal reflux disease).Symptoms include dysphagia, regurgitation, malnutrition, and recurrent aspirationpneumonia. Management includes invasive surgery and non-invasive endoscopy.

Double-opposing Z-Plasty Extended with a Pedicled Buccal Fat Pad Flap for Correcting Velopharyngeal Insufficiency after Primary Palatoplasty

Introduction Furlow double-opposing Z-plasty (DOZ) lengthens the soft palate; however, this lengthening is achieved at the expense of increased mucosal flap tension. Thus, its use is limited in patients with severe tension applied on mucosal flap after DOZ. In this study, DOZ was combined with a buccal fat pad (BFP) flap to maximize palatal lengthening and muscle repositioning. Methods This study included patients who underwent surgical correction for velopharyngeal insufficiency between December 2016 and February 2019. Patients with more than moderate degree hypernasality following primary palatoplasty were included in the study. Patients younger than 4 years of age, those with a submucous cleft palate, or syndromic patients were excluded. Speech outcomes were investigated for those who underwent DOZ only (DOZ group, n = 17) and those in whom a BFP was used (BFP group, n = 15) pre- and postoperatively. The velopharyngeal gaps between the uvula and pharyngeal wall were measured before and immediately after surgery to estimate the palatal length. Results Most patients who received a BFP showed improvement in hypernasality. However, the hypernasality of the DOZ group was more severe than that of the BFP group (p = 0.023). The extent of palatal lengthening was 4.4 ± 1.7 mm and 7.5 ± 2.1 mm in the DOZ and BFP groups, respectively (p = 0.001). Conclusions BFPs reduced the tension of the DOZ mucosal flap and maximized palatal lengthening and muscle repositioning. They promoted velopharyngeal closure in patients with moderate and moderate-to-severe velopharyngeal insufficiency. Hence, our method improves the surgical outcomes of patients with velopharyngeal insufficiency after primary palatoplasty.

Characterization of dysphagia following anterior cervical spine surgery

BACKGROUND: Post-operative dysphagia is one of the most common complications of anterior cervical spine surgery (ACSS). OBJECTIVE: Examine post-operative structural and physiologic swallowing changes in patients with dysphagia following ACSS as compared with healthy age and gender matched controls. METHODS: Videofluoroscopic swallow studies of adults with dysphagia after ACSS were retrospectively reviewed. Seventy-five patients were divided into early (≤2 months) and late (> 2 months) post-surgical groups. Modified Barium Swallow Impairment Profile (MBSImP), Penetration-Aspiration Scale (PAS) scores, and pharyngeal wall thickness (PWT) metrics were compared. RESULTS: Significant differences were identified for all parameters between the control and early post-operative group. MBSImP Pharyngeal Total (PT) scores were greater in the early group (Interquartile Range (IQR) = 9–14, median = 12) versus controls (4–7, 5, P < 0.001) and late group (0.75–7.25, 2, P < 0.001). The early group had significantly higher maximum PAS scores (IQR = 3–8, median = 7) than both the control group (1–2, 1, P < 0.001) and late post-operative group (1–1.25, 1, P < 0.001). PWT was significantly greater in the early (IQR = 11.12–17.33 mm, median = 14.32 mm) and late groups (5.31–13.01, 9.15 mm) than controls (3.81–5.41, 4.68 mm, P < 0.001). CONCLUSION: Dysphagic complaints can persist more than two months following ACSS, but often do not correlate with validated physiologic swallowing dysfunction on VFSS. Future studies should focus on applications of newer technology to elucidate relevant deficits.

Amyloid deposition in oral cavity and larynx, a single institute experience

Introduction/Objective Amyloidosis is characterized by extracellular accumulation of insoluble amyloid fibril. Amyloid deposition in the head and neck area is rare. Methods/Case Report In this study, we reviewed 34 specimens from 26 patients including: 18 specimens from the larynx and/or pharynx (13 patients) and 16 specimens from the oral cavity (13 patients). The clinical presentation, related laboratory results, and pathologic finding were reviewed. Results (if a Case Study enter NA) Within the 18 laryngeal specimens were: 10 glottic, 4 supraglottic, 3 nasopharyngeal or pharyngeal wall, and 1 subglottic. Of the 16 cases from oral cavity there were 9 lingual, 3 labial, 2 palatine, 1 tonsillar, and 1 alveolar ridge. Ten out of 13 patients with laryngeal amyloid deposition had protein electrophoresis performed and only 3 of the patients had monoclonal light chain detected. Among these three patients, one had multiple myeloma, one had lymphoplasmacytic lymphoma and one had the diagnosis of plasma cell dyscrasia. Interestingly, in the patients with oral cavity amyloidosis, 10 out of 11 patients tested had abnormal findings. Six of the patients had monoclonal light chain, two demonstrated monoclonal peak of IgG kappa, one with IgG lambda and one with IgA lambda. Among these 10 patients, 6 of them had biopsy-proved or history of multiple myeloma, one patient had marginal zone lymphoma, two patients had systematic amyloidosis. Only one patient did not have any malignancy or systematic involvement identified. Conclusion In our small cohort, the most common location of amyloid deposition in the larynx is glottis. When it involves the oral cavity, tongue is the most common location. Compared to the larynx, amyloid deposition in the oral cavity tends to be associated with hematopoietic malignancy or systematic involvement, although this finding needs to be confirmed by a larger scale of study.

Utilization of Silicone Sheet as a Protective Guide During Transoral Robotic Tongue Base Surgery

This article presents a simple technique where a silicone sheet is used during transoral robotic surgery (TORS) to protect the upper airway structures from thermal damage during a base of tongue procedure. We review 10 cases of TORS tongue base reduction with the use of this technique, with no complications and with reduction of thermal damage to the lingual epiglottis and surrounding pharyngeal wall. Furthermore, it served as a guide during tongue base dissection to provide visual and tactile feedback to the inferior limit of resection, as well as to protect the endotracheal tube. The silicone sheet is an ideal material for use as a thermal barrier due to its widespread availability, intrinsic thermal properties, and translucency. The technique of using the silicone sheet is easy to implement and may prove useful to many transoral robotic surgeons, especially for newly trained TORS users and trainees.