Pitfalls in the management of subglottic paragangliomas at unusual location: a case report and literature review

Background Subglottic paragangliomas (PGs) are exceptionally rare and unpredictable, occasionally presenting at an atypical location. There are three different clinical forms of subglottic PGs: intraluminal (tracheal PGs), extraluminal (thyroid PGs) and the mixed type (both intraluminal and extraluminal, mixed-subglottic PGs). These tumors are usually misdiagnosed as other relatively common primary thyroid or laryngotracheal tumors, and the treatment is troublesome. Case presentation A 22-year-old male patient with subglottic PGs has been successively misdiagnosed as thyroid tumors and subglottic hemangiomas, and lastly underwent local extended lumpectomy and laryngotracheal reconstruction with a pedicled thoracoacromial artery perforator flap (PTAPF). The patient was decannulated successfully after the second-stage tracheal reconstruction with a local flap, and no evidence of local recurrence and distant metastasis of the tumor until now. Conclusion Subglottic PGs can be easily misdiagnosed as laryngotracheal or thyroid tumors when presented at an atypical location. It is essential for otolaryngologists and head and neck surgeons to remain vigilant against these tumors. If the tumor is not diagnosed or removed completely, patients may encounter a risk of lethal paroxysm, which is incredibly troublesome.

Morphometric Study of Nutrient Foramina in Dry Human Clavicles in Central India

BACKGROUND The clavicle or collar bone is a modified long bone. It is the first bone to ossify in the membrane. The inferior surface of shaft of clavicle presents a subclavian groove. A nutrient foramen lies at the lateral end of the groove. The nutrient artery is derived from the supraclavicular or clavicular branch of thoracoacromial artery. A bone is supplied by a nutrient artery which passes through the small tunnel called as nutrient foramina. In orthopaedic procedures to preserve the circulation, the topographical knowledge of the nutrient foramen is important. The study was undertaken to analyse nutrient foramina in adult human clavicles in relation to their number, position, direction, and distribution over bone length. METHODS Our study consisted of 67 adult dry human clavicles (31 right sides and 36 left sides). The number, topography and direction of the foramina were studied. The distance of foramina from the sternal end & total length of the clavicles were measured in millimetres by using digital Vernier calipers. The foramen index was calculated by applying the Hughes formula: FI = (DNF TL) x 100. RESULTS Nutrient foramina were present in all the clavicles. Most of the clavicles have single nutrient foramen. We observed 62 (68.13 %) foramina on the posterior surface mostly in the middle 1 / 3rd region. All the nutrient foramina were directed towards acromial end and the foramina index (FI) was 50.2. CONCLUSIONS The topographical knowledge of the nutrient foramen is important in orthopaedic procedures like nail plating, K wire fixation, reduction, internal fixation devices for the treatment of fracture, coracoclavicular ligament repair and in free vascularized bone graft to preserve the circulation. KEY WORDS Clavicle, Nutrient Foramina, Nutrient Artery, Foramina Index (FI)

Perforator flaps based on the deltoid branch of the thoracoacromial artery: anatomical study

Objectives: Tissue defects in the lateral triangle of the neck and the anterior cervical region represent a high demand for plastic and reconstructive surgery. Their management most often requires regional or free flaps. The perforator flap based on the deltoid branch of the thoracoacromial artery (TAA) may be a good solution for these indications. The objective of this work is to propose anatomical landmarks to raise perforator flaps pedicled on the deltoid branch of the TAA. Methods: We carried out dissection of 24 perforator flaps based on the deltoid branch of the TAA, in body donor specimens preserved in a glycerin-rich, formalin-free solution. The TAA was first injected with methylene blue. The vascular territory, location of perforators relative to known landmarks, along with the flap’s potential amplitude and arc of rotation were studied. Results: The main perforating arteries of the flap were located in the middle of the deltopectoral groove, often surrounded by adipose tissue in 18 out of 24 dissections. In 22 out of 24 dissections, there were at least 2 perforator arteries originating from the deltoid branch. The average diameter of the perforator arteries was 1 mm. The flap’s amplitude of movement made it possible to reach in all cases the lateral triangle of the neck and the anterolateral cervical region. Conclusion: The thoracoacromial artery has already been used for perforator flaps. However, the individualization of its deltoid branch offers to practitioners new surgical options. This anatomical study of the perforator flap based on the deltoid branch of the TAA made it possible to review the anatomical bases for the raising of this flap, and to fix useful landmarks for the surgeon in order to propose an easily feasible surgical technique.

Role of pectoralis major flap in resource limited settings (developing world): A case report of huge neck cancer done in Tanzania

Skin cancers are common in head and neck region particularly Basal cell carcinoma and Squamous cell carcinoma. Treatment options includes wide local excision with neck dissection followed by adjuvant radiation/chemo/chemoradiation. We report a case of a huge skin cancer of the neck about 8.5 cm in its greatest dimensions and reconstructive techniques of the defect using pectoralis major flap in a 61-years old Albino patient, what’s important is good understanding of anatomy and surgical land marks to identify the thoracoacromial artery which is the main feeder to the flap. Reconstruction was successful with acceptable morbidity and the patient was sent for chemoradiation with no reported recurrence. Presentation from this case demonstrates that the pectoralis major flap still remains the ‘workhorse’ of reconstruction in Tanzania. It is advocated to be used in resource limited countries, effectively with acceptable morbidity and results.

Clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction

Background Large or complex trachea defects often require some tissue to reconstruct, various flaps have been reported for reconstructing this defect. However, pedicled thoracoacromial artery perforator flap have not been reported in tracheal reconstruction. Therefore, this study is to assess the efficacy and clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction. Methods Eight patients who underwent tracheal reconstructions with pedicled TAAP flaps between December 2017 and October 2019 were retrospectively reviewed. Results All of the pedicled TAAP flaps in our study survived. The flap size ranged from 2 cm × 5 cm to 4 cm × 10 cm, and the size of each island of one double-island flap was 2 cm × 2.5 cm. The mean thickness was 0.6 cm, and the pedicle length varied between 6 and 9 cm (mean 7.9 cm). The mean time of flap harvest was 17 min. The mean age of the patients was 62.4 years and five elderly patients had comorbidities, such as diabetes, hypertension and asthma. One patient received a double-island flap for tracheal and esophageal reconstruction, and the other patient received simple tracheal reconstruction. One patient died due to cancer metastasis. Six patients obtained functional recovery of breathing, except one patients who did not experience closure of the tracheostomy opening due to uncompleted I131 treatment. Conclusion Pedicled TAAP flaps provide a short harvesting time, thin thickness and stable blood supply, and they do not require microsurgical skills. This flap is a good choice for the reconstruction of tracheal defects, especially in the aged or patients with comorbidities who are not able to tolerate prolonged surgery.

Clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction

Background: Large or complex trachea defects often require some tissue to reconstruct,various flaps have been reported for reconstructing this defect.However, pedicled thoracoacromial artery perforator flap have not been reported in tracheal reconstruction.Therefore,this study is to assess the efficacy and clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction.Methods: Eight patients who underwent tracheal reconstructions with pedicled TAAP flaps between December 2017 and October 2019 were retrospectively reviewed.Results: All of the pedicled TAAP flaps in our study survived. The flap size ranged from 2 cm x 5 cm to 4 cm x 10 cm, and the size of each island of one double-island flap was 2 cm x 2.5 cm. The mean thickness was 0.6 cm, and the pedicle length varied between 6 cm and 9 cm (mean 7.9 cm). The mean time of flap harvest was 17 min. The mean age of the patients was 62.4 years and five elderly patients had comorbidities,such as diabetes,hypertension and asthma. One patient received a double-island flap for tracheal and esophageal reconstruction, and the other patient received simple tracheal reconstruction. One patient died due to cancer metastasis.Six patients obtained functional recovery of breathing, except one patients who did not experience closure of the tracheostomy opening due to uncompleted I131 treatment.Conclusion: Pedicled TAAP flaps provide a short harvesting time, thin thickness and stable blood supply, and they do not require microsurgical skills. This flap is a good choice for the reconstruction of tracheal defects,especially in the aged or patients with comorbidities who are not able to tolerate prolonged surgery.