Anterior Cervical Region Research Articles

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.

Successful management of retropharyngeal hematoma by trans-arterial embolism without intubation

BackgroundRetropharyngeal hematoma can cause suffocation if there is delay in securing the airway by intubation. However, there are also concerns about complications that can arise with intubation; it is still unknown which cases do not require intubation.Case presentationAn 88-year-old woman slipped and was found prone and was transported to the emergency room. She was alert without any stridor. Physical examination revealed a subcutaneous hematoma in the anterior cervical region. Computed tomography revealed a retropharyngeal hematoma. Angiography and computed tomography angiography showed extravasation from the right costocervical trunk. A radiologist performed trans-arterial embolization, and she had an uneventful course without intubation or developing any complication. She became ambulatory on postoperative day 5.ConclusionAngiography and computed tomography angiography help in early recognition of extravasation in retropharyngeal hematoma, and trans-arterial embolization can help to avoid intubation and its complications.

Children with cervical lymphadenopathy: reactive or not?

This study aims to evaluate the etiology of cervical lymphadenopathies in children and to define the significance of demographic, clinical, and laboratory features in the prediction of malignancy. Medical records of 527 patients were reviewed retrospectively between 2015 and 2019. The patients were examined in terms of demographics, clinical, radiologic, and serologic findings. A lymph node biopsy was performed in selected patients. The risk factors for malignancy were evaluated. Out of 527 children, 26 had neck masses mimicking lymphadenopathy; 501 had lymphadenopathy. The most common location was the anterior cervical region and the median age was 5.7 years. Thirty-nine patients had malignancy (lymphoma in 34, nasopharyngeal carcinoma in 3, leukemia in 1 and neuroblastoma in 1). The risk of malignancy was associated with older age, duration of > 4 weeks, lymph node size > 3 cm, supraclavicular location, presence of systemic symptoms, and hepatosplenomegaly (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001). On laboratory evaluation, anemia, leukocytosis, and increased erythrocyte sedimentation rate were found to be associated with malignancy (p < 0.001, p=0.003, p < 0.001). Cervical lymphadenopathies in children are generally benign but patients with persisting cervical lymphadenopathy, adolescent age, accompanying systemic symptoms and abnormal laboratory findings should be considered for an early biopsy.

MORPHOGENETICAL FEATURES OF SOME STRUCTURES IN THE ANTERIOR NECK REGION IN HUMAN EMBRYOS

One of the topical direction in morphology, aimed at ethiopathogenesis clarification ofthe birth defects and complement of the data concerning neck formation as a separatepart of the body, is the elucidation of the peculiarities of anlage and formation of thestructure of the anterior cervical area on early stages of intrauterine development of ahuman being.Purpose. To specify the anlage sources and make clear chronological sequence andmorphological transformations of some structures of the anterior cervical region inhuman embryos.Material and methods. We have examined 15 specimens of human embryos (4,0–13,5mm parietal-coccygeal length) by using a set of morphological methods of investigation:microscopy, creation of a series of histological slides, three-dimensional reconstruction,morphometry and statistical analyses.Results. The first components of II, III and IV pharyngeal arches have been found onthe 4th week of prenatal development. and their derivate is considered as a presumptivecervical region. Anlage of the hyoid bone is found on the 5th week of development asmesenchymal condensation and a derivative from II and III pharyngeal arches. On the 6thweek of development the hyoid bone precursor is on prechondrification stage, platysma isobserved as a derivative of II pharyngeal arch and sternocleidomastoid is separated fromthe common muscle rudiment with the trapezius muscle.Conclusions. 1. At the end of the 4th week of intrauterine development, Ⅰ, Ⅱ and Ⅲpharyngeal arches, pharyngeal pouches and hyoid bone anlage have been found. 2.During the 5th week of intrauterine development, narrowing and deepening of the cervicalsinus was observed. 3. At the end of embryonic period of intrauterine development wehave observed formation of the precartilaginous rudiment of the hyoid bone, secession ofplatysma and separation of sternocleidomastoid take place. We consider the 6th monthof intrauterine development as a first critical period in the formation of anterior cervicalregion.

Peculiarities of development of the suprahyoid muscles of the neck at an early period of human ontogenesis

Objective – of the work is to clarify the sources of germs and find out the chronological sequence of morphogenesis of the muscular structures of the suprahyoid triangles of the anterior cervical region in the embryonic and prefetal periods of human ontogenesis.Material and methods. 25 series of consecutive histological sections of human embryos and prefetuses aged from 5 till 12 weeks of development (6.0-80.0 mm parietal-coccygeal length (PCL)) using a complex methods of morphological examination (anthropometry, morphometry, microscopy, three-dimensional computer reconstruction and statistical analysis) were studied.Results. The rudiment of digastric muscle was first detected in 7-week-old prefetuses (15.5-16.0 mm PCL). The medial surface of Meckel’s cartilage is the site of attachment of the superior belly of the digastric muscle. At the 12th week of intrauterine development, the digastric muscle finally acquires its definitive attachment to the internal surface of the body of mandible. The rudiment of the mylohyoid muscle was first detected in 6-week-old embryos (10.0-12.0 mm PCL). The place of its attachment begins near the mental symphysis, the attachment of the muscle to the anlage of the hyoid bone was detected only at the end of the 7th week of intrauterine development (prefetuses 19.0-20.0 mm PCL). The anlage of the geniohyoid muscle was first determined in the 6-week-old human embryos. In prefetuses of 15.5- 40.0 mm PCL, geniohyoid muscle begins on the medial surface of Meckel’s cartilage, and from the 12th week of intrauterine development (prefetuses 75.0-77.0 mm PCL), the muscle attachment is localized on the internal surface of the body of mandible. The genioglossus muscle is found on the internal and caudal surfaces of Mekel’s cartilage, but from the middle of the 12th week of intrauterine development the site of its attachment moves to the medial-caudal surface of the body of mandible.Conclusions. 1. The anlages of all muscles that delimit the boundaries of the suprahyoid triangles of the neck were identified at the beginning of the 7 th week of intrauterine development (prefetuses 15.5-16.0 mm PCL). 2. The suprahyoid muscles attach to the medial surface of Meckel’s cartilage, but during the 8-11th weeks of intrauterine development, the attachment sites gradually move to the bony edges of the mandible, which cover Meckel’s cartilage. 3. In the prenatal period of development, bundles of the mylohyoid muscle leave the anterior region of the mental symphysis free. 4. In human prefetuses, only the geniohyoid and mylohyoid muscles were attached to the hyoid bone.

FETAL ANATOMICAL VARIABILITY OF STRUCTURES IN INFRAHYOID AREA

When performing myoplastic operations and surgical interventions on the thyroid gland, trachea and esophagus, information on the variant anatomy of the infrahyoid muscles, the features of their innervation and blood supply are of great clinical importance. Moreover, when additional muscles are attached to the thyroid gland, intraoperative bleeding can occur resulting in hematoma and tissue scarring in the postoperative period. There are fragmentary data in the literature on the variants of the structure and topography of the human infrahyoid area muscles. The specificity of branching nerves and blood vessels, their vascular-nervous relationships in a separate part of the sternohyoid, sternothyroid, thyrohyoid, and omohyoid muscles should be taken into account when performing rational incisions in the neck, moving both the flaps and the above muscles in plastic surgery. The purpose of study was to establish the anatomical variability and features of innervation and blood supply of the infrahyoid muscles of the neck in human foetuses of 4 – 10 gestational months age. Material and methods. The study was performed on 36 human foetuses, whose parieto-coccygeal length was 81.0 – 375.0 mm, without visible signs of anatomical abnormalities or anomalies in the cervical region. Thin sections of the structures from the anterior and lateral parts of the neck were prepared under the control of binocular magnifier, vascular injection technique, and morphometry. Foetal preparations weighing over 500.0 g were studied directly at Chernivtsi Regional Paediatric Pathological Bureau. Foetal preparations were taken from the Museum of M.G. Turkevich Human Anatomy Department, Bukovinian State Medical University. Results and discussion. The study demonstrated anatomical variability of the infrahyoid area muscles during the foetal period of human ontogenesis. Human foetuses were mainly found to have loose extending intramuscular branching of the nerves of the cervical loop in the infrahyoid muscles. The only exception is the inferior belly of the omohyoid muscle, where main nerve branching is found out. The distribution of nerves in the thickness of the infrahyoid muscles is uneven. Macroscopic examination revealed the smallest number of nerve branches was found within the middle third of the sternohyoid and upper third of the sternothyroid muscles. Arteries and nerves enter the sternothyroid and thyrohyoid muscles through the anterior surface, and the omohyoid and sternohyoid muscles enter mainly through the posterior surface of these muscles. The infrahyoid muscles are characterized by the main form of intramuscular branching of the arteries. The data on the peculiarities of intramuscular branching of arteries and nerves in the infrahyoid muscles we obtained, as well as the variant anatomy of the infrahyoid area muscles must be taken into account when performing a surgical access to the neck, or when operating on in the anterior cervical region, in particular myoplastic and reconstructive operations, in order to avoid muscle injuries.

Morphometric and topographic-anatomical features of the suprahyoid triangle of the anterior cervical region in the fetal period of human ontogenesis

Background. The study of the features of spatio-temporal transformations and the variant anatomy of the suprahyoid region (SHR), the clarification of the critical periods of development and topography of its structures in the fetal period of intrauterine development (IUD) is an important area of morphological research, the development of which contributes to the improvement of methods of prevention, early diagnosis and effective correction of congenital malformations and acquired diseases of the human neck and face. Objective. To find out the dynamics of morphometric and topographic-anatomical changes of the suprahyoid triangle of the anterior cervical region in human fetuses. Methods. 61 specimens of human fetuses 160.0-480.0 mm of parieto-coccygeal length (TCD) (4-10 months of VUR) were investigated, among which 34 were male and 27 were female. A set of methods of morphological research was applied, which included anthropometry, morphometry, X-ray techniques, preparation, three-dimensional reconstruction, statistical analysis. Results. It was found that the anterior angle of SHR in males decreases slightly during the fetal period of IUD, except for dolichomorphic objects, which tend to increase from the middle of the fetal period, while in females – almost unchanged in mesomorphic objects. In mesomorphic males and dolichomorphic females, the anterior angle of the SHR decreases at 7th month of IUD, while in brachymorphic females it increases. The length of the lateral and posterior borders, anterior-posterior length and area of SHR tend to decrease in male brachymorphic fetuses. In dolichomorphic female fetuses, it decreases by the 6th month of IUD with subsequent growth by the end of the fetal period of development. Irregular temporal dynamics of changes in these morphometric parameters of SHR is observed in dolichomorphic male fetuses and in brachymorphic female fetuses, where accelerated growth was detected in the 6th month of IUD and slowed down during the 7th month of development. Conclusion. The critical periods of morphogenesis of the SHR of human fetuses – the time of the change in the growth rate of the region depending on gender and constitutional type – are 6-7 months of IUD, which may indicate the formation of variants of the structure during this period, and the possible occurrence of congenital defects of the neck and maxillofacial region.

Compendium of Vascular Variations in the Anterior Cervical Region and Right Upper Limb – A Case Report

It is axiomatic that knowledge of variations of the major vessels is crucial, not only from anatomical standpoint, but also clinically. During the routine dissection for undergraduate study in Department of Anatomy, Faculty of Medicine, University of Jaffna, Sri Lanka, we came across compendium of vascular variations. Brachiocephalic trunk originated to the left of midline and its branches, the right common carotid and subclavian arteries, crossed the cervical trachea in front from left to right just above the left brachiocephalic vein. The right axillary artery divided into radial and ulnar arteries at the level of lower border of the teres major and these two branches travelled between the biceps brachial and median nerve. Radial artery took the course of the brachial artery in the arm and cubital fossa. Ulnar artery passed in a deeper plane in the arm medial to the biceps brachii and radial artery and passed deep to pronator teres and continued in the forearm lateral to the ulnar nerve as usual. The lateral root of median nerve crossed in front of axillary to unit with the medial root to form the median nerve, which coursed medial to the radial and ulnar arteries in the brachium The aim of this case reportis to compare with the variations reported and to discuss its clinical implications. In conclusion, we present a report of multiple arterial variations in the anterior cervical region and upper limb. Correct identification of variations is necessary for clinical practice, appropriate invasive techniques and to avoid complications.

Case Report: Neurofibromatos Type 1, Surgical Management

BACKGROUND: Neurofibromatosis type 1, first described by von Recklinghausen in 1884, is an autosomal dominant genetically transmitted disease, caused by a spectrum of mutations in the NF-1 gen, with unpredictable evolution, that affects multiple organs and systems, such as the skin and the nervous system, also affecting child development and neurocognitive functions. It often requires complex management decisions from the physician that involve a multidisciplinary approach. CASE REPORTS: 9 year old female patient with a history of type 1 neurofibromatosis. She presented with a mass located in the anterior cervical region, occupying also the left hemithorax, compressing the anterior mediastinum, the trachea from its left side, the heart, and the left lung; the mass produced symptoms: dyspnea, dysphagia and pain, so surgical excision of the mass was scheduled. A left cervical-sternotomy-thoracotomy was performed, a 12 x 7cm mass, located at aortic arch level, closely adhered to the cervical-thoracic spine, was excised. EVOLUTION: During the surgical procedure, the patient had profuse bleeding, coming form the left common carotid colateral artery, so abdominal packing was performed, for later resolution. 24 hours later, bleeding control was achieved after the surgical re-intervention. The pathology lab results established that the mass was in fact a neurofibroma. Subsequent follow-up determined symptoms improvement, without late surgical complications. CONCLUSIONS: Neurofibromatosis is a congenital infrequent, disease, with a complex treatment. Although there is no definitive treatment for type 1 neurofibromatosis, comprehensive management can be achieved to improve the patient’s quality of life. Tumors can be surgically removed, although they often grow back.

Методи препарування та виготовлення топографо-анатомічних зрізів для встановлення фетальної анатомічної мінливості органів і структур передньої та бічних ділянок шиї

Методи препарування та виготовлення топографо-анатомічних зрізів для встановлення фетальної анатомічної мінливості органів і структур передньої та бічних ділянок шиї

Functional outcome of Anterior Cervical Discectomy and Fusion with Anterior Cervical Plating Among Patients of Cervical Disc Disease at a Tertiary Health Care Centre

Introduction: Cervical spondylosis means osteoarthritis of cervical spinal column. The degenerative process mainly affects the vertebrae, neural foramina and the facet joints. It leads to compression of the spinal cord resulting in progressive neural cell loss and neurological deterioration in 40 to 60 % of patients. Cervical myelopathy is a constellation of symptoms and physical findings including motor and sensory abnormalities. Spasticity and paresis are frequently seen. The patient often complaints of gait disturbance due to abnormalities incorticospinal tract and spinal spinocerebellar tracts. There is also associated loss of grip strength and finger movements. Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure to remove a herniated or degenerative disc. An incision is made in the anterior cervical region and the disc is then removed. A graft is then placed to fuse the vertebrae above and below the disc. ACDF was first described by Cloward, Smith and Robinson in 1958 and shortly later by Hirsch in 1960 who described anterior cervical decompression and debated the necessity for inter body fusion. Anterior cervical discectomy and fusion has been widely performed since the late 1950s and is currently recommended in patients in whom the nonoperative modalities for single level or multilevel disease have failed. Objectives: To study the functional outcome of cervical discectomy and fusion with anterior cervical plating among patients of cervical disc disease. Materials and Methods: 46 patients treated with ACDF with anterior cervical plating were considered in this study. Results and Conclusion: All the patients showed significant post-operative improvement in their symptoms and diagnostic scores. Thus, we can conclude that ACDF with anterior cervical plating is an efficient procedure in patients with cervical myelopathic symptoms not responding to conservative treatment.

Platysmal Lineaments of the Neck With Emphasis on Endoscopic Endocrine Surgery.

In endoscopic neck endocrine surgery, the subplatysmal plane is an anatomic key structure that must be identified and preserved, to progress with the dissection. We define the prevalence of platysma, in the intermediate plane of the anterior cervical region, and evaluate potential statistical correlations with clinical and pathologic variables. The study included patients who had thyroid surgery. Morphologies, asymmetry, and patterns of the platysma were described. The analysis of the different considered variables was quantitative and qualitative, using multiple data reports. A total of 23 men and 90 women, aged 19 to 70 (median 41±19) years constituted the study cohort. Their neck circumference and height were 388.5±45 mm (334 to 479 mm) and 200±30 mm (160 to 270 mm), respectively. The hemi-platysmal muscle was bilaterally identified in 109 (96.4%). The mean platysmal thickness was 2.7±1.7 mm (range: 0.7 to 8.2 mm). The intermediate plane between the platysmal muscles was classified into 4 types, depending on the muscle features in the midline: Type A: the left and right platysmal fibers were interlaced with each other in the midline (7%); type B: the platysmal fibers were disconnected by <1 cm (27%); type C: between 1 and 3 cm (52%); and type D separated >3 cm (14%). We provide descriptive characteristics of the cervical platysma. A better understanding of the anatomic variability in cervical platysma may be useful in performing a more accurate dissection in endoscopic endocrine neck surgery.

Percutaneous endoscopic gastrostomy through a cervical esophageal fistula. An alternative, much improved technique for patient safety.

Percutaneous endoscopic gastrostomy [PEG] by the pull-technique is easy and safe to perform through the oral cavity. However, the presence of a cervical esophageal fistula, either due to tumor invasion or simply inflammation and tissue necrosis after previous intervention or radiotherapy, in the anterior cervical region is of crucial importance when passing the endoscope and the PEG catheter from the mouth downwards. We describe a modification of the standard peroral PEG, which is to insert the endoscope from the cervical esophageal opening instead of the oral cavity, and we support the use of this "stoma" as a way to protect it and avoid possible forceful dilatation/expansion when advancing the endoscope and the gastrostomy catheter through the mouth. The performance of PEG through the cervical esophageal opening was applied in 8 cases of esophageal fistula of different primary etiology but where the oro-pharyngeal passage was easily accessible. The procedure was technically successful in all patients, and no bleeding or tearing of the friable esophageal wall was evident. The use of the esophageal fistula at the anterior cervical region as a route for PEG insertion is a safe and practical alternative, highly to be recommended.

Airbag deployment induced paediatric cervical injury following a car accident

A 12-year-old girl was involved in a 50 km/h motor vehicle accident that resulted in the deployment of both airbags. She was a front seat passenger well restrained by a three-point seatbelt. The driver (his father) was uninjured but the patient complained of a stiff and painful neck. On arrival in the emergency room, she was alert and hemodynamically stable. Physical examination showed swelling and excoriation of the skin over the anterior cervical area and mandibular region (A). Neurological examination results were normal except for torticollis and neck pain. Cervical spine radiography showed no abnormality except the loss of cervical lordosis. She was admitted for observation and was discharged ten hours later with a cervical collar and symptomatic drugs. At 15-day follow-up visit, the patient had no neck pain, and the neurological examination finding was normal. Airbags drastically reduce both morbidity and mortality from crashes, but a wide range of injuries has been reported as a result of direct contact of hot gas with facial skin and energy transmitted directly from the airbag system to the child´s head and neck. This device may cause ocular and facial injuries, abdomen and chest trauma, upper extremity injuries, and cervical spine lesions especially in pediatric populations. All children below 12 years of age or less than 40 kg of weight must not occupy the front seat passenger. Airbags may induce injuries that vary from minor to fatalities whatever the impact velocities. Practitioners should be aware about lesions induced by airbag deployment.

Multi-Level Anterior Cervical Decompression in Multi-Level Cervical Spondylotic Myelopathy without Extending the Corpus Resection: A Cadaveric Study of a Novel Surgical Technique.

To perform three-level decompression with a single-level corpectomy by modifying the fusion with anterior cervical corpectomy (ACC-F) method on a cadaver. The anterior cervical region of four whole-head cadavers was dissected. The corpectomy was performed under a surgical microscope with a MT4-20+ ultrasonic bone dissector (UBD) tip. Superior and inferior decompression were conducted and viewed with a 70° neuroendoscope using two types (vertically and horizontally oriented) of specially designed 23 mm-long, 90°-angled UBD tips. After neck dissection and the removal of the thyroid and cricoid cartilages, C5 corpectomy and adjacent-level discectomies were performed. Following discectomy and corpectomy, superior and inferior decompression were conducted with specially designed UBD tips and viewed with a 70° neuroendoscope. A three-level anterior cervical decompression was provided with a single-level corpectomy. This study demonstrated that two more level decompression is possible with a single-level corpectomy in the cervical region using the new technique.

Unraveling the role of ectopic thymic tissue in patients undergoing thymectomy for myasthenia gravis.

Extended thymectomy has been considered the goal of surgery for myasthenia gravis (MG) mainly due to the existence of ectopic thymic tissue. Recently, ectopic thymic tissue has attracted increasing attention in patients with MG following thymectomy. However, the specific role of ectopic thymic tissue in patients with MG is still under debate. A systematic search of the literature was performed on PubMed and Medline according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISM) statement. Studies evaluating the rate of ectopic thymic tissue in patients with MG with or without thymoma were included. Extraction was performed for all eligible studies and the rate of ectopic thymic tissue at common locations was calculated. Eighteen out of fifty-nine studies were eligible for inclusion, of which ten studies reported the common locations of ectopic thymic tissue in mediastinal fat. Of these ten studies, the presence of ectopic thymic tissue was investigated in different anatomical locations in 882 patients, of whom, 509 patients (58%) have at least one positive location with the most common ones being anterior mediastinal fat, pericardiophrenic angles, aortopulmonary window, cervical region (pretracheal fat) and lateral to phrenic nerves. On the other hand, nine studies analyzed the influence of the presence of ectopic thymic tissue on the clinical outcomes of MG patients. Of these, six found that the presence of ectopic thymic tissue in MG patients is a significant predictor of poor outcome after thymectomy, however, the other three did not find a significance. Altogether, ectopic thymic tissue is likely to present in more than a half of patients undergoing thymectomy for MG. Besides, MG patients who have ectopic thymic tissue after thymectomy do not seem to have as good outcome as those who have not.

Tiroides Lingual Ectópica en Paciente Adulta Hipotiroidea. Diagnóstico Casual por Tomografía Computarizada

Introducción: Los casos de tiroides ectópica localizados en la base de la lengua son anormalidades congénitas raras y difíciles de diagnosticar. Razón de presentación del caso.&#x0D; Caso Clínico: El caso corresponde a una mujer de 41 años con tiroides en base de la lengua diagnosticada incidentalmente con tomografía computarizada (TC), con antecedentes de hipotiroidismo y cáncer de mama derecha. Al examen físico de cuello no se palpa glándula tiroidea ni se observa masa o protuberancia en cavidad bucal. Por control del cáncer de mama, se solicita tomografía por emisión de positrones (PET) y ecografía de cuello, reportándose captación del radiofármaco en la región cervical anterior y superior de cuello, y ausencia de tejido glandular tiroideo a nivel habitual, respectivamente. Por cuanto, se realiza TC simple y contrastada observándose a nivel de la raíz de la lengua una imagen nodular hipercaptante que mide 23x20x20 mm, bien definida, contornos regulares, no infiltra tejidos adyacentes, impronta luz de la orofaringe, sin individualizar la glándula tiroides a nivel habitual, corroborando así el diagnóstico de tiroides ectópica lingual.&#x0D; Conclusión: El diagnóstico de tiroides ectópica en paciente adulto hipotiroideo es raro, por lo que debe considerarse la realización de TC si al examen físico y ecográfico no es palpable ni observable.

Unusual case of a fatal upper esophageal trauma caused by a toothpick

The authors report the case of the unexpected death of a fifty-year-old female found by her partner in the bathroom floor. External examination revealed some contusions dispersed by different corporal areas and an unusually placed green discoloration of the anterior cervical region. After neck dissection and opening the esophagus, a three and a half centimeter wooden toothpick fragment was found at the upper region, covered by a purulent substance associated with puncture wounds. Histopathological and microbiological studies revealed “acute bilateral cervical cellulitis” and Klebsiella Oxytoca, respectively. Further investigation revealed that during the five days prior to her death, the victim was observed twice in an emergency department with complains of throat discomfort after eating some bread with salami. X-Ray and a laryngoscopy were performed but did not reveal any significant findings. Due to the victim's medical history, she was evaluated by a psychiatrist that dismissed a non-somatic setting due to the type of complains and the elevation of blood inflammatory parameters. Rinopharyngitis was then assumed as the most likely diagnosis and was treated accordingly. The victim died the following day. This case reports an unusual fatal traumatic lesion to the upper esophagus that is a very important remainder, particularly for clinical practitioners, to maintain a high degree of suspicion, avoid diagnostic biases such as those related to psychiatric disorders and meticulously evaluate patients in order to deliver the most evidence-based diagnosis possible. To the best of the authors' knowledge there are no other cases described in the literature of a death caused by esophageal toothpick lesion.

Giant Lipomas of Anterior and Lateral Cervical Region: Management of a Rare Entity

Giant Lipomas of Anterior and Lateral Cervical Region: Management of a Rare Entity

Dissection and observation of a large unnamed nerve in the posterior cervical triangle

To characterize the anatomical features of a large unnamed nerve in the posterior cervical triangle and clarify its relationship with the lesser occipital nerve. We dissected 31 adult formalin-fixed cadaver head and neck specimens (62 sides). The lateral cervical region, the anterior cervical region, the sternocleidomastoid region, and the occipital region were dissected to define the anatomical features of the unnamed nerve. This unnamed nerve was identified in the posterior cervical triangle in 96.8% of the specimens. The main trunk of the nerve had a diameter of about 3 mm with a length of around 10 cm. The nerve arose from the anterior branch of the second cervical nerve (C2, C2-3), entered the posterior cervical triangle at 1-3 cm above the accessory nerve, and continued to ascend along or in parallel with the posterior border of the sternocleidomastoid muscle. It passed between the attachments of the sternocleidomastoid and the trapezius to the occiput and divided into 3-5 branches, which innervated the skin area between the lesser and greater occipital nerves. We identified a large unnamed nerve in the posterior cervical triangle, for which we coined the name "long occipital nerve" based on its unique anatomical features. The discovery of this nerve can be important for local surgery and for diagnosis and treatment of related diseases.