Left Side Of Neck Research Articles

Differences in the diagnosis and management of pyriform sinus fistula between newborns and children

Pyriform sinus fistula (PSF) is a rare congenital entity. We hypothesized that clinical features, diagnosis and treatment may differ between newborns and children. 190 patients diagnosed with PSF were divided into two groups: neonatal (n = 15) and childhood (n = 175). The medical records including demographic and clinical data were retrospectively analyzed. There were 102 boys and 88 girls in this study. Most patients presented as a left-sided neck lesion. A neck mass, with or without infection and respiratory distress, was the common finding in newborn patients. Prenatal diagnosis was made in three cases. However, in childhood group, initial symptoms were neck abscess (78.8%), acute thyroiditis (11.4%), neck mass (6.9%), and thyroid lesion (2.8%). The presence of a cervical mass with air pocket showed on CT image was thought to be the pathognomonic finding of neonatal PSF. The diagnosis was usually established by barium esophagography in older children. Delayed accurate diagnosis was detected in both groups. The median time from onset to diagnosis was 22 months and 1 year respectively. Endoscopic-assisted open surgery was performed successfully in all patients, with good outcomes in majority cases of both groups (93.3% and 95.4%). Recurrence was developed in 5 patients. PSF should be suspected in newborns with cervical mass and in children with recurrent neck infection, especially on the left side. Early diagnosis and treatment might avoid repeated surgical procedures. Complete resection of the cyst and fistula in non-infected state is essential for good outcomes.

METASTATIC ANGIOMATOID FIBROUS HISTIOCYTOMA PRESENTING AS RECURRENT PNEUMOTHORAX

SESSION TITLE: Lung Cancer: Unusual Presentations SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/21/2019 3:15 PM - 4:15 PM INTRODUCTION: Angiomatoid fibrous histiocytoma (AFH) is known as an uncommon low-grade malignant soft tissue tumor of uncertain histogenesis. It tends to occur most commonly in the subcutaneous or deep dermis of the extremities in children and young adults. The majority of the cases occur in the extremities, although lesions occurring in the head and neck region (10%) have been reported. World Health Organization (WHO) in 2002 removed AFH as a subtype of malignant sarcoma and placed it in the category of tumors of uncertain differentiation because a majority of patients (73.2%) were disease-free after local excision, while a minority (23.2%) developed recurrent disease and 8.7% developed metastatic disease within 24 months post operation . Here, we present an uncommon case of a rare tumor where metastatic disease to the lung was diagnosed after the patient had episodes of spontaneous pneumothoraxes. CASE PRESENTATION: This is a 27-year-old male with no significant history that presented with left-sided neck pain. A CT scan of the neck revealed a 4 x 4 x 5 cm neck mass and subsequently had surgical excision. Pathology showed clear margins with a spindle cell neoplasm consistent with angiomatoid fibrous histiocytoma. He then completed a course of adjuvant radiotherapy. Several months later, the patient developed right-sided pneumothorax which recurred twice, imaging revealed bilateral pulmonary nodules. He had another admission with recurrent pneumothorax and repeat imaging revealed enlargement of these nodules, the larges 2.6 x 3.8 cm in size. He underwent CT-guided biopsy of the right-sided nodule along with bilateral pleurodesis. The pathology results showed metastatic disease consistent with the pathology of his primary malignancy. DISCUSSION: AFH is a rare neoplasm with a typically benign clinical course, metastatic disease is extremely rare. A recent review of the literature found 17 cases of metastatic AFH, 7 of those cases had metastatic disease to the lung. Unfortunately, patients with distant metastases tend to have fatal outcomes and in the review, those treated with chemotherapy had no improvement in their survival. EWSR1-CREB1 gene fusion is the most common genetic abnormality described in 70% of AFH with interleukin-6 (IL-6) secretion thought to promote tumor growth. A recent case report of a patient with metastatic AFH that did not respond to chemotherapy had improvement with anti-IL-6 targeted treatment. As more research in targeted therapies are conducted there is hope that better outcomes will be found in patients with metastatic AFH CONCLUSIONS: AFHs are extremely rare, with metastatic disease being even rarer. Due to the uncommon nature of the disease, it can often lead to erroneous diagnosis of a malignant disease potentially leading to inappropriate treatment. Therefore, it is of significant relevance to increase its awareness among health care providers. Reference #1: Chen G et al. Angiomatoid fibrous histiocytoma: unusual sites and unusual morphology. Modern Pathology 2011; volume 24: 1560-1570 Reference #2: Saito K et al. Angiomatoid fibrous histiocytoma: a series of seven cases including genetically confirmed aggressive cases and a literature review. Musculoskeletal Disorders (2017) 18:31 DOI 10.1186/s12891-017-1390-y Reference #3: Maher et al. Characterization of Metastatic Angiomatoid Fibrous Histiocytoma. J Pediatri Hematol Oncol. 2015; 37:268-271 DISCLOSURES: No relevant relationships by Augusto Amaral Neto, source=Web Response No relevant relationships by Omar Ibrahim, source=Web Response No relevant relationships by Stefan Kachala, source=Web Response No relevant relationships by Vinay Mathew-Thomas, source=Web Response No relevant relationships by Carissa Monterroso, source=Web Response

Visual Vignette

Case Presentation: A 58-year-old male patient presented with a 1-year history of an enlarging left-sided neck mass. There was no obvious dysphagia, stridor, or symptoms of hyperthyroidism or hypercalcemia. On examination, there was a firm, painless mass in the left thyroid lobe. Biochemical testing revealed normal thyroid function tests but elevated serum calcium of 3.01 mmol/L (normal, 2.2 to 2.5 mmol/L), creatinine 124 μmol/L (normal, 64 to 111 μmol/L), parathyroid hormone (PTH) 57.0 pmol/L (normal, 1.6 to 7.9 pmol/L), and decreased phosphate 0.65 mmol/L (normal, 0.74 to 1.52 mmol/L). Thyroid ultrasonography showed a giant hypoechoic nodule in the left lobe, measuring 5.6 × 3.8 cm. Pertechnetate sestamibi parathyroid scintigraphy demonstrated intense activity in the left thyroid bed (Fig. 1), which was shown as a hypodense mass with a dot calcification and clear rim in the left thyroid lobe by single photon emission–computed tomography (Fig. 2). What is the diagnosis? Fig. 2 View Large Image Figure Viewer

Association of Upper Extremity and Neck Access With Stroke in Endovascular Aortic Repair

Upper extremity and neck access is increasingly being used for complex endovascular aortic repairs. We sought to compare perioperative stroke and other complications of (1) arm/neck with femoral/iliac access (AN) vs femoral/iliac access alone (FI), (2) right- vs left-sided AN, and (3) arm vs neck access sites. Patients entered in the thoracic endovascular aortic repair/complex endovascular aneurysm repair registry in the Vascular Quality Initiative from 2009 to 2018 were analyzed. Patients with a missing access variable were excluded. The primary outcome was perioperative stroke. Secondary outcomes were other postoperative complications and 1-year survival. Kaplan-Meier curves and log-rank test were used for survival analysis. Of 11,774 patients, 9229 met criteria for analysis (2364 AN, 6865 FI). AN patients had a higher rate of smoking history (77.3% vs 72.8%; P < .0001) and prior cerebrovascular events (11.8% vs 9.6%; P = .004). Operative time (250 ± 123 minutes vs 155 ± 102 minutes; P < .0001), contrast material load (136 ± 77 mL vs 105 ± 67 mL; P < .0001), and estimated blood loss (250 mL vs 100 mL; P < .0001) were larger in the AN group indicating these were likely to be more complex cases. Overall, AN had a higher rate of stroke (4.2% vs 2.8%; P = .0005) than FI (Table I). There was no difference in stroke in comparing right and left AN access (4.9% vs 3.8%; P = .28; Table II). Stroke rates were similar between arm, axillary, and carotid access but were significantly higher in patients with multiple simultaneous AN access sites (3.9% vs 4.1% vs 4.4% vs 11.4%; P = .01). AN also had higher rates of puncture site hematoma, access site occlusion, arm ischemia, and in-hospital mortality (Table I). There was no difference in 1-year survival (87.6% vs 85.9%; P = .12). Upper extremity and neck access for complex aortic repairs has a higher risk of stroke compared with femoral and iliac access alone. Right-sided access does not have a higher stroke rate than left-sided access. Neck access does not have a higher stroke rate than arm access, but stroke rate is increased when multiple arm and neck sites are used.Table IPostoperative complications in arm/neck (AN) access compared with femoral/iliac (FI) accessComplicationAN access (n = 2364), No. (%)FI access (n = 6865), No. (%)P valueStroke100 (4.2)191 (2.8).0005Postoperative complications723 (30.6)1512 (22)<.0001Puncture site hematoma104 (4.4)123 (1.8)<.0001Access site occlusion29 (1.2)31 (0.5)<.0001Arm ischemia25 (1.1)34 (0.5).003In-hospital mortality338 (4.9)156 (6.6).002 Open table in a new tab Table IIPostoperative complications comparing right- and left-sided arm/neck (AN) accessComplicationRight (n = 427), No. (%)Left (n = 1826), No. (%)P valueStroke21 (4.9)60 (3.8).28Postoperative complications143 (33.5)544 (29.8).14Puncture site hematoma21 (4.9)77 (4.2).53Access site occlusion5 (1.2)24 (1.3).99Arm ischemia4 (1)21 (1.2).99 Open table in a new tab

Providing insight into the incubation period of Mycobacterium ulcerans disease: two case reports

BackgroundBuruli ulcer caused by Mycobacterium ulcerans is endemic in parts of West Africa and is most prevalent among the 5–15 years age group; Buruli ulcer is uncommon among neonates. The mode of transmission and incubation period of Buruli ulcer are unknown. We report two cases of confirmed Buruli ulcer in human immunodeficiency virus-unexposed, vaginally delivered term neonates in Ghana.Case presentationPatient 1: Two weeks after hospital delivery, a baby born to natives of the Ashanti ethnic group of Ghana was noticed by her mother to have a papule with associated edema on the right anterior chest wall and neck that later ulcerated. There was no restriction of neck movements. The diagnosis of Buruli ulcer was confirmed on the basis of a swab sample that had a positive polymerase chain reaction result for the IS2404 repeat sequence of M. ulcerans. Patient 2: This patient, from the Ashanti ethnic group in Ghana, had the mother noticing a swelling in the baby’s left gluteal region 4 days after birth. The lesion progressively increased in size to involve almost the entire left gluteal region. Around the same time, the mother noticed a second, smaller lesion on the forehead and left side of neck. The diagnosis of Buruli ulcer was confirmed by polymerase chain reaction when the child was aged 4 weeks. Both patients 1 and 2 were treated with oral rifampicin and clarithromycin at recommended doses for 8 weeks in addition to appropriate daily wound dressing, leading to complete healing. Our report details two cases of polymerase chain reaction-confirmed Buruli ulcer in children whose lesions appeared at ages 14 and 4 days, respectively. The mode of transmission of M. ulcerans infection is unknown, so the incubation period is difficult to estimate and is probably dependent on the infective dose and the age of exposure. In our study, lesions appeared 4 days after birth in patient 2. Unless the infection was acquired in utero, this would be the shortest incubation period ever recorded.ConclusionsBuruli ulcer should be included in the differential diagnosis of neonates who present with characteristic lesions. The incubation period of Buruli ulcer in neonates is probably shorter than is reported for adults.

Cosmetic use of Tikshna Kadalikanda Kshara application in management of Charmakeela (Common Warts) - A Single Case Study

Warts, a Verruca, are one of the most common viral infections seen in primary care and affect approximately 7% to 10% of the population. Warts are the diseases which has troubled the humans since antiquity. Warts cause disfigurement by occurring on the areas, which cause loss of beauty like on face, neck, hand etc; depression can occur by cosmetic values. The most common treatment modality used to treat the warts include electric cautery, cryotherapy, surgical excision etc, which are invasive procedures and commonly leads to scarring, hyper pigmentation and high incidence of recurrence and disfigurement. In Ayurveda Acharya Sushrutha had considered it under Kshudra Rogadikara. Sushrutha Acharya has mentioned Pratisaraniya Kshara (Local application of Kshara) as one among treatment modalities in the management of Charmakeela. In this case report, a male patient of 25 years consulted to outpatient department, with complaints of pedunculated common warts on left side of neck. The patient was treated with local application of Tikshna Kadalikanda kshara for 2 times in single sitting. Hence the study concluded that excision of Charmakeela through kshara karma is one of the potential treatment options to avoid recurrence.

HPV-negative oropharyngeal carcinoma as a separate prognostkally unfavorable form of cancer, requiring new approaches to treatment (case report)

The study objective is to demonstrate the difficulties associated with treatment of HPV-negative oropharyngeal cancer. Material and methods . A 52-year-old male patient visited a doctor in P.A. Herzen Moscow Oncology Research Institute in January 2017 with complaints of pain in the right part of the oropharynx irradiating to the right ear and difficulties with swallowing food and liquids. The patient was diagnosed with stage IVA oropharyngeal cancer (cT3N2bM0). Results. The patient underwent a course chemoradiotherapy (CRT); as a result, the tumor in the area of the right tonsil became indeterminable 2 weeks later. Three months after completing the course of CRT, the patient underwent modified radical right-sided lymph node dissection. Histological examination revealed metastases from poorly differentiated squamous cell carcinoma in 3 lymph nodes (LNs) with an invasion into adjacent adipose tissue. In October 2017, we received a histological confirmation of ongoing tumor growth in the area of the tongue root and LN metastases in the left side of the neck (yrpT4aN2cM0). We performed resection of the mandible, tongue, soft tissues of the oral floor, and right side of the oropharynx with installation of an oropharyngeal stoma, extended radical left-sided neck lym-phadenectomy with excision of soft tissues (levels I—V), defect repair using an autologous pectoral musculocutaneous flap, and tracheostomy. In March 2018, the patient was found to have continuing tumor growth in the area of the epiglottis and floor of the oral cavity. The patient underwent laryngectomy with oropharyngeal resection and end tracheostomy. In July 2018, we again received a histological confirmation of tumor growth in soft tissues of the anterior neck. We performed resection of the tumor and soft tissues with subsequent plastic reconstruction of the defect. In October 2018, the patient presented with multiple metastases in both lungs. He received a course of immune therapy. Positron emission tomography revealed neoplastic foci with pathological metabolic activity in the area of the alveolar process of the mandible (left side), soft tissues of the neck, lungs, left-sided axillary LNs, and mediastinal LNs. It was decided to continue immune therapy. Conclusion. HPV-negative oropharyngeal cancer requires an optimized treatment algorithm and, possibly, more aggressive therapeutic measures, such as increased radiation doses. Both overall management strategy and recommended standard scheme of CRT should be revised; the role of surgical and chemotherapeutic components of treatment should also be reassessed. We believe that surgical intervention should be considered regardless of the effect of radiation therapy, while the duration of follow-up after CRT should be reduced.

57-Year-Old Man With Vertigo

57-Year-Old Man With Vertigo

Current concepts in parathyroid carcinoma: a single Centre experience

BackgroundParathyroid carcinoma is a rare neoplasm that may present sporadically or in the context of a genetic syndrome. Diagnosis and management are challenging due to the lack of clinical and pathological features that may reliably distinguish malignant from benign disease.MethodsFrom January 2013 to December 2017, from 358 consecutive patients affected by parathyroid diseases, 3 patients with parathyroid carcinoma were treated at our academic Department of General Surgery. We present our experience as illustrative of the different features of clinical presentation of parathyroid carcinoma and review its management considering the recent relevant literature.ResultsCase 1: A 62-year-old man was hospitalized for left-sided palpable neck mass, hypercalcemia and elevated PTH. US-guided FNA was suspect for parathyroid carcinoma. A large cystic mass was excised in bloc with total thyroidectomy and central neck dissection. Genetic studies framed a pathologically confirmed parathyroid carcinoma within MEN1 syndrome. Case 2: A 48-year-old woman with hypothyroidism had total thyroidectomy performed for a suspect for right follicular thyroid lesion. Pathology revealed parathyroid carcinoma. Case 3: A 47 year-old man was admitted for hypercalcaemic crisis and renal failure in the context of PHPT. A lesion suggestive on US and MIBI scan for parathyroid adenoma in the right lower position was removed by mini-invasive approach. Pathology revealed parathyroid cancer and patient had completion hemythyroidectomy and central neck dissection.ConclusionParathyroid cancer is a particularly rare endocrine malignancy, however it should be suspected in patients with primary hyperparathyroidism when severe hypercalcemia is associated to cervical mass, renal and skeletal disease. Parathyroid surgery remains the mainstay of treatment. Radical tumour resection and expedited treatment in a dedicated endocrine Center represent crucial prognostic factors.

SUN-598 Neck Pain as an Initial Presentation of Medullary Thyroid Cancer

Background: Neck pain is common in adults and can be caused by various conditions, most commonly due to musculoskeletal disorder. Thyroid cancer is not usually considered as an etiology for neck pain. We report a patient with an initial presentation of neck pain due to medullary thyroid cancer (MTC). Case Presentation: A 40-year-old female without significant medical history initially presented to her primary care provider with 12 months of left-sided neck pain, point tenderness in the lower neck, and minimal improvement in pain despite multiple courses of physical therapy for presumed musculoskeletal pathology. She noted recent hoarseness, but no esophageal, respiratory, or endocrine symptoms. On physical examination, a discrete left-sided thyroid nodule was palpated. Thyroid ultrasound confirmed a 1.0 x 1.0 x 1.5 cm solid, hypoechoic, taller than wide nodule with irregular borders in the left thyroid lobe. Thyroid function tests including TSH and free T4 were normal. Fine needle aspiration (FNA) of the nodule showed numerous malignant appearing cells with background amyloid suggestive of MTC. Serum calcitonin and CEA were found to be elevated to 206 pg/mL and 8.5 ng/mL, respectively (reference ranges 0-5 pg/mL and 0.2-4.7 ng/mL). Calcium stimulation testing was performed with elevation of calcitonin to 413 pg/mL. Further evaluation disclosed left-sided vocal fold paresis. She was scheduled for total thyroidectomy with central and left lateral neck lymph node dissections and referred for genetic testing. Discussion: Neck pain is an uncommon presentation of thyroid cancer with a reported prevalence of 22% in patients with MTC, 6% with papillary thyroid cancer (1), and 26% in anaplastic thyroid cancer (2). Diagnosis of MTC is usually made by FNA and confirmed with elevated serum calcitonin. In indeterminate cases, calcium stimulation testing can be a useful adjunct to confirm MTC. Given its association with familial tumor syndromes, genetic testing is recommended in all new MTC cases to identify at risk families for early intervention, potentially to include prophylactic thyroidectomy. MTC patients also require serial calcitonin monitoring after surgery to identify recurrences and residual disease. It is important to examine the neck and thyroid gland carefully in patients with neck pain.

Virchow's node: a case report of an extremely rare presentation of metastasis of adenocarcinoma with mucinous features from the colon.

Colon cancer is one of the most common causes of cancer-related mortality. Adenocarcinoma with mucinous features accounts for 10–15% of colon carcinoma. Distal nodal metastatic colorectal cancer is uncommon, and metastasis of colorectal cancer to the left supraclavicular lymph node is extremely rare without signs of metastatic organ involvement. We present a case of a 54-year-old Caucasian male with colonic adenocarcinoma that presented initially as a left-sided neck mass that had progressively increased in size over 9 months. On physical exam, a left supraclavicular soft tissue mass 6 cm in diameter was appreciated, it was non-tender with no submandibular lymphadenopathy. Soft tissue mass was palpable on the anterior abdominal wall in the epigastric region. Open excisional tissue biopsy of the left supraclavicular mass revealed metastatic adenocarcinoma with mucinous features and colonoscopy revealed a 6 cm obstructing mass in the transverse colon with biopsy revealing primary adenocarcinoma of the mucinous type. Palliative care with comfort measures was agreed upon. Typically, the most common sites of colon cancer metastasis are regional lymph nodes, liver, lung, bone and brain, and ours demonstrated an extremely rare pattern of colon cancer metastasis. The presentation to metastasize to the left supraclavicular node without solid end organ involvement makes this case even more novel.

Visual Vignette

Case Presentation: A 41-year-old woman noted a lump in her neck on self-exam. The patient denied shortness of breath, dysphagia, dysphonia, polyuria, abdominal pain, constipation, bone pain, or nephrolithiasis. She denied history of neck radiation. She also denied family history of thyroid disorder, including cancer. On exam, the patient had a visible left-sided neck mass that moved with swallowing. It was palpable but nontender. Biochemical analysis revealed normal serum calcium 9.1 mg/dL (normal, 8.6 to 10.3 mg/dL), albumin 4.3 g/dL (normal, 3.5 to 5.2 g/dL), ionized calcium 1.24 mmol/L (normal, 1.14 to 1.33 mmol/L), 25-hydroxyvitamin D level 32.4 ng/mL (normal, 30 to 100 ng/mL), intact parathyroid hormone (PTH) 104 pg/mL (normal, 12 to 88 pg/mL), and thyroid-stimulating hormone 2.21 μIU/mL (normal, 0.47 to 5.01 μIU/mL). Neck ultrasound showed a 2.3-cm exophytic cystic lesion with septation that arose from the left lower thyroid lobe (Fig. 1) as well as a 0.9-cm isoechoic nodule in the left lobe. The patient was offered watchful approach, but she was interested in obtaining a definitive diagnosis. She underwent ultrasound-guided fine-needle aspiration (FNA), and 2 mL of clear fluid was aspirated. Cytologic interpretation was nondiagnostic. What is the diagnosis?

The Lymph Node Content of Supraclavicular Lymph Node Flap: A Histological Study on Fresh Human Specimens.

Introduction: Vascularized lymph node transfer (VLNT) has become the established treatment for secondary lymphedema. The proposed mechanisms of VLNT include lymphangiogenesis and absorptive action of transplanted lymphatic tissue. Therefore, in theory, the lymph node content of lymph node flap is crucial to clinical response. The supraclavicular lymph node flap (SCLNF) has been described as one of the flap options for VLNT. However, its lymph node content has not been fully studied. The aim of this study is to find out the lymph node content of SCLNF with histological examination. Methods: Patients who required radical neck dissection or modified radical neck dissection due to cervical lymph node metastasis from head and neck cancer were included in this study. The SCLNF harvesting was performed as the first part of neck dissection. After flap harvesting, neck dissection was continued. The fresh SCLNF specimens were then sent for histological study. Results: Twelve SCLNFs were studied. The mean age of patients was 67.5 (range, 54-84) years. There were 10 males and 2 females. Seven flaps were harvested from the left side of neck, while five flaps were harvested from the right side of neck. The mean width, height, and thickness of SCLNF were 5.9 ± 0.6, 4.0 ± 0.5, and 1.8 ± 0.2 cm, respectively. The mean number of lymph nodes per flap was 8 ± 4.7 (range, 3-15). Conclusion: The lymph node content of SCLNF was confirmed. Its lymph node content is comparable to other lymph node flaps used in VLNT.

Spontaneous Resolution of Fourth Branchial Fistula Following Thyroid Surgery: Case Report.

Fourth branchial pouch anomalies represent one of the rarest types of all branchial apparatus anomalies. They appear in the first lifedecade in a form of recurrent left-sided neck masses which demands surgical treatment. Accidental finding, appearance later in life and spontaneous resolving are really rare. We present a case of a 43-year-old man with accidental finding of asymptomatic fourth pouch cyst and fistula following follicular thyroid cancer surgery. The day after the surgery, suction bottle was filled with little white crumbs and the wound started to suppurate. Barium swallow revealed the presence of a fistulous canal that arose from the left pyriform sinus. Meanwhile, the pathologist confirmed the presence of a lateral neck cyst within this thyroid lobe. The patient was operated on but fistulous canal was not visualized. In the meantime, wound discharge ceased spontaneously. At 1-year follow up, the patient was still well and free from any symptoms. These anomalies may manifest not only in childhood but may stay asymptomatic for a long time. It seems that the fistula can resolve spontaneously and that conservative approach is an alternative to multiple surgical procedures.

Sequential aneurysms of the internal carotid artery with fibromuscular dysplasia

A 50-year-old woman presented with a 6-month history of left-sided neck discomfort and headaches. She denied any history of lateralizing neurologic deficits and denied vascular risk factors including smoking and connective tissue disorders. Her physical examination demonstrated a tender pulsatile mass on the left side of the neck and an associated carotid bruit. Carotid duplex ultrasound revealed four left internal carotid artery (ICA) aneurysms consistent with aneurysmal degeneration secondary to fibromuscular dysplasia. Computed tomography angiography of the neck confirmed these findings and revealed a bovine aortic arch without significant occlusive disease. The largest aneurysm measured 2.0 cm in diameter with three smaller “string-of-beads” dilations extending to within 1 cm of the skull base (A/Cover). Treatment options included ongoing surveillance, open repair with an interposition graft, and endovascular repair using stent grafts to exclude the aneurysms. The patient rejected surveillance, given her symptoms and concern for thromboembolization. Open repair was deemed high risk because of the superior extent of the aneurysms. Therefore, we proceeded with an endovascular strategy using transfemoral access to select the left common carotid artery. Embolic protection was deferred because of the low atherosclerotic burden, and awake neuromonitoring was performed. Selective arteriography demonstrated the known left ICA aneurysms (B). A 0.018-inch wire was used to traverse the ICA aneurysms. A 6-mm × 5-cm Viabahn (W. L. Gore & Associates, Flagstaff, Ariz) stent graft was placed distally and overlapped with an 8-mm × 5-cm Viabahn stent graft proximally to accommodate tapering of the native vessel. Completion arteriography revealed aneurysm exclusion and excellent flow to the intracranial ICA (C). The patient was maintained on clopidogrel postoperatively. At 1 month, she was free from complications, and follow-up computed tomography angiography demonstrated aneurysm exclusion and patent stent grafts (D). The patient's consent was obtained for publication. Extracranial carotid artery aneurysms (ECAAs) are rare and have primarily been treated with open surgery.1McCollum C.H. Wheeler W.G. Noon G.P. DeBakey M.E. Aneurysms of the extracranial carotid artery. Twenty-one years' experience.Am J Surg. 1979; 137: 196-200Abstract Full Text PDF PubMed Scopus (231) Google Scholar Common causes of ECAAs remain atherosclerosis and trauma; however, fibromuscular dysplasia is responsible for 8% to 11% of all ECAAs.2El-Sabrout R. Cooley D.A. Extracranial carotid artery aneurysms: Texas Heart Institute experience.J Vasc Surg. 2000; 31: 702-712Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar, 3Fankhauser G.T. Stone W.M. Fowl R.J. O'Donnell M.E. Bower T.C. Meyer F.B. et al.Surgical and medical management of extracranial carotid artery aneurysms.J Vasc Surg. 2015; 61: 389-393Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar Endovascular repair of ECAAs is increasingly used to decrease morbidity and mortality associated with repair of ECAAs complicated by redo surgical fields or prior radiation exposure and for those that extend to the skull base.2El-Sabrout R. Cooley D.A. Extracranial carotid artery aneurysms: Texas Heart Institute experience.J Vasc Surg. 2000; 31: 702-712Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar, 3Fankhauser G.T. Stone W.M. Fowl R.J. O'Donnell M.E. Bower T.C. Meyer F.B. et al.Surgical and medical management of extracranial carotid artery aneurysms.J Vasc Surg. 2015; 61: 389-393Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 4Zhou W. Lin P.H. Bush R.L. Peden E. Guerrero M.A. Terramani T. et al.Carotid artery aneurysm: evolution of management over two decades.J Vasc Surg. 2006; 43 (discussion: 497): 493-496Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 5Li Z. Chang G. Yao C. Guo L. Liu Y. Wang M. et al.Endovascular stenting of extracranial carotid artery aneurysm: a systematic review.Eur J Vasc Endovasc Surg. 2011; 42: 419-426Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar

Microlaryngoscopic surgery for pyriform sinus fistulas in children: a report of two cases

BackgroundA pyriform sinus fistula (PSF) is a rare branchial anomaly that causes recurrent cervical infections. Open neck surgery has widely been accepted as a definitive treatment for PSFs, and endoscopic surgery has been reported in recent years. However, both approaches are not satisfactory because of high recurrence rates and postoperative complications. Microlaryngoscopic surgery (MLS) is a transoral surgical technique involving the use of an operating microscope. In this report, we present a new procedure involving MLS for resection and closure of a PSF without a skin incision.Case presentationTechnique: MLS was performed under general anesthesia with endotracheal intubation. The patient was placed in the supine position, and a direct laryngoscope was inserted to expose the pyriform sinus, which was then magnified using an operating microscope. The mucosal layer was carefully resected using scissors and cupped forceps with sharp edges. The fistula was securely sutured using absorbable suture material. Case 1: A 9-year-old boy with recurrent neck abscesses since 8 years of age presented to our hospital after receiving antibiotics and undergoing drainage in other hospitals. After admission to our hospital, barium esophagography and oral contrast coronal computed tomography showed a PSF on the left side, and open neck surgery was performed to resect the fistula. He was eventually discharged from the hospital without any problem. However, a PSF recurred 2 weeks later. As reoperation with the cervical approach was considered difficult owing to severe adhesions, we adopted MLS as a definitive operation. The postoperative course was uneventful. No recurrence was observed during an 18-month follow-up. Case 2: A 10-year-old girl presented to our hospital with recurrent left-sided neck swelling since 6 years of age. After inflammation control, a PSF was identified on the left side on barium esophagography and computed tomography. MLS was performed safely, and the postoperative course was uneventful. No recurrence was observed during a 10-month follow-up.ConclusionsMLS allows excellent visualization and effective closure for PSFs, and this approach is suitable for recurrence after open neck surgery. Therefore, MLS might become a first-line treatment for PSFs in children.

Case Report: Anterior Pneumomediastinum, Secondary to Dental Procedure

BACKGROUND: Neumomediastinum is defined as the presence of air in the mediastinum, It has variable incidence that oscillates between 1/80000 and 1/420000, generates a diversity of clinical characteristics. It can be secondary to thoracic or extra thoracic entities, within extrathoracic causes; it can be associated with dental procedures, being of vital importance consider the possibility and the association to this procedure to get to an adequate diagnosis and treatment. CASE REPORT: A 23-year-old female patient who, 24 hours prior to admission, underwent a dental procedure such as a third-molar left third molar extraction, in which manual instruments and pneumatics dental lathe were used, which had to be suspended; the patient presented severe pain plus respiratory difficulty, after that she presented oppressive chest pain, mandibular and left side neck, accompanied by subcutaneous emphysema in the left side of the face, neck bilaterally and left subclavicular EVOLUTION: The patient was hospitalize with a diagnosis of neumomediastinum secondary to dental procedure to receive treatment with broad spectrum antibiotic and surveillance, during her hospitalization for three days she remains stable, afebrile with general clinical improvement. CONCLUSIONS: The neumomediastinum is a rare complication after odontological interventions. It should be suspected when pneumatic instrument lathe are used that dissect facial, neck and thorax soft tissues; the patient had a favorable evolution based on the diagnosis and early treatment proposed by the doctors according to the patients symptoms.

Vallecular cyst in an infant with stridor: a case report

Background and Objectives: Vallecular cysts are rare and generally asymptomatic. In infants and children they present with stridor, feeding difficulties, failure to thrive. Treatment is surgical excision with cautery or laser.Presentation of Case: We discuss the clinical, radiological presentation of a 7 months old child with vallecular cyst which was surgically treated with deroofing and marsupialisation with elecrocautery. There was no recurrence even up 2 years of follow-up.Discussion: Flexible nasopharyngolaryngoscopic examination was done which showed present of swelling in the left vallecula pushing the epiglottis posteriorly and to the right with narrowed normal endolarynx. Radiological investigations with CT scan showed cystic lesion noted in left side of neck with no septation and solid component. The lesion was extending to ipsilateral vallecula and paraglottic region with narrowing of endolarynx.Conclusion: Vallecular cyst is rare cause of noisy breathing in infants and children. In adults it is usually asymptomatic. Treatment of choice is marsupialization with electrocautery or laser.

Decompression for botulinum toxin-exacerbated cervical myeloradiculopathy in the setting of congenital stenosis and Arnold-Chiari I malformation.

We present a case describing the management of a woman with severe, functionally limiting cervical myeloradiculopathy in the setting of congenital cervical canal stenosis and Arnold-Chiari I malformation. The subject is a 57-year-old woman with prior anterior cervical discectomy and fusion who presented with left-sided neck pain associated with radiculopathy, migraine, gait incoordination, and cervical dystonia. Cervical stenosis and Chiari malformation were confirmed using MRI. Conservative management with botulinum toxin, oral muscle relaxants, and cervical brace led to gradual exacerbation of symptoms. Due to failure of conservative management, surgical decompression with C3-C6 posterior laminoplasty was performed, resulting in complete resolution of all symptoms and markedly improved quality of life. This case reports a severe and nonspecific presentation of cervical myeloradiculopathy. Surgery for cervical myeloradiculopathy is controversial, and conservative therapy is initially preferred. However, in this case, conservative treatments likely led to paraspinal weakness, cervical hypermobility, and biomechanical instability, resulting in exacerbation of symptoms. Stretch/shear forces have been postulated to accelerate cervical myelopathy, and excessive cervical instability and range of motion are significant predictors of deterioration. In this case, surgical decompression with posterior cervical laminoplasty after 1 year of conservative management yielded significant pain relief and functional restoration, indicating the utility of this procedure even in the presence of Arnold-Chiari I malformation. This case illustrates that decompression can be effective for refractory cervical myeloradiculopathy associated with Chiari malformation, congenital stenosis, and prior anterior instrumentation, and highlights the potential risks of prolonged conservative management.

Endoscopic Management of Recurrent Third Branchial Fistula using Histoacryl Glue

Third branchial cleft anomalies are rare accounting for 2-8% of all branchial abnormalities. We report a case of a 9 year old boy who presented with discharging sinus on the left side of neck. A sinogram revealed third branchial arch fistula. The tract was surgically removed, however, on follow up the fistula was recurred. He was later taken for endoscopic cauterization and injection of Histoacryl (n-Butyl cyanoacrylate ) glue into the tract, after which his wound healed swiftly. Historically, surgical excision of the fistulous tract has been the mainstay of treatment. Recently, minimally invasive methods are gaining wider acclaim and may potentially become the treatment of choice in the future.