Transcervical Approach Research Articles

A Case of Multiple Cervico-Mediastinal Parathyroid Adenomatosis

The most common cause of primary hyperparathyroidism is a single adenoma accounts for more than 85% and about 1-2% in multiple occurrence. The adenoma arises mainly in the neck and rarely in the mediastinum. The simultaneous occurrence is extremely rare. A 73-year-old man came to our clinic complained about sense of falling forward during last eight months. The brain MRI and vestibular function test showed non-specific findings but total calcium and intact parathyroid hormone levels were markedly elevated. Radiologic studies and sesta-MIBI scan revealed multiple masses in lower paratracheal area and superior mediastinum. We performed mass excision with transcervical approach and all of them were diagnosed as parathyroid adenoma. After surgery, intact PTH and calcium levels returned to the normal range and his symptoms were dramatically improved. We report the unique and rare disease entity with a brief literature review. Key Words: Neck, Mediastinum, Parathyroid adenoma

Pleomorphic adenoma of parapharyngeal space: a rare case report

<p>Parapharyngeal space is one of the potential facial planes for neoplasms representing less than 1% of all head and neck tumours, often pose therapeutic and diagnostic problems due to variable nonspecific symptoms and the complex anatomy of the space and tend to delay the diagnosis resulting in poor prognosis. We here with report a 21 years old female patient, who presented with change in voice and swelling in right submandibular area. On examination of oral cavity, a smooth firm bulging mass was seen in the right tonsillar and para-tonsillar region with medialisation of right tonsil. Contrast enhanced computed tomography showed minimally enhancing encapsulated soft tissue density mass in right parapharyngeal space. Patient underwent excision through transcervical approach. Histopathology of the specimen showed pleomorphic adenoma. No evidence of recurrence till date.</p>

Submandibular Gland Surgery; Transoral Versus Conventional Transcervical Approach.

Transcervical approach (TCA) is a widely accepted method of surgery in submandibular gland (SMG) excision. The main purpose of the present study is to compare the surgical and functional outcomes of TCA and transoral approach (TOA) in SMG excision. The participants of this prospective study are 31 consecutive patients in whom SMG excision was performed via TOA (n = 14) and TCA (n = 17). Operative time, complications, hospitalization time, postoperative morbidities, and histopathological results were noted and compared between the groups. The numerical rating scale was used to grade the postoperative morbidities including, pain, eating and swallowing difficulty, and abnormal sense of tongue. The number of females (n = 10) was higher than males (n = 4) in the TOA group due to aesthetic concerns. The average operative time of TOA group (85.3 ± 17.8 minutes) was significantly longer than the TCA group (40.8 ± 7.3 minutes), whereas the mean hospitalization time in TOA group (28.5 ± 4.6 hours) was remarkably shorter than TCA group (49.4 ± 6.9 hours). The mean pain scores were significantly less in the TOA group than the TCA group during the first 3 days postoperatively (P < 0.001). The mean numerical rating scale scores of eating and swallowing difficulty and abnormal sense of tongue were significantly higher in the TOA group compared to the TCA group postoperatively. There was no postoperative marginal mandibular nerve (MMN) dysfunction seen in the TAO group, whereas temporary dysfunction of MMN was observed in 3 (17.6%) patients in the TCA group. In selected patients, transoral SMG excision is an indisputable superior method in terms of MMN inadvertent injury risk, cosmetic results and postoperative pain compared to the conventional method of TCA in selected cases. Especially in young female patients with serious aesthetic concerns, excision of SMG via a TOA without any visible incision provides cosmetically excellent satisfactory results.

Plunging ranula in 26 years old male: a case report

&lt;p&gt;Ranula is a bluish translucent cystic lesion in the floor of mouth. It can be true cyst occurring due to obstruction of the sublingual gland or a minor salivary gland or a pseudocyst as a result of ductal injury leading to extravasation and accumulation of saliva in surrounding tissues. Two variants of ranula are described in the literature: simple oral ranula and deep diving or plunging ranula. We report a case of plunging ranula with both oral and cervical components which is treated successfully by surgical excision. This case report involves an unusually large ranula involving floor of mouth with cervical extension, more towards left side, in a 26 years old male. It is successfully removed in- toto by transcervical approach. The patient was followed up on a regular basis and was disease free.&lt;/p&gt;

Submandibular gland excision: From external surgery to robotic intraoral and extraoral approaches.

Submandibular gland excision is generally performed through a transcervical approach, a safe procedure that, however, carries few neurological, functional and aesthetic drawbacks. Intraoral approach to the submandibular gland has been described many years ago but it has been newly proposed in recent years thanks to endoscope-assisted and robot-assisted surgical procedures. The main purpose of intraoral approaches is to avoid cosmetic sequelae and to reduce the risk of marginal nerve injury although the recent introduction of retroauricular, postauricular, facelift and transhairline neck incisions has overcome the need for an alternative to traditional transcervical approach. Different surgical approaches (transoral versus transcervical) to the submandibular gland as well as different type of cutaneous incisions will be illustrated and discussed in the light of advancement of endoscope-assisted and robot-assisted procedures.

Transoral robotic submandibular sialadenectomy: how and when.

Traditional removal of the submandibular gland is done through a transcervical approach; new proposals have come into the scientific limelight such as endoscopy-assisted transcervical sialadenectomy or (robot-assisted) submandibular sialadenectomy through a postauricular facelift transcervical approach. Transoral submandibular sialadenectomy has been described in the past, but with the advent of transoral robotic surgery, the proposal of removing the submandibular gland from the oral floor is gaining strength. A transoral robotic submandibular sialadenectomy by the Si Da Vinci Surgical Robot was performed in a 68-years-old female patient under general anaesthesia. The transoral robotic procedure was successful with no major postoperative complications. A mild tingling of the tip of the tongue was described by the patient 3 months after. The surgical time took 110 minutes. No residual gland was observed at ultrasonography. The transoral robotic submandibular sialadenectomy seems to be, with selective indication based on clinical and radiological assessment, a viable and safe alternative to traditional management in patients who refuse a cervical scar and the risk of paralysis of the facial nerve.

Transcervical LVAD Outflow Graft Implantation as Sternotomy Free Procedure: Proof-of-Concept

Minimally invasive methods to implant left ventricular assist devices (LVAD) have emerged as alternatives to the classic median sternotomy as they have been shown to decrease bleeding and periprocedural complications, plus speed up recovery and make future sternotomies easier. While implantation of a centrifugal LVAD within the LV apex can be performed via a left thoracotomy, the outflow graft anastomosis to ascending aorta is still routinely done via upper hemi-sternotomy which, although limited, has some of the above disadvantages. We present a technique of transcervical outflow graft implantation which completely avoids sternotomy. This is a proof-of-concept implantation performed on a cadaveric model. The procedure is facilitated by a novel access system (CoreVista® Retractor, CardioPrecision Ltd, Glasgow UK) designed for surgery via a transcervical approach. This device comprises a frame fixed to the operating table to which a disposable transcervical retractor with inbuilt illumination modes used for the different steps of the procedure is attached plus an HD display offering optimal views. The technique can be broken down into a number of reproducible steps: transverse neck incision, retractor insertion, sternal elevation, illumination, dissection of anterior mediastinum and exposure of aorta. The outflow graft is pulled into the field and, after trimming to avoid kinking, a side clamp is placed on the aorta and the graft is sutured in continuous fashion. This is greatly aided by the retractor illumination and HD visualisation on-screen. Sutures are tied, clamp released, haemostasis confirmed, retractor removed and the small neck incision closed. This proof of concept demonstrates that a sternotomy-free implantation of a LVAD is feasible and should prove reproducible with the help of the novel transcervical access system. The approach may also be suitable for implantation of an axial flow pump without the current limitations imposed by access vessel size.

Bi-institutional experience of transoral endoscopic thyroidectomy: Challenges and outcomes.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a novel remote-access endoscopic approach. In this study, we compared the surgical outcomes of TOETVA with those of conventional transcervical approach (TCA) in two tertiary hospitals. A total of 82 patients were done by TOETVA and 233 patients received TCA between January 2018 and April 2019. Propensity score matching was used to reduce selection bias. Operation time of the TOETVA group was longer than that of the TCA group. The mean number or retrieved lymph nodes were significantly higher in the TOETVA group. No significant difference was observed in the overall perioperative complications. TOETVA is technically acceptable when compared to TCA in terms of equal baseline characteristics of patients. Although future large-scale multicenter studies with longer follow-up periods are needed, we expect this novel technique can be performed not only for cosmetic purposes but also for patients with papillary thyroid carcinoma.

Simulations and simulators in head and neck endocrine surgery.

Simulations and simulators have become an increasingly important tool in trainee education across many surgical disciplines, particularly for robotic and minimally invasive procedures. Thyroidectomy and parathyroidectomy are common procedures performed across multiple surgical disciplines, however, there is limited literature regarding training models/simulators for these operations. This is despite the advent and growing popularity of remote-access thyroidectomy techniques, where simulators may provide significant value in trainee education and safe implementation. Here we review the literature regarding available simulations/simulators in head and neck endocrine surgery for both conventional transcervical approaches and newer remote-access thyroidectomy techniques.

Trans-oral robotic surgery in the management of parapharyngeal space tumors: A systematic review.

To perform a systematic review of studies evaluating Trans-oral Robotic Surgery (TORS) in the treatment of parapharyngeal space (PPS) tumors. A comprehensive electronic search was performed in PubMed/MEDLINE, Cochrane Library, and Google Scholar databases for appropriate published studies. The last search was conducted on November 9, 2019. Twenty-two studies were included for the systematic review which analyzed a total of 113 patients (median age 53.5, IQR 41.5-58.1). The most common PPS tumor treated with TORS was the pleomorphic adenoma (n=66; 58.4%). All tumors were successfully resected. The median tumor size was 4.8cm (n=73; IQR 3.8-5.4). Combined transcervical (TORS-TC) and transparotid (TORS-TP) approaches were used in 13 (11.5%) and 5 (4.4%) patients, respectively. Capsule disruption was noted in 11 cases (14.5%), while tumor fragmentation was observed in 7 patients (10.3%). The median time of hospitalization was 3days (n=79; IQR 2-4.1). Oral diet was possible from the day after surgery in the majority of patients (n=34, 68%). The most common complication was dysphagia (n=5, 4.5%). This systematic review confirms the safety and feasibility of TORS in the treatment of PPS lesions. Given the low quality of included studies, further evidence is needed in order to establish clinical guidelines.

The importance of sublingual gland removal in treatment of ranulas: A large retrospective study.

Investigate the efficacy of sublingual gland removal for the treatment of simple and plunging ranulas. After IRB approval, a retrospective review was performed on patients treated for a ranula from February 2013 to May 2018 at Texas Children's Hospital in Houston, TX. Clinical data was collected from medical records and patients were contacted in November 2018 to obtain additional information about recurrences or complications. This study included 52 patients with ranulas (10 plunging, 42 simple; M:F 21:31) with a mean age of 9.68years. Eighteen patients provided information in the extended follow-up period. Simple ranulas were treated with intraoral excision of the cyst and the sublingual gland (27 cases), marsupialization (7 cases), intraoral excision of the cyst alone (7 cases), and intraoral excision of the cystic component and subsequent marsupialization after recurrence (1 case); intraoral excision of the sublingual gland was not associated with any recurrence. Plunging ranulas were treated with intraoral excision of the cyst and/or sublingual gland (7 cases) or with a transcervical approach (3 cases). One patient was initially treated with sclerotherapy before undergoing intraoral excision of the sublingual gland. Two patients treated with transcervical excision of the cyst experienced recurrence compared to no recurrence with intraoral excision of the sublingual gland. Intraoral removal of the sublingual gland is the most effective treatment for both simple and plunging ranulas. Plunging ranulas must be considered in patients presenting with a submandibular and submental cystic mass given intraoral extension may not be apparent.

Transoral Mandibular Tongue-Splitting Approach in Upper Cervical Epidural Abscess: A Case Report and Review of the Literature.

Introduction The transoral mandibular tongue-splitting approach is typically performed for the treatment of upper cervical tumor and instability but has not been performed for the treatment of upper cervical epidural abscess (UCEA). We report the first case of UCEA successfully treated with a transoral mandibular tongue-splitting approach. Technical Note A 62-year-old man who had medical histories of tracheotomy with intubation and dermatopathy due to radiation therapy for the treatment of nasopharyngeal carcinoma presented with neck pain and limb weakness. The imaging examination revealed bone erosion of C2-C4 vertebrae and abscess at the level of C2-C4, supporting a diagnosis of UCEA. The transcervical approach could not be used for treatment; therefore, the transoral mandibular tongue-splitting approach was used successfully to perform decompression, debridement, and iliac bone grafting. Subsequently, we reviewed the literature pertaining to the use of the transoral mandibular tongue-splitting approach. The approach can be invasive and cause some complications. However, no fatal complications have been reported, and all patients demonstrated a favorable neurological outcome with reduced neurological deficits. Conclusions This case and subsequent literature review suggest that the transoral mandibular tongue-splitting approach may be effective for the improvement of neurological outcomes without fatal complications in patients with UCEA. There may be an increasing number of patients with UCEA requiring the transoral mandibular tongue-splitting approach due to the increasing prevalence of immunocompromized status and the aging population.

Transcervical endoscopic approach for parapharyngeal space: a cadaver study and clinical practice

Background: The traditional transcervical approach is frequently applied but limited in handling the tumors in parapharyngeal space.Objectives: We explore a new transcervical endoscopic approach with more direct visualization, less complications, and better outcomes.Material and methods: Eight cadaver heads (sixteen sides) were prepared for endoscopic dissection. Clinical cases were carefully selected, and thirty patients accepted the transcervical endoscopic surgery.Results: The transcervical approach with an endoscopic video system clearly exposed the detailed structures in the parapharyngeal space. The stylopharyngeus, styloglossus muscles, and styloid process were critical landmarks in this approach. During the thirty cases of clinical surgeries, internal carotid arteries and cranial nerves could be effectively exposed and protected with the endoscopic video system. Accurate hemostasis could be achieved under endoscopic transcervical approach with a mean amount between 30 to 100 ml of hemorrhaging. There was no postoperative hemorrhages and emergency tracheotomies. The follow up led to promising results.Conclusions and significance: The transcervical endoscopic approach provides a wide corridor for surgery in the parapharyngeal space. With accurate hemostasis, this approach can be applied as the first-line strategy for parapharyngeal surgeries in selected patients.

Risk factors for failed chorionic villus sampling: results of a 4-year retrospective study

Objectives Chorionic villus sampling (CVS) allows for earlier results for aneuploidy or genomic abnormalities compared to amniocentesis. Nevertheless, the inability to provide complete results has been described as being more frequent with CVS. This study was conducted in order to identify risk factors for such failures. Study design A retrospective single-center study was performed from January 2014 to December 2018. Participants were divided into two groups depending on whether complete CVS results were issued (“successful CVS group”) or not (“failed CVS group”). Failure affected preliminary short-term cultures, long-term cultures, or both. Results During the study period, 214 CVS were performed, 73 (34%) of which were classified in the failed CVS group. We observed significant intergroup differences between the successful and failed CVS groups for four variables: BMI (respectively 23.9 [±5.88] and 25.9 [±6.13] kg/m2), term at sampling (12.9 [±1.35] and 12.6 [±1.09] weeks gestation), trophoblastic location (posterior in 49 [40%] and 37 [66%] cases), and sampling approach (transcervical in 54 [43%] and 36 [64%] cases) (p < .05). In a stepwise binary logistic regression analysis, higher BMI, posterior trophoblastic location, and transcervical sampling approach were the only variables negatively influencing CVS success, with respective aOR [95% CI] of 0.947 [0.898; 0.996], 0.322 [0.160; 0.634], and 0.466 [0.238; 0.900]. Conclusions In the presence of CVS failure risk factors, a discussion could be initiated regarding a deferred amniocentesis as a first option.

Our Experience with Intraoral Submandibular Gland Excision.

The aim of this paper is to present our experience with intraoral approach for submandibular glandexcision in terms of effectiveness and safety in patients with chronic sialadenitis. This is a prospective study carried out from November, 2016 to April, 2018 analyzing 13 patients of chronic sialadenitis. The indication of intraoral approach was either failed attempt to remove the stone endoscopically, chronic sialadenitis or benign tumor. The surgical triangle was used as the landmark for hilar area and gland was dissected close to the capsule and removed via intraoral incision and preserving the sublingual gland. We were successfully able to remove the submandibular gland via intraoral approach in 10 cases. Two patients had to undergo transcervical gland excision and one patient refused for transcervical approach. Intraoral excision of submandibular gland is a safe and viable approach to be utilized in carefully selected patients. The major advantages being avoidance of transcervical scar and of injury to marginal mandibular branch of facial nerve.

Surgical Approaches to Benign Parapharyngeal Space Tumors-5-Year Experience.

Introduction:Various surgical approaches to parapharyngeal space (PPS) tumors are introduced to obtain complete removal with the preservation of the surrounding structures in parapharyngealneoplasms. Here, we will discuss the main techniques and their outcome.Materials and Methods:This retrospective study was conducted on 78 patients undergone either transoral, transcervical or a combination of these two approaches for the resection of PSS tumors from January 2010 to January 2015.Results:A number of 33 male and 45 female patients with the mean age of 40.9 ± 9.1 were evaluated. 42.3% of the patients were asymptomatic at the initial presentation. Pleomorphic adenoma and schwannoma were a permanent diagnosis in 61(78.2%) and 11(14.1%) patients, respectively. PPS tumors were resected using transoral, transcervical and combined approaches in 35(44.8%), 33(42.3%) and 10 (12.9%) cases, respectively. Recurrence occurred in 10 patients all of whom had apre-styloid pleomorphic adenoma, operated transcervical (P< 0.0001).Three cases of tenth nerve palsy occurred in schwannomas which were operatedtranscervically (P=0.04). Mean hospital stays were 2.11,3.69, and 4.9 days after transoral, transcervical and combined approaches, respectively (P= 0.001).Conclusion:Transoral, transcervical and combined approaches are all able to provide adequate visualization with comparable outcomes.

Anterior cervical osteophytes causing dysphagia: Choice of the approach and surgical problems.

Background:Anterior cervical osteophytes (ACOs) may rarely cause dysphagia, dysphonia, and dyspnea. Symptomatic ACOs are most commonly located between C3 and C7, whereas those at higher cervical (C1–C2) levels are rarer. We report a case series of 4 patients and discuss the best surgical approach according to the ostheophyte location and size, mainly for those located at C1–C2, and the related surgical problems.Materials and Methods:Four patients (two males and two females) aged from 57 to 72 years were operated on for ACOs, causing variable dysphagia (and dyspnea with respiratory arrest in one). Three patients with osteophytes between C3 and C5 were approached through antero-lateral cervical approach, and one with a large osteophyte between C1 and C3–C4 level underwent a two-stage transcervical and transoral approach. All had significant postoperative improvement of dysphagia.Results:The patient operated on though the transoral approach experienced postoperative flogosis of the prevertebral tissues and occipital muscles and thrombosis of the right jugular vein and transverse-sigmoid sinuses (Lemierre syndrome).Conclusion:The transoral approach is the best surgical route to resect C1 and C2 ACOs, whereas the endoscopic endonasal approach is not indicated. The anterior transcervical approach is easier to resect osteophytes at C3, as well as those located below C3. A combined transoral and anterior cervical approach may be necessary for multilevel osteophytes.

The Role of Transoral Robotic Surgery for Parapharyngeal Space: Experience of a Tertiary Center.

The parapharyngeal space (PPS) is an anatomically and functionally complex region of the craniofacial district. Tumors that originate from this region are rare, and surgery is currently the best practice in the vast majority of cases with different surgical approaches being reported in the literature. Recently, mini-invasive robotic/endoscopic techniques have begun to emerge as effective alternatives in selected cases. In this work, we retrospectively analyzed 17 patients affected by PPS tumors, and managed by transoral robotic surgery (TORS) as a therapeutic or diagnostic procedure. TORS was used alone or combined with a transcervical approach for huge lesions of the PPS, at risk of fragmentation (curative intent). TORS also permitted biopsies of unknown lesions of the PPS to be conducted (diagnostic intent) otherwise unreachable without performing a mandibulotomy. All patients treated with curative intent benefited from radical surgery. No major complications were observed, and tumor fragmentation occurred only in 2 of 17 patients (11.8%). All patients receiving TORS with diagnostic intent were successfully referred to nonsurgical treatments based on the final histhopathological findings. This work also demonstrated TORS to be effective and safe on a larger group of patients compared to our preliminary study in 2016. TORS provides good oncological and functional outcomes when used with curative intent and is an effective diagnostic tool in cases of suspicious lesions of the PPS.

Endoscopic-assisted Transoral Approach to Parapharyngeal Space Tumours

Parapharyngeal space tumours are rare, mostly benign and present few symptoms, being difficult to diagnose it early. CT scan and MR are necessary for topographical diagnosis. Surgical resection is the best possible treatment option, but the approach remains a challenge, as there are several vital elements contained in the parapharyngeal space and, thus, adequate visualization is needed. Different surgical approaches have been described: transcervical-submandibular, transparotid, transmandibular, transoral and combined approaches. Transoral approach is the most controversial one due to cited limited exposure, which can lead to neurovascular injury or incomplete removal of the lesion. It is seldom performed and only for small, extra-parotid and non-vascular tumours of the parapharyngeal space. Wide access to endoscopic equipment in our institute allowed us to perform medium to large benign parapharyngeal tumour resection usig the transoral approach. The use of endoscopic assistance for transoral approach provided direct and magnified visualization of the parapharyngeal space, reducing tissue damage, ensuring adequate hemostasis (which lead to less amount of bleeding) and also confirming complete resection prior to closure. In addition, compared to transcervical approach, transoral approach shortened hospitalization time and improved cosmetic appearance. Benign parapharyngeal space tumours not involving critical structures from the parapharyngeal space can be completely resected by an endoscopic-assisted transoral approach with good functional and cosmetic outcome.

Deep cervical and paratracheal drainage for descending necrotizing mediastinitis.

Background Descending necrotizing mediastinitis is life-threatening and extends into the deep cervical fascia including the pretracheal, perivascular and retrovisceral, and prevertebral spaces. Deep cervical and paratracheal drainage via a transcervical approach prevents the spread of infection into the deep mediastinum. It is effective for local neck drainage and important in the primary treatment of descending necrotizing mediastinitis. Transthoracic mediastinal drainage is also effective for treating this condition. Methods Nine patients with descending necrotizing mediastinitis were treated by deep cervical and paratracheal drainage via a transcervical approach at our institution from April 2007 to December 2017. Four patients with diagnoses of extensive descending necrotizing mediastinitis had progressive extension of abscesses into the lower mediastinum, below the level of the carina. The other five had localized descending necrotizing mediastinitis with infection in the upper mediastinum above the level of the carina. Results All 9 patients (4 with extensive and 5 with localized descending necrotizing mediastinitis) initially underwent deep cervical and paratracheal drainage via a transcervical approach, and all recovered. Two of the patients with extensive infection required no additional surgical intervention. Conclusions Fluid collections in the deep cervical fascia must be drained urgently. Deep cervical and paratracheal drainage via a transcervical approach effectively controls all types of descending necrotizing mediastinitis, and it is less invasive than transthoracic approaches via thoracotomy. However, a thoracotomy for mediastinal drainage must be considered if infection is not controlled by transcervical drainage. Thoracic surgeons and otolaryngologists must plan efficacious treatment before surgical procedures for descending necrotizing mediastinitis.