Sotos Syndrome: Surgical Correction of Abnormal Craniofacial Features

The otolaryngologic manifestations of Sotos syndrome 1: A systematic review

OBJECTIVES

Sotos syndrome 1 (SOTOS1; MIM:117550) is rare genetic disorder characterized by excessive physical growth before and after birth, distinctive facial features, a large and elongated head, and intellectual disability (Sotos et al., 1964; Tatton-Brown et al., 1993). This systematic review aims to determine otolaryngologic conditions and complications of SOTOS1 based on existing literature through a review of current and past case reports and studies regarding SOTOS1.

METHODS

A systematic review of all published literature (1964-2020) describing otolaryngologic conditions and/or complications of patients with SOTOS1. Twenty journal articles met inclusion criteria. These articles included 160 patients diagnosed with SOTOS1.

RESULTS

Of the 160 individuals with SOTOS1 included in this review, 22 (14%) were reported to have otologic conditions. 4 (3%) individuals were reported to have conditions involving the thyroid and parathyroid glands. 2 (1%) individuals were reported to have head & neck tumors. 39 (24%) individuals were reported to have congenital malformations or abnormalities of the head & neck. 47 (29%) individuals were reported to have feeding difficulties. 16% of individuals were reported to have other otolaryngologic conditions.

CONCLUSIONS

Our review found multiple otolaryngologic conditions present in patients with SOTOS1, including hearing loss, otitis, hyperthyroidism, hypothyroidism, head & neck tumors, congenital malformations (high arched palate, cleft lip and palate, macroglossia), feeding difficulties, respiratory difficulties, and speech disorders. Additional studies should be conducted to further assess these associations.

Treatment Principle Based on the Clinical Staging of Pharyngocutaneous Fistula

Objective

Studies on factors affecting pharyngocutaneous fistulas (PCFs) and PCF repair methods have been widely reported. However, the healing phases of PCF are unclear, and their elucidation could guide clinical treatment.

Methods

Clinical stages of the PCF healing process were identified by a retrospective study of 39 patients with head and neck cancer who developed a PCF.

Results

Different conservative treatments were performed in turn according to three defined stages of the PCF healing process: stage I (drainage and debriding period), stage II (pressure dressing period), and stage III (healing period). A 7-day course of antibiotic therapy was only performed in stage I in 23 patients. The PCF was cured in 30 (76.9%) of 39 patients; the remaining 9 patients underwent subsequent surgical interventions for PCF healing.

Conclusion

The three stages of PCF healing have a certain reference value in guiding clinical treatments. Moreover, antibiotics should be used in stage I when signs of infection are present, but they should not be used in all three phases of conservative treatment.

Hinge Flap with Triangular Extension for Reconstruction of Pharyngocutaneous and Laryngocutaneous Fistulas

Supplemental Digital Content is available in the text.

Hinge flaps are commonly used for closure of a pharyngocutaneous fistula (PCF) or laryngocutaneous fistula. These flaps are employed to augment the wall of the pharynx or larynx, but the junction between the reconstructed and native lumens can eventually become narrow and irregular after reconstruction with standard hinge flaps. We devised a method of adding a triangular extension to the end of either or both flaps and used it to treat 3 patients. In 1 patient who developed a PCF (4 × 10 cm) after laryngectomy followed by radiotherapy, the fistula was closed with 2 hinge flaps. One flap had a caudal triangular extension. The residual skin defect was covered by a pedicled latissimus dorsi musculocutaneous flap. Another patient who developed a PCF (2.5 × 3 cm) after laryngectomy underwent 2-stage reconstruction using a buccal mucosal graft with a triangular extension, followed by 2 hinge flaps. A patient who developed an laryngocutaneous fistula (1 × 2 cm) after radiotherapy and subsequent partial laryngectomy underwent reconstruction using 2 hinge flaps, each of which had a triangular extension. The skin defect was covered by another flap. Postoperative CT or video fluoroscopic examination of swallowing showed a smooth lumen with no strictures in all 3 patients. The triangular extension of the hinge flap supplements the pharyngeal/laryngeal wall at the junction between the reconstructed and intact regions, thus avoiding postoperative stricture. Especially with PCF reconstruction, restoration of a smooth luminal surface minimizes dysphagia.

Vascular anatomy is a determining factor of successful submental flap raising: a retrospective study of 70 clinical cases

The vascular anatomy of submental flaps (SFs) represents a determining factor in successful SF raising. However, little attention has been focused on the venous return of SFs. Thus, the present study aimed to investigate SF venous return. This study enrolled patients who underwent SF reconstructive surgery in a tertiary referral center between November 2009 and October 2016. The drainage pathway of the SF venous return was routinely identified during the course of our operations to prevent damage during head and neck surgery. The venous return data of 70 patients were reviewed. The size of the flaps ranged from 15 to 84 cm², and total flap loss was not observed in the case series. All of the submental arteries originated from the facial artery; however, the submental veins of 70 patients returned to either the internal jugular vein (IJV, 72.9%) or the external jugular vein (EJV, 27.1%). Our data suggest that drainage of the submental vein into the EJV, which has been previously overlooked, should receive greater attention during SF surgeries. The results support mandatory preservation of the EJV and IJV and indicate that vascular anatomy is a determining factor for successful SF raising.

[Submental artery island flaps for reconstruction in the head and neck region]

BACKGROUND

Reconstruction of defects after extirpation of head and neck neoplasms is a highly challenging and complex surgical undertaking. Commonly used techniques, such as the radial forearm flap or anterior lateral thigh flap, have numerous disadvantages, e.g., donor-site morbidity, poor color match for cutaneous reconstruction, and excessive tissue bulk for intraoral reconstruction. Use of a submental artery island flap is a relatively new and increasingly performed option for reconstruction in the head and neck region.

MATERIALS AND METHODS

From March 2013 to August 2015, 12 patients were treated with a submental island flap after surgical resection of intraoral carcinomas or cutaneous neoplasms of the lower half of the face.

CASE DESCRIPTION

This paper reports on two cases. The first case describes reconstruction of the floor of the mouth using a pull-through technique after resection of a squamous cell carcinoma. The submental flap was pedicled on the contralateral side, since neck dissection of regions I-V had been performed on the ipsilateral side. The second case is a reconstruction of the lower midface with parts of the upper lip, after removal of a cutaneous spinalioma. In a N0 neck, no neck dissection was performed. The flap healed without problems in both patients, leading to a very good functional and cosmetic outcome.

CONCLUSION

The submental island flap demonstrates reliability and versatility for head and neck reconstructions. Its minimal donor site morbidity, excellent cosmetic match, pliability, and relative ease of dissection and application confer a definite advantage over distant flaps.

Exclusion of musculature from the submental flap: a contingency plan for facial nerve palsy

Summary:

Submental flap surgery is a useful and versatile reconstructive procedure. Currently, disagreement exists regarding the need to include the anterior belly of the digastric muscle or mylohyoid in the submental flap. The report outlines the value of excluding normal and variant anterior digastric and mylohyoid musculature from the submental flap as a contingency plan for marginal mandibular branch of facial nerve palsy. Also, the article addresses variant anterior digastric musculature, a common anatomical finding, as it relates to the submental flap. The question of whether or not to include the anterior digastric musculature does not necessitate an all-or-none decision. In the case of multiple anterior digastric bellies, some bellies may be included in the flap, whereas others are not. The location of the submental vessels and the desired bulk or contour of the flap should guide the decision of which anterior digastric bellies, if any, are included in the flap.

A case of refractory perforation at the floor of the mouth with ectopic bone formation

Although most fistulae are not problematic, surgeons occasionally encounter recurrent and/or refractory fistulae in the field of oral and maxillofacial surgery. In this case report, the authors describe a case in which a patient experienced a recurrent and refractory fistula or perforation at his oral floor through the submandible, with heterotopic bone formation arising on both sides of the mylohyoid line. These heterotopic bones were connected to each other, forming a bone bridge at the center of the oral floor. A fistulectomy and wound closure with a tongue flap was successful. The perforation has not recurred after over four years of follow-up, and the bone bridge is still present.

The submental flap for oral cavity reconstruction: extended indications and technical refinements

Background and purpose

The submental flap is gaining popularity as a simple technique for reconstruction of small to moderate size defects of the oral cavity. However, its role in composite defects involving the jaw is not clearly defined. Indeed, controversy exists about the flap's interference with an oncologically sound neck dissection

Patients and Methods

A total of 21 patients with oral cavity cancers over a three year period were included. All patients underwent surgical resection and immediate reconstruction with submental flap except one patient who had delayed reconstruction with reversed flap. The flap was used for reconstruction of intra-oral soft tissue defect in 13 patients and composite defects in 8 patients.

Results

Of 21 patients 12 were males and 9 were females, age ranged from 32 to 83 years. The primary tumor sites included buccal mucosa (7), tongue (4), alveolar margin (3), floor of mouth (5) and lip (2). Eventually in this study, we adopted completing the neck dissection first before flap harvest. Complete flap loss occurred in 2 whereas 3 patients had partial flap loss. Follow up ranged from 3 to 44 months, one patient died from metastatic disease. Four patients developed neck recurrences.

Conclusion

The submental flap is a valid option for reconstruction of intra-oral soft tissue as well as composite oral defects particularly in elderly patients. However, oncologically sound neck dissection should be assured.

[Microvascular submental island flap prelaminated with oral mucosa in reconstruction of the lateral defect of nose]

INTRODUCTION

Reconstruction of perinasal area is still a challenge for the surgeon who is involved in excisional tumor surgery. The authors report their experience in reconstruction of hemi-nose defects with the free microvascular submental island flap prelaminated with oral mucosa.

MATERIAL AND METHODS

A 73-year-old male patient with recurrent extensive basal cell carcinoma of the right hemi-nose (nasal ala and lateral nasal part) and portion of the upper lip underwent to excisional surgery and creation of lateral nasal defect 3 x 2 cm in size. Six months after the first surgery the reconstruction of postoperative defect was done by means of free microvascular submental flap prelaminated with oral mucosa.

RESULTS

After necrosis of flap 3 mm x 4 mm in size around the tip zone of the nose on the 7" postoperative days, the rest of microvascular submental flap prelaminated with oral mucosa survived completely with good cosmetic and nasal respiratory results.

CONCLUSION

This flap can be used successfully in reconstruction of the hemi-nose area. Color and texture of the flap match with adjacent tissue and adequate diameter of submental vessels and reasonably long vascular pedicle enables successful microvascular anastomosis.

Novel flaps for head and neck reconstruction

The head and neck region is important both functionally and aesthetically and its reconstruction poses a formidable challenge for plastic surgeons. A perforator flap is a flap of skin or subcutaneous tissue supplied by a vessel that perforates the deep fascia to gain access to flap. With improvement in our knowledge of the anatomy of blood supply to the skin, the perforator flaps have opened a whole new horizon for the plastic surgeon to choose flaps with better function and cosmesis. The locally available perforators enable flaps to be designed with excellent match in tissue characteristics. Perforator flaps limit donor site morbidity and as they are islanded complete insetting is possible in a single stage. The principal perforator flaps such as facial artery perforator flap, platysma flap and its variant the submental flap and supra-clavicular artery flap used in the head and neck reconstruction are discussed. The more commonly used flaps are the free radial artery forearm flap and the anterolateral thigh flap while the novel ones are the thoracodorsal artery perforator flap, medial sural artery perforator flap and the toe-web flap for commissure reconstruction. The indications, reach and drawbacks of these flaps have been discussed in this review.

Surgical closure of postlaryngectomy pharyngocutaneous fistula: a defect based approach

Surgical repair of postlaryngectomy pharyngocutaneous fistula (PCF) can be challenging. Although several studies describe separate reconstruction methods, only few address the variability in defect characteristics and hence flap selection. The current clinical study presents a retrospective review of 19 patients who underwent surgical repair of persistent PCFs, over a 4-year period in a tertiary referral institute by a single primary surgeon. All but one patient were men with a mean age of 61 +/- 10 years. Nine patients had previous unsuccessful attempts for surgical closure. Previous neck irradiation was the most common comorbid condition encountered (52.6%), followed by low hemoglobin level (47.4%), hepatic disease (36.8%) and diabetes mellitus (31.6%). According to defect characteristics, six patients received a local cervical skin procedure, ten patients had reconstructions using the pectoralis major musculocutaneous flap and three patients required a radial forearm free flap repair. All PCFs were eventually successfully closed with no major complications. Patients were followed-up for an average of 19.7 months (range, 5-38 months). Acceptable oral swallowing results were achieved in all but one patient. In conclusion, successful results are achievable in difficult persistent PCF cases with a defect based reconstruction approach kept in mind.

Soft-Tissue Augmentation of the Middle and Lower Face Using the Deepithelialized Submental Flap

BACKGROUND

Facial contour augmentation is an entity often encountered by reconstructive surgeons. To date, very different autologous tissues such as fat, dermofat, dermal fascia, muscle, cartilage, and bone in the manner of grafts or flaps according to the requirements of the defect have been used for facial augmentation. Although many free flap procedures have become popular in facial contouring, these microsurgical methods have some limitations and risks, especially in patients who are not suitable for microsurgery. Moreover, the patient may wish to be treated by means of a more conservative procedure.

METHODS

The authors used the submental flap in deepithelialized fashion successfully for augmentation of the face in three patients who presented with hemifacial microsomia (n = 2) and longstanding facial paralysis (n = 1).

RESULTS

Adequate augmentation was achieved in all cases, without any complications. All donor sites were closed primarily and healed well. Patient satisfaction was perfect in all cases. A second debulking procedure was performed in case 3 only. The average follow-up was 1 year.

CONCLUSIONS

The authors believe that the deepithelialized submental flap can be used safely for all facial contour restorations of the lower and midface necessitated by various causes, including hemifacial microsomia and facial paralysis as a main or adjunct procedure. In these cases, this flap may be a good alternative, especially for patients who are not suitable for microsurgery.

Reconstruction of the columella using the prefabricated reverse flow submental flap: A case report

BACKGROUND

The reconstruction of columellar defects is still a challenging procedure because of limited local and regional flap options and the characteristics of the anatomy of this site. Although a number of methods are available to repair nasal columella defects, no treatment of choice ensuring an excellent texture- and color-matched tissue in one stage has been determined to date.

METHOD

In this case, we used a reverse-flow submental island flap prefabricated with the costal cartilage for the reconstruction of a complex columellar defect.

RESULT

The flap survived completely with reversible venous congestion. The cosmetic result and nasal respiratory function were acceptable during the follow-up time of 6 months.

CONCLUSION

We propose that the prefabricated reverse submental flap may be an alternative among the surgical options for columellar defects. This flap may also be considered in the reconstructive repertoire of other composite defects of the head and neck region.

A case of Sotos syndrome with subduroperitoneal shunt

The authors present a case of Sotos syndrome with increasing severity of subdural hygroma from the age of 5 months, which was managed with a subduroperitoneal shunt at 10 months of age. The patient had been followed up until 30 months of age with continuing improvement of symptoms. The patient initially presented with dolichocephaly accompanied by macrocrania, early tooth development, repeated pneumonia infections and developmental retardation concerning crawling, sitting, walking and speaking at 5 months of age. Magnetic resonance imaging (MRI) demonstrated partial hypoplasia of the corpus callosum and bifrontal subdural hygroma. The patient underwent subduroperitoneal shunting at 10 months of age with partial improvement of symptoms. At 18 months of age, the patient showed increased irritability and sweating, and development of spinal kyphosis, which resulted from shunt malfunction as shown in the shuntogram. The appearance of cervical syringomyelia was also seen in the MRI. After shunt revision, the irritability, sweating and kyphosis improved along with disappearance of the syringomyelia. The authors describe a case of Sotos syndrome with subduroperitoneal shunt that showed syringomyelia which developed with shunt malfunction but disappeared after shunt revision. We emphasize the importance of active management such as subduroperitoneal shunting to drain the cerebrospinal fluid in the Sotos syndrome.