Morphological and functional changes of the geniohyoid muscle in elderly patients after hip fracture surgery: Comparison of ultrasound images with a focus on swallowing function

OBJECTIVE

The purpose of this study was to clarify, using ultrasound imaging, (1) whether the area and contraction of GH change in elderly patients after hip fracture surgery and (2) whether the changes in the area and contraction of GH are related to decline in swallowing function.

METHODS

The participants were 21 female patients over 65 years of age who underwent hip fracture surgery. The patients were divided into two groups based on the results of swallowing assessment by water drinking: One with normal swallowing function (NSF) and the other with suspected decline in swallowing function (DSF). Sagittal cross-sectional area (SA) of GH at rest and the shortening rate (SR) of GH upon contraction during swallowing were compared at two time points: immediately and 2 weeks after surgery. Wilcoxon signed-rank test was used for intra-group comparisons, and Mann-Whitney U-test was used for between-group comparisons.

RESULT

SA of GH decreased significantly at 2 weeks after surgery in both groups, regardless of their swallowing function. In the intra-group comparison, SR significantly decreased (worsened) only in DSF group. SR at 2 weeks after surgery was significantly higher in NSF than in the DSF. In the inter-group comparison, DSF showed a significantly smaller (worse) change of SR than NSF in 2 weeks after surgery.

CONCLUSION

Decrease in muscle mass, or atrophy, of GH observed in both NSF and DSF, did not coincide with the post-operative change in GH contraction of the two groups. The results suggest the importance of continuous swallowing assessment in the elderly individuals during their perioperative period.

A case of sinonasal teratocarcinosarcoma treated with surgery and post-operative intensity-modulated radiotherapy (IMRT)

Sinonasal teratocarcinosarcoma (SNTCS) is a rare and aggressive malignant neoplasm, which has poor prognosis. SNTCS is histologically characterized by the combination of one or more epithelial elements and mesenchymal components. We report a 59-year-old man with SNTCS involving right maxillary and ethmoid sinuses. He complained of numbness of the right cheek for 1 month. Computed tomography and magnetic resonance imaging revealed soft tissue filling the right maxillary and ethmoid sinuses, protruding into the nasal cavity. Tumor was removed with Denker rhinotomy, and post-operative intensity-modulated radiation therapy (IMRT: 64Gy in 32 fractions) was performed. Follow-up examination for 2 years after the IMRT has shown no evidence of recurrence or metastasis. IMRT is a new type of conformal radiotherapy that is based on the use of non-uniform radiation beam intensities. IMRT can achieve optimal dose distributions and may improve the clinical outcomes dramatically with minimal complications. This report describes this patient's clinical course, etiology, diagnosis and management of SNTCS, and the advantage of IMRT in the treatment of SNTCS.

Sclerosing polycystic adenosis of the left parotid gland: report of a case with fine needle aspiration cytology

BACKGROUND

Sclerosing polycystic adenosis (SPCA) of major salivary glands is a rare recently described entity. We report a case of SPCA of the left parotid gland, including the cytologic and histopathologic findings.

CASE

A 20-year-old man presented with a left parotid mass that had been growing slowly for 3 years. Fine needle aspiration cytology showed many syncytial cell clusters of variable size and some ductal structures with an inflammatory background. The cells forming syncytial clusters were large and polygonal, with abundant, eosinophilic, granular or lacelike cytoplasm. Apocrine differentiation with decapitation secretion was commonly seen. The ductal cells had a relatively high nuclear/cytoplasmic ratio, with granular cytoplasm. Grossly, the 5-cm lesion was a discrete, pale, cystic nodule embedded within the parotid gland parenchyma. Microscopically, the lesion was a nonencapsulated, circumscribed mass of sclerotic and hyalinized, collagenous tissue with lymphoplasmacytic infiltration. Sclerosing adenosis and cystic ducts with frequent apocrinelike cells were commonly seen. Some acinar cells contained eosinophilic, intracytoplasmic granules of various sizes.

CONCLUSION

The presence of syncytial clusters with apocrine metaplasia and ductal structures in a lymphoplasmacytic background should suggest a diagnosis of SPCA of a major salivary gland.

Tracheoesophageal shunt method with omohyoid muscle loop for voice restoration

OBJECTIVE

To decrease the aspiration rate of the previously reported simple mucodermal tracheoesophageal (TE) shunt method for voice restoration after total laryngectomy with the use of omohyoid muscle loop.

DESIGN

Retrospective clinical analysis.

SETTING

Department of Otorhinolaryngology, Fukui Medical University, Fukui, Japan.

PATIENTS

Ten male patients underwent total laryngectomy and received TE shunt by the omohyoid muscle loop method for voice restoration. There were 5 patients with glottic laryngeal cancer, 2 with supraglottic laryngeal cancer, and 3 with hypopharyngeal cancer. Patients' age ranged from 46 to 66 years.

INTERVENTION

The dermal incision on the neck was U-shaped with a superiorly pedicled, small U-shaped dermal flap. This small flap was used to form the anterior wall of the shunt. Bilateral omohyoid muscles were preserved at the total laryngectomy site with or without neck dissection. After creating a TE shunt directly on the posterior wall of the tracheal stump, the bilateral omohyoid muscles were looped through each other beneath the TE shunt.

MAIN OUTCOME MEASUREMENTS

Maximum phonation time, maximum phonation intensity, and rating scales of shunt voice, aspiration rate, and survival time.

RESULTS

Mean maximum phonation time was 20 seconds, while mean maximum phonation intensity was 83 dB. The first voice was obtained on postoperative day 29 on average. Of the 10 patients, 9 could phonate, with 1 case (10%) of slight aspiration 3 months after the surgery.

CONCLUSIONS

Although this omohyoid muscle loop method needs to preserve the hyoid bone with those muscles, aspiration was prevented more effectively compared with the former, direct mucodermal TE shunt method. The indication for this method is preferably glottic laryngeal cancer.

Free peroneal skin flap for oropharyngeal reconstruction

The thicknesses of three dermal flaps, platysma, forearm, and fibula, which are often used for oropharyngeal reconstruction, were measured in 21 subjects using 15 MHz Doppler ultrasonography. The mean (SD) thicknesses were 2.2 (0.3), 3.1 (0.5), and 3.8 (0.6) mm, respectively. The free peroneal skin flap from the leg was used in 14 patients with head and neck cancer. These flaps were successfully transplanted in 13 of 14 patients (93%) with no problems at the donor site. This flap offers many advantages, including its distance from the head and neck, its cosmetic superiority to a forearm flap, it allows two flaps with two cutaneous branches, it is possible to close the donor site primarily without a skin graft, and it has thin subcutaneous tissue. We found that the free peroneal skin flap is particularly useful for oropharyngeal reconstruction.

Timing for removal of tympanic ventilation tube in children

The medical records of 220 ears of 137 pediatric patients (85 male and 52 female) in which three kinds of ventilation tubes were inserted for treating otitis media with effusion (OME) were reviewed. The tubes selected were the Shepard grommet (75 ears), Goode-T (39 ears), and Paparella type II tube (106 ears). The criteria for tube placement were as follows: (1) continuous conductive hearing loss with over 25 dB air-bone gap, (2) resistance to conservative therapy for over 6 months, and (3) retracted and glue-colored tympanic membrane with type B tympanogram. The tubes that remained in place for over 18-24 months were removed intentionally in combination with a freshening of the perforation edge and tape-patch technique using Steri-Strip tape (3M) for preventing permanent eardrum perforation, because the incidence of persistent perforation became higher after long-term intubation. Shepard grommets tended to be extruded earlier, while Paparella type II tubes tended to stay longer. The OME recurrence rate decreased 12 months or more after tubal insertion. There was a tendency for the recurrence rate to decrease the longer the tube stayed in the eardrum. The number of recurrences decreased when the patient's age at the tube removal or extrusion was 7-8 years old. Adenoidectomy did not influence the recurrence rate of OME. Although the Goode-T and Paparella tube II tubes showed high perforation rates, the perforation rate after extrusion or removal of the tube was decreased by the use of the tape patch technique in combination with a freshening of the perforation edge. From these findings, it was concluded that the appropriate intubation period for the treatment of OME in children is over 12 months with the use of a long-term tube, and that if the patient's age at the time of tube insertion was below 6 years, it might be better that the removal of the tube is postponed until the patient is 8 years of age.

Platysma myocutaneous flap including the external jugular vein with special reference to neck dissection

Although platysma myocutaneous flap (PTMCF) is suitable for a small intraoral defect, combination with neck dissection (ND) decreases the viability. Therefore, a version of PTMCF was devised to increase the viability. This version consists of three points: preservation of the external jugular vein (EJV), preservation of the facial artery after skeletonization from the submandibular gland, and a new incision around the flap. This procedure was applied to 21 patients with intraoral cancer. All 21 patients underwent some kind of ND. The average viable area of transferred skin was 80%. This rate was significantly better than that for 46 previous cases using Farr's modification with ND, in which the facial artery was divided. Viability of the flaps was analyzed by the vessels preserved, especially by EJV. ND is not a contraindication with this version.

Fluorine-18-fluorodeoxyglucose PET versus thallium-201 scintigraphy evaluation of thyroid tumors

To determine whether PET could help differentiate malignant from benign thyroid tumors, 18F-fluorodeoxyglucose (FDG) accumulation and 201Tl scintigraphy were examined relative to histological diagnosis.

METHODS

Nodular thyroid lesions in 11 patients were evaluated before surgical resection. Static PET scanning with 370 MBq FDG was done for 20 min (from 40 to 60 min postinjection) in all patients, and standardized uptake values (SUVs) in these lesions were calculated. In addition, eight patients were evaluated with dynamic PET scan up to 60 min postinjection, and the lesions were further evaluated using graphical analysis. Thallium-201 delayed images were visually evaluated in 10 patients.

RESULTS

Four of 11 nodules were well-differentiated papillary carcinoma, another five were benign follicular adenomas, one was a multinodular goiter and another a case of chronic thyroiditis that was proved not to contain a nodule. Time-activity curves of FDG uptake showed different patterns in malignant and benign tumors. In the malignant tumors, FDG uptake increased with time after the tracer injection. By contrast, FDG uptake in benign tumors gradually decreased. With use of a cutoff value of 5.0 mg/ml for SUV and 10 microl x min(-1) x ml(-1) for Kc (K complex value determined using the linear fitting of the time-activity curve of FDG accumulation), all of the four malignant nodules and the six benign nodules were separated correctly. Chronic thyroiditis had high SUV in the malignant range. Of the four patients with thyroid carcinoma, the delayed 201Tl images revealed a slightly higher or equal uptake to background activity. In a patient with chronic thyroiditis, the delayed 201Tl images revealed diffuse accumulation higher than background activity.

CONCLUSION

FDG-PET is superior to 201Tl in differentiating malignant from benign tumors. Both SUVs and Kc values were useful indexes for this discrimination. Although careful evaluation is needed for chronic inflammatory lesions, this technique appears to be useful in evaluating thyroid nodules.

Free peroneal and its composite flap: a distant donor for head and neck reconstruction

Free peroneal or its composite flap from the leg has been transferred in four patients for oro-mandibular and hypopharyngeal defects following surgery for malignancy. These flaps were successfully transplanted in all patients: two cases of free peroneal flap and two of free fibular graft with skin with no resulting problems with the leg. The peroneal osteocutaneous flap offers the following advantages: The axial vessels are preferable for microvascular surgery. Two flaps can be used with two cutaneous branches. A flap measuring up to 16 x 4.5 cm can be utilized with primary closure at the donor site. A long bone can be obtained together with skin. Surgery on the neck and harvesting of the flap can be done at the same time. The donor site is not conspicuous.

[Reconstruction with peroneal free flap after ablation of head and neck cancer]

One-stage reconstruction of head and neck defects following radical surgery was performed for two patients with the peroneal flaps which had the peroneal artery, vein and their branches as a pedicle. These flaps were viable without any post-operative complications. The advantages of these flaps are described as follows. (1) The subcutaneous fat is thin, and thus the flap is flexible and not bulky. (2) The diameters of the peroneal artery and vein are relatively large and the pedicle is long. (3) A pretty large size of the flap can be utilized. (4) A relatively long bone can be obtained together with skin at the same time, and the angle of the fibula can be easily changed. (5) Bleeding is little when the flap is taken out. (6) The resection of the tumor and the harvest of the flap can be done at the same time, due to different surgical areas. (7) The skin graft to the donor defect is not necessary, and the defect can be closed at one-stage. (8) The donor site does not stand out. Thus, this method is cosmetically excellent. This procedure has many advantages. Reconstruction with the peroneal flap offers a safe, reliable, and versatile method.

Simple mucodermal tracheoesophageal shunt method for voice restoration

A newly devised simple primary tracheoesophageal shunt method, involving a mucodermal tunnel, was performed on 14 patients. Aspiration was prevented by percutaneous digital pressure on the shunt, with silicone or collagen injection around it, or the use of a voice prosthesis. The overall success rate was 79% (11/14). This method was an easy one-stage procedure that could be performed in about 15 minutes.

Ototoxicity of carboplatin in guinea pigs

Since carboplatin (CBDCA) is a platinum compound of second generation, its ototoxicity was investigated. In order to assess the ototoxicity, hearing acuity was measured based on the compound action potential (AP), and the organ of Corti was morphologically studied using scanning electron microscopy (SEM) and succinate dehydrogenase (SDH) staining in guinea pigs treated with CBDCA. CBDCA induced morphological changes in the organ of Corti when the guinea pigs received 50 mg/kg daily for 2 or 3 days. The threshold value of AP was elevated 10 to 25 dB in treated animals, as compared with the control value. The SEM study and SDH staining revealed that the administration caused scattered degeneration of the outer hair cells (OHCs), and the inner hair cells remained intact. These lesions were milder than those of OHCs treated with cisplatin (CDDP). The rapid elimination of CBDCA from the kidney and the inner ear seems to account for the low ototoxicity of this compound. Although CBDCA is less toxic than CDDP, it may affect hearing function if patients suffer from renal dysfunction or if the organ of Corti is vulnerable.