Subtotal temporal bone resection en bloc with the parotid gland and temporomandibular joint: a 2-dimensional operative video

Primary temporal bone squamous cell carcinoma is sporadic. According to previous studies, margin-negative resection provides the best prognosis (Nakagawa et al., 2006; Moody et al., 2000; Yin et al., 2006; Komune et al., 2021 [1-4]). When tumors extend behind the tympanic membrane, lateral temporal bone resection, which is a well-established procedure, is insufficient to achieve a tumor-free margin. For these cases, subtotal temporal bone resection (STBR) can achieve a complete en bloc resection with a tumor-free margin. Furthermore, STBR en bloc with surrounding structures, including the temporomandibular joint and parotid gland, complicates surgical techniques. We previously reported this surgical procedure in a stepwise manner using cadaveric dissection (Komune et al., 2014 [5]). The STBR en bloc with the parotid gland and temporomandibular joint is composed of three approaches according to our previous report: high cervical exposure (neck dissection), a subtemporal-infratemporal fossa approach, and a retromastoid-paracondylar approach. However, we currently lack demonstrative surgical videos. According to our previous report, this video first demonstrates STBR en bloc with the parotid gland and temporomandibular joint (Komune et al., 2014 [5]). The histopathological diagnosis of a 57-year-old woman suffering from a large tumor protruding from her auricle indicated squamous cell carcinoma; after the diagnosis she was referred to our hospital. Computed tomography revealed the full extent of the tumor, which was about 8 cm in diameter and had damaged the middle cranial base, mastoid bone, and middle ear cavity. Magnetic resonance imaging indicated invasion of the glenoid fossa and parotid gland, equivalent to a Pittsburg stage cT4 tumor. The patient underwent STBR en bloc with the parotid gland and temporomandibular joint. Lower cranial nerves (CN IX-XII) were preserved, and the patient achieved normal oral intake without additional procedures after surgery. At six months post-operation, no recurrence was noted. In this video, we first demonstrate the surgical procedure of the STBR en bloc with the parotid gland and temporomandibular joint for far-advanced temporal bone squamous cell carcinoma, and it can be one of the surgical options to achieve the complete resection without exposure of the tumor. Informed consent was obtained from the patient. The video was reproduced with the written informed consent of the patient. Primary temporal bone squamous cell carcinoma is sporadic. According to previous studies, margin-negative resection provides the best prognosis (Nakagawa et al., 2006; Moody et al., 2000; Yin et al., 2006; Komune et al., 2021 [1-4]). When tumors extend behind the tympanic membrane, lateral temporal bone resection, which is a well-established procedure, is insufficient to achieve a tumor-free margin. For these cases, subtotal temporal bone resection (STBR) can achieve a complete en bloc resection with a tumor-free margin. Furthermore, STBR en bloc with surrounding structures, including the temporomandibular joint and parotid gland, complicates surgical techniques. We previously reported this surgical procedure in a stepwise manner using cadaveric dissection (Komune et al., 2014 [5]). The STBR en bloc with the parotid gland and temporomandibular joint is composed of three approaches according to our previous report: high cervical exposure (neck dissection), a subtemporal-infratemporal fossa approach, and a retromastoid-paracondylar approach. However, we currently lack demonstrative surgical videos. According to our previous report, this video first demonstrates STBR en bloc with the parotid gland and temporomandibular joint (Komune et al., 2014 [5]). The histopathological diagnosis of a 57-year-old woman suffering from a large tumor protruding from her auricle indicated squamous cell carcinoma; after the diagnosis she was referred to our hospital. Computed tomography revealed the full extent of the tumor, which was about 8 cm in diameter and had damaged the middle cranial base, mastoid bone, and middle ear cavity. Magnetic resonance imaging indicated invasion of the glenoid fossa and parotid gland, equivalent to a Pittsburg stage cT4 tumor. The patient underwent STBR en bloc with the parotid gland and temporomandibular joint. Lower cranial nerves (CN IX-XII) were preserved, and the patient achieved normal oral intake without additional procedures after surgery. At six months post-operation, no recurrence was noted. In this video, we first demonstrate the surgical procedure of the STBR en bloc with the parotid gland and temporomandibular joint for far-advanced temporal bone squamous cell carcinoma, and it can be one of the surgical options to achieve the complete resection without exposure of the tumor. Informed consent was obtained from the patient. The video was reproduced with the written informed consent of the patient.

Lymphaticovenular anastomosis for lymph vessel injury in the pelvis and groin

BACKGROUND

Lymphatic diseases due to lymph vessel injuries in the pelvis and groin require immediate clinical attention when conventional treatments fail. We aimed to clarify the effectiveness of and indications for lymphaticovenular anastomosis (LVA) to treat these lymphatic diseases.

METHODS

We retrospectively evaluated six patients who underwent LVA for lymphatic diseases due to lymph vessel injuries in the pelvis and groin. Specific pathologies included groin lymphorrhea (N = 3), chylous ascites (N = 2), and retroperitoneal lymphocele (N = 1). The maximum lymphatic fluid leakage volume was 150-2600 mL daily. Conventional treatments (compression, drainage, fasting, somatostatin administration, negative pressure wound therapy, or lymph vessel ligation) had failed to control leakage in all cases. We performed lower extremity LVAs after confirming the site of lymph vessel injury using lymphoscintigraphy. We preferentially placed LVAs in thigh sites that showed a linear pattern by indocyanine green lymphography. Postoperative lymphatic fluid leakage volume reduction was evaluated, and leakage cessation was recorded when the drainage volume approached 0 mL.

RESULTS

LVA was performed at an average of 4.3 sites (range, 3-6 sites) in the thigh and 2.7 sites (range, 0-6 sites) in the lower leg. Lymphatic fluid leakage ceased in all cases after a mean of 6 days (range, 1-11 days) postoperatively. No recurrence of symptoms was observed during an average follow-up of 2.9 (range, 0.5-5.5) years.

CONCLUSIONS

LVA demonstrates excellent and rapid effects. We recommend lower extremity LVA for the treatment of lymphatic diseases due to lymph vessel injuries in the pelvis and groin.

Utility of negative-pressure wound therapy for orocutaneous and pharyngocutaneous fistula following head and neck surgery

BACKGROUND

Because of the difficulty of airtight sealing and risk of salivary contamination, negative-pressure wound therapy (NPWT) has rarely been applied for postoperative fistula following head and neck surgery; thus, its utility remains unclear.

METHODS

We applied NPWT in 34 patients who developed orocutaneous and pharyngocutaneous fistula after head and neck surgery. Here we retrospectively analyzed the utility of NPWT for managing those fistulas.

RESULTS

Thirty-two patients (94.1%) underwent NPWT as scheduled without adverse events. In 28 patients (82.4%), fistula closure was completed only by NPWT, and the mean period to fistula closure was 30.4 days. The mean period to closure did not differ significantly between fistulas with (21.7 days) and without (39.1 days) previous irradiation.

CONCLUSIONS

Airtight sealing can be maintained and postoperative fistula can be closed by NPWT with a high success rate, even after previous irradiation. NPWT is an effective and minimally invasive treatment for postoperative fistula.

The surgical anatomy of soft tissue layers in the mastoid region

Background

An understanding of the soft tissue layers in the mastoid region has become important for otologic reconstructive surgery. The objective of this study was to clarify the surgical anatomy of the soft tissue layers in the mastoid region and reveal its clinical significance.

Methods

Cadaveric study.

Results

Our dissections showed the soft tissue layers consisting of skin, subcutaneous layer, superficial and deep mastoid fasciae, and periosteum. The superficial mastoid fascia was continuous with the temporoparietal fascia cranially and the superficial cervical fascia caudally. The deep mastoid fascia could be clearly separated from the superficial mastoid fascia and has continuity to the loose alveolar layer in the temporoparietal region. However, it caudally fused with the fascia and ligament of the sternocleidomastoid.

Conclusions

A comprehensive understanding of soft tissue layers would improve otologic reconstructive surgery.

Level of Evidence

NA

Neutrophil-lymphocyte ratio and platelet-lymphocyte ratio as predictors of wound healing failure in head and neck reconstruction

CONCLUSIONS

In microsurgical head and neck reconstruction, a higher rate of post-operative wound complication could be predicted by a lower pre-operative neutrophil ratio (< 64.9%), neutrophil-lymphocyte ratio (NLR) (< 3.5), and platelet-lymphocyte ratio (PLR) (< 160).

OBJECTIVES

To evaluate the predictor of post-operative wound complications in microsurgical head and neck reconstruction.

METHODS

Patients who were undergoing tumor ablation and microsurgical reconstruction from April 2011 to March 2014 were analyzed retrospectively. The pre-operative hematological data, age, sex, co-morbidities, body mass index (BMI), adjuvant therapies, smoking, operation time, blood loss, total protein, T-stage, and Anesthesiologists Performance Status (ASA-PS) score were collected. Cases of post-operative wound healing failure were reviewed.

RESULTS

One hundred and three consecutive patients were enrolled. Among these, the results of 77 patients who were younger than 70 years of age were analyzed. The distributions of the neutrophil ratio (p = .0005), lymphocyte ratio (p = .0166), monocyte ratio (p = .0341), NLR (p = .005), and PLR (p = .008) differed significantly between the patients with and without post-operative wound healing failure. Neutrophil ratio, NLR, and PLR cut-off values of 64.9, 3.5, and 160 were significantly associated with the rate of wound healing failure rate (p = .0002, .00021, .0042, respectively).

Clinical implication of left precordial T wave inversions in the presence of complete right bundle branch block

This study was designed to elucidate whether left precordial negative T waves are electrocardiographic indicators for the diagnosis of hypertrophic cardiomyopathy (HCM) even in the presence of complete right bundle branch block (CRBBB). In 7 consecutive patients with CRBBB accompanied by negative T waves in at least one of the left precordial leads (V4, V5, V6, maximal negativity; 1.06 +/- 0.40 mVol) (left precordial negative T wave group) and in 15 randomly selected CRBBB patients without left precordial T wave inversions (control group), echocardiography was performed to rule out underlying diseases causing left ventricular overload and to identify candidates for magnetic resonance (MR) imaging. None had anginal pain indicating ischemic heart disease. When 2-dimensional echocardiography indicated left ventricular hypertrophy with wall thickness > or = 15 mm, the magnitude and distribution of hypertrophy were scrutinized on contiguous left ventricular MR short-axis images. The diagnostic criterion of HCM was the demonstration of hypertrophy with a wall thickness of 20 mm or more on the left ventricular MR short-axis images. All patients in the left precordial negative T wave group had negative T waves in both I (negativity; 0.27 +/- 0.17 mVol) and aVL (negativity; 0.23 +/- 0.14 mVol), whereas none in the control group did. The diagnostic criterion for HCM was fulfilled in six patients in the left precordial negative T wave group. However there were no patients who fulfilled the criterion in the control group. Negative T waves were recorded in the I (negativity; 0.30 +/- 0.17 mVol), aVL (negativity; 0.25 +/- 0.14 mVol), V4 (negativity; 1.03 +/- 0.46 mVol), V5 (negativity; 0.83 +/- 0.37 mVol) and V6 leads (negativity; 0.31 +/- 0.31 mVol) in all patients with HCM, while they were recorded in only 6% of the patients without HCM. In conclusion, the existence of left precordial negative T waves in the presence of CRBBB strongly indicates HCM.

Morphological onset and early diagnosis in apical hypertrophic cardiomyopathy: a long term analysis with nuclear magnetic resonance imaging

OBJECTIVES

A long-term follow-up study with nuclear magnetic resonance (NMR) imaging was undertaken to detect the morphological onset and to establish the early diagnosis in apical hypertrophic cardiomyopathy (HCM).

BACKGROUND

A spadelike configuration on left ventriculogram (LVG) is regarded as a diagnostic criterion for the classical apical HCM. There also exists a segmented hypertrophy at the apical level without indicating the spadelike features (a nonspade configuration). To detect the hypertrophied myocardium of the nonspade configuration, circumferential scrutiny of the apex is required. Although both configurations can be underlying causes of giant negative T waves, etiological relationship between the two is not clarified.

METHODS

The criteria for the spadelike configuration defined on left ventricular short-axis NMR images were as follows: (apical maximal thickness > or = 15 mm), (apical anterior thickness over basal anterior thickness > or = 1.3) and (apical posterior thickness over basal posterior thickness > or =1.3). Thirteen patients who had predominant hypertrophy (> or = 15 mm) at the apical level without the spadelike configuration underwent NMR imaging twice before and after 54+/-10 months' follow-up.

RESULTS

Apical hypertrophy that had been confined to the lateral wall in four, the anterior-lateral wall in two, and the septal-anterior wall in one developed to become circumferential hypertrophy that fulfilled the criteria for the spadelike configuration after the follow-up period.

CONCLUSIONS

The spadelike configuration can begin with the nonspade configuration and therefore, both can constitute a single disease entity of apical HCM. The early diagnosis of apical HCM can be achieved by identifying the hypertrophy frequently confined to the lateral wall at the apical level.

Vector analysis of the hemodynamics of atherogenesis in the human thoracic aorta using MR velocity mapping

OBJECTIVE

Our study was designed to assess the applicability of MR velocity mapping for vector analysis of the hemodynamics of atherogenesis.

SUBJECTS AND METHODS

MR velocity mapping was used to measure axial and nonaxial elements and the length of the wall shear rate (a spatial gradient of near-wall flow velocity parallel to the vessel wall) vector at 16 time points per cardiac cycle at eight anatomic locations of the thoracic aorta in six healthy subjects. An oscillatory shear index (a ratio of blood flow volume in the recessive direction divided by the sum of blood flow volume in both dominant and recessive directions) was introduced for analysis of the degree of oscillation.

RESULTS

The time-averaged length, axial element, and nonaxial element of the wall shear rate vector were 118+/-53 sec(-1), 106+/-55 sec(-1), and 33+/-23 sec(-1), respectively. The oscillatory shear index in the axial direction was 0.06+/-0.10 and that in the nonaxial direction was 0.07+/-0.13. At the inner wall of the distal portion of the aortic arch, the length of the wall shear rate was smallest (74+/-32 sec(-1)) and oscillation in the axial direction was largest (0.16+/-0.19).

CONCLUSION

Vector analysis of the wall shear rate in the thoracic aorta was successfully done with MR velocity mapping in humans. MR velocity mapping can noninvasively evaluate the hemodynamics of atherogenesis induced by the complicated blood flow.

Measuring the diameter of coronary arteries on MR angiograms using spatial profile curves

OBJECTIVE

The spatial profile curve of the nuclear MR intensity across the short axis of a coronary artery in an MR angiogram results in a gradual up-and-down slope lacking sharp definition, which indicates that display parameters may influence edge recognition. Therefore, our study was designed to determine the appropriate window setting and to devise a method of accurately measuring the diameter or width of the artery independent of window parameters.

CONCLUSION

The diameter of a coronary artery measured on MR coronary arteriography significantly varied with experimentally selected display parameters. When compared with the diameter on contrast-enhanced coronary arteriograms, the window center on MR angiograms at the midpoint between the peak intensity of the intravascular lumen and the background intensity and the window width of a quarter or a half of the intensity difference between the two were proven to be appropriate. The angiographic diameter corresponded to the diameter obtained at 65% +/- 9% of the peak intensity on the spatial profile curve across the short-axis MR coronary angiogram. Accordingly, 65% of the peak intensity indicates the diameter of the coronary artery. Thus, the intensity profile curve independent of the window setting provided a new method for measurement of the diameter of the coronary artery.

Earlobe reconstruction with a reversed-flow chondrocutaneous postauricular flap and a local flap

An earlobe reconstructive method using a reserved-flow chondrocutaneous flap and a local flap is described. Two patients are reported whose earlobes were reconstructed by this method. By this method, earlobes of bilateral symmetry can be produced without fail. The blood circulation of both flaps is satisfactory. Since conchal cartilage is used, an earlobe of satisfactory shape can be maintained for a long period, but the reconstructed earlobe is slightly firm when palpated.

Free composite latissimus dorsi muscle-rib flap not containing the intercostal artery and vein for reconstruction of bone and soft-tissue defects

Reconstruction of bone and soft-tissue defects of the forehead and leg was done with use of a free latissimus dorsi muscle-rib flap. By utilizing the curve characteristic of the rib and by filling the cavity with latissimus dorsi muscle, the forehead could be restored in a good shape. In our application of this flap to the leg, it is considered in retrospect that reconstruction with the use of two ribs should have been done. Furthermore, it was concluded that in comparison with the heretofore employed vascularized rib graft, the scope of operative invasion is small in the use of this flap with hardly any risk of thoracostomy.

[A modification of the Aulhorn flicker test with results of physiological and pathological conditions]

The Aulhorn flicker test measures the subjective brightness of various frequencies of flickering light. We modified an Aulhorn flicker test with light emitting diode (LED) and the results of 21 normal eyes and 18 affected eyes (7 eyes with idiopathic optic neuritis, one eye with rhinogenous optic neuropathy (ethmoid sinus mucocele), two eyes with preoperative pituitary tumor, one eye with empty sella, one eye with anterior ischemic optic neuropathy, one eye with syphilitic optic neuritis, five eyes with primary open angle glaucoma) were presented. All normal eyes showed the Brücke-Bartley effect which refers to an enhanced subjective brightness at lower frequencies. Six eyes with idiopathic optic neuritis and one eye with rhinogenous optic neuropathy in the acute stage demonstrated the Aulhorn effect which refers to a reduced subjective brightness at lower frequencies. Four eyes with the Aulhorn effect that were followed up showed less prominent Aulhorn effect. One eye with idiopathic optic neuritis and 10 eyes with other conditions did not show the Aulhorn effect. It was suggested that the modified Aulhorn flicker test with LED is a useful method for diagnosis of optic neuritis in the acute stage.