Abel, Kathryn M. Van

Split cord malformation (SCM) is a rare abnormality of notochord development. The majority of cases occur in the thoracolumbar region, with more than 30 cases of cervical SCM reported. The clinical impact of SCMs involving the cervical cord is therefore largely unknown. In addition, the concomitant finding of brainstem involvement is presumably incompatible with life in the majority of patients, resulting in a paucity of data regarding this clinical scenario. In this paper the authors present the first case, to their knowledge, of an incomplete cervical SCM involving the brainstem and discuss its clinical impact, diagnosis, and management.

Objectives/HypothesisDiscuss current techniques utilizing the scapular tip and subscapular system for free tissue reconstruction of maxillary defects and highlight the impact of medical modeling on these techniques with a case series.Study DesignCase review series at an academic hospital of patients undergoing maxillectomy + thoracodorsal scapula composite free flap (TSCF) reconstruction. Three‐dimensional (3D) models were used in the last five cases.Methods3D modeling, surgical, functional, and aesthetic outcomes were reviewed.ResultsNine patients underwent TSCF reconstruction for maxillectomy defects (median age = 43 years; range, 19–66 years). Five patients (55%) had a total maxillectomy (TM) ± orbital exenteration, whereas four patients (44%) underwent subtotal palatal maxillectomy. For TM, the contralateral scapula tip was positioned with its natural concavity recreating facial contour. The laterally based vascular pedicle was ideally positioned for facial vessel anastomosis. For subtotal‐palatal defect, an ipsilateral flap was harvested, but inset with the convex surface facing superiorly. Once 3D models were available from our anatomic modeling lab, they were used for intraoperative planning of the last five patients. Use of the model intraoperatively improved efficiency and allowed for better contouring/plating of the TSCF. At last follow‐up, all patients had good functional outcomes. Aesthetic outcomes were more successful in patients where 3D‐modeling was used (100% vs. 50%). There were no flap failures. Median follow‐up >1 month was 5.2 months (range, 1–32.7 months).ConclusionsReconstruction of maxillectomy defects is complex. Successful aesthetic and functional outcomes are critical to patient satisfaction. The TSCF is a versatile flap. Based on defect type, choosing laterality is crucial for proper vessel orientation and outcomes. The use of internally produced 3D models has helped refine intraoperative contouring and flap inset, leading to more successful outcomes.Level of Evidence4. Laryngoscope, 127:E8–E14, 2017

ObjectiveDemonstrate the association of radiographic dural enhancement with increased tumor adherence at the porus acusticus, which may influence completeness of resection and facial nerve outcome.Study DesignCase series with chart review.SettingAcademic referral center.Subjects and MethodsA total of 205 consecutive patients with histopathologically confirmed vestibular schwannoma (VS) were evaluated. Patients with tumors exhibiting dural enhancement on postgadolinium T1‐weighted magnetic resonance imaging were identified and compared with matched controls. Completeness of resection, intraoperative details, and facial nerve outcomes were analyzed.ResultsExcluding strictly intracanalicular tumors (n = 32, 16%) and those with NF2 (n = 10, 4.9%), the presence of dural enhancement was radiographically confirmed in 16 (9.8%) cases. Paired analysis did not reveal significant baseline differences between cases and controls. Subtotal resection was performed in 5 (31%) of the 16 patients with tumors exhibiting dural enhancement, in contrast to 1 (3%) of the matched controls (P =. 01). Four (25%) demonstrated increased tumor adherence at the porus acusticus intraoperatively, compared with 1 control (3%, P =. 04). Long‐term facial nerve function was similar between cases and controls (81% vs 84% House‐Brackmann I‐II function, P = 1.00).ConclusionDural enhancement is present in approximately 10% of extracanalicular VS. Dural enhancement at the porus acusticus may represent hypervascularity, dural reaction, or infiltration, and portends increased tumor adherence and greater likelihood of subtotal resection to preserve facial nerve function. To our knowledge, this is the first series that reports the prevalence of this phenomenon in VS and the potential surgical implications. Recognition preoperatively may be valuable toward patient counseling.

Objectives/HypothesisTransoral surgery (TOS) is commonly performed in a supine patient with an oral retractor. Paradoxically, this strategy can create difficulty with visualizing and accessing pathology at the base of tongue, inferior pharynx, and larynx. We investigate the feasibility of TOS with the patient in the seated position.Study DesignPilot study.MethodsTOS utilizing the da Vinci Robotic Surgical Xi and Si systems (Intuitive Surgical, Sunnyvale, CA) was performed on a fresh cadaver placed in both the traditional supine position and the seated position. Transoral robotic surgery (TORS) in the seated position was then performed on two patients for a supraglottic laryngectomy and a hypopharyngeal carcinoma resection.ResultsVisualization of the entire upper aerodigestive tract was possible in the cadaver and two patients in the seated position. The Si was superior for docking, instrumentation, and assistant access. The minimum operating table height is critical for successful access. Advantages of this position included increased posterior airway/operative space by approximately 2 cm, ability to manipulate the surgical field (nonrigid retraction), and improved visualization. Surgical procedures were completed in comparable times compared with standard TORS procedures. There were no complications related to seated TORS.ConclusionsTORS in the seated position was both safe and effective in this pilot study. It allows the surgeon to optimally operate in the inferior pharynx and larynx without the limitation of line of site access and visualization. A paradigm shift in patient positioning during TOS may allow improved surgical access and even greater patient candidacy. Further clinical investigation into this technique is warranted.Level of EvidenceNA Laryngoscope, 127:122–126, 2017

OBJECTIVE Vagus nerve and sympathetic chain cervical schwannomas (VNCSs and SCCSs) are benign nerve sheath tumors that arise in the head and neck. Despite similar presentations that make accurate preoperative diagnosis more difficult, the potential for morbidity following resection is significantly higher for patients with VNCS. Therefore, the authors analyzed a retrospective case series and performed a comparative analysis of the literature to establish diagnostic criteria to facilitate more accurate preoperative diagnoses. METHODS The authors conducted a blinded review of imaging studies from retrospectively collected, operatively confirmed cases of VNCS and SCCS. They also performed a systematic review of published series that reported patient-specific preoperative imaging findings in VNCS or SCCS. RESULTS Nine patients with VNCS and 11 with SCCS were identified. In the study cohort, splaying of the internal carotid artery (ICA) and internal jugular vein (IJV) did not significantly predict the nerve of origin (p = 0.06); however, medial and lateral ICA displacement were significantly associated with VNCS and SCCS, respectively (p = 0.01 and p = 0.003, respectively). Multivariate analysis demonstrated that ICA and IJV splaying with medial ICA displacement carried an 86% probability of VNCS (p = 0.001), while the absence of splaying with lateral ICA displacement carried a 91% probability of SCCS (p = 0.006). The presence of vocal cord symptoms or peripheral enhancement significantly augmented the predictive probability of VNCS, as did Horner's syndrome or homogeneous enhancement for SCCS. A review of the literature produced 25 publications that incorporated a total of 106 patients, including the present series. Splaying of the ICA and IJV was significantly, but not uniquely, associated with VNCS (p < 0.0001); multivariate analysis demonstrated that ICA and IJV splaying with medial ICA displacement carries a 75% probability of VNCS (p < 0.0001), while the absence of such splaying with lateral ICA displacement carries an 87% probability of SCCS (p = 0.0003). CONCLUSIONS ICA and IJV splaying frequently predicts VNCS; however, this finding is also commonly observed in SCCS and, among the 9 cases in the present study, was observed more often than previously reported. When congruent with splaying, medial or lateral ICA displacement significantly enhances the reliability of preoperative predictions, empowering more accurate prognostication.

OBJECT Endoscopic approaches to the anterior craniocervical junction are increasing in frequency. Choice of oral versus endoscopic endonasal approach to the odontoid often depends on the relationship of the C1–2 complex to the hard palate. However, it is not known how this relevant anatomy changes with age. We hypothesize that there is a dynamic relationship of C-2 and the hard palate, which changes with age, and potentially affects the choice of surgical approach. The aim of this study was to characterize the relationship of C-2 relative to the hard palate with respect to age and sex. METHODS Emergency department billing and trauma records from 2008 to 2014 were reviewed for patients of all ages who underwent cervical or maxillofacial CT as part of a trauma evaluation for closed head injury. Patients who had a CT scan that allowed adequate visualization of the hard palate, opisthion, and upper cervical spine (C-1 and C-2) were included. Patients who had cervical or displaced facial/skull base fractures, a history of rheumatoid arthritis, or craniofacial anomalies were excluded. The distance from McGregor's palatooccipital line to the midpoint of the inferior endplate of C-2 (McL–C2) was measured on midsagittal CT scans. Patients were grouped by decile of age and by sex. A 1-way ANOVA was performed with each respective grouping. RESULTS Ultimately, 483 patients (29% female) were included. The mean age was 46 ± 24 years. The majority of patients studied were in the 2nd through 8th decades of life (85%). Significant variation was found between McL–C2 and decile of age (p < 0.001) and sex (p < 0.001). The mean McL–C2 was 27 mm in the 1st decade of life compared with the population mean of 37 mm. The mean McL–C2 was also noted to be smaller in females (mean difference 4.8 mm, p < 0.0001). Both decile of age (p = 0.0009) and sex (p < 0.0001) were independently correlated with McL–C2 on multivariate analysis. CONCLUSIONS The relationship of C-2 and the hard palate significantly varies with respect to age and sex, descending relative to the hard palate a full centimeter on average in adulthood. These findings may have relevance in determining optimal surgical approaches for addressing pathology involving the anterior craniocervical junction.

ObjectiveTo prospectively analyze quality‐of‐life outcomes following transoral diverticulotomy with cricopharyngeal myotomy (DCPM) for Zenker’s diverticulum (ZD).Study DesignProspective single‐group study.SettingsTertiary academic institution.Subjects and MethodsA prospective multicenter study performed from January 1, 2012, to July 1, 2014, included 18 patients presenting with ZD undergoing DCPM. Standardized questionnaires—including the 10‐item Eating Assessment Tool (EAT‐10), Functional Outcome of Swallowing Scale (FOSS), and the Reflux Symptom Index (RSI)—were completed preoperatively and at 3 and 6 months postoperatively. Videofluoroscopic studies were obtained and analyzed by our senior speech‐language pathologist, who was blinded to the clinical outcomes.ResultsEighteen patients were included (11 women; mean age, 72.6 years; range, 53‐86 years). All patients had ZD on preoperative videofluoroscopic swallowing studies. The most common comorbidities included hypertension (10 of 18, 55.6%), dyslipidemia (8 of 18, 44.4%), hiatal hernia (6 of 18, 33.3%), and gastroesophageal reflux disease (5 of 18, 27.8%). Median preoperative RSI was 27 (interquartile range [IQR], 22.5‐31.5); FOSS, 2 (IQR, 2‐3); and EAT‐10, 21.5 (IQR, 13.5‐27.5). The 3‐month questionnaire (88.9% completion) demonstrated an improved median RSI of 5 (IQR, 1‐7.5; P <. 001), FOSS of 0 (IQR, 0; P <. 001), and EAT‐10 of 0 (IQR, 0‐3; P <. 001). Fourteen patients (77.8%) completed the 6‐month questionnaire, demonstrating a median RSI of 4 (IQR, 0‐8), FOSS of 0 (IQR, 0‐0.5), and EAT‐10 of 1 (IQR, 0‐3). While regurgitation decreased following surgery (P =. 007), nighttime cough did not (P =. 25).ConclusionThis study supports an improvement in functional outcome and quality of life in patients with ZD undergoing DCPM.

Object Swallowing dysfunction is common following transoral (TO) odontoidectomy. Preliminary experience with newer endoscopic transnasal (TN) approaches suggests that dysphagia may be reduced with this alternative. However, the reasons for this are unclear. The authors hypothesized that the TN approach results in less disruption of the pharyngeal plexus and anatomical structures associated with swallowing. The authors investigate the histological and gross surgical anatomical relationship between pharyngeal plexus innervation of the upper aerodigestive tract and the surgical approaches used (TN and TO). They also review the TN literature to evaluate swallowing outcomes following this approach. Methods Seven cadaveric specimens were used for histological (n = 3) and gross anatomical (n = 4) examination of the pharyngeal plexus with the TO and TN surgical approaches. Particular attention was given to identifying the location of cranial nerves (CNs) IX and X and the sympathetic chain and their contributions to the pharyngeal plexus. S100 staining was performed to assess for the presence of neural tissue in proximity to the midline, and fiber density counts were performed within 1 cm of midline. The relationship between the pharyngeal plexus, clivus, and upper cervical spine (C1-3) was defined. Results Histological analysis revealed the presence of pharyngeal plexus fibers in the midline and a significant reduction in paramedian fiber density from C-2 to the lower clivus (p < 0.001). None of these paramedian fibers, however, could be visualized with gross inspection or layer-by-layer dissection. Laterally based primary pharyngeal plexus nerves were identified by tracing their origins from CNs IX and X and the sympathetic chain at the skull base and following them to the pharyngeal musculature. In addition, the authors found 15 studies presenting 52 patients undergoing TN odontoidectomy. Of these patients, only 48 had been swallowing preoperatively. When looking only at this population, 83% (40 of 48) were swallowing by Day 3 and 92% (44 of 48) were swallowing by Day 7. Conclusions Despite the midline approach, both TO and TN approaches may injure a portion of the pharyngeal plexus. By limiting the TN incision to above the palatal plane, the surgeon avoids the high-density neural plexus found in the oropharyngeal wall and limits injury to oropharyngeal musculature involved in swallowing. This may explain the decreased incidence of postoperative dysphagia seen in TN approaches. However, further clinical investigation is warranted.