Objective:To design affordable, easy-to-use self-retaining retractors that can provide adequate exposure of the operative area in head and neck surgery Methods: Design: Surgical Instrumentation Setting: Tertiary government hospital Subjects: One Results: Self-retaining retractors were designed and fabricated from stainless steel with tissue prongs on one end and a loop for rubber-band attachment to surgical drapes via a towel clip on the other end. Varying prong lengths were devised for different depths of required retraction. Traction tension could be adjusted by varying rubber-band attachment distance. The retractors were tested on a patient undergoing open reduction and internal fixation for a mandibular fractureand evaluated according to ease of application, adequacy of exposure and tissue trauma. Conclusion: The self-retaining retractors may be affordable alternatives to commercially-available self-retaining retractors. They are easily applied with adjustable tension and depth of retraction that can provide adequate exposure with minimal tissue trauma.
INSTRUMENTATION

INTRODUCTION: The restoration of function after surgery with mandibular reconstruction is of utmost importance. Mastication and deglutition are compromised if pre-operative dental occlusion is not reestablished. For this purpose, occlusal splints are fabricated pre-operatively. Various methods of occlusal splint fabrication are at hand. DESIGN: Surgical Instrumentation SETTING: Tertiary Academic Hospital OBJECTIVE: This paper presents a simple, quick and inexpensive way of fabricating an occlusal splint with the use of dental modeling compound. MATERIALS AND METHODS: The dental modeling compound is used pre-operatively to make an occlusal appliance. Occlusal splint fabricated with this method was used in 6 patients who underwent segmental mandibular resection with reconstruction for various pathologies. Post-operatively, patients were assessed in terms of occlusion, type of diet and pain on mastication. RESULTS: Out of the 6 patients, only 5 patients were available for evaluation. One patient suffered a myocardial infarction 3 days post-operation and subsequently died. The five patients had good mandibular-maxillary relation post-surgery. They were able to tolerate regular diet with no pain on mastication. CONCLUSION: In conclusion, we have discussed a simple, quick and cost-effective way of fabricating an occlusal splint for use in mandibular reconstruction. (Author)
OCCLUSAL SPLINTS

Objective: To test the antibacterial properties of three commercially available nasal corticosteroid preparations containing Mometasone Furoate (MF), Fluticasone Propionate (FP) and Fluticasone Furoate (FF) against S. pneumoniae, S. viridans, S. aureus, H. influenza, P. aeruginosa and E. coli. Methods: Study Design: Experimental in vitro study using the disc diffusion method. Clinical isolates of Streptococcus pneumoniae, Hemophilus influenzae, Streptococcus viridans, Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli were inoculated on separate plates. 0.15 ml of nasal corticosteroid preparations containing MF, FP and FF were applied to blank paper discs, then placed on the plates, including an empty disc. Following 24 and 48 hours of incubation, the inhibition zones were measured to the nearest mm from the point of abrupt inhibition of growth. Results: After 24 and 48 hours of incubation, S. pneumoniae, S. viridans, and S. aureus showed inhibition zones to all three preparations. S. aureus and S. viridans show the largest zones of inhibition at 24 and 48 hours respectively. H. influenza, P. aeruginosa and E. coli were negative. The inhibition zones of each bacteria were shown to be statistically different. The preparation containing FP had the largest zone of inhibition at 24 and 48 hours, although post hoc tests showed their difference was not significant. Conclusion: The present study demonstrates possible antimicrobial properties of commercially available nasal corticosteroid preparations. However, it is unclear whether these can be attributed to the steroids, their excipients, or both. Further studies testing each component may offer better insights into their therapeutic use.

BACKGROUND: Free flap reconstruction was first introduced in 1959 and has since been used for reconstruction of various defects in the head and neck. It has been shown to be the most reliable and efficient way of restoring tissue in the head and neck region secondary to surgical or traumatic defects. It has allowed single stage reconstruction of even complex defects with high flap viability rates. Here in the Philippine setting, free flaps have not been the reconstructive option of choice. It is viewed as a special option for selective cases not amenable to pedicled reconstruction. OBJECTIVE: To describe the experience of one microvascular team in head and neck reconstruction using free flaps from 1996 to March 2004. DESIGN AND SETTING: Retrospective chart review of all patients who underwent free flap reconstruction of head and neck defects from 1996 to March 2004 at six tertiary hospitals in Manila. PATIENTS AND METHODS: Atotal of 69 patients who underwent 71 free-flap reconstructions of the head and neck for various pathologies and with a range of bony and soft tissue defects from 1996 to March 2004 were included in the study. All free flap reconstructions were done by only one microvascular team. The success and viability of free tissue transfer, length of hospital stay, length of operation, complications and morbidities encountered and functional outcome based on length of time to removal of the nasogastric tube and decannulation were reviewed. RESULTS: Of the 71 free flap reconstructions that were performed, 64 flaps were viable leading to an overall success rate of 90 percent. The first 36 cases had a success rate of 86 percent while the subsequent 35 cases had a success rate of 94 percent. Average length of hospital stay was 24 days and the average length of operation was 13 hours 40 minutes. There were 6 mortalities secondary to medical problems and 7 patients had major surgical complications. Twenty-one patients (29 percent) did not have any complication post-operation. Average time post-operation to decannulation was 14 days while return to oral diet was noted at 17 days post-operation. There were 8 patients who were discharged with either a nasogastric tube or percutaneous endoscopic gastrostomy. The results are at par with the review of literature reviewed. CONCLUSIONS: The success of the use of free flaps in head and neck reconstruction was demonstrated in this series. There were minimal complications noted. All patients were decannulated with majority able to return to an oral diet. (Author)
HEAD NECK

DESIGN: Surgical Innovation SETTING: Academic Tertiary Hospital OBJECTIVE: The objective of the study was to describe an alternative technique using a condylar autograft in conjunction with a fibular free flap in mandibular reconstruction and to prospectively assess the functional outcome in terms of inter-incisal distance, lateral excursion, maximum protrusion, occlusion, type of diet, speech and mandibular contour. METHODOLOGY: All patients who underwent segmental mandibulectomy with fibular free flap reconstruction done by one microvascular team from 1997 to 2004 were reviewed. From a total of 38 patients who underwent fibular free flap reconstruction, 7 patients who had condylar disarticulation, rigid fixation using miniplates to the fibula then replacement into the glenoid fossa were identified but 2 patients were excluded due to poor follow-up. Functional outcomes in terms of inter-incisal distance, lateral excursion, maximum protrusion, occlusion, type of diet, speech and mandibular contour were assessed post-operatively. Presence of tumor recurrence was also noted. RESULTS: Five patients were included in the study. The inter-incisal distance was noted to be 31 mm (+/- 12.5) with maximum protrusion of 1.4 mm (+/- 0.9). For those with right hemimandibulectomy (n=2), the right lateral excursion was 2.34mm (+/- 3.3) and left lateral excursion was 1.66mm (+/- 2.35). For those with left hemimandibulectomy (n=3), the right lateral excursion was 8.17m (+/- 2.25) and left lateral excursion was 3 mm (+/- 2.65). Four out of 5 patients had normal diet with excellent intelligible speech. The same 4 patients had good mandibular contour with a Class I occlusion as assessed by a dentist. The only patient with fair outcome had a mucoepidermoid carcinoma of the floor of the mouth with extensive soft tissue reconstruction aside from the bony reconstruction. No patient had tumor recurrence. CONCLUSION: The use of condylar autograft in conjunction with fibular free flaps holds promise as a way to restore temporomandibular function in mandibular reconstruction. (Author)
NONE

Objective: To present the case of a patient with left facial swelling as the primary manifestation of Multiple Myeloma, and discuss the surgical management, diagnostic dilemma, and subsequent medical management done for this unusual presentation. Methods: Design: Case Report. Setting: Tertiary Government Hospital. Patient: One (1). Results: A 55-year old man with an enlarging left pre-auricular mass of one (1) year duration underwent superficial parotidectomy with facial nerve preservation and selective lymphadenectomy for pleomorphic adenoma based on initial clinical and cytologic findings. Histopathologic examination showed plasmacytoid proliferation, and subsequent work-ups finally revealed Multiple Myeloma. Conclusion Emphasized in this case report is the thorough work-up and targeted therapy needed for the timely diagnosis and treatment of a patient with Multiple Myeloma.
Multiple Myeloma ; Plasmacytoma ; Parotid Gland ; Adenoma, Pleomorphic

OBJECTIVE: To determine whether the interval from pathological diagnosis to treatment is significantly delayed, and the presence or absence of disease progression occurring in those with, and without treatment delay, among head and neck cancer patients in our institution.
METHODS:
Design: Retrospective Chart Review
Setting: Tertiary Government Hospital
Participants: Medical records of 70 patients with newly diagnosed head and neck cancer who underwent primary surgery from January 2011 to December 2015 were retrieved and available data were extracted.
RESULTS: A total of 28 patients were included in this study. Majority of the cancers were in the larynx (42.9%) and oral cavity (42.9%). The mean diagnostic-to-treatment interval (DTI) was 54 days but 5 (17.8%) out of the 28 had a DTI of more than 60 days. Four (80%) with a DTI more than 60 days had an upstage during surgery while 4 (17.4%) patients with DTI less than or equal to 60 days also had an upstage. 2 (60%) patients with treatment delay had tumor progression compared to 5 (21.7%) of those without treatment delay. Only 1 (20%) out of the 5 patients with treatment delay had increased nodal metastasis in contrast to 8 (34.8%) of those who did not have treatment delay.
CONCLUSION: A number of patients undergoing surgery in our institution experienced delay to initiate treatment of more than 60 days and majority of these patients were noted to have disease progression. However, even patients with treatment prior to 60 days had increases in tumor stage, which may suggest that the interval aimed for should be shorter than 60 days.

Human ; Male ; Female ; Head And Neck Neoplasms ; Neoplastic Processes ; Mouth ; Larynx ; Disease Progression ; Medical Records ; Government

Branchial cleft anomalies are among the most common causes of congenital anterior neck masses in the pediatric population. They present as epithelial-lined, single cysts. The definitive management is surgical excision. However, failure to remove the entire cyst and tract may lead to recurrence of the mass.

Unusual presentations of this condition may lead to incomplete excision if inadequately evaluated. There is a scarcity of material documenting atypical presentations of branchial cleft anomalies-- in particular, presentation as 2 distinct cysts in one region. In our literature search of PubMed, Google Scholar and HERDIN using the terms: "congenital mass," "branchial cleft cyst," and "multiple cysts," only 3 similar cases were found.

We report a case of a second branchial cleft anomaly presenting as a dumbbell-shaped mass (two cystic structures, connected by a tubular structure) in the right lateral neck, the subsequent management and outcomes.

Human ; Female ; Child Preschool ; Branchioma ; Branchial Cleft Anomalies ; Branchial Region ; Pharyngeal Diseases ; Craniofacial Abnormalities ; Neoplasm Recurrence, Local ; Head And Neck Neoplasms

OBJECTIVE: To determine the prevalence of, and describe transglottic cancer with thyroid cartilage invasion as a possible risk for, thyroid gland invasion in a series of patients with laryngeal carcinoma who underwent total laryngectomy with thyroidectomy.
METHODS:
Design: Retrospective Case Series
Setting: Tertiary Government Training Hospital
Participants: 61 laryngeal carcinoma patients who underwent total laryngectomy with hemi- or total thyroidectomy from January 2010 to August 2017.
RESULTS: Out of 61 patients with laryngeal carcinoma, 11 patients had supraglottic, 11 glottic, 2 subglottic and 37 had transglottic involvement. Eleven had thyroid cartilage invasion, all of whom had transglottic tumors. Of these 11 patients, only 1 had thyroid gland invasion. This was a case of a 78 year-old male patient with poorly differentiated SCC stage IVa transglottic tumor with thyroid cartilage invasion.
CONCLUSION: Thyroid gland invasion was uncommon in our sample of laryngeal carcinoma patients who underwent laryngectomy and thyroidectomy. Although transglottic involvement with thyroid cartilage invasion may increase the risk of thyroid gland invasion, it could not be confirmed by our series. Perhaps thyroidectomy should not be routinely performed on all patients with laryngeal carcinoma who undergo total laryngectomy but more rigorous studies are needed to establish this.

Human ; Male ; Female ; Aged ; Middle Aged ; Laryngectomy ; Thyroidectomy ; Thyroid Gland ; Thyroid Cartilage ; Prevalence ; Laryngeal Neoplasms ; Glottis

A 50-year-old single Filipino woman was referred to our clinic by the Dermatology Department due to multiple large nevi on the face. Her history started 29 years prior to consult when a 0.5 cm by 0.5 cm nevus appeared on her right lower eyelid. Excision of the mass and histopathology revealed basal cell carcinoma of the skin and she ceased followup visits. Meanwhile, progressively enlarging nevi appeared over multiple sites of her face. Some of the lesions developed ulceration and occasionally bled. Finally, she consulted again at our institution due to disfiguring multiple large nevi, and was seen by Dermatology and Ophthalmology services and underwent excision biopsy revealing basal cell carcinoma. She was then referred to us for definitive surgical management

The patient was a non-smoker, non-alcoholic beverage drinker and work did not undergo any prolonged sun exposure. She recalled that her mother had a similar condition and expired due to complications of the disease

Physical examination revealed many large nevi over multiple sites of the face, the largest over the left nasolabial area. (Figure 1A) There were hyperpigmented nevi over the central forehead and left infraorbital area, and the patient's left eye was closed due to scarring from the previous excision in the left medial canthal area. (Figure 1B) An ulcerating lesion that occasionally bled, involved multiple subsites of the nose. (Figure 1C)

Due to the recurrent multiple basal cell carcinoma on the face, we suspected a possible syndromic disease. Complete systemic physical examination revealed multiple nevi over the chest and back as well as plantar and palmar pits. (Figure 2A, B) Chest radiography revealed an incidental finding of a bifid third rib on the left. (Figure 3) With these findings, we diagnosed her condition as Gorlin-Goltz syndrome with multiple basal cell carcinoma on the face.

Our goal of treatment was complete excision of tumors with preservation of function and cosmesis. Following the National Comprehensive Cancer Network (NCCN) Guidelines1 surgical excision with frozen section for adequate margins was performed. (Figure 4) Reconstruction with multiple skin grafts was performed to cover the defects. However, graft failures were noted over multiple sites two weeks post-operatively. (Figure 5) 

Our patient continued to follow-up for a year but declined any offers of reconstructive surgery. She maintained a good disposition and was satisfied with her appearance despite a less than ideal aesthetic postoperative outcome. (Figure 6)

DISCUSSION Nevoid Basal Cell Carcinoma or Gorlin-Goltz Syndrome is a rare autosomal dominant syndrome with near complete penetrance and extreme variable expressivity.2,3 This was first described in depth by Doctors Robert Gorlin and Robert Goltz in 1960. Genetic mutation in PTCH1 and SUFU that are related with the Hedgehog signalling pathway were identified in the pathogenesis of this disease.2 GorlinGoltz syndrome commonly presents with dermatologic, odontogenic and neurologic findings and affected patients have developmental anomalies and predisposition to cancer, specifically basal cell carcinoma (BCC). The incidence of Gorlin-Goltz syndrome ranges from 1 in 50,000 to 1 in 560,0004 with only one published case reported in the Philippines.5

To establish the diagnosis of Gorlin-Goltz syndrome, either one major and two minor criteria or two major criteria must be fulfilled.6,7 Our patient presented with multiple BCC, bifid third left rib and palmar and plantar pits, fulfilling three major criteria.

Only 67% of patients diagnosed with Gorlin-Goltz syndrome present with basal cell carcinoma with an equal male to female ratio.8 The mean age of BCC presentation in Gorlin-Goltz syndrome is roughly 25 years old and the probability of developing increases with age.9 There are racial differences in the occurrence of BCC; higher in Caucasians than in African-Americans and Asians.6,8 However, BCC in patients diagnosed with Gorlin-Goltz syndrome have the same histology and presentation as sporadic cases.

Palmar and plantar pits are among the common dermatologic findings in Gorlin-Goltz syndrome. These lesions are found in 45% to 87% of Gorlin-Goltz syndrome and the percentage rises with age.6 The presence of palmar and plantar pits in a child should prompt a complete physical evaluation due to its association with other diseases.

A bifid or forked rib is a developmental abnormality in which the sternal end is cleaved in two. This may be asymptomatic and is oftentimes an incidental finding, and can be observed as an isolated defect or may be associated with other multisystem malformations. In the general population, it was reported to occur at 3 to 6.3 per 1,000.10 Among the rib anomalies, bifid rib occurs in 28% of cases.11 In GorlinGoltz syndrome, it occurs in 36.4% of cases.12

Gorlin-Goltz Syndrome has a wide spectrum of presentations varying from livable symptoms until adulthood to detrimental complications even during childhood. Since this is a genetic mutation, there is no cure for disease and treatment is symptomatic. In our case, there is higher chance of recurrence or new lesions that may require multiple surgical procedures in the future. Other lesions associated with this syndrome may still appear and immediate consultation is advised to prevent complications. Genetic counselling is highly advised since it has high inheritance.

In summary, our experience taught us that a high index of suspicion for syndromic disease and a complete physical examination are especially important in such cases. The diagnosis and management are challenging, and should consider the biopsychosocial context of the patient. As long as full disclosure of the condition is made and all options are clearly communicated, the patient's wishes should be respected.

 

Human ; Female ; Middle Aged (a Person 45-64 Years Of Age) ; Gorlin Goltz Syndrome