Mucoepidermoid carcinoma (MEC) is the most common malignant tumor of the salivary glands, predominantly affecting the parotid gland. It commonly presents as a painless neck mass. Diagnostic workup includes physical examination, imaging, and fine needle aspiration biopsy. Superficial, subtotal, or total parotidectomy, with or without neck dissection and possible adjuvant radiation therapy, is recommended in most cases according to tumor stage, grade, and adverse pathological features. In the case presented here, subtotal parotidectomy with facial nerve preservation and neck dissection followed by adjuvant radiation therapy was elected. Post-treatment imaging at three-month intervals showed no evidence of persistent disease. The attached video demonstrates subtotal right parotidectomy via combined anterograde and retrograde nerve dissection and right selective neck dissection of levels IIa, IIb, III, and IV.
Anterolateral Thigh Free Flap Reconstruction of Parotidectomy Defect Kunal A. Koka, BS1,2; Quentin C. Durfee, BS1; Veenadhari Kollipara, BA1,2; Emily K. Funk, MD2; Guy Slonimsky, MD2; Neerav Goyal, MD, MPH, FACS2 1Penn State College of Medicine 2Penn State Health Milton S. Hershey Medical Center
Anterolateral Thigh (ALT) free flap is a widely utilized technique for the reconstruction of head and neck soft tissue defects. Key steps of this procedure include flap design for reconstruction of surgical defect, identification and dissection of perforator vessels and vascular pedicle for harvest of the anterolateral thigh free flap, microvascular anastomosis of the pedicle to head and neck vessels, and flap inset for reconstruction at recipient site. The ALT free flap is a versatile tool that can be utilized for reconstruction throughout the body but is very frequently utilized for reconstruction in oncologic resections of the head and neck. In this case, it was utilized for reconstruction of a soft tissue defect resulting from a parotidectomy with resulting skin and soft tissue defect, performed for removal of a mucoepidermoid carcinoma.
Thyroid nodules are common with a higher prevalence in women and the older population. They can be found in more than 50% of the older population. Malignancy risk is reported to be 7–15% depending on age, sex, radiation exposure history, and family history. Thyroid nodules can be detected either by palpation or incidentally by imaging done for irrelevant purposes. About 16% of chest CT scans show an incidental thyroid nodule. Subsequent ultrasound scans would evaluate the nodule size and characteristics. If the nodules meet the biopsy criteria based on TIRADS (Thyroid Imaging Reporting and Data Systems) criteria, referral for fine-needle aspiration biopsy (FNA) is necessary. This video delivers a thorough demonstration of the correct technique for ultrasound-guided thyroid FNA with rapid on-site cytology evaluation (ROSE).
Hemithyroidectomy, or unilateral thyroid lobectomy, refers to removal of half the thyroid gland. The procedure is typically performed for suspicious thyroid nodules or small differentiated thyroid cancers based on biopsy via fine needle aspiration (FNA) and occasionally for symptomatic benign thyroid nodules.
At most institutions the operation can be completed safely in an outpatient fashion with patient discharge from the hospital the same day. It is typically performed via a transcervical collar incision, but endoscopic, transoral routes and remote access approach with robotic instrumentation have been described. The procedure involves mobilization of the thyroid lobe, ligation of thyroid vessels, preservation of parathyroids, protection of the recurrent laryngeal nerve, and dissection away from the trachea. In this patient, a thyroid nodule was detected and found to have indeterminate features on biopsy via FNA. A hemithyroidectomy was then performed for diagnostic purposes.
Radical neck dissection was once the standard of care for the surgical management of patients with thyroid cancer and cervical lymph node metastases. However, due to the significant morbidity of this procedure, the development of cervical lymphadenectomy procedures that could provide oncologic cure while minimizing morbidity was undertaken by many surgeons. Such an investigation has led to the development of the modified radical neck dissection (MRND). Still, many institutions are not familiar with performing a comprehensive MRND in the setting of thyroid cancer metastatic to the lateral lymph node compartments. This article presents such an operation under general anesthesia.
Thyroidectomy (Cadaver) Kristen L. Zayan, BS1; Adam Honeybrook, MBBS2; C. Scott Brown, MD2; Daniel J. Rocke MD, JD2 1University of Miami Miller School of Medicine 2Duke University Medical Center
Thyroidectomy may be performed for various pathologies, consisting of either thyroid lobectomy or total gland removal. Both benign and malignant disease processes necessitate surgical intervention. Thyroid nodules, compressive thyroid goiter, or persistent thyrotoxicosis represent some of the benign indications. Malignant conditions affecting the thyroid include papillary, follicular, medullary, and anaplastic carcinomas. In the present case, a thyroidectomy via standard cervical incision is performed on a cadaver with overlying animations to emphasize the key anatomy. The discussion is in relation to a patient with obstructive goiter presenting with worsening wheezing, cough, and dysphagia, with the ultimate goal of relieving the compressive symptoms through the removal of the gland.
Revision canal wall down (CWD) mastoidectomy with mastoid obliteration is most often performed to manage persistent otorrhea and debris accumulation in the mastoid bowl following CWD mastoidectomy. In this case, obliteration is performed for persistent otorrhea from the mastoid bowl and revision CWD mastoidectomy is completed to address a new retraction pocket following a prior CWD mastoidectomy for chronic otitis media with cholesteatoma in a 23-year old male.
There have been numerous reported techniques used for mastoid obliteration, and in this case, a posterior periosteal flap is made, and the mastoid cavity is filled with autogenous bone paté. Following obliteration of the mastoid, a perichondrial graft is used to cover the area. In this case, a titanium total ossicular reconstruction prosthesis is used to rebuild the ossicular chain, and a second perichondrial graft is used to reconstruct the tympanic membrane. The canal is packed with Gelfoam to secure the fascial grafts in place. Postoperatively, patients are typically advised to remove their head dressing 24 hours following the surgery and to apply a topical antibiotic ointment daily to a cotton ball in the ear.
DCR and Nasolacrimal System (Cadaver) Prithwijit Roychowdhury, BS1; C. Scott Brown, MD2; Matthew D. Ellison, MD2 1University of Massachusetts Medical School 2 Department of Otolaryngology, Duke University
Nasolacrimal duct obstruction (NDO) is the most common disorder of the lacrimal system that affects patients of every age and results in excessive tearing (epiphora) and if untreated, painful infection (dacryocystitis). When NDO symptoms progress and can no longer be managed with conservative measures, endoscopic dacryocystorhinostomy (DCR) is indicated.
In this case, DCR exploration of the nasolacrimal anatomy is performed on a cadaver. The typical presentation of NDO is epiphora but the presence of painful swelling of the medial canthus and mucoid or purulent discharge may indicate the presence of dacryocystitis. The approach presented here involves the creation of a mucosal flap and subsequent use of the DCR drill to expose the nasolacrimal duct anatomy.
The application of minimally-invasive approaches in otologic surgery, including the management of middle ear tumors like glomus tympanicum tumors, represents a promising advancement in the field, potentially improving surgical outcomes and patient recovery. In this article, a patient with pulsatile tinnitus is found to have a glomus tympanicum tumor of the right ear. Calhoun Cunningham III, MD performs a transcanal resection of the mass using the KTP laser.
Parotid dissection is a delicate surgical procedure that requires a deep understanding of the relevant anatomy and a careful approach to ensure the preservation of critical structures, particularly the facial nerve. The comprehensive overview provided in this video is a valuable resource for understanding the step-by-step process of parotid dissection. The detailed narration and visual references help to reinforce the importance of accurate identification and preservation of the facial nerve, as well as the other key anatomical structures involved in the procedure. This information is crucial for surgeons in training, as well as for experienced practitioners, to ensure the safe and effective removal of parotid gland tumors while minimizing the risk of complications.
