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This was the case of a male patient in his 60s, who suddenly collapsed. When the ambulance team arrived, the initial waveform was pulseless electrical activity; accordingly, a supraglottic airway device was inserted, and the patient was immediately transported to a referring hospital. On arrival, the patient resumed spontaneous circulation, the patient was diagnosed with Stanford type B acute aortic dissection and was referred to the author's hospital, where diffuse swelling of the anterior cervical region was revealed. CT performed by the previous hospital revealed compression of the trachea. The cause of cardiac arrest was considered to be severe airway stenosis secondary to a retropharyngeal haematoma associated with Stanford type B acute aortic dissection. Stanford type B acute aortic dissection can be complicated by retropharyngeal haematomas, which can lead to airway obstruction and even cardiac arrest. This condition also requires careful airway examination., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

A pharyngeal recess cyst is a benign lesion, located at the nasopharyngeal recess with limited development. Pharyngeal recess cysts rarely occur. This case report describes a young male patient presenting with a foreign body sensation in the pharynx. Electronic nasopharyngoscope examination revealed a large nasopharyngeal cyst, whose root was located in the left pharyngeal recess. Complete surgical resection was performed, and the patient successfully recovered.Pharyngeal recess cysts are rare lesions that can be diagnosed based on imaging and endoscopy findings. It is treated surgically and has a favorable prognosis., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: We aimed to assess the effectiveness of a single-institution protocol of videofluoroscopic swallowing study (VFSS) for the detection of pharyngeal leak (PL) and its usefulness to mitigate evolution into subsequent pharyngocutaneous fistula (PCF) after total (pharyngo-) laryngectomy (TL)., Methods: This retrospective single-center study was conducted between February 2014 and December 2022. We included all patients who underwent TL and performed a VFSS between Day 7 and Day 14 postoperatively to detect a subclinical PL., Results: Two-hundred and forty-eight patients met the inclusion criteria. Among the 186 patients (75%) with a negative VFSS, 11 patients (5.9%) developed a secondary PCF after oral intake resumption (false negative of VFSS). Among the 62 patients (25%) with a positive VFSS, the occurrence of a PCF was avoided in 59.7% of cases., Conclusion: This study showed a good effectiveness of VFSS in the detection of PL after TL, alongside a usefulness to mitigate evolution into subsequent PCF., (© 2024 Wiley Periodicals LLC.)

Parapharyngeal abscesses leading to complications, although rare after the advent of antibiotics, can lead to serious complications. One such complication is carotid erosion that can lead to a potentially fatal carotid artery blowout. We report a case of a previously healthy infant who presented with fever, ear bleed and progressively increasing swelling in the right side of his neck that led to airway compromise. The child required immediate securing of the airway at presentation. Imaging revealed lobulated abscess with multiple bleeding points eroding the carotid vessels, along with internal jugular venous thrombus. Surgical exploration was done and abscess debulked. Histopathology revealed aspergillus, which was treated with antifungals. He was discharged on oral warfarin after 40 days of hospital stay and remains well on follow-up. Sentinel ear bleed warrants close observation for possibility of carotid artery blowout in children with parapharyngeal abscesses., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To study the mechanisms of injury, clinical manifestations, radiological findings, management, and outcomes of traumatic retropharyngeal hematoma (RH)., Methods: We used the Preferred Reporting Items of Systematic Reviews guidelines to carry out a systematic literature review to identify all published cases of traumatic RH by searching the PubMed database. Articles published between 1988 and 2022 that reported traumatic RH were included. However, articles that reported non-traumatic RHs and non-English articles were excluded from this study., Results: Of the 62 articles screened, 56 were included. Most patients (55%) were above the mean age of 61.7. The majority of patients were male (69.7%). The main symptom was dyspnea (66.6%) and symptoms usually presented within 24 hours. Among the patients, 90.9% did not take anticoagulants or have coagulation disorders, and the main injury mechanism was falling (54.5%). Most of the computed tomography findings reported retropharyngeal (38%) and prevertebral (15%) hematoma. Meanwhile, magnetic resonance imaging revealed 2 masses in the retropharyngeal space and 2 RHs. With several treatment modalities, more than 50% of the cases were only observed (44 cases), and endotracheal intubation was the most commonly used airway management method (n=35)., Conclusion: Traumatic RH is often caused by falls, particularly in elderly patients. Dyspnea is the primary symptom, usually appearing within 24 hours. Cervical vertebral fractures are the leading cause, and observation is the most common treatment approach. PROSPERO Reg. No.: CRD42022349010 ., (Copyright: © Saudi Medical Journal.)

Objective: (1) Compare proportions of collapse, obstruction, or mixed instances on drug-induced sleep endoscopy findings of obese and nonobese children with obstructive sleep disordered breathing. (2) Determine the frequency of collapse in general between both groups., Study Design: Retrospective case-control study., Setting: Tertiary pediatric center., Methods: Obese (body mass index >95 percentile) children presenting with obstructive sleep disordered breathing (>33 on the pediatric sleep questionnaire) were identified from a prospectively kept surgical database. Only those who had undergone drug-induced sleep endoscopy were eligible. Age and sex pair-matched nonobese children were identified. Only nonsyndromic, neurologically normal, surgically naïve patients were included. The frequency of obstructive, collapse, and mixed pharyngeal patterns was documented in both groups. A comparison of proportions was then undertaken (χ 2 test)., Results: Over a 5-year period, 73 consecutive children with obesity were identified (40 males; mean of 8.5 ± 3.0 years, 2.8-13.1). They were matched with 73 nonobese children (8.4 ± 3.0 years, 2.6-14.1). The obese group exhibited significantly more pharyngeal collapses (62:47) (p = .0021 odds ratio [OR] 3.358, 95% confidence interval [CI] 1.52-7.42). The proportion of pharyngeal findings on drug-induced sleep endoscopy was significantly different (p = .000129) between the 2 groups; obese (61 mixed: 3 obstruction: 9 collapse) and nonobese (48 mixed: 22 obstruction: 4 collapse)., Conclusion: The predominance of hypopharyngeal collapse in children with obesity may explain the likelihood of failure of surgery directed at obstructive findings. This may also strengthen the case for drug-induced sleep endoscopy in this group at the initial surgery to guide it rather than after the failure of adenotonsillectomy., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objective: The aim of this study is to present a comparison between panoramic radiographs and USG imaging with a focus on revealing the advantages of USG over radiographs, and to show the distribution of calcifications detected in USG by considering the age and gender., Methods: A total of 148 patients with soft tissue calcifications as seen on panoramic radiographs were examined with USG imaging. Sialoliths, carotid artery calcifications, tonsilloliths, phleboliths and lymph node calcifications were examined in terms of anatomical localization, distribution and shape., Results: In the USG evaluation of these 148 patients, soft tissue calcifications were observed in 113 (76.4%) patients. The mean age of the patients with calcification was 55.6 ± 13.1 (min: 22-max: 77). Bilateral calcifications were detected in 25 (22.1%) patients, whereas unilateral calcifications were found in 88 (77.9%) patients. While the rates of tonsilloliths, sialoliths, phleboliths, and lymph node calcifications were statistically similar in male and female patients, the rate of carotid artery calcifications was found to be higher in men than in women (P = 0.017). No statistical significance was found between age groups in terms of the formation of soft tissue calcifications (P = 0.117)., Conclusions: Panoramic radiographs may mislead clinicians in the diagnosis and differential diagnosis of soft tissue calcifications in the head and neck region due to the presence of distortion, superpositions, metal artefacts, and ghost images. USG is an important diagnostic tool in determining the localization of soft tissue calcifications that can be confused on two-dimensional radiographs, their relationship with neighboring structures, and defining calcification. It can be used safely in the detection of soft tissue calcifications as it provides dynamic imaging without the use of radiation or contrast material compared to other advanced imaging methods., (© 2022 American Institute of Ultrasound in Medicine.)

This study aimed to prospectively assess nasopharyngeal luminal changes in brachycephalic dogs without respiratory signs using cervical radiography. Forty brachycephalic dogs without cardiopulmonary diseases were included. The nasopharyngeal luminal change was calculated on inspiratory and expiratory cervical lateral radiographs. The median nasopharyngeal luminal change was 21.6% (range, 0.3-85.6%). In five dogs, a nasopharyngeal luminal change of >50% was identified. There was no correlation between nasopharyngeal luminal changes and age, sex, body weight, or body condition score. These results suggest that brachycephalic dogs without cardiopulmonary diseases may be over-diagnosed with partial pharyngeal collapse. Further studies comparing nasopharyngeal luminal changes between clinically healthy brachycephalic dogs and dogs with respiratory signs are warranted.

Pharyngocutaneous fistula (PCF) caused by a previous anterior cervical spine fixation plate more than a decade ago has not been reported yet. A 70-year-old man with dysphagia was diagnosed as supraglottic cancer. After partial laryngectomy and concurrent chemoradiation, due to increasing arytenoid lesion, total laryngectomy was followed. Pharyngocutaneous fistula occurred but resolved spontaneously. However, retropharyngeal granulation tissue emerging from the anterior cervical spine fixation plate caused delayed PCF. Dysphagia and PCF resolved after fixation plate removal., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Purpose: To characterize the clinical features and outcomes of pediatric patients with retropharyngeal (RPA) or parapharyngeal abscesses (PPA) managed only with medical treatment and showing the importance of early symptoms and imaging studies in the diagnosis of deep neck space infections (DNIs) in children., Methods: A retrospective analysis of all patients diagnosed with RPA and PPA between 2007 and 2017 was performed in Hospital Universitario Central de Asturias., Results: 30 children were identified, with 11 RPA and 19 PPA. 23 children (76.7%) were under 5 years old, and all were treated with intravenous amoxicillin/clavulanic acid and corticosteroids. Torticollis and fever were present in all patients. The mean length of hospital stay was 7.5 days. There were no complications associated., Conclusion: DNIs can be treated in a conservative way, reserving the surgical drainage for cases with a complication associated (airway compromise, lack of response to antibiotic therapy, immunocompromised patients). Treatment with intravenous antibiotics and corticosteroids is a safe option, reducing the duration of symptoms and the length of hospital stay., (© 2022. The Author(s).)

Pharyngeal collapse has been described as a decrease of more than 50% in the diameter of the lumen. However, there has been no study on changes in the pharyngeal lumen in clinically normal dogs. The hypothesis of this prospective, observational, and pilot study was that change in nasopharyngeal lumen would be over 50% in Beagle dogs without cardiopulmonary diseases. Thus, we assessed the nasopharyngeal luminal change using cervical radiography in Beagle dogs without respiratory signs or cardiac abnormalities. The study sample included 42 Beagle dogs without cardiopulmonary diseases. Cervical radiographies were acquired during inspiration and expiration, and nasopharyngeal luminal change (%) was calculated. The median nasopharyngeal luminal change was 16.6%, and nasopharyngeal luminal change over 50% was identified in two dogs. The nasopharyngeal luminal change was significantly associated with body condition score and body weight. There was no correlation between nasopharyngeal luminal change and age. This study revealed that change in nasopharyngeal lumen over 50% can be identified in Beagle dogs without cardiopulmonary diseases and may be over-diagnosed as partial pharyngeal collapse. Further studies for comparing change in nasopharyngeal lumen between clinically normal dogs and dogs with respiratory signs are warranted., (© 2022 American College of Veterinary Radiology.)

Purpose: Skeletal muscle mass (SMM) loss and sarcopenia have been identified as risk factors for postoperative complications. The aim of this study was to investigate the relationship between pharyngocutaneous fistula (PCF) formation after total laryngectomy (TL) and SMM assessed from a computed tomography image of the 3rd cervical vertebra (C3)., Methods: Retrospective study of 86 male patients who underwent TL between 2013 and 2019 in a single institution. We excluded women from the analysis due to our limited sample. SMM was determined from cross-sectional muscle area (CSMA) measurement at C3 using the ImageJ software. Results were compared with those for the skeletal muscle mass index (SMMI) calculated from the estimated measure at 3rd lumbar vertebra (L3)., Results: PCF formation occurred in 21/86 patients. According to the CSMA at a C3 cut-off of 35.5cm2, of 18 patients (20.9%) with low SMM, 9 developed PCFs (50.0%). Among patients with normal SMM (n = 68, 79.1%), 12 developed PCFs (17.6%). The CSMA at C3 was the only variable significantly associated with PCF risk, which was 4.7 times greater in patients with low SMM (p = 0.007). Sarcopenia was more frequent in underweight patients (p = 0.0001), patients undergoing extended surgeries (p = 0.003), or presenting preoperative anaemia (p = 0.009) or hypoalbuminemia (p = 0.027)., Conclusion: Measuring the CSMA at C3 obtained results equivalent to those obtained by calculating the SMMI at L3, suggesting that direct SMM assessment from C3 is a useful approach to evaluating PCF formation risk after TL., (© 2021. The Author(s).)

Background: Research in esophageal surgery showed that computed tomography (CT) assessed arterial calcification (AC) is associated with postoperative complications. We investigated the association between AC and pharyngocutaneous fistula (PCF) formation after laryngectomy., Methods: This was a retrospective cohort study of patients undergoing laryngectomy. AC was scored at 10 different anatomical locations on CT imaging, blinded for PCF occurrence. Association with PCF was investigated using logistic regression., Results: The 224 patients were included; 62 (27.7%) developed a PCF. Moderate to severe AC was widespread in patients undergoing TL; 7.1% of patients had at most mild AC, of whom 1 experienced a PCF (p = 0.05). A higher cumulative calcification score was associated with PCF in univariable (OR 1.11, p = 0.04) and multivariable analysis (OR 1.14, p = 0.05)., Conclusion: AC is widespread in patients undergoing laryngectomy and its burden is associated with PCF. Extensive AC on preoperative imaging may be considered a risk factor for PCF., (© 2021 The Authors. Head & Neck published by Wiley Periodicals LLC.)

Objective: The purpose of this study was to analyse the prevalence of tonsilloliths and to determine radiographically whether there is a relationship between tonsilloliths and dental plaque-related pathologies in a series of digital panoramic radiographs., Materials and Methods: This retrospective study included digital panoramic radiographs of 859 patients admitted for routine dental examination. The panoramic images were examined for both the presence of tonsilloliths and the number of decayed, missing, restored teeth and apical periodontitis. Periodontal bone loss was also measured in thirds of optimal bone height according to the root length and a percentage of bone loss was obtained for each panoramic radiograph evaluated., Results: Tonsilloliths were observed in 141 (16.4%) of all individuals. While there was no significant difference regarding the number of decayed teeth and restored teeth between tonsillolith cases (TT) and cases without tonsillolith (TC), the number of missing teeth and apical periodontitis in TT was significantly higher than TC (p: 0.004, p: 0.030, respectively). There was a significant difference between the groups in terms of the mean percentage of bone loss (p: 0.001; p < 0.05). In addition, cases showing bone loss between one-third and two-thirds of the optimal bone height in the TT group (52.5%) were significantly higher than those in TC (45.5%) (p: 0.035; p < 0.05)., Conclusion: The relationship between dental plaque-related pathologies and tonsilloliths observed in this retrospective study should be confirmed by computed tomography studies and randomized, prospective, clinical trials conducted in a multidisciplinary manner., (© 2021 The Author(s). Published by S. Karger AG, Basel.)

External penetrating wounds of the neck leading to pharyngeal perforations are relatively uncommon. The small area of the neck contains the vital vascular, aerodigestive and nervous structures, which are difficult to access surgically. Pharyngeal perforations are challenging to treat, especially in children, as primary wound inspection may be difficult, leading to life-threatening complications like retropharyngeal abscesses, mediastinitis or airway compromise. The following is a case report of a 5-year-old girl who had a road traffic accident causing a neck laceration with a pharyngeal tear, which was only identified during emergency neck exploration in the operating room. A review of known literature and a proposed algorithm for managing penetrating neck injuries with pharyngeal injury is described., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives/hypothesis: We aimed to analyze the clinical characteristics and introduce a new subclassification system for type II first branchial cleft anomalies (FBCAs) based on magnetic resonance imaging (MRI) findings., Study Design: Retrospective cases study., Methods: We conducted an analysis of data from patients with type II FBCAs. MRI findings were used to categorize FBCAs into three subtypes. FBCAs located between the subcutaneous tissue and parotid were classified as type IIa. FBCAs located between the deep and superficial lobes of the parotid were classified as type IIb. FBCAs located between the parotid and the carotid sheath were classified as type IIc., Results: Patients with type II FBCAs were classified as type IIa, IIb, and IIc in 14, 14, and seven cases, respectively. Type IIa lesions exhibited a close relationship with the facial nerve in 42.9% of cases. In these cases, the main trunk of the facial nerve adhered to the lesion and was located superficially to the FBCA. In all patients with type IIb lesions, the main trunk and marginal mandibular branch of the facial nerve adhered to the lesion. The main trunk of the facial nerve adhered to the lesion in one patient with a type IIc. There was no relationship between the lesion and the facial nerve in the remaining type IIc cases., Conclusions: MRI can be used to identify the locations of FBCA and the parotid, which can aid surgeons in predicting the relationship between the lesion and the facial nerve. It is feasible to classify type II FBCAs into three subtypes based on MRI., Level of Evidence: 4 Laryngoscope, 131:916-920, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objectives: Acute hemorrhage in the head and neck (AHNH) is life-threatening due to asphyxiation and hemorrhagic shock. When conservative measures fail, some patients benefit from endovascular therapy (EVT). While CTA is routinely used to localize bleeding and plan EVT in gastrointestinal hemorrhage, the diagnostic value of CTA in AHNH and role of CTA in treatment-planning are uncertain., Methods: We retrospectively reviewed neck CTAs from June 2015 to October 2018 indicated for AHNH. When performed, digital subtraction angiography (DSA) findings and EVT were documented. Extravasation or pseudoaneurysm on DSA was considered positive for bleed localization., Results: Thirty CTA exams were performed for AHNH in 18 patients (mean age = 56.6, male% = 55.6%). Eleven out of 30 exams (36.7%) had immediate DSA follow-up within 24 h. Etiologies of hemorrhage included malignancy 11/18 (61.1%) and coagulopathy (4/18, 22.2%) among others. CTA reports identified definite or possible source of bleeding in 7/30 (23.3%) exams. Seven out of 7 (100%) patients with definite or possible source of bleeding on CTA underwent DSA and 4/23 (17.4%) patients underwent DSA despite negative CTA. With DSA as the gold standard, CTA had a sensitivity of 70% and a specificity of 100%., Conclusions: CTA has high specificity and reasonable sensitivity for detecting arterial source of bleeding in patients presenting with AHNH. Patients with negative CTA may avoid catheter angiography in most cases; however, false-negative CTA should not preclude angiography in high-risk patients.

Introduction: Narrow Band Imaging (NBI) is an endoscopic optical imaging enhancement technology that improves the contrast of mucosal surface texture and enhances visualization of mucosal and submucosal vasculature. Due to its properties, it can visualize suspected malignant or precancerous lesions earlier than conventional white light endoscopy. The aim of this study was to analyze the benefit of NBI in visualization of precancerous and malignant lesions in preoperative and intraoperative diagnostics and correlation with histopathologic results., Methods: A total of 589 patients with suspicious laryngeal or hypopharyngeal lesion were investigated using conventional white light endoscopy (WLE) and NBI endoscopy with high-definition TV (HDTV NBI) from 10/2013 to 12/2019. Patients were divided into two groups based on pre-operative NBI examination (group A, 345 patients) and intraoperative NBI examination (group B, 244 patients). All suspicious lesions were graded to 5 types of Ni classification and correlated with histopathologic results. The SPSS version 8.0.4 statistical software package was used for statistical analysis. In diagnosing premalignant and malignant lesions sensitivity, specificity, positive predictive value, and negative predictive value were calculated., Results: The agreement between NBI endoscopy and histopathological analysis in group A was statistically significant (Қ = 0.76, p < 0.001), with a sensitivity of 86.2% (95% IS: 65.4-95.2) and specificity of 90.9% (95% IS: 70.6-94.1). Moreover, in group B was proven almost perfect agreement between NBI and histopathological analysis (Қ = 0.8461, p < 0.001), with a sensitivity of 84.0% (95% IS: 60.2-92.4) and specificity of 96.0% (95% IS: 87.0-99.2)., Conclusions: Based on our results, NBI using the Ni classification has great potential in improving diagnosis of precancerous and malignant lesions and correlates strongly with histopathologic results. It serves as a useful adjunct to white light endoscopy in the diagnosis of laryngeal and hypopharyngeal lesions, especially using HDTV NBI.

Parapharyngeal and retropharyngeal abscesses (PPA) in children are a rare pathology, for the diagnosis of which it is necessary to use additional instrumental examination methods. The tactics of treating patients remains a subject of discussion., Objective: To analyze the features of the clinic, diagnosis and treatment of PPA in children., Material and Methods: According to the hospital database, a retrospective analysis of the medical histories of children discharged from the clinic with a diagnosis of "J39.0 Retropharyngeal and parapharyngeal abscess" was carried out in the period from 01.01.14 to 31.12.19. In all cases, the diagnosis was confirmed by computed tomography (CT) data with contrast enhancement. Complaints at the time of treatment, anamnesis and instrumental diagnosis data, clinical features of the course of the disease and the effectiveness of treatment were analyzed., Results: 121 children were treated for PPA (average age 73±41 months; Me=52.5 months), which is 0.4% of all hospitalized in the otorhinolaryngological department, 0.7% of the number of emergency hospitalizations, 0.8% of the number of hospitalized children with pharyngeal diseases, and 8.3% of the number of patients with pharyngeal abscess. Abscesses were more often localized in the upper pharynx, at the level of the I-II cervical vertebrae (49.6% of all observations); abscesses were found least often in the pharyngeal space (5.8%), there was no statistically significant difference between the right-sided and left-sided location: 47.9% and 46.2%, respectively. Surgical treatment was performed in 98 (81%) patients in the presence of an abscess capsule or an abscess diameter of more than 2 cm according to CT; the remaining 23 (19%) children were treated conservatively. The opening of the abscess was performed endopharyngeal, in the case of a pronounced deep lateral location of the abscess and its proximity to large blood vessels - with access through the tonsillar niche after preliminary tonsillectomy (19.4% of those operated)., Conclusion: The final diagnosis of parapharyngeal and retropharyngeal abscess can be established by contrast-enhanced computed tomography. Conservative treatment is indicated for a limited group of patients at the initial stages of the disease, most patients need surgical treatment.

Competing Interests: Competing interests: None declared.

Background: Specify place of video-fluoroscopic swallowing study (VFS) in the decision of oral refeeding after total pharyngolaryngectomy., Methods: At postoperative day 7, a blue dye testing was performed. If negative, a VFS was performed looking for a blind fistula. If this exam was negative, oral refeeding was started, but if a blind fistula was observed, cervical compression bandage was performed., Results: In 186 patients, a VFS was performed for 142 patients with negative blue dye testing. It was negative for 98 patients (69%) and positive for 44 patients (31%) (blind fistula). Patients had a probability of 7.1% to have a secondary pharyngocutaneous fistula (PCF) if the VFS was negative, and 15.9% if it was positive. No risk factor for the development of a secondary PCF or a blind fistula emerged from our analysis., Conclusion: VFS should be performed before any oral refeeding in all patients operated with a total pharyngolaryngectomy., (© 2020 Wiley Periodicals LLC.)

Background: Second branchial cleft fistulae are rare pediatric anomalies managed with surgical excision and, in certain cases, ipsilateral tonsillectomy to prevent postoperative recurrence or wound infection. Limited information is available in the published literature regarding surgical techniques to maximize patient outcomes and minimize recurrence. Our objective was to describe outcomes for the largest series of branchial cleft fistulae excised using a uniform technique based on embryologic principles., Methods: We conducted a retrospective analysis of pediatric patients who underwent surgery for second branchial cleft fistula using a uniform technique developed by the senior surgeon between 2006 and 2018 at a tertiary care pediatric hospital. The technique involves dissection to the level of the greater cornu of the hyoid bone as the point of transection, which is the landmark for the base of the tonsillar fossa. Data collected included age at surgery, initial presentation, laterality of fistula tract, final pathology, and follow up data. Measured outcomes included fistula recurrence, wound infection, and other complications., Results: Of 67 patients, 28 (42%) were male and 10 (15%) had bilateral fistulae, for a total of 77 tracts excised. After a median follow up of 31 months, there were no recurrences and one wound infection that was treated successfully with oral antibiotic therapy. No patients underwent tonsillectomy., Conclusion: Effective management of second branchial cleft fistulae can be challenging. We present the largest cohort of results using a uniform surgical technique performed at a single center that obviates the need for tonsillectomy, and thus represents a less morbid and effective approach with no evidence of recurrence.

Objective: Retropharyngeal lymphatic malformations (LMs) are uncommon congenital anomalies. Open surgery, sclerotherapy and various pharmaceutical agents have been described to manage these lesions. However, when such lesions involve the retropharyngeal space with evidence of airway compromise, none of the above aforementioned modalities has shown superior result without repeated imaging and procedures. We describe the use of radiofrequency ablation (Coblation) in an endoscopic-assisted, transoral approach as a one-off treatment for pediatric retropharyngeal lymphatic malformations., Methods: Six patients with retropharyngeal lymphatic malformations, presented with airway compromise, were treated with endoscopic-assisted, transoral submucosal coblation in our unit between April 2015 to August 2018. We retrospectively reviewed their medical records, imaging and endoscopic findings., Results: Five out of our six patients had LMs involving only the retropharyngeal space, who received the coblation as their sole treatment. One patient with extensive LMs involving multiple neck compartments received coblation to the retropharyngeal part as an adjunct procedure. The average operation time was 62.8 min, and the average intraoperative blood loss was 3.8 ml. All patients were safely extubated immediately after the surgery. None required admission to pediatric intensive care unit (PICU), nor prolonged dysphagia reported. They were observed for 2-5 days post operatively. The average follow up was 28 months (1-5 years) and none required re-operation to date., Conclusions: We presented our approach and outcome of 6 children with endoscopic-assisted, transoral submucosal coblation to retropharyngeal lymphatic malformation. We believe it is a safe and effective primary treatment to these patients, and a possible adjunct to complex vascular malformation involving multiple sites., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest., (Copyright © 2020. Published by Elsevier B.V.)

Objective: The aim of this study was to detect the prevalence of soft tissue calcifications in the head and neck using cone beam computed tomography (CBCT) and to determine their clinical importance., Subjects and Methods: Soft tissue calcifications in the head and neck region were retrospectively evaluated in 1557 CBCT images obtained between 2013 and 2015. The findings were categorized as follows: tonsillolith (calcified tonsil), carotid artery calcification (CAC), sialolith (salivary stone), calcified triticeous cartilage (CTC), calcified lymph node (CLN), rhinolith, antrolith, calcification of the superior cornu of the thyroid cartilage (CSCTC), calcified stylohyoid ligaments (CSL), myositis ossifican, osteoma cutis, and intracranial calcification. A Chi-square test was performed for categorical variables. In the 1557 CBCT images, 520 (33.4%) contained had at least one soft tissue calcification in the head and neck region., Results: Tonsilloliths (18.8%) were the most prevalent soft tissue calcification, followed by CTC (5.8%), CAC (4.3%), intracranial calcifications (3.9%), CSL (3.7%), CSCTC (2.1%), osteoma cutis (1%), sialoliths (0.7%), antroliths (0.5%), myositis ossificans (0.4%), rhinoliths, and CLN (0.2%)., Conclusion: There was a high prevalence of soft tissue calcifications in the head and neck region on CBCT images. Tonsilloliths were the most common type of calcification. CBCT imaging may aid the diagnosis and assessment of these calcifications., Competing Interests: None

Purpose: Pharyngeal or esophageal perforation with mediastinal abscess is notably dangerous in children and can be very difficult to treat. We aimed to determine the safety and efficacy of the transnasal placement of a mediastinal drainage catheter and a nasojejunal feeding tube, with or without gastric decompression, in the treatment of the above perforations in children., Methods: We placed transnasal mediastinal drainage catheters and nasojejunal feeding tubes in 14 pediatric patients. Patients with esophageal perforation also underwent the placement of a gastric decompression tube. Four of these patients additionally received chest drainage tubes., Results: The fistula healed after a median of 66 days (range, 5-404 days). Corrosive esophagitis occurred in two patients with pharyngeal perforations. One of these patients underwent surgical treatment 2 months after fistula healing, and the other underwent repeated balloon dilatation procedures for cicatricial restenosis. Four months after the fistula had healed, the patients with esophageal perforations were all free from recurrence., Conclusion: The use of interventional radiology to place a transnasal mediastinal drainage catheter, a nasojejunal feeding tube, and a gastric decompression tube is a safe, easy, inexpensive, and efficacious way to treat pharyngeal or esophageal perforation complicated by mediastinal abscess in children., Type of Study: Treatment study., Level of Evidence: Level IV., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Brachycephalic airway syndrome (BAS) is a common disease in certain "flat-faced" dog breeds. This syndrome includes stenotic nares, elongated and thickened soft palate, laryngeal collapse, and tracheal hypoplasia. Pharyngeal collapse is also commonly observed, but it is unclear if laryngopharynx motions are merely sequelae or actually contribute to BAS respiratory symptoms. Laryngopharynx motion was imaged using dynamic four-dimensional computed tomography (4D-CT) during spontaneous respiration in four dogs with different BAS types. Dynamic 4D-CT showed laryngopharynx motion in the following order during inspiration: pharyngeal collapse, contraction, and laryngospasm. We concluded that dynamic 4D-CT is a highly-detailed diagnostic approach for detecting laryngopharynx motion. Pharyngeal contraction during inspiration appears to contribute toward the worsening of clinical respiratory signs of BAS.

Background: Mediastinal hematoma rarely occurs after a minor traffic injury., Case Presentation: A woman in her forties was transferred to the emergency room by ambulance due to a traffic accident. Computed tomography (CT) revealed no abnormal findings, and she went home. Two days after the accident, the contrast-enhanced CT was repeated, which revealed cervical and mediastinal hematomas. Because it was possible that there was active bleeding from the right inferior thyroid artery, embolization of the right inferior thyroid artery was performed; however, her condition further deteriorated, so we performed emergency surgery to achieve hemostasis and remove the hematoma. Because of oozing from the right thyroid lobe, we performed right hemithyroidectomy and drainage of mediastinal space and right thoracic cavity. Since there was no bleeding site in the mediastinum, we thought that the mediastinal hematoma was due to bleeding from the thyroid gland. Her postoperative course was uneventful, and she is doing well at 9 months of follow-up after surgery., Conclusions: It is possible that mediastinal hematoma might be caused by a minor traffic injury.

Objective: A tonsillolith is a concretion of the tonsillar crypt. The aim of this retrospective study was to compare panoramic radiography (PR) and cone-beam computed tomography (CBCT) for the detection of tonsilloliths., Materials and Methods: The CBCT images of 527 patients with maxillofacial volume were evaluated retrospectively. Of these, 175 patients (81 females, 94 males; mean age 51.05 years) had unilateral or bilateral tonsilloliths. In total, 151 of them (67 females, 84 males; mean age, 51.03 years) had PR images performed in the same period and were included in the study. The PR images were examined to ascertain whether known tonsilloliths (from CBCT images) could be detected. The location (unilateral; left or right and bilateral), size, and number of the tonsilloliths were examined on both CBCT and PR images. Descriptive analysis, Spearman's rho correlation coefficient, and χ2 tests were used for the statistical analysis., Results: The detection rate of tonsillolith was 33.2% on CBCT images. Only 51.4% of the tonsilloliths detected on CBCT were evaluated by PR; the correlation between CBCT and PR was found to be significant (Spearman's r = 0.399, p = 0.000). PR was not adequate to detect tonsilloliths 1 mm or smaller in size. All the calcifications larger than 5 mm were detected on PR images., Conclusion: The results of this study showed that more than half of the tonsilloliths observed in CBCT were also detected in PR. Tonsilloliths larger than 2 mm were more likely to be detected on PR images., (© 2019 The Author(s) Published by S. Karger AG, Basel.)

Purpose: To explore the applied value of the selective neck dissection to treat second, third, and fourth branchial cleft anomalies with recurrent or repeated neck infections., Method: We made a retrospective study about 29 patients with the second, third, and fourth branchial cleft anomalies with recurrent or repeated neck infections who were treated by surgery from 2002 to 2018 in Sichuan Province Cancer Hospital. According to the characteristics of branchial cleft anomaly on embryology and anatomy, different types of selective neck dissection were chosen to remove pathological scar tissue or inflammatory tissue en bloc., Result: Of 29 cases, 28 had primary healing, and 1 had local infection, healing after dressing change for a long time. In 1 case, branchial cleft anomalies adhered to the internal jugular vein, which was ruptured and sutured. During the follow-up time of 12∼195 months with an average of 91.76 months, there were no recurrent cases., Conclusion: The selective neck dissection technique is safe and effective in the treatment of branchial cleft anomalies with recurrent or repeated neck infection., (© 2020 S. Karger AG, Basel.)

High-frequency ultrasonography represents a promising tool for pediatric dermatologists. It is a noninvasive and harmless diagnostic technique that is especially appealing when working with children. It can be easily performed at the patient's bedside, avoiding diagnostic delays, sedation, or multiple visits. It represents a useful adjunct to clinical examination and aids our understanding of cutaneous pathology. In this second part, we describe the ultrasonographic findings of developmental anomalies and vascular lesions., (© 2019 Wiley Periodicals, Inc.)

Background: Infections of the neck are frequently seen in young children and are usually harmless and transient. In the case of atypical symptoms, however, it is important to be alert to the possibility of less common causes requiring specific treatment., Case Description: A 4-year-old girl was seen in the outpatient clinic with a recurrent, inflamed swelling in the neck. The swelling persisted despite repeated incision and drainage. Further investigation with MRI revealed a primary branchial cleft fistula, Work type 2. The epithelialized cartilaginous fistula tract ran from the external auditory canal to the neck, very close to the facial nerve, but could be surgically removed without damage to the nerve., Conclusion: In a child with a recurrent swelling or abscess in the neck, with or without a fistula, an extensive differential diagnosis is required including branchial cleft fistula.

Objective: To determine whether airway narrowing during obstructive events occurs predominantly at the retropalatal level and results from dynamic changes in the lateral pharyngeal walls and in tongue position., Methods: We evaluated 11 patients with severe obstructive sleep apnea (OSA) and 7 healthy controls without OSA during wakefulness and during natural sleep (documented by full polysomnography). Using fast multidetector CT, we obtained images of the upper airway in the waking and sleep states., Results: Upper airway narrowing during sleep was significantly greater at the retropalatal level than at the retroglossal level in the OSA group (p < 0.001) and in the control group (p < 0.05). The retropalatal airway volume was smaller in the OSA group than in the control group during wakefulness (p < 0.05) and decreased significantly from wakefulness to sleep only among the OSA group subjects. Retropalatal pharyngeal narrowing was attributed to reductions in the anteroposterior diameter (p = 0.001) and lateral diameter (p = 0.006), which correlated with an increase in lateral pharyngeal wall volume (p = 0.001) and posterior displacement of the tongue (p = 0.001), respectively. Retroglossal pharyngeal narrowing during sleep did not occur in the OSA group subjects., Conclusions: In patients with OSA, upper airway narrowing during sleep occurs predominantly at the retropalatal level, affecting the anteroposterior and lateral dimensions, being associated with lateral pharyngeal wall enlargement and posterior tongue displacement.

Dynamic pharyngeal collapse (PC) is a rarely reported condition in cats defined as the partial or complete collapse of the pharyngeal lumen during inspiration. Herein, we report the imaging findings and clinical features of three cats with dynamic PC. Lateral radiograph of the head was insufficient to detect dynamic PC, but fluoroscopy in conscious cats revealed dynamic PC. Magnetic resonance imaging was not helpful to reveal dynamic PC and underlying diseases. We obtained biopsy samples from the irregular nasopharyngeal mucosal membrane through endoscopy in two of the three cases and high-grade B-cell lymphoma was histopathologically diagnosed. In feline cases with abnormal upper respiratory sounds, dynamic PC should be considered, and fluoroscopy is the imaging technique of choice to diagnose the condition.

Objective: First branchial cleft anomalies (FBCAs) are rare and often misdiagnosed, which can delay proper management and increase surgical risks. Complete excision often requires parotidectomy with facial nerve dissection. The literature reports that younger patients more often have lesions deep to the nerve with higher rates of nerve injury. We hypothesized that the rate of nerve injury and complications in children with FBCAs was not different in those ≤2 years of age compared to those >2 years of age., Methods: Retrospective review of pediatric patients who underwent resection of histopathologically confirmed FBCAs between 2007 and 2017 at a tertiary care, pediatric hospital. Presenting symptoms, lesion classification, prior procedures, imaging techniques, extent of surgery performed, facial nerve position, and complications were reviewed and compared between patients ≤2 years of age and >2 years of age at time of surgery., Results: 43 cases of FBCAs were included in the study: 12 in the younger group and 31 in the older group. There was no difference between groups regarding the presenting symptoms, gender breakdown, lesion classification, prior procedures performed, or extent of surgery. Lesions were more commonly deep to or running between branches of the facial nerve in the younger group (33.3% vs 9.7%, p = .0496). Rates of postoperative complications and facial nerve weakness were comparable between the younger and older groups (8.3% vs 25.8%, p = .206; 25.0% vs 16.1%, p = .503). In combining the age groups, FBCAs located deep to the facial nerve had increased risk of nerve weakness postoperatively (RR 7.2) and those with a history of prior incision and drainage or resection had increased risk of postoperative complications (RR 2.36). Imaging was obtained on all subjects with accuracy rates of 80-100%., Conclusion: Presenting characteristics of FBCAs in patients ≤2 years of age and >2 years of age are comparable, but lesions in younger subjects had a greater likelihood of being deep to or coursing between branches of the facial nerve. However, the rates of facial nerve injury and postoperative complications are comparable in younger and older children, owing likely to accurate preoperative imaging and appropriate surgical planning., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Midline cervical cleft is a very rare congenital anomaly. According to a literature search, until 2014 only 205 cases were reported., Case Presentation: We present a classic case of congenital midline cervical cleft. This was a case of a 3-year-old Middle Eastern boy. The lesion was excised and the defect was closed via multiple Z-plasties., Conclusions: Midline cervical cleft, although a rarity, when presented needs surgical treatment, which comprises surgical excision and closure that lessens the possibility of scar visibility and contracture.

Competing Interests: The authors have no conflicts of interest to disclose.

Background: The current study investigated the feasibility of ultrasonographic swallowing examination (USSE) for the evaluation of neopharynx and early detection of neopharyngeal fistula after salvage total laryngectomy., Methods: A prospective case series-based study involving 16 patients who underwent salvage total laryngectomy was conducted. USSE was performed on postoperative days 5-7, and oral diet initiation was determined based on the USSE results., Results: Fistula of the neopharynx was detected in four patients (25%) via USSE, as was the specific site of the fistula. In these patients, oral diet was delayed and immediate interventions including ultrasound-guided fluid aspiration and compression dressing were applied, and all fistulas were subsequently closed. In the remaining 12 patients with no neopharyngeal fistula on USSE, an oral diet was started immediately and no fistula occurred., Conclusions: USSE is a promising method for neopharynx evaluation and early detection of neopharyngeal fistula after salvage total laryngectomy., (© 2019 Wiley Periodicals, Inc.)

Purpose: Although office-based transnasal esophagoscopy has been investigated extensively, a cost analysis is still lacking. We performed a cost analysis combined with feasibility study for two diagnostic processes: patients with globus pharyngeus and/or dysphagia, and hypopharyngeal carcinoma., Methods: Prospective cohort study., Results: Forty-one procedures were performed, of which 35 were fully completed. The procedure was well tolerated with mild complaints such as nasal or pharyngeal pain and burping. Four complications occurred: two minor epistaxis and two vasovagal reactions. In patients with globus pharyngeus and/or dysphagia, transnasal esophagoscopy resulted in a cost saving of €94.43 (p 0.026) per procedure, compared to our regular diagnostic process. In patients with suspicion of hypopharyngeal carcinoma, cost savings were €831.41 (p 0.000) per case., Conclusions: Cost analysis showed that office-based transnasal esophagoscopy can provide significant cost savings for the current standard of care. Furthermore, this procedure resulted in good patient acceptability and few complications.

Background: Technology to assess tissue perfusion is exciting with translational potential, although data supporting its clinical applications have been lagging. Patients who have undergone radiation are at particular risk of poor tissue perfusion and would benefit from this expanding technology. We designed a prospective clinical trial using intraoperative indocyanine green angiography to evaluate for wound-healing complications in patients undergoing salvage laryngectomy after radiation failure., Patients and Methods: This prospective trial included patients undergoing salvage laryngectomy at a National Cancer Institute-designated tertiary cancer center between 2016 and 2018. After tumor extirpation and prior to reconstruction, 10 mg indocyanine green dye was infused and the fluorescence (F HYPO ) and ingress rate of the pharyngeal mucosa recorded. The primary outcome measure was formation of a pharyngocutaneous fistula (PCF)., Results: Patients who developed a PCF had significantly lower F HYPO (87 vs 172, p < 0.001) and ingress rates (6.7 vs 15.8, p = 0.043) compared with those who did not develop a fistula. There were no fistulas in patients with F HYPO  > 150 (n = 21) or ingress > 15 (n = 15). There was a 50% fistula rate in patients with F HYPO  ≤ 103 (n = 10) and ingress rate ≤ 6 (n = 6)., Conclusions: Intraoperative indocyanine green angiography can assess hypoperfusion in patients and predict risk of PCFs after salvage laryngectomy, and can thus intraoperatively risk-stratify patients for postoperative wound-healing complications.

The aim of this study was to assess pharyngeal swallowing impairments in thyroidectomy patients and to delineate the contributory kinematic components. Forty consecutive patients (mean age = 47.33 years) and fourteen age- and sex-matched heathy adult volunteers (mean age = 42.64 years) participated in this study. A videofluoroscopic swallowing study (VFSS) was performed 1 day prior to surgery, and at 1 week and 3 months post-surgery. VFSS images were evaluated using the Modified Barium Swallowing Impairment Profile (MBSImp). Kinematic and temporal aspects of swallowing were characterized by measurement of maximum hyoid and laryngeal excursion, pharyngeal transit duration, laryngeal response duration (LRD), and laryngeal closure duration at each three time-points. At 1 week post-surgery, only pharyngeal impairment was significantly deteriorated than pre-surgery (p = 0.001). However, at 3 months, a significant improvement was observed to pre-surgery level (p = 0.01). Post-surgery, maximum hyoid excursion was significantly reduced in patients compared controls (p = 0.001). Although the maximal distance of the hyoid and the laryngeal excursion was shorter than before surgery, laryngeal excursion at all three time-points was similar to that of controls. At all three time-points, LRD was significantly longer in patients than in controls (p = 0.01). Following thyroidectomy, pharyngeal aspects of swallowing as measured by the MBSImp and kinematic aspects of swallowing were reduced with incomplete recovery at 3 months. These exploratory data may guide decision regarding management of pharyngeal swallowing impairment with patients undergoing total thyroidectomy.

Pharyngeal emergencies, which can be subdivided into traumatic versus nontraumatic, are a common cause of Emergency Department visits. Patients often present to Emergency Department with a wide variety of pharyngeal symptoms, for which computed tomography imaging has become the first line imaging modality. Familiarity with these conditions enables a radiologist to make a prompt diagnosis, assess the extent of disease, and evaluate for potential complications. In this chapter, we present a brief overview of nontraumatic pharyngeal emergencies based on anatomic subdivisions (nasopharynx, oropharynx, and hypopharynx), discuss their etiologies, clinical presentations, computed tomography imaging findings, and management options. We will also discuss differential diagnoses based on imaging findings., (Copyright © 2018. Published by Elsevier Inc.)