Joey Sui
Midcentral DHB

A Bilobed Cervicofacial Rotation Flap in Head and Neck Reconstruction
Authors: Siu, J* and Kumar, A.
Department and Institution:,Department of Otorhinolaryngology and Head and Neck Surgery, MidCentral District Health Board, Palmerston North

Introduction: 
Reconstruction for large cutaneous defects of the cheek and external ear can be a challenge, often requiring large local or distant flaps and in some cases free tissue transfer.  Cervicofacial rotation flaps provide a straightforward and reliable means of reconstruction. These are commonly performed as a large rotation flap utilising the neck dissection incision which often leads to ectropion of the lower eyelid secondary to tight closure.

Aims:
We describe our experience in four patients utilizing a bilobed approach to cervicofacial rotation flaps performed for facial cutaneous defects.

Methods: 
We retrospectively reviewed our database from December 2014 - February 2016 to identify patients who underwent a bilobed cervicofacial rotation flap.

Results:
Pathology included three squamous cell carcinomas of the cheek and one squamous cell carcinoma of the pinna. Defect diameter varied from 4 cm – 6cm. The first lobe of the flap was moved from behind the ear and the second lobe was moved from the posterior triangle of the neck. Reliable coverage of the defect and tension free closure was achieved in all cases. One patient had a minor wound dehiscence in the post-auricular region and required a skin graft. None of the patients had inadvertent nerve injury. One patient whose facial nerve was sacrificed due to the tumour involvement developed ectropion of the lower lid. This patient had a gold weight implant to the upper lid and permanent tarsorrhaphy. Exposure that was provided by flap elevation facilitated performing other procedures including parotidectomy and neck dissection in all patients.

Conclusion: 
Cervicofacial flaps designed in a bilobed fashion provides good mobility of the donor skin to achieve a tension free closure with excellent functional and cosmetic outcomes. Key advantages to our flap design are tension free closure and adequate exposure to perform parotid and neck surgery.

References:
1. Moore BA, Wine T, Netterville JL. Cervicofacial and cervicothoracic rotation flaps in head and neck reconstruction. Head Neck. 2005 Dec;27(12):1092-101 
2. Liu FY, Xu ZF, Li P, et al. The versatile application of cervicofacial and cervicothoracic rotation flaps in head and neck surgery. World J Surg Oncol. 2011 Oct;9:135. 

Epithelial-myoepithelial carcinoma: report of a case presenting with ear canal occlusion and review of the literature
Authors: Siu, J1*, Joice, P1, Kumar, A1 and Tan, ST2.
Department and Institution: 
1. Department of Otorhinolaryngology and Head and Neck Surgery, Midcentral District Health Board, Palmerston North, NZ
2. Wellington Regional Plastic, Maxillofacial & Burns Unit, Hutt Valley District Health Board, NZ

Aims: 
Epithelial-myoepithelial carcinoma (EMC) represent less than 1% of all salivary gland tumours and is conventionally defined as a low grade malignancy with a dual histological composition of inner duct lining epithelial cells and outer myoepithelial cells.1 There is a high potential for loco-regional recurrence. Most EMC’s arise in the parotid gland and usually present as a bulky, non-infiltrating mass, due to the myoepithelial phenotype.2 There are few reports which consider the diagnosis of EMC prior to surgery, as the cytological features on FNA are not well recognized1, and computed tomography (CT) and magnetic resonance imaging (MRI) appearances are non-specific.2 We report a case of EMC that unusually presented with ear canal occlusion by tumour. 

Case report: 
A 57 year old female presented with a 4 month history of progressive hearing loss, otalgia, pre-auricular swelling and occlusion of the lateral ear canal with a polypoid mass. The patient had a history of chronic lymphocytic leukaemia and had completed treatment with Fludarabine and Ritixumab two years previously. There was no clinically palpable lymphadenopathy. Facial nerve function was intact. CT and MRI demonstrated a vascular lesion arising from the posterior parotid. It surrounded and invaded the lateral ear canal, stylomastoid foramen and extended into the mastoid tip. Biopsies of the ear canal lesion demonstrated histological features in keeping with EMC. The patient underwent total parotidectomy with facial nerve sacrifice, lateral temporal bone resection, selective neck dissection and facial reanimation. Postoperative histopathology was consistent with EMC. 

Conclusion:
An unusual presentation of a rare malignancy is illustrated. A literature review suggests this lesion demonstrates more aggressive behaviour than previously described, raising a need for prognostic markers. The patient ‘s immunocompromised state may have been a significant factor in tumour behaviour. 

References:
1. Deere H, Hore I, McDermott N, Levin T. Epithelial-myoepithelial carcinoma of the parotid gland: a case report and review of the cytological and histological features. J Laryngol Otol 2001;115:424-6.
2. Silvers AR, Som PM, Brandwein M. Epithelial-myoepithelial carcinoma of the parotid gland. AJNR Am J Neuroradiol 1996;17:560-2.

Relapsing polychondritis as a secondary phenomenon of primary systemic vasculitis: A Case Report and Review of the Literature
Authors: Siu, J1* and Cabraal, Dilhan1
Department and Institution: 
1. Department of Otorhinolaryngology and Head and Neck Surgery, Midcentral District Health Board, Palmerston North, NZ

Aims: 
Relapsing polychondritis (RP) is a rare connective tissue disease associated with episodic yet generally progressive inflammation of cartilaginous tissues of the nose, ears, respiratory tract, and joints, as well as proteoglycan-rich tissues including the media of the arteries, the conjunctiva and sclera of the eye.1, 2 We report a 53 year old woman presenting with secondary RP with ANCA associated vasculitis (c-anca positive) which was diagnosed after emergence of right auricular chondritis and debilitating symptoms which required hospitalization.

Case report: 
A 53 year old female presented with right auricular chondritis and bilateral conjunctivitis. This was preceded by a four month history of polyarthralgia, cutaneous vasculitic rash, fevers, fatigue and malaise. The diagnosis was made based on McAdam’s criteria1, and Damini and Levine’s modified criteria2. After initiating steroid and cyclophosphamide therapy the patient’s condition improved significantly. 

Conclusion:
Early manifestations of RP often remain unrecognized which can cause a significant delay in establishing the diagnosis. It most commonly presents in patients aged 40-60.1 The median time to presentation is 2.9 years. Approximately one third of RP occurs in association with other autoimmune diseases, of which vasculitis is the most common.1 RP is life-threatening, and mortality is associated with infection related to immunosuppression, respiratory tract involvement, and cardiac valvular or vasculitic involvement. This case illustrates that symptoms of RP and associated inflammatory conditions can severely impact quality of life. Early diagnosis is the key to management.

References
1. McAdam LP, O’Hanlan MA, Bluestone R, Pearson CM. Relapsing polychondritis: prospective study of 23 patietns and a review of the literature. Medicine (Baltimore). May 1976;55(3):193-215
2. Daminiani JM, Levine HL. Relapsing polychondritis – report of ten cases. Laryngoscope. 1979 June;89:929-46.

Cutting depth for flat tip versus needle tip monopolar diathermy: an in vitro study using deer tongue
Authors: Siu, J1*, Godfrey, AJ2 and Kumar, A1.
Department and Institution: 
1. Department of Otorhinolaryngology and Head and Neck Surgery, Midcentral District Health Board, Palmerston North, NZ
2. Institute of Fundamental Sciences, Massey University, Palmerston North, NZ

Introduction:
Electrosurgery is fundamental to the practice of surgery, however associated thermal injury can be hazardous to vital structures.1 Although heat generation and resulting tissue damage is considered proportional to the electrode-tissue contact surface area2, there are no studies demonstrating the physical outcomes of thermal injury caused by different contact electrode diameters. 

Aims:
To evaluate the histopathological difference in thermal injury measured by thickness of coagulative necrosis using monopolar diathermy with a flat versus needle tip in an in vitro deer tongue model. 

Methods:
16 fresh deer tongues were used. A 4cm incision was made with a flat or needle tip on the dorsum of 32 tongue halves. Power settings were altered between 15watts and 30watts; and cut and coagulation mode. The thickness of coagulative necrosis was measured at the midpoint of the incision by a pathologist who was blinded. An initial analysis of the 32 samples was performed in which 5 did not have a measurable diathermy artefact. As a result a further 12 specimens were collected to confirm the preliminary findings. 

Results:
We account for the lack of homogeneity of the raw material (p=0.018).There was no difference in thickness of coagulative necrosis between the flap tip and needle tip electrode regardless of the mode or power used (p= 0.728). Coagulation versus cut mode resulted in mean depths of 2.09 mm and 3.43mm respectively (p=0.004). A higher power level resulted in an increased mean depth using cut mode but not coagulation mode (p=0.036).

Conclusion:
There was no difference in microscopic thermal injury with the type of electrode tip used. An increase in power in coagulation mode did not correlate with an increase in the thickness of coagulative necrosis. Findings in this study may facilitate a knowledgeable selection of the application of electrosurgery for use in head and neck surgery.

References:
1. Keenan KM, Rodeheaver GT, Kenney J, et al. Surgical caughtry revisited. Am J Surg 1984;147:818-821
2. Palanker D, Vankov A, Jayaraman P. On mechanisms of interaction in electrosurgery. New J Phys 2008;10:123022.