Selective neck dissection (SND) is performed to prevent head and neck cancers metastasis. We tried to determine the incidence of level IIb lymph nodes metastasis and it is associations in head and neck cancers for selection of patients requiring SND.

A retrospective study was conducted on 57 patients who underwent surgical removal of the head and neck tumor by 84 neck dissections. Fisher exact test was used to measure the association between positive IIb nodes and the other variables.

Nine (15.8%) of 57 patients showed level IIb lymph nodes metastasis comprising 10.71% of the 84 neck dissections. Six (66.66%) were associated with oral cavity cancers, 8 (88.9%) with squamous cell carcinoma (SCC), 6 (66.66%) with T4 tumor. Five (55.6%) were N2b, and 7 (77.8%) were found in N+ necks. All (100%) positive IIb nodes were associated with metastatic level IIa. Significant associations were found betweenpositive IIbnodesand N2b (p= 0.005), clinically N+ necks (p = 0.005) and IIa (p < 0.01).

The incidence of level IIb nodes metastasis is high so they should be removed in any oral tumor, SCC, advanced staging, N+ necks or positive IIa lymph nodes metastasis.

Al zahrani F, Al-Qahtani K, Alshahrani m, Almufargi K, Alkhudhayri A, Obad l, Islam T. Incidence of lymphatic metastasis to Neck Nodes level IIb in Neck Dissection for Head and Neck Cancers: A Retrospective Study. Int J Head Neck Surg 2014;5(3):99-103.

Formic acid (FA) being pungent, odorless, easily available and consumed for suicidal purposes and the dilute form being colorless and odorless is consumed accidentally. Accidental ingestion is rare and deliberate self-harm is very painful and violent which has been a rare modality of committing suicide but for these areas where it is easily available.

This a retrospective case series analysis study 14 patients with acute formic acid poisoning. There were 14 patients, with 3 females and 11 males. The average age was 35.5 years, with the average in males being 34.9 and 37.6 in females. Thirty milliliter were considered as cutoff range as diluted/undiluted FA below 30 ml were managed in our institution and 30 ml+ were referred to higher toxicology speciality care.

Act of deliberate self-harm was seen in 11 cases (78.5%) and accidental ingestion in three cases (21.5%). All had orofacial burns, 4 had mild hematemesis and 3 severe hematemesis with impending renal complications. All the stabilized and referred cases were no further evaluated for follow-up. Facial burns and contracture needing cosmetic correction was seen in three cases, while corneal and lid scarring seen in two cases while a case of esophageal stricture with lower GIT and renal complications were seen in one case.

Formic acid poisoning is uncommon, and limited literature review is available with fewer protocols laid. So, immediate management of this corrosive poisoning with supportive measures reduces the mortality drastically. Serial upper gastrointestinal imaging diagnose stricture earlier and cosmetic reconstruction helps in facial scarring and contractures.

Bhat RS, Naik SM, Goutham MK, Bhat CR, Appaji M, Chidananda KV, Devi NP, Joseph S, Nayak P. Acute Formic Acid Poisoning: A Case Series Analysis with Current management Protocols and Review of Literature. Int J head Neck Surg 2014;5(3):104-107.

Surgical managements which form the mainstay of these branchial apparatus anomalies are based on accurate understanding of the embryology and surgical anatomy. The conspicuous scarring in the young which becomes conspicuous as the age advances are reduced by newer approaches, the facelift approach, retroauricular approach and endoscope-assisted neck approach.

A retrospective case series analysis of eight patients with complete fistula managed by the combined trans cervical approach. The recurrence was nil, with good surgical access and minimal scar at the incision site.

Combined transcervical approach is the conventional procedure of choice for branchial fistulas. While retroauricular hairline incision (RAHI) approach and endo-scopic approaches need expertise and more instrumentation, meticulous cosmetic surgery techniques helps reduces scars of the transcervical approach.

Bhat RS, Naik SM, Goutham MK, Bhat S, Appaji M, Chidananda KV, Devi NP, Joseph S, Nayak P. Branchial Fistulas—A Rare Entity in Pediatric Otorhinolaryngology: Current Management Protocols and Review of Literature. Int J Head Neck Surg 2014;5(3):108-111.

Physiotherapy has an important role in cancer rehabilitation, particularly with the head and neck cancer patients, in an attempt to minimize the morbidities caused by the disease and its treatment.

To determine the role of physiotherapy treatment in morbidities of head and neck cancer, in a retrospective investigation, at one oncologic hospital.

Retrospective study based on the analysis of medical records of 32 patients treated at the outpatient Physiotherapy department at the Brazilian Institute of Cancer Control (IBCC), from August 2008 to July 2010.

Twenty-nine medical records were evaluated, 86.2% were males with cancer in the oral cavity (41.4%) that had radical neck dissection (69%) and radiotherapy (86.2%), evolving with lymphedema (89.7%), pain (82.8%), normotrophic scar (65.5%), tissue adherence (27.6%) and hypoesthesia (51.7%). The physiotherapeutic treatment included: manual lymphatic drainage (89.7%), transcutaneous electrical nerve stimulation (TENS; 51.7%), mechanical massage therapy (37.9%), stretching exercises (79.3%) and patient education (100%). The results showed a reduction of pain and lymphedema, increased normotrophic scars and normoesthesia, with an average of 19.3 ± 14.5 sessions and treatment discharge of 65.5%.

Physical therapy in morbidities of head and neck cancer was effective in reducing pain and lymphedema, combining manual lymphatic drainage, transcutaneous electrical nerve stimulation (TENS), mechanical massage therapy, stretching exercises and patient education, with an average of 19 sessions and discharge after treatment.

Tacani RE, Machado AFP, Goes JCGS, Marx AG, Franceschini JP, Tacani PM. Physiotherapy on the Complications of Head and Neck Cancer: Retrospective Study. Int J Head Neck Surg 2014;5(3):112-118.

The classical Shamblin's classification predicts only vascular morbidity without remarking on the neurological morbidity, while the neurological damage increase with vessel ligation and reconstruction. A modified Shamblin's classification described by Luna-ortiz with incorporation of the Hallett's zones of injury has been studied here.

We present a case series analysis of carotid body paraganglioma managed in our institute. The study included 17 patients, 14 females and three males with a mean duration of presentation of 6.82 months. All were imaged with multislicer computed tomography angiography (CTA) and magnetic resonance angiography (MRA) for preoperative assessment and operated in the craniocaudal technique. The tumors were graded according to the modified Shamblin's criteria: grades I (2), II (13), IIIa (2), IIIb (0).

All the preoperative assessment of grading matched with the intraoperative findings. External carotid artery (ECA) ligation was done in two cases, no internal carotid artery (ICA) ligation and reconstruction were done. Two cases of permanent damage to the 12th nerve, two vagal nerve weakness was seen. No stroke or mortality recorded. The tumor was confirmed on immunohistochemistry. The patients were followed up for 6 months to 5 years with a mean follow-up of 2.5 years.

Preoperative imaging assessment using multislicer computed tomography angiography (MSCTA) and MRA helps to measuring the circumferential vessel involvement in grade III tumors. So, a craniocaudal dissection with assessment of all the zones of injury reduced blood loss and minimized neurovascular complications.

Halkud R, Shenoy AM, Nanjundappa A, Chavan P, Sidappa KT, Madhu SD, Biswas S, Naik SM. Paradigm Shift of Carotid Body Paraganglioma Surgical Technique from Caudocranial to Craniocaudal Dissection: Analysis of Recent Literature. Int J Head Neck Surg 2014;5(3):119-125.

Salivary gland neoplasms are uncommon, but they are of much interest and debate because of their remarkable variability in structure, clinical presentation, and behavior. We have studied 56 cases of parotid tumors and shared our views on the diagnosis and management of these rare tumors.

Fifty-six patients with parotid swelling presented to us over a period of 5 years. Preoperatively, all these patients were evaluated with fine needle aspiration cytology (FNAC). Depending on the report, they were subjected to further treatment.

Out of 56 cases, 44 (79%) were benign and 12 (21%) were malignant. Pleomorphic adenoma being the commonest benign tumor [32 cases (72%)] and among the malignant tumors, mucoepidermoid carcinoma was the commonest. Parotidectomy is the gold standard treatment for both the benign and malignant parotid tumors.

Parotid tumors are a rare entity. Among which benign tumors are more common than malignant. An accurate diagnosis preoperatively and timely surgical management would reduce the recurrence rate and risk of complications.

Aroor R, Shetty AS, Bhandary SK, Bhat VS, Somayaji KSG. Parotid Tumors: How Rare are They? Int J Head Neck Surg 2014;5(3):126-129.

With widespread and sophisticated imaging techniques, micro papillary thyroid cancers (PTCs) may be discovered prior to developing the classic pathological determinants of aggressiveness, such as extrathyroidal extent (ETE). Many studies have suggested that the V600E B-Raf proto-oncogene (BRAF) mutation can be used as a marker for aggressive disease. One objective of this study is to determine what prognostic value this mutation holds. However, nearly all of current studies have focused solely on classically aggressive tumors, not classically nonaggressive samples. This study also seeks to determine the BRAF mutation status in both the groups of tumors.

Sixty-six PTC samples were tested for the V600E BRAF mutation using competitive allele-specific TaqMan probes in real-time PCR (Applied Biosystems/Life Technologies). Testing demonstrates that this assay has at least a <5% sensitivity to the mutation. Forty-five samples had at least one of four aggressive features. Samples with vascular invasion, ETE or lymph node metastasis (LNM) were also characterized as having poor prognosis.

The V600E BRAF mutation was found in 27 of the 45 aggressive samples (60.0%) and 5 of the 21 nonaggressive samples. The Fisher exact test resulted in a correlation between aggressiveness and BRAF mutation as well as correlations between ETE, LNM and the BRAF mutation. When using the BRAF mutation as a predictor of prognosis based on the pathological features of aggressiveness, there was 60% sensitivity and 80% specificity.

The V600E BRAF mutation is correlated with pathological aggressive features, but may lack sufficient specificity or sensitivity to be used as a marker to predict outcome.

Quong A, Wynne C, Curry J, Scott K, Rosen D, Cognetti D, Pribitkin E, Duddy E. BRAF Mutation Correlates with Aggressive Features, Little Predictive Value. Int J Head Neck Surg 2014;5(3):130-134.

Bakshi N, Mukherjee S, Chauhan YS. Surgical Decision Making in Oral Mucosal Melanoma with Lymphadenopathy: Review of Literature. Int J Head Neck Surg 2014;5(3):135-139.

Neck dissection forms integral part in the radical treatment of carcinoma of the oral cavity. In this study, we have examined usefulness of the single drop neck incision.

All the patients with carcinoma of oral cavity which were operated with the single drop neck incision were studied as they were called for follow-up. Their complications, cosmetic outcome and range of shoulder and neck movements were studied.

Total 32 patients were eligible for the study. Average follow-up was about 7 months (1-16 months). Twelve (38%) patients had difficulty in lifting weights and doing manual work at occupation like farm work, etc. Four (12.5%) patients were not happy with their cosmetic outcome. Three (9.4%) patients had hypertrophied scar. One patient had severe trismus and four (12.5%) had marginal skin necrosis.

This study concluded that the single drop neck incision is a very useful tool to perform neck dissection with acceptable morbidity with good postoperative cosmetic outcome.

Gosavi VS, Kale SS. The Study of Utility of Single Drop Neck Incision for Neck Dissection. Int J Head Neck Surg 2014;5(3):140-143.

Adnexal components tumors of the skin are very rare and are seen as benign lesions of the scalp in aged women. Trichilemmal tumor is usually benign and rarely under-goes malignant transformation in a stepwise manner starting with an adenomatous stage of the trichilemmal cyst to an epitheliomatous stage of the proliferating trichilemmal tumor (PTT) evolving into the carcinomatous stage of the malignant proliferating trichilemmal tumor (MPTT).

A 53-year-old woman reported with huge swelling in the posterior region of the scalp. The swelling was mobile and soft to firm in consistency not fixed to the skull bone. The surface was smooth and getting under the swelling was not possible, needle biopsy reported as trichilemmal tumor. Contrast enhanced computed tomography (CECT) neck did not show any nodes in the neck, especially the posterior compartment. The tumor was widely excised with 1 cm margin and the periosteum was kept intact with split skin graft. An area of periosteal adher ence to the tumor seen was excised. The histopathology report on serial sectioning reported grade 1 moderately differentiated squamous cell carcinoma (SCC). Postoperative external beam radiotherapy of 66 Gy was given. The patient is being followed up and no recurrence is seen.

Malignant transformation in a proliferating trichilemmal tumor a rare entity and should be differentiated from SCC and the better prognostic trichilemmal carcinoma. A protocolbased adjuvant therapy is available for squamous cell carcinoma but not for trichilemmal carcinoma (TLC) and MPTT. A major meta-analysis may help to establish a clinical outcome-based classification and management protocol for these tumors.

Nanjundappa A, Halkud R, Venugopal B, Chavan P, Sidappa KT, Biswas S, Samskruthi M, Naik SM. Squamous Cell Carcinoma of the Scalp Masquerading as Trichi-lemmal Tumor of the Scalp. Int J Head Neck Surg 2014;5(3):144-147.

Vascular complications are seen in 2 to 13% of cases with internal carotid artery (ICA) injuries with or without reconstruction. The hypoglossal and vagus appeared most vulnerable for permanent paralysis due to traction or resection. Mortality with surgical excision of carotid body tumor (CBT) has become negligible with newer vascular surgical techniques and the morbidity has fallen to minimal 2.56%.

We report a case of 24-year-old female with symptomatic CBT excision with external carotid artery (ECA) ligation. She developed asymptomatic infarction of the occipital lobe. All the cranial nerves were intact with a follow-up uneventful for the past 2 years.

Minimizing complications in CBT surgery include an accurate preoperative imaging assessment of the tumor with comorbidities and evidence-based management.

Rao V, Naik SM, Goutham MK, Appaji M, Bhat S, Hiremat R, Rangnath N, Bhat RSS. Asymptomatic Occipital Area Infarction following Carotid Body Paraganglioma Excision. Int J Head Neck Surg 2014;5(3):148-151.

Ekhar VR, Shelkar RN, Rane S, Anand A, Lanjewar K, Jain SKT. Rosai-Dorfman Disease: A Rare Cause of Cervical Lymphadenopathy. Int J Head Neck Surg 2014;5(3): 152-154.

Kaur P, Khurana A, Chauhan AK, Singh G, Kataria SP. Non-Hodgkin's Lymphoma of Thyroid Synchronously with Squamous Cell Carcinoma Base of Tongue: A Rare Coincidence and Treatment Strategy. Int J Head Neck Surg 2014;5(3):155-157.

We reported a case who presented with vasovagal syncope and cardiogenic shock was found to have huge branchial cleft cyst. Carotid sinus syndrome secondary to compression by the branchial cyst was suspected. It was managed with inotropic support and needle decompression. She later readmitted for superimposed infection which was treated by antibiotics. Surgical excision was performed to render her complete cure. This was the second reported case of a benign branchial cleft cyst causing cardiac compromise in the literature.

Benign branchial cleft cyst may present with lifethreatening carotid sinus syndrome. Timely needle decompression should be performed for temporary relieve and definitive surgery is required for cure.

Yam SDF, Fung TLD, Tang LCD. Life-threatening Cardiac Failure: A Rare Complication of Branchial Cleft Cyst. Int J Head Neck Surg 2014;5(3):158-160.

Manekar VS, Dewalwar V. Solitary Peripheral Osteoma of the Mandible presented as Trismus. Int J Head Neck Surg 2014;5(3):161-164.