Lymphatic malformations (LM) are composed of dilated, abnormal lymphatic vessels classified as macrocystic (single or multiple cysts >2 cm3), microcystic (<2 cm3), or mixed. This patient is a 5-month-old with a right neck mass consistent with macrocystic lymphatic malformation on MRI. This low-flow vascular malformation required surgical intervention.
Methods
The site was marked in a natural skin crease. Subplatysmal flaps were raised and malformation was immediately encountered. Blunt soft tissue dissection was performed immediately adjacent to the mass to reflect tissue off the fluid-filled lesion. Neurovascular structures were preserved in this process. Mass was removed in total and Penrose drain and neck dressing were placed.
Results
A complete resection was performed. LM was confirmed on pathology. Patient is doing well with no deficits noted. The drain was removed after 1 week. One-month follow-up showed no recurrence.
Conclusion
Macrocystic lymphatic malformations are amenable to surgical resection at low risk and without recurrence.
By: Ravi W Sun, BE
Surgeons:
Luke T Small, MD
Gresham Richter, MD
Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
Arkansas Children's Hospital, Little Rock, AR, USA
Recruited by: Gresham T Richter, MD
1. A 6 centimeter incision was made and carried through the platysma.
2. Subplatysmal flaps were elevated superiorly and inferiorly.
3. Fascial bands overlying the mass were divided.
4. Overlying fascial tissue was gently dissected circumferentially around the mass.
5. Great care was taken to not violate the surrounding structures.
6. Bipolar cautery was used to divide the facial attachments of the deep layer of the mass.
7. The incision was closed in a layered fashion.
8. A 1/4 inch penrose drain was added and removed a few days later.
Enlarging neck mass
Lymphatic malformation
None apparent. More complicated if prior treatment or sclerotherapy.
Arrange field and instrumentation for standard neck dissection.
MRI imaging and follow up to note changes in mass.
Anatomy described in the video. We note standard landmarks defined in any neck dissection.
Advantage
Surgical excision often is the definitive treatment, with low risk of recurrence that can be treated with touch up sclerotherapy if needed.
Disadvantage
In comparison to sclerotherapy, potential for scarring increased as well as marginal risk of damage to surrounding structures.
Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
Arkansas Children's Hospital, Little Rock, AR, USA
Richter GT, Suen JY. Head and Neck Vascular Anomalies. (Plural Publishing Inc., San Diego, CA, USA, 2015), pp. 229-314.
Review Excision of Macrocystic Lymphatic Malformation. Cancel reply
Related Videos
This video shows a transotic approach for a cochlear schwannoma in a 59-year-old female who presented with sudden sensorineural hearing loss in her left three years prior. She was found to have subsequent growth of her tumor on imaging and elected to undergo surgery. The transotic approach is a valuable approach within the armamentarium of a skull base team and differs from the transcochlear approach in the handling of the facial nerve. Techniques for ear canal overclosure, eustachian tube packing and mastoid obliteration are also highlighted.
Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
We present the harvest of a osteocutaneous fibula free flap for head and neck reconstruction performed at the University of Cincinnati. This reconstructive technique has a wide variety of implications but has found greatest utility in the reconstruction of mandibular defects.
Review Excision of Macrocystic Lymphatic Malformation.