Conservative thickness layers (CTLs) are occasionally used during Mohs micrographic surgery (MMS) to preserve tissue and reduce cosmetic or functional morbidity, particularly in anatomically sensitive areas. While CTLs offer advantages such as improved healing and expanded reconstructive options, they pose challenges during histologic processing due to their thinness, including tissue folding, epidermal separation, and incomplete flattening. These issues can compromise slide quality and hinder accurate margin assessment. This article describes a novel approach, the “bubble technique,” developed to improve slide preparation and facilitate complete evaluation of CTL margins. The technique involves placing a frozen bead of embedding medium on a glass slide to support the center of the specimen, allowing the peripheral epidermis to be flattened against the surface. After sectioning this initial specimen to assess the epidermal margin, the tissue and medium are thawed, and the tissue is re-embedded and processed in accordance with standard MMS procedures. Together, the resulting slides ensure comprehensive evaluation of peripheral and deep margins. This method is most appropriate for tumors that are superficial, non-aggressive, and amenable to complete margin visualization with this two-step process. It is not recommended for large, thick, endophytic tumors or those with histologic features indicating deeper extension. While not universally applicable, the bubble technique offers a practical solution to a frequent technical limitation when processing CTLs. By improving slide quality and margin visualization, it may reduce the need for additional MMS stages and help optimize outcomes. Further studies are warranted to assess its potential effect on recurrence rates and long-term efficacy.
IntroductionLudwig's angina is a rapidly progressive and life-threatening cellulitis of the soft tissue of the floor of the mouth and neck. Streptococcal and Staphylococcal infections are the most common causes, arising from poor dentition, oral procedures, alcoholism, diabetes or vascular disease, immunocompromised states such as malignancy, or malnutrition. Treatment involves securing the airway, broad spectrum antibiotic coverage, and surgical drainage for any abscess or drainable collection of fluid.CaseA 22-year-old transgender woman with a history of pre-diabetes, hypertension, asthma, hyperlipidemia, and alcohol use disorder reported poor dentition with dysphagia, drooling, and pain in ears and throat for about 1 week. She was taking amoxicillin after being seen at an urgent care 4 days prior for cough, fever, chills, and suspected pharyngitis and tonsillitis. Her oropharynx and tonsils were erythematous with tongue protrusion, dysphonia, poor dentition, diffuse swelling and induration in the submandibular area with tenderness to palpation, and limited neck range of motion. She was placed on mechanical ventilation and broad spectrum antibiotics. She was then taken for an incision and drainage (I & D) of submental and submandibular abscesses followed by removal of 5 teeth with dental carry debridement. Subsequent chest tube insertions into the pleura and mediastinum were performed for fluid collection as well as repeated I & D procedures. We found bilateral otomastoiditis with an abscess on the right extending to the sternocleidomastoid, drained abscesses on the right mastoid, and performed a tympanostomy on the left. Infection spread to the cerebellum necessitated initiation of high dose ceftriaxone. Her condition improved after a 45-day stay and she was sent to a long-term acute care hospital.ConclusionThis Ludwig angina case illustrates the tendency of S. constellatus to form abscesses elsewhere. The steroid hormone treatments, elevated cortisol state of Cushing's Syndrome, and severe metabolic syndrome provided ample opportunity for this infection to persist and spread to the mediastinum, pleura, and central nervous system. Source control is critical, as well as early and frequent evaluations by Otolaryngology and Oromaxillofacial surgery to provide extraction, drainage, and additional measures if needed.
Hydralazine is a vasodilator medication commonly used for treating hypertension. While generally well-tolerated, in rare cases it can induce autoimmune reactions, including anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis. This case report presents a patient who developed ANCA-associated vasculitis resulting in crescentic glomerulonephritis (CrGN) following long-term hydralazine therapy, highlighting the importance of considering this rare adverse effect in patients with unexplained renal decline.
The sign of Leser-Trelat is considered to be a fairly rare paraneoplastic cutaneous marker of internal malignancy with the hallmark finding being an abrupt eruption of multiple seborrheic keratoses. To date, there have been no standardized or quantified diagnostic criteria defining the sign of Leser-Trelat, but instead, the colloquial definition includes an increase in the number and/or size of the seborrheic keratoses. Seborrheic keratoses (SK) are a nearly ubiquitous benign skin lesion in patients greater than 40 years of age, and generally, even healthy patients may have multiple seborrheic keratoses. This “sign” has been met with a significant amount of skepticism by many considering the commonality of both seborrheic keratoses and malignancy in elderly patients.The sign of Leser-Trelat was first described by in the 1800s by Edmund Leser and Ulysse Trelat, but instead of eruptive seborrheic keratoses, they were studying the presence of cherry angiomas in oncology patients. In 1900, Hollander was the first to describe seborrheic keratoses in association with malignancy, but the names Leser and Trelat remained affixed to the condition.
Erythema elevatum diutinum (EED) is a rare, chronic dermatosis that is characterized by red–violet to red–brown papules, plaques, and nodules that favor the extensor surfaces. Lesions often are asymptomatic, though patients may experience pain or a burning sensation. Extracutaneous symptoms include arthralgia, fever, or other constitutional symptoms. The condition is benign in nature but may be associated with infections, hematologic abnormalities, autoimmune diseases, or other conditions. Spontaneous resolution often occurs after 5 to 10 years.
