Delay and completion of treatment in head and neck cancer patients employing a multidisciplinary team approach: A single institution experience

Objective@#To explore possible associations of a multidisciplinary team approach compared to a non-multidisciplinary team approach on delay and completion of treatment of head and neck cancer patients.@*Methods@#Design: Historical Cohort Study Setting: Tertiary Private Training Hospital Participants: A total of 240 records of head and neck cancer patients from January 2016 and December 2018 were included in the study; 117 underwent a multidisciplinary team approach and 123 underwent a non- multidisciplinary team approach.@*Results@#Only 24.79% of head and neck cancer patients under the multidisciplinary team approach had treatment delays compared to 37.40% under the non-multidisciplinary team approach. The proportion of treatment delays was significantly higher (χ2 = 4.44, p = .035) with the non-multidisciplinary team approach. Comparative treatment completion of 77.78% and 69.11% under the multidisciplinary and non-multidisciplinary team approaches, respectively, were not significantly different (χ2 = 2.31, p = .129). @*Conclusion@#The multidisciplinary approach might be associated with decreased delay in treatment among patients with head and neck cancer compared to the non-multidisciplinary team approach. A possible trend toward better treatment completion rate was also observed, but it did not reach statistical significance.

Morbidity outcomes of prophylactic central neck dissection with total thyroidectomy versus total thyroidectomy alone in patients with node-negative papillary thyroid cancer: a meta-analysis of observational studies

@#<p><strong>Objective: </strong>The primary objective of this meta-analysis is to compare locoregional recurrence, vocal cord paralysis, and permanent hypoparathyroidism in patients with thyroid papillary carcinoma without neck node metastases, after total thyroidectomy with and without prophylactic central neck dissection.</p><p><strong>Methods: </strong>Two independent reviewers performed a detailed literature search of MEDLINE (PubMed), HERDIN and Cochrane Library electronic databases to assess research studies until 2018 for inclusion. The primary endpoints of locoregional recurrence, permanent hypoparathyroidism, and vocal cord paralysis were included in the assessment.</p><p><strong>Design:           </strong>Meta-analysis of Retrospective Cohort Studies</p><p><strong>Setting:          </strong>University Hospitals and Tertiary Referral Centers</p><p><strong>Participants:            </strong>Patients with node-negative papillary thyroid cancer who underwent either total thyroidectomy alone or total thyroidectomy with prophylactic central neck dissection (either unilateral or bilateral).</p><p><strong>Results: </strong>This meta-analysis showed that there is a significantly increased risk for locoregional recurrence in the total thyroidectomy alone group (1.96% TT with pCND VS 2.60% TT, RR=0.62, 95% Cl=0.40-0.95, p=.03), permanent hypoparathyroidism in the total thyroidectomy with prophylactic central neck dissection group (5.72% TT with pCND vs 3.34% TT, RR=2.19, 95% Cl=1.62-2.98, p=.00001) and no significant difference for vocal cord paralysis between the 2 groups (RR=1.56, 95% Cl=0.86-2.84, p=.14).</p><p><strong>Conclusion: </strong>This meta-analysis revealed that performing pCND in patients with node-negative PTC increases the risk of morbidity for hypoparathyroidism but not for vocal cord paralysis. More importantly, the incidence of recurrence is decreased in the pCND group, which may have implications on the overall survival of patients. The benefit of performing pCND may outweigh the risk but the role of prophylactic CND in the treatment of patients with PTC with clinically negative lymph nodes is still debatable in terms of overall survival.</p><p> </p><p><strong>Keywords:</strong>  thyroidectomy, complications; neck dissection; papillary thyroid carcinoma; lymph node dissection; recurrence; vocal cord paralysis; hypoparathyroidism</p>

Peripheral T-cell lymphoma presenting as an auricle mass

@#<p class="MsoNormal"> </p><p class="MsoNormal" style="text-align: justify; text-indent: .5in;">When evaluating patients with a non-traumatic auricular deformity that presents like a soft tissue infection unresponsive to antibiotic therapy and progressively resembles a tumor, immediate biopsy and imaging should be instituted to obtain an accurate diagnosis and avoid unnecessary procedures. After all, not all head and neck masses are managed with surgery. </p><p class="MsoNormal" style="text-align: justify;"><b> </b></p><p class="MsoNormal" style="text-align: center;" align="center"><b>CASE REPORT</b></p><p class="MsoNormal" style="text-align: justify; text-indent: .5in;">A 64-year-old diabetic man with a 30 pack-year smoking history presented with progressive diffuse swelling of the right auricule with exudative yellow non-foul smelling discharge. Initially diagnosed with auricular cellulitis by an ENT specialist, there was no response to oral and topical antibiotic treatment as the swelling developed into a large cauliflower-like deformity. Incisional biopsy only revealed fibrocollagenous tissue with chronic inflammation without evident granuloma. </p><p class="MsoNormal" style="text-align: justify; text-indent: .5in;">With the progressively enlarging right auricular mass unresponsive to medical treatment for over six months, the man underwent a series of multi-disciplinary consultations in our institution. Also noted were left tragal enlargement without ulceration or bleeding, palpable level II-III cervical lymph nodes (measuring 2.5 cm in widest diameter), but no palpable skin lesions, other signs or associated symptoms. (Figure 1) Otoscopy was normal with normal hearing thresholds on the right and mild conductive hearing loss on the left on pure tone audiometry. The rest of the physical examination and blood laboratory tests were unremarkable. </p><p class="MsoNormal" style="text-align: justify; text-indent: .5in;">A temporal bone CT scan (to determine mass extent and the best site for repeat incisional biopsy) showed an intensely enhancing external ear mass extending to the outer cartilaginous portion of the auditory canal with multiple sub-centimeter enhancing nodules in the right parotid gland. (Figure 2) An excision biopsy between the junction of the mass and grossly normal-looking tissue of the right helix revealed Atypical Round Cell Tumor, subsequently diagnosed as T-cell Lymphoma after strongly staining with CD3 and Ki67 immunohistochemistry studies. </p><p class="MsoNormal" style="text-align: justify; text-indent: .5in;">After unremarkable repeat chest x-ray and abdominal CT findings, the patient underwent six cycles of chemotherapy using the CHOP (Doxorubicin, Vincristine, Cyclophosphamide, Prednisone) protocol for Peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS), Stage II. Significant decrease in size of the auricular mass was noted from the second cycle until no mass was evident after completion of the regimen. No recurrence was noted during a 48-month follow-up period. (Figure 3) </p><p class="MsoNormal" style="text-align: justify;"><b> </b></p><p class="MsoNormal" style="text-align: center;" align="center"><b>DISCUSSION</b></p><p class="MsoNormal" style="text-align: center;" align="center"> </p><p class="MsoNormal" style="text-align: justify; text-indent: .5in;">Because the external ear and auditory canal can be affected by various organisms especially in elderly, diabetic, and immunocompromised individuals, aggressive medical treatment is often warranted. A neoplastic etiology should be suspected when rapidly progressive ear deformities arise in cases of perichondritis and other non-infectious inflammatory conditions that are non-responsive even to culture-guided therapy. In the absence of trauma, such other causes of ear deformity as sarcoidosis, perniosis, polychondritis, and auricular pseudocyst must be carefully investigated by adequate biopsies and histopathologic studies to rule out malignant processes.1,2</p><p class="MsoNormal" style="text-align: justify; text-indent: .5in;">Lymphomas represent approximately 2.5% of head and neck malignancies, and the majority present with cervical lymph node involvement.2 While 40% of head and neck lymphomas occur in such extranodal sites as the nasopharynx, lacrimal sac, temporal bone, or salivary glands, they rarely involve the auricle and external auditory canal.2 More common malignancies that may lead to auricular masses and deformities such as squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, mucoepidermoid carcinoma, basal cell carcinoma, and rhabdomyosarcoma, must be ruled out.3,4 These conditions have distinct presentations and may arise from the external ear, middle ear or temporal bone before affecting the external auditory canal.5</p><p class="MsoNormal" style="text-align: justify; text-indent: .5in;">The literature on extra-nodal lymphomas is scarce, with B- cell origin more commonly reported. On the other hand, peripheral T-cell lymphomas (PTCL) represent only 10-15% of non-Hodgkin lymphoma, categorized as nodal, extra nodal or leukemic.6 A subtype of PTCL that do not correspond to any of the specifically defined T-cell entities in the World Health Organization (WHO) classification are defined as not otherwise specified PCTL (PTCL-NOS).7,8 However, based on a search of PubMed and HERDIN using the search terms "peripheral T-cell lymphoma," "auricle," and "external ear," to the best of our knowledge, PTCL-NOS has not been locally reported as primarily affecting the external ear.6,8 </p><p class="MsoNormal" style="text-align: justify; text-indent: .5in;">The clinical presentation of primary lymphomas of the EAC is non-specific and they can be easily misdiagnosed and treated as infectious or inflammatory conditions of the external ear. As with other conditions, early and accurate diagnosis based on good clinical correlation with imaging studies must be achieved to allow early and specific treatment. For PTCL-NOS, the Ann Arbor staging system still applies although it was originally designed for Hodgkin lymphoma.7 Surgical management has been reported for isolated auricular lymphomas but disseminated disease or involvement of complex structures such as the external ear warrant chemotherapy as the primary and definitive treatment.2 External beam radiation has likewise been reported as an option but may not be applicable in this particular case where structural preservation of the auricle is considered.2 To date, no therapeutic guidelines have been established due to the paucity of cases.</p><p class="MsoNormal" style="text-align: justify; text-indent: .5in; line-height: 200%;"> </p><p class="MsoNormal" style="text-align: justify; text-indent: .5in;">This case of PTCL-NOS of the auricle, just like other reported cases of lymphoma arising from the external auditory canal, appear to respond well with the standard CHOP regimen.  The favorable resolution in our case suggests that surgical resection of the auricle should be reserved for non-response to standard treatment for lymphoma. </p>

Fibular dimensions for mandibular reconstruction among Filipinos

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> To determine if the anatomic dimensions (length, cross-sectional width, cortical thickness) of the Filipino fibula are ideal for mandibular reconstruction.<br /><strong>METHODS:</strong><br /><strong>Design:</strong> Cross-Sectional Study<br /><strong>Setting:</strong> Anatomy dissection laboratory<br /><strong>Participants:</strong> 40 fibulas from 20 adult cadavers<br /><strong>RESULTS:</strong> Morphometric examination showed the mean length of the harvested fibulas was 33.5 cm. The mean horizontal (a-d) and vertical (b-c) widths of the proximal cross-section (point B) were 15.1 ± 0.28 mm and 9.9 ± 0.15 mm respectively. The mean horizontal (a-d) and vertical (b-c) widths of the distal cross-section (point D) were 15.4 ± 0.24 mm and 10.3 ± 0.49 mm, respectively. The mean cortical thickness of the anterior (a), lateral (b), posterior (c) and medial (d) aspects of the proximal cross-section (point B) were 5.2 ± 0.1 mm, 3.2 ± 0.04 mm, 3.6 ± 0.01 mm, and 2.9 ± 0.06 mm, respectively. The mean cortical thickness of the anterior (a), lateral (b), posterior (c) and medial (d) aspects of the distal cross-section (point D) were 5.1 ± 0.21 mm, 3.1 ± 0.11 mm, 3.5 ± 0.04 mm, and 2.9 ± 0.09 mm, respectively.<br /><strong>CONCLUSION:</strong> Our findings show that the Filipino fibulas studied have dimensions that are ideal for mandibular reconstruction.</p>

Reconstruction of a large through and through defect of the oral cavity using a double anterolateral thigh free flap

Objective@#To present our application of a double anterolateral thigh (ALT) free flap in reconstruction of a large full thickness defect of the oral cavity, cheek and cervical area.@*Methods@#Design: Case Report Setting: Tertiary Government Hospital Patient: One@*Results@#A 77-year-old male with a 20 x 25 cm full thickness soft tissue defect on the facial and cervical area contiguous with a 6 x 6 cm buccal defect resulting from wide tumor ablation of a Stage IVA (T4aN2bM0) squamous cell carcinoma of the buccal mucosa underwent reconstruction using two ALT free flaps. An ALT flap was designed to cover the intraoral and cheek defect, while another ALT flap was used for external coverage of the cervical defect. The first ALT flap measured approximately 8 x 22 cm while the second ALT flap measured 6 x 22 cm harvested from the left and right thigh respectively. Temporary venous congestion was observed on the inferiorly placed ALT flap due to neck edema that spontaneously resolved on the 2nd post-operative day. Minimal donor site complications observed were linear scars, and a 1 x 4 cm dehiscence on the right thigh that healed spontaneously by secondary intention.@*Conclusion@#The utilization of a double anterolateral thigh free flap allowed single-stage reconstruction of the large soft tissue head and neck defect with little donor site morbidity, shorter operating time and shorter hospital stay.

Combination of autologous platelet-rich fibrin and bone graft: An invaluable option for reconstruction of segmental mandibular defects

@#Dear Editor, Reconstruction of mandibular defects resulting from ablative surgery for benign and malignant tumors remains a reconstructive challenge. For the past decade, the fibular free flap has been the workhorse for large mandibular defects because of its length, versatility, and ability to be harvested with a skin paddle for soft tissue closure. Although its success rate has continuously improved to almost 95%, donor site morbidity remains a matter of concern.1,2 Bone grafts are already widely used in dental surgery but only as fillers for chipped or marginal defects and not for large segmental mandibular defects. We present a new technique of reconstructing segmental mandibular defects using bone grafts combined with autologous platelet-rich fibrin (PRF), a biomaterial derived intra-operatively from the patient that incorporates leukocytes, platelets, growth factors, and a wide range of glycoproteins in a dense fibrin matrix. Moreover, we describe the essential role of PRF in bone healing and regeneration that offers an invaluable reconstructive option that is free of donor site morbidity without sacrificing the main goal of reconstruction in restoring both form and function.

Endoscopic myringotomy and ventilation tube placement: A valuable otolaryngologic procedure under topical anesthesia

@#Dear Editor: Time has proven that endoscopy is generally a safe and effective tool in the diagnosis and treatment of various conditions. It offers superior visualization with markedly decreased morbidity and mortality. In Otolaryngology, otoendoscopy has been gaining acceptance in providing improved otoscopic visualization and video recording of the tympanic membrane. We describe a technique of myringotomy and ventilation tube insertion under endoscopic visualization using a rigid Hopkins rod scope previously described by other authors based on their accepted clinical guidelines for myringotomy. 1,2 The use of rigid endoscopes provides visualization of the entire tympanic membrane with excellent resolution, better fidelity of color with a well-angled or side-to-side vision. The procedure is generally safe, convenient and can be performed in an out-patient setting. Correspondingly, the video recordings could improve disease documentation for baseline and post-myringotomy evaluation. They can also be a tool to enable better understanding for patients.

An anatomical study of the cochlea among Filipinos using high-resolution computed tomography scans

Objective@#To describe the cochlear anatomy among Filipinos through high resolution computed tomography (HRCT) imaging. @*Methods@#Design: Retrospective Study Setting: Tertiary Private University Hospital Patients: Cochlear images retrospectively obtained from computed tomography (CT) scans of subjects who underwent cranial, facial, paranasal sinus and temporal bone computed tomography from October 2009 to July 2010 were reconstructed and analyzed. @*Results@#388 cochlear images were obtained from the scans of 194 subjects (101 males and 93 females, aged 1 to 90 years old, mean = 52 years) and reconstructed for analysis. The mean coiled cochlear height measured 4.36 mm on the right (A.D.) and 4.34 mm on the left (A.S.). Measurement from the oval window to the distal end of the basal turn (equivalent to the horizontal dimension of the cochlea or the mean length of the basal turn) was 7.55 mm A.D. and 7.60 mm A.S. The vertical and horizontal dimensions of right and left cochleas were identical in all subjects (S.D. = 0.35). The right and left cochlear turns were identical in each subject, exhibiting 2 1/2 turns in 92.3% of subjects and 2 3/4 turns in 7.7% of subjects.The cochlear dimensions were similar in all subjects, regardless of age. No cochlear ossification or malformation was noted on any CT image.@*Conclusion@#The 7.55 mm mean length of the cochlear basal turn among Filipinos in this study was 1.24 mm shorter than the average length of the basal turn of 8.81 mm reported elsewhere. Further studies of the cochlear dimensions in specific age groups and its correlation to audiometric status are recommended to determine other significant physiologic correlations.