Aspiration Patterns Observed in Patients With Free Flap Reconstruction Following T3 and T4 Tongue and Oropharyngeal Cancer Surgery: A Fiberoptic Endoscopic Evaluation of Swallowing / 대한이비인후과학회지

Background and Objectives@#The objectives of this study were to investigate the aspiration patterns in patients with T3 and T4 oral and oropharyngeal cancers after free flap reconstruction following primary tumor resection and determine the effect of tongue base resection on aspiration patterns in these patients.Subjects and Method The aspiration pattern was evaluated via fiberoptic endoscopic evaluation of swallowing and classified into three groups based on the timing of aspiration in relation to the swallowing process. More than two types of aspiration patterns observed simultaneously in a patient suggested combined aspiration pattern. @*Results@#The major pattern of aspiration in 31 patients with oral cavity cancer was aspiration after swallowing in the group with base of tongue (BOT) preserved (83.3%, 10/12) and combined aspiration in the group with BOT resection (63.2%, 12/19), showing a significant difference in aspiration pattern between the two groups (p<0.001). In oropharyngeal malignancies, the major pattern of aspiration was aspiration after swallowing in both BOT-preserving (87.5%, 21/24) and BOT-resecting groups (75.0%, 9/12), showing a significant difference in aspiration pattern between the two groups (p=0.031). @*Conclusion@#The most common pattern observed in the advanced T stage tongue cancer patients after glossectomy was aspiration after swallowing. Resection of BOT greater than 25% in the tongue and oropharyngeal cancer was a significant factor causing the combined type of aspiration.

Value of the Post-Operative CT in Predicting Delayed Flap Failures Following Head and Neck Cancer Surgery

OBJECTIVE: To identify post-operative computed tomography (CT) findings associated with delayed flap failures following head and neck cancer surgery. MATERIALS AND METHODS: We retrospectively reviewed 60 patients who underwent flap reconstruction after head and neck cancer surgery and post-operative (3–14 days) contrast-enhanced CT scans for suspected complications. Patients were divided into two groups: delayed flap failure patients (patients required flap revision) (n = 18) and flap success patients (n = 42). Clinical data (age, sex, T-stage, type of flap, and time interval between reconstruction surgery and CT) and post-operative CT findings of flap status (maximum dimension of the flap, intra- or peri-flap fluid collection and intra- or peri-flap air collection, fat infiltration within the flap, fistula to adjacent aerodigestive tract or skin, and enhanced vascular pedicle) were assessed and compared between the two groups. RESULTS: CT findings showed that the following flap anomalies were observed more frequently in the delayed flap failure group than in the flap success group: intra- or peri-flap fluid collection > 4 cm (61.1% vs. 23.8%, p 2 cm (61.1% vs. 2.4%, p < 0.001), and fistula to adjacent aerodigestive tract or skin (44.4% vs. 0%, p < 0.001). The maximum dimension of the flap, fat infiltration within the flap, and enhanced vascular pedicle were not associated with delayed flap failures. CONCLUSION: A large amount of fluid or air collection and fistula are the CT findings that were associated with delayed flap failures in patients with suspected post-operative complications after head and neck cancer surgery.

Risk Factors of and Treatments for Pharyngocutaneous Fistula Occurring after Oropharynx and Hypopharynx Reconstruction

BACKGROUND: A pharyngocutaneous fistula is a common and difficult-to-manage complication after head and neck reconstruction. It can lead to serious complications such as flap failure, carotid artery rupture, and pharyngeal stricture, and may require additional surgery. Previous radiotherapy, a low serum albumin level, and a higher T stage have been proposed as contributing factors. We aimed to clarify the risk factors for pharyngocutaneous fistula in patients who underwent flap reconstruction and to describe our experiences in treating pharyngocutaneous fistula. METHODS: Squamous cell carcinoma cases that underwent flap reconstruction after cancer resection from 1995 to 2013 were analyzed retrospectively. We investigated several significant clinical risk factors. The treatment modality was selected according to the size of the fistula and the state of the surrounding tissue, with options including conservative management, direct closure, flap surgery, and pharyngostoma formation. RESULTS: A total of 127 cases (18 with fistulae) were analyzed. A higher T stage (P=0.048) and tube-type reconstruction (P=0.007) increased fistula incidence; other factors did not show statistical significance (P>0.05). Two cases were treated with conservative management, 1 case with direct closure, 4 cases with immediate reconstruction using a pectoralis major musculocutaneous flap, and 11 cases with direct closure (4 cases) or additional flap surgery (7 cases) after pharyngostoma formation. CONCLUSIONS: Pharyngocutaneous fistula requires global management from prevention to treatment. In cases of advanced-stage cancer and tube-type reconstruction, a more cautious approach should be employed. Once it occurs, an accurate diagnosis of the fistula and a thorough assessment of the surrounding tissue are necessary, and aggressive treatment should be implemented in order to ensure satisfactory long-term results.

Is a Preoperative Gastrointestinal Endoscopy for Second Primary Cancer Detection in Head and Neck Cancer Necessary? Ten-year Registry Data / 대한소화기학회지

BACKGROUND/AIMS: In head and neck squamous cell carcinoma, second primary gastrointestinal tumors are not uncommon. However, it is unclear whether a screening endoscopy is needed for detecting gastrointestinal neoplasm in patients with head and neck cancer. Therefore, we analyzed the prevalence and independent risk factors for second primary gastrointestinal neoplasm in head and neck squamous cell carcinoma. METHODS: A consecutive series of 328 patients with primary head and neck squamous cell carcinoma that underwent esophagogastroduodenoscopy or colonoscopy were included using our registry. An age- and sex-matched group of 328 control subjects was enrolled. We assessed risk factors of synchronous gastrointestinal cancer. RESULTS: The prevalence of esophageal cancer with head and neck squamous cell carcinoma was significantly higher than that of the control group (1.5% vs. 0.0%, p=0.011). An age of 54 years or more (OR, 1.033; 95% CI, 1.008-1.059; p=0.009) and male gender (OR, 4.974; 95% CI, 1.648-15.013; p=0.004) were risk factors for concomitant colorectal cancer or adenomas in the head and neck squamous cell carcinoma patients. CONCLUSIONS: Preoperative colonoscopy can be recommended for detecting synchronous second primary colorectal lesions in head and neck squamous cell carcinoma patients with male sex regardless of age, and esophagogastroduodenoscopy is necessary in all head and neck squamous cell carcinoma patients for detecting esophageal cancer.

2016 Revised Korean Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Thyroid Cancer

No abstract available.

2016 Revised Korean Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Thyroid Cancer

No abstract available.

Risk factors and etiology of surgical site infection after radical neck dissection in patients with head and neck cancer

BACKGROUND/AIMS: Surgical site infection (SSI) is a major complication after radical neck dissection (RND) in patients with head and neck cancer (HNC). We investigated the incidence, risk factors, and etiology of SSI among patients who underwent RND. METHODS: A retrospective cohort study was performed on HNC patients, excluding those with thyroid cancer, who underwent first RND at a teaching hospital between January 2006 and June 2010. Medical records were collected and analyzed to evaluate the risk factors and microbiological etiologies. RESULTS: A total of 370 patients underwent first RND. The overall incidence of SSI was 19.7% (73/370). Multivariate analysis showed that male sex (odds ratio [OR], 4.281; p = 0.004), cardiovascular diseases (OR, 1.941; p = 0.020), large amount of blood loss during surgery (OR, 4.213; p = 0.001), and surgery lasting longer than 6 hours (OR, 4.213; p = 0.002) were significantly associated with SSI. The most common causative pathogen was Staphylococcus aureus (32.6%), and 93.2% of S. aureus isolates were methicillin-resistant. Klebsiella pneumoniae (13/92, 14.1%), Pseudomonas aeruginosa (11/92, 12.0%), and Enterococcus species (11/92, 12.0%) were also frequently detected. CONCLUSIONS: Based on our results, we predict that certain groups of patients are at high risk for SSIs after major HNC surgery. Preventive measures or close monitoring in these patients may be required to reduce the likelihood of postoperative SSIs. Furthermore, even though additional research is required, we would consider changing the prophylactic antibiotic regimens according to the causative organisms.

The Role of Transnasal Esophagoscopy in ENT Office: A Prospective, Multicenter Study in Korea

OBJECTIVES: The purpose of study was to report the current role of transnasal esophagoscopy (TNE) in Korea. METHODS: One hundred thirty-seven patients who underwent TNE at Soonchunhyang University Bucheon Hospital (n=69) and Korea University Anam Hospital (n=68) from July 2007 to February 2009 were prospectively analyzed. Laryngopharyngeal reflux disease (LPRD) patients without any response to proton-pump inhibitor (n=102), and patients with complaints that require esophagoscopy as part of their evaluation (n=35) were included in this study; investigation of metachronous lesions or routine follow-up screening of head and neck cancer patients, n=17; dysphagia, n=9; blood tinged saliva, n=4; to determine the cause of vocal fold paralysis as screening tool, n=4; suspicious esophageal foreign body, n=1. RESULTS: Fifty-three patients (38.7%) had positive findings on TNE. Positive finding ratio was highest in group of dysphagia (7 among 9 patients, 78%). Forty-two patients (41.1%) were found to have pathology (esophagitis, n=41; esophageal diverticulum, n=1) during the screening examination for LPRD. There were no significant complications in any of the patients. CONCLUSION: TNE is a high-yield diagnostic and therapeutic modality available to otolaryngologists for use on awake patients in the office setting.

Loss of Heterozygosities in Five Tumor Suppressor Genes (FHIT Gene, p16, pRb, E-Cadherin and p53) in Thyroid Tumors

OBJECTIVES: To evaluate the loss of heterozygosities (LOH) of chromosomes 3p14 (FHIT gene), 9p21 (p16), 13q21 (pRb), 6q22 (E-cadherin) and 17p13 (p53) in various thyroid tumors. METHODS: Eighty thyroid tumor cases (20 follicular adenomas, 10 follicular carcinomas, and 50 papillary carcinomas) have been analyzed for the presence of LOH in chromosomes 3p14, 9p21, 13q21, 6q22, and 17p13 allelic loss, using microsatellite markers and DNA obtained from formalin-fixed paraffin-embedded archival tissues. RESULTS: LOH on 3p14 was found in 10.5%, 33.3%, and 30.4% of follicular adenomas, follicular carcinomas, and papillary carcinomas, respectively. LOH on 9p21 was detected in 6%, 44.4%, and 47.8%, respectively. LOH on pRb gene was found in 5.3%, 20.0%, and 35.4%, respectively. LOH on E-cadherin gene was found in 5.3%, 22.2%, and 43.8%, respectively. LOH on 17p13 was detected in 0%, 40%, and 45.8%, respectively. LOH in FHIT gene, p16, pRb, E-cadherin, and p53 genes were more frequently identified in follicular carcinoma and papillary carcinoma than in follicular adenoma. CONCLUSION: LOH results of the five tumor suppressor genes (FHIT gene, p16, pRb, E-cadherin, and p53) showed statistical differences between benign tumor and malignant tumor. Among papillary carcinoma, LOH in p16, E-cadherin and p53 genes well correlated with poorly differentiated grade, and LOH of E-cadherin was associated with lymph node metastasis.

Conversion from Selective to Comprehensive Neck Dissection: Is It Necessary for Occult Nodal Metastasis? 5-Year Observational Study

OBJECTIVES: To compare the therapeutic results between selective neck dissection (SND) and conversion modified radical neck dissection (MRND) for the occult nodal metastasis cases in head and neck squamous cell carcinoma. METHODS: Forty-four cases with occult nodal metastasis were enrolled in this observational cohort study. For twenty-nine cases, SNDs were done and for fifteen cases, as metastatic nodes were found in the operative field, conversion from selective to MRNDs type II were done. Baseline data on primary site, T and N stage, extent of SND, extracapsular spread of occult metastatic node and type of postoperative adjuvant therapy were obtained. We compared locoregional control rate, overall survival rate and disease specific survival rate between two groups. RESULTS: Among the 29 patients who underwent SND, only one patient had a nodal recurrence which occurred in the contralateral undissected neck. On the other hand, among the 15 patients who underwent conversion MRND, two patients had nodal recurrences which occurred in previously undissected neck. According to the Kaplan Meier survival curve, there was no statistically significant difference for locoregional control rate, overall survival rate and disease specific survival rate between two groups (P=0.2719, P=0.7596, and P=0.2405, respectively). CONCLUSION: SND is enough to treat occult nodal metastasis in head and neck squamous cell carcinoma and it is not necessary to convert from SND to comprehensive neck dissection.

Histopathologic Predictors of Lymph Node Metastasis and Prognosis in Tonsillar Squamous Cell Carcinoma

BACKGROUND: Risk factors for lymph node metastasis in tonsillar squamous cell carcinoma (TSCC) need to be established to determine the degree of surgery required to achieve high curative rates. However, little is known currently about the histopathological features predicting prognosis, specifically in TSCC. METHODS: This study included 53 patients who underwent surgical resection with neck dissection. Clinicopathological factors investigated included age, gender, alcohol use, tobacco consumption, tumor stage, adjacent structure involvement, cell differentiation, squamous dysplasia, in situ carcinoma associated with primary invasive cancer, carcinoma in situ skip lesions, necrosis, invasive front, depth of invasion, and lymphatic, muscle, or perineural invasion. RESULTS: Contralateral cervical metastasis was associated with higher T stages and soft palate invasion. Lymphatic and muscle invasion were associated with ipsilateral cervical metastasis. Advanced T stage, invasion to the base of tongue, and skip lesions were associated with decreased disease-free survival. Advanced T stage and skip lesions were associated with worse overall survival. CONCLUSIONS: Advanced T stage and soft palate invasion may predict a high risk of contralateral nodal metastasis. T stage and skip lesion are worse prognostic factors in TSCC and should be commented in pathology reports.

Analysis of 120 Pectoralis Major Flaps for Head and Neck Reconstruction

BACKGROUND: A pectoralis major flap is one of the standard tools for the reconstruction of defects of the head and neck. Despite the technical advancement in free tissue transfer in head and neck reconstruction, the benefits of a pectoralis major flap should not be overlooked. The purpose of this study is to evaluate our 17 years of experience in reconstructing defects of the head and neck region using the pectoralis major flap. METHODS: We retrospectively reviewed the medical records of 112 patients (120 cases) who underwent pectoralis major flap operations for head and neck reconstruction during a period ranging from 1994 to 2010. RESULTS: In our series, no total necrosis of the flap occurred. Of the total cases, 30.8% presented with flap-related complications. Major complications occurred in 20% of all of the cases but were then all successfully treated. The male sex was correlated with the occurrence of overall complications (P=0.020) and major complications (P=0.007). Preoperative albumin levels of <3.8 g/dL were correlated with the formation of fistula (P=0.030). Defects of the hypopharynx were correlated with the occurrence of major complications (P=0.019) and the formation of fistula (P=0.012). Secondary reconstructions were correlated with the occurrence of overall complications (P=0.013) and the formation of fistula (P=0.030). CONCLUSIONS: A pectoralis major flap is still considered to be a safe, versatile one-stage reconstruction procedure in the management of the defects of head and neck and the protection of the carotid artery.

Osteoclast-like Giant Cell Tumor of the Parotid Gland Accompanied with Carcinoma ex Pleomorphic Adenoma

The origin of osteoclast-like giant cell tumor (OGCT) of the salivary gland has been debated because the prototypic cells of osteoclast-like cells and mononuclear stromal cells are largely unexplained in this gland. Bone marrow-derived CD14+ and CD45+ monocyte-derived multipotential cells (CD14+/CD45+ MOMC) may be one of the possible origins of OGCTs of salivary glands, which have never been explored in salivary OGCTs. We present a case of OGCT accompanied with carcinoma ex pleomorphic adenoma in the parotid gland of a 67-year-old Korean female. The tumor presented as a rapidly growing cervical mass comprising a central area of carcinoma ex pleomorphic adenoma and a peripheral circumferential area of OGCT. The immunohistochemical staining pattern was phenotypically consistent with bone marrow-derived CD14+/CD45+ MOMC. This case is the first report of a salivary OGCT in Korea.

Osteoclast-like Giant Cell Tumor of the Parotid Gland Accompanied with Carcinoma ex Pleomorphic Adenoma

The origin of osteoclast-like giant cell tumor (OGCT) of the salivary gland has been debated because the prototypic cells of osteoclast-like cells and mononuclear stromal cells are largely unexplained in this gland. Bone marrow-derived CD14+ and CD45+ monocyte-derived multipotential cells (CD14+/CD45+ MOMC) may be one of the possible origins of OGCTs of salivary glands, which have never been explored in salivary OGCTs. We present a case of OGCT accompanied with carcinoma ex pleomorphic adenoma in the parotid gland of a 67-year-old Korean female. The tumor presented as a rapidly growing cervical mass comprising a central area of carcinoma ex pleomorphic adenoma and a peripheral circumferential area of OGCT. The immunohistochemical staining pattern was phenotypically consistent with bone marrow-derived CD14+/CD45+ MOMC. This case is the first report of a salivary OGCT in Korea.

Reconstruction of Midfacial Defects with Free Flaps after Maxillectomy

PURPOSE: Maxillectomy for malignant tumor resection often leads to functional and aesthetic sequalae. Reconstruction following maxillectomy has been a challenging problem in the field of head and neck cancer surgery. In this article, we described three dimensional midface reconstructions using free flaps and their functional and aesthetic outcomes. METHODS: We reconstructed 35 cases of maxillectomy defects using 9 radial forearm free flaps, 7 lattisimus dorsi musculocutaneous free flaps, 6 rectus abdominis musculocutaneous free flaps, 4 fibular osteocutaneous free flaps, and 9 anterolateral thigh free flaps, respectively. We classified post-maxillectomy defects by Brown's classification.1 Articulation clarity was measured with picture consonant articulation test. Swallowing function was evaluated with the University of Washington quality-of-life Head and Neck questionnaire by 4 steps. Aesthetic outcomes were checked to compare preoperative with postoperative full face photographs by 5 medical doctors who did not involve in our operation. RESULTS: The average articulation clarity was 92.4% (100-41.9%). 27 (81.9%) patients were able to eat an unrestricted diet. Aesthetic results were considered excellent in 18 patients (51.4%). Functional results were best in the group reconstructed with fibular osteocutaneous free flap. Considering the range of wide excision, aesthetic results is best in the group reconstructed with anterolateral thigh free flap. CONCLUSION: The free flap is a useful technique for the reconstruction of the midface leading to good results, both functionally and aesthetically. Especially, because osteocutaneous flap such as fibular osteocutaneous free flap offered bone source for osteointegrated implant, It produces the best functional results. And perforator flap like as anterolateral thigh free flap reliably provides the best aesthetic results, because it provides sufficient volume and has no postoperative volume diminution.

A Case of Sarcomatoid Carcinoma of Auricular Skin Lesion / 대한이비인후과학회지

Sarcomatoid carcinoma is a biphasic tumor composed of squamous and spindle cell component, both of which are malignant. The diagnostic tool of sarcomatoid carcinoma is immunohistologic staining. The atypical cells react to be positive for vimentin and negative for S-100, desmin, carcinoembrionic antigen, smooth muscle actin. The primary cutaneous involvement of head and neck area is extremely rare. Therefore, it has been difficult to characterize the histognensis, biologic behavior, optimal treatment and prognosis. We experienced a case of a 24-years old female with sarcomatoid carcinoma at the auricular skin lesion, which has been treated successfully with wide excision of tumor and postoperative radiotherapy.

Necrotizing Sialometaplasia Accompanied by Adenoid Cystic Carcinoma on the Soft Palate

Necrotizing Sialometaplasia (NS) is a benign, self-limiting inflammatory disease of the mucus-secreting glands, and this illness mainly involves the minor salivary glands. The significance of NS resides in its clinical and histopathological resemblance to malignancy. We present here a case of necrotizing sialometaplasia on the soft palate, and this was accompanied by adenoid cystic carcinoma. We report here on this case to draw attention to the difficulty for deciding the extent of resecting a malignancy, and especially when the malignancy is simultaneously accompanied by necrotizing sialometaplasia.

A Case of Dysplastic Nevus of the External Auditory Canal Presenting with Conductive Hearing Loss

A nevus which is a benign melanocytic neoplasm rarely occurs within the external auditory canal (EAC). A dysplastic nevus presents atypical features both clinically and histologically, and is important as a potential precursor for melanoma. We present a case of a 33-year-old female patient with a dysplastic nevus in her EAC. Physical examination revealed a protruding mass arising from the posterior wall of the left cartilaginous EAC. The mass showed clinically characteristic findings of a melanocytic nevus. The patient underwent excisional biopsy via a transcanal approach under local anesthesia. Histopathological examination revealed an intradermal nevus with atypical melanocytes without pleomorphism. There was no evidence of recurrence two years after surgical excision.

Surgical Management of Sinonasal Cancer / 한양의대학술지

Sinonasal cancers account for less than 1% of all malignancies and comprise 3% of all head and neck malignancies. The most common malignant neoplasm in the sinuses and nose is squamous cell carcinoma, which accounts for 70% of these neoplasms. Most of these arise in the maxillary antrum, and only 10% to 30% occur in the nasal cavity or ethmoid sinus. It is well known the surgery is primary treatment for sinonasal malignancies. Adjunctive irradiation and/or chemoradiatioin has resulted in improved locoregional control and increased survival rates. The goal of surgical resection is to remove the cancer en bloc, with clear margin devoid of neoplastic cells. For maxillary sinus neoplasms, maxillectomy is a standard surgical procedure. Neoplasms involving the ethmoid, frontal, or sphenoid sinuses may require a craniofacial approach because of frequent invasion into the skull base. The proximity of the nasal cavity and paranasal sinuses to the adjacent structures including the orbit, dura, brain, cranial nerves, and carotid arteries mandates careful radiologic and neurologic evaluations throughout the course of the disease. Surgical advances now permit complex tumor removal and reconstruction surrounding these structures resulting in functional and cosmetic improvements when compared to earlier techniques.

Diagnosis of Salivary Gland Function Using Oral Schirmer Test / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The accurate measure of salivary flow rate requires a variety of clinical and experimental protocols. Several methods have traditionally been used to collect and measure the whole mouth saliva. The objective of this study was to verify usefulness of a newly developed oral Schirmer test for detecting salivary gland hypofunction. SUBJECTS AND METHOD: The control group consisted of 85 healthy patients, while another group consisted of 30 patients with salivary grand resection or post-head and neck irradiation and a third group of 30 patients who suffered from subjective xerostomia caused by other pathologies. Oral Schirmer test was carried out in all subjects. The main outcome was the wetted length after 5 minutes. RESULTS: The mean saliva flow was 59.3+/-16.99 mm/5 min in the control group, 47.0+/-13.50 mm/5 min in the 2nd group and 39.9+/-11.65 mm/ 5 min in the third group. The differences between the control group and the other two groups were statistically different (p<0.001). A cut-off value 40 mm/5 min showed sensitivity of 83.7% and specificity of 62.5%. CONCLUSION: The oral Schirmer test is valid and reliable for identifying subjects with xerostomia.